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Outcomes Following Revision Joint Arthroplasty Among Hemodialysis-Dependent Patients
The Journal of Arthroplasty xxx (2019) 1e5
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Outcomes Following Revision Joint Arthroplasty Among Hemodialysis-Dependent Patients Lawal A. Labaran, BS a, Sean Sequeira, BS a, Surajudeen A. Bolarinwa, MD a, Jomar Aryee, BS a, Samuel R. Montgomery Jr, BS a, Eugene Nwankwo, BS b, Emanuel Haug, MD a, Joshua Bell, MD a, Quanjun Cui, MD a, * a b
Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA Department of Orthopaedic Surgery, Texas Tech University, Lubbock, TX
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 August 2019 Received in revised form 6 October 2019 Accepted 21 October 2019 Available online xxx
Background: Hemodialysis (HD) dependence is known to impact the integrity of bone and has long been associated with metabolic bone disease and other adverse events postoperatively. The aim of this study is to analyze postoperative outcomes following revision hip and knee arthroplasty in hemodialysisdependent (HDD) patients and to characterize the common indications for revision procedures among this patient population. Methods: A total of 1779 HDD patients who underwent a revision joint arthroplasty (930 revision total knee arthroplasty [TKA] and 849 revision total hip arthroplasty [THA]) between 2005 and 2014 were identified from a retrospective database review. Our resulting study groups of revision TKA and THA HDD patients were compared to their respective matched control groups for hospital length of stay (LOS), 90day mean total cost, hospital readmission, and other major medical and surgical complications. Results: HD was significantly associated with increased LOS (7.7 ± 8.3 vs 4.8 ± 4.5; P < .001), mean 90day total cost ($47,478 ± $33,413 vs $24,286 ± $21,472; P < .001), hospital readmission (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.96-2.58; P < .001), septicemia (OR, 3.18; 95% CI, 2.70-3.74; P < .001), postoperative infection (OR, 1.72; 95% CI, 1.50-1.98; P < .001), and mortality (OR, 3.99; 95% CI, 3.12-5.06; P < .001) following revision TKA. Among revision THA patients, HD was associated with increased LOS (9.4 ± 9.5 vs 5.7 ± 5.7; P < .001), mean 90-day total cost ($40,182 ± $27,082 vs $26,519 ± $22,856; P < .001), hospital readmission (OR, 2.33; 95% CI, 2.02-2.68; P < .001), septicemia (OR, 3.61; 95% CI, 3.05-4.27; P < .001), and mortality (OR, 3.55; 95% CI, 2.86-4.37; P < .001). Conclusion: HD remains a significant risk factor for increased LOS, mean total cost, hospital readmission, septicemia, and mortality following revision joint arthroplasty. Published by Elsevier Inc.
Keywords: revision joint arthroplasty revision TKA/THA hemodialysis complications end-stage renal disease dialysis
Total hip (THA) and total knee arthroplasty (TKA) are increasingly common procedures that have wide patient demographics and surgical indication profiles. First performed in the early 1960s, THAs historically had good outcomes, had manageable complications, and provided patients with the retention of their prosthesis for up to15-20 years [1,2]. Similarly, TKAs are among the most
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.10.041. * Reprint requests: Quanjun Cui, MD, Department of Orthopaedic Surgery, University of Virginia, 400 Ray C Hunt Drive, Charlottesville, VA, 22908. https://doi.org/10.1016/j.arth.2019.10.041 0883-5403/Published by Elsevier Inc.
efficacious surgeries for those with refractory knee pain for both cost and outcomes [3]. While often successful, common causes of revision joint arthroplasty include wear, loosening, dislocation, infection, and fracture [4,5]. Although complications have progressively been reduced and long-term outcomes have improved, there still exist several areas of further investigation and optimization. Certain patient demographics, namely chronic renal disease patients, have demonstrated higher rates of complications and poorer outcomes associated with joint arthroplasties and revisions [6,7]. While chronic renal disease patients have been extensively studied in terms of their capacity to achieve successful THA and TKAs, literature on revision joint arthroplasty in hemodialysis (HD) patients is less well documented [5,8e10]. Hemodialysis patients
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comprise of a prominent fraction of joint arthroplasty candidates, a correlation that has multiple hypotheses as to its pathogenesis. One etiology can be traced to HD patients’ high rates of renal osteodystrophy. Renal osteodystrophy results in abnormal (high or low) bone turnover and increases the risk of skeletal fractures, reduces quality of life, and worsens clinical outcomes [11]. A second hypothesis is that beta 2-microglobulin amyloid deposition in periprosthetic tissues contributes to primary and revision joint arthroplasty [12]. Typically, patients on HD also have a number of comorbidities that contribute to worsened outcomes and complication rates as well as obscure hemodialysis’ true effect on revision joint arthroplasty outcomes. In terms of diabetes, the most common cause of chronic kidney disease in the United States, unregulated chronic hyperglycemia, can result in increased incidence of surgical site infections, deep periprosthetic infections, length of stay (LOS), and morbidity [13]. In fact, the presence of diabetes mellitus, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), congestive heart failure, and peripheral vascular disease has all been demonstrated as poor prognostic indicators of joint arthroplasty outcomes and complication rates [13e17]. Due to increased longevity for hemodialysis-dependent (HDD) patients from improved HD mortality and outcomes, an increasing number of HDD patients tend to accumulate more wear, loosening, dislocation, infection, and fracture, prompting repeat surgical intervention for revision. Although few joint arthroplasties require revision, HDD patients are more likely to require a revision joint arthroplasty prompting extensive research in surgical indications, outcomes, and complications for this unique set of patients undergoing revision arthroplasty [18]. The aims of this study are to analyze outcomes following revision joint arthroplasty among HDD patients and to identify the common indications for revision arthroplasty in this patient population. Methods Data Source A retrospective database review was conducted, using the commercially available PearlDiver Patient Records Database (www. pearldiverinc.com; PearlDiver Inc, Colorado Springs, CO), which contains all Medicare patient records from 2005 to 2014, searchable by International Classification of Diseases (ICD), Current Procedural Terminology, and Diagnosis-Related Group codes among others. Queried data are de-identified and Health Insurance Portability and Accountability Act compliant; therefore, institutional review board approval was waived for this study. Study Population All Medicare patients from the years of 2005 to 2014 who underwent revision TKA (ICD-9-CM: 00.80, 00.81, 00.82, 00.83, 00.84, and 81.55) were queried. Patients 85 years or older and those with a preexisting diagnosis of lower extremity neoplasm involving the hip or knee joints (ICD-9-CM: 171.3, 173.70, 173.79, 215.3, 216.7, 213.7, and 170.7) were excluded from the study. This was repeated in a separate query for patients who underwent revision THA (ICD9-CM: 00.70, 00.71, 00.72, 00.73, and 81.53). The resulting groups were further divided into the resulting populations: those who were identified as HDD (ICD-9-D-V420, ICD-9-P-556.9) before revision arthroplasty and those with no history of HDD. Revision arthroplasty patients and corresponding controls were then matched based on age, sex, obesity, tobacco use, alcohol use, diabetes mellitus, peripheral vascular disease, congestive heart failure, COPD, hypertension, and hyperlipidemia.
Postoperative Outcome Following Revision Joint Arthroplasty in HDD Patients Revision TKA and THA groups were then compared to their respective controls for LOS, 90-day mean total cost, 90-day readmission rates, and 90-day major medical complications including pulmonary embolism, cardiovascular accident, myocardial infarction, pneumonia, and venous thromboembolism. In addition, 1year postoperative outcomes including septicemia, infection, and mortality rates were compared. Primary Indications for Revision Joint Arthroplasty in HDD Patients The primary diagnosis at the time of respective revision arthroplasty was queried. The following diagnoses were evaluated: periprosthetic infection/inflammation, other acquired deformities such as valgus and varus deformities, other mechanical complications (not otherwise specified), mechanical loosening, dislocation of prosthetic joint, periprosthetic fracture, and broken prosthetic joint implant. Statistical Analysis Both groups’ baseline demographics and preexisting comorbidities were compared using Pearson’s chi-square analysis. Pearson’s chi-squared analysis was then used to compare rates of septicemia, infection, mortality, readmission, and major medical complications between both study groups and their respective matched controls. Multivariate logistical regression was applied to determine the isolated effect HDD had on all postoperative outcomes following revision TKA and THA. This was adjusted for age, sex, morbid obesity, tobacco use, alcohol use, and preexisting identified comorbidities as covariates. LOS and 90-day hospital cost was compared using Student t-test. A linear regression was calculated to determine independent effect of HDD on LOS adjusted using previously mentioned covariates. All statistical analyses were performed using R Project for Statistical Computing. Significance was determined for P values <.05. Results Patient Demographics and Comorbidities In total, 930 and 849 HDD patients who underwent a revision TKA and THA, respectively, were identified. Also, 18,359 revision TKA and 16,596 revision THA matched control patients were selected. Following a matched selection of the control groups, there were no significant differences in demographic factors and preexisting comorbidities. An increase in the Charlson Comorbidity Index was noted in both the HDD patients undergoing revision TKA (9.62 ± 2.96 vs 7.00 ± 2.99; P < .001) and those undergoing revision THA (9.2 ± 3.3 vs 6.6 ± 3.2; P < .001; Table 1). Postoperative Outcome Following Revision Joint Arthroplasty Among Hemodialysis Patients Revision Knee Arthroplasty Within the revision TKA population, HDD was associated with increased rates of 90-day hospital readmission (42.4% vs 23.7%; odds ratio [OR], 2.25, 95% confidence interval [CI], 1.96-2.58; P < .001) and greater LOS (7.7 ± 8.3 days vs 4.8 ± 4.5 days; P < .001). Following an adjusted linear regression, HDD independently increased LOS by approximately 2.26 days (P < .001). And 90-day mean total cost was also significantly higher ($47,478 ± $33,413 vs $24,286 ± $21,472; P < .001) among HDD patients undergoing
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Table 1 Patient Demographics. Total Numbers
Age (y) <65 65-69 70-74 75-79 80-84 Male sex Obesity (BMI > 30 kg/m2) Tobacco use Alcohol abuse CCI Comorbidities Diabetes mellitus Peripheral vascular disease Congestive heart failure COPD Hypertension Hyperlipidemia
Revision TKA
P Value
Hemodialysis 930 (%)
Matched Control 18,359 (%)
280 (30.1) 175 (18.8) 211 (22.7) 162 (17.4) 102 (11.0) 401 (43.1) 409 (44.0) 359 (38.6) 25 (2.7) 9.62 ± 2.96
5419 (29.5) 3334 (18.2) 4170 (22.7) 3381 (18.4) 2055 (11.2) 7879 (42.9) 8055 (43.9) 7059 (38.4) 444 (2.4) 7.00 ± 2.99
678 195 570 496 756 922
13,432 3821 11,211 9779 14,988 18,210
Revision THA
P Value
Hemodialysis 849 (%)
Matched Control 16,596 (%)
.930 .978 .953 .680 <.001
316 (37.2) 125 (14.7) 151 (17.8) 143 (16.8) 114 (13.4) 425 (50.1) 165 (19.4) 341 (40.2) 48 (5.7) 9.2 ± 3.3
6074 (36.6) 2343 (14.1) 2962 (17.8) 2851 (17.2) 2366 (14.3) 8332 (50.2) 3179 (19.2) 6632 (40.0) 861 (5.2) 6.6 ± 3.2
.962 .875 .935 .606 <.001
.891 .942 .918 .995 1.000 .823
494 154 433 409 834 593
9656 2869 8388 7974 16,308 11,589
1.000 .553 .822 .971 1.000 1.000
.934
(72.9) (21.0) (61.3) (53.3) (81.3) (99.1)
(73.2) (20.8) (61.1) (53.3) (81.6) (99.2)
.946
(58.2) (18.1) (51.0) (48.2) (98.2) (69.8)
(58.2) (17.2) (50.5) (48.0) (98.3) (69.8)
TKA, total knee arthroplasty; THA, total hip arthroplasty; BMI, body mass index; CCI, Charlson Comorbidity Index; COPD, chronic obstructive pulmonary disease.
revision compared to controls. HDD was also an independent predictor of septicemia (24.2% vs 8.6%; OR, 3.18; 95% CI, 2.70-3.74; P < .001), infection (37.8% vs 25.3%; OR, 1.72; 95% CI, 1.50-1.98; P < .001), and mortality (9.7% vs 2.4%; OR, 3.99; 95% CI, 3.12-5.06; P < .001) within 1 year compared to non-HDD patients. No significant difference was seen in 90-day major medical complications including pulmonary embolism, venous thromboembolism, myocardial infarction, cardiovascular accident, and pneumonia (11.7% vs 11.0%; P ¼ .510) between HDD and non-HDD patients (Table 2). Revision Hip Arthroplasty Within the revision THA population, HDD was associated with increased rates of 90-day hospital readmission (46.4% vs 26.4%; OR, 2.33; 95% CI, 2.02-2.68; P < .001) and greater LOS (9.4 ± 9.5 days vs 5.7 ± 5.7 days; P < .001). Likewise, following a linear regression, HDD independently increased LOS by about 2.73 days (P < .001). And 90-day mean total cost ($40,182 ± $27,082 vs $26,519
± $22,856; P < .001) was also significantly higher in the HDD patients undergoing revision compared to controls. HDD was also an independent predictor of septicemia (25.6% vs 8.2%; OR, 3.61; 95% CI, 3.05-4.27; P < .001) and mortality (14.4% vs 4.1%; OR, 3.55; 95% CI, 2.86-4.37; P < .001) within 1 year compared to non-HDD patients. No significant difference was seen in 90-day major medical complications (13.8% vs 12.1%; P ¼ .159) and 1-year infection rates (19.7% vs 18.5%; P ¼ .404) between HDD and non-HDD patients (Table 2). Primary Indications for Revision Arthroplasty Among Hemodialysis Patients Among HDD patients undergoing revision TKA, the most common preoperative diagnoses were periprosthetic infection and/or inflammation (46.5%), acquired deformities of the knee joint (21.2%), other mechanical complications (10.5%), mechanical loosening (6.3%), dislocation (3.8%), periprosthetic fracture (1.9%), and
Table 2 Postoperative Outcome Following Revision Knee Arthroplasty in Hemodialysis-Dependent Patients. TKA
Length of stay (d) 90-d Mean total cost 90-d Readmission 90-d Major medical complications 1-y Septicemia 1-y Infection 1-y Mortality
Hemodialysis 930 (%)
Matched Control 18,359 (%)
P Value
Adjusted OR (95% CI)
7.7 ± 8.3 $47,478 ± $33,413 394 (42.4) 109 (11.7) 225 (24.2) 352 (37.8) 90 (9.7)
4.8 ± 4.5 $24,286 ± $21,472 4382 (23.7) 2014 (11.0) 1575 (8.6) 4642 (25.3) 440 (2.4)
<.001 <.001 <.001 .510 <.001 <.001 <.001
2.26 d 2.25 1.00 3.18 1.72 3.99
Hemodialysis 849 (%)
Matched Control 16,596 (%)
P Value
Adjusted OR (95% CI)
9.4 þ 9.5 $40,182 ± $27,082 394 (46.4) 117 (13.8) 218 (25.6) 167 (19.7) 122 (14.4)
5.7 ± 5.7 $26,519 ± $22,856 4376 (26.4) 2008 (12.1) 1366 (8.2) 3065 (18.5) 679 (4.1)
<.001 <.001 <.001 .159 <.001 .404 <.001
2.73 d 2.33 1.06 3.61 1.05 3.55
(1.71-2.81)a (1.96-2.58) (0.81-1.23) (2.70-3.74) (1.50-1.98) (3.12-5.06)
P Value <.001 d <.001 .987 <.001 <.001 <.001
THA
Length of stay (d) 90-d Mean total cost 90-d Readmission 90-d Major medical complications 1-y Septicemia 1-y Infection 1-y Mortality
TKA, total knee arthroplasty; THA, total hip arthroplasty; OR, odds ratio; CI, confidence interval. a Adjust linear regression coefficient (b).
(2.14-3.33)a (2.02-2.68) (0.86-1.30) (3.05-4.27) (0.88-1.25) (2.86-4.37)
P Value <.001 d <.001 .549 <.001 .564 <.001
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broken prosthetic joint implant (1.7%). The most common indications for revision THA among HDD were dislocation of prosthetic hip joint (24.3%), periprosthetic infection (20.5), other mechanical complications (14.0%), mechanical loosening (12.8%), periprosthetic fracture (6.9%), acquired deformity of hip joint (6.6), and broken prosthetic hip implant (3.8%; Table 3). Discussion Hip and knee arthroplasties are some of the most common orthopedic procedures worldwide today for refractory joint pain from end-stage osteoarthritis. The incidence will only grow as life expectancy and normal “wear-and-tear” on the joints continue to rise. While arthroplasty often provides lifetime improvement in pain and activities of daily living, complications like wear, loosening, dislocation, infection, and fracture often necessitate revision joint arthroplasty [3,19]. HDD patients with THA and TKA are not spared, and in fact, due to the nature of their disease may be more predisposed to having indications for revision surgery. In this study, HD was associated with increased LOS, 90-day cost, 90-day readmission, septicemia, and 1-year mortality following both revision TKA and THA. Additionally, dislocation and periprosthetic infections were the most common indications for revision THA and TKA among HDD patients. Etiology of the poor outcome of joint arthroplasty among HDD cannot be overlooked. In patients with chronic kidney disease, beta-2 microglobulin has been hypothesized to be at least contributory, if not the main factor, behind this patient populations’ poor outcomes [20]. The increase in beta-2 microglobulin produces a dialysis arthropathy that exerts detrimental effects on the health of native and prosthetic joints often producing indications for primary arthroplasty and, occasionally, revision arthroplasty. Crawford and Athanasou [12] studied the histopathologic, radiographic, and clinical effects of dialysis arthropathy on patients who had primary THA. It was determined that beta-2 microglobulin was present in 60% of cases with large amyloid deposits in collagenous connective tissue. Subsequently, Crawford and Athanasou hypothesized that wear particles, namely beta-2 microglobulin, can migrate through small fissures to the bone-implant interface, inducing aseptic loosening and acting as a nidus for infection. Harris [21] postulated that it was the mounted macrophage response that elicited prostaglandin, proteases, and other inflammatory cytokines to navigate to the site, causing aseptic loosening. Results obtained in this study align well with the existing literature that has demonstrated that HDD patients generally have a greater morbidity and mortality associated with hip and knee arthroplasty. Sunday et al [8], in their small retrospective study evaluating joint arthroplasty in HDD patients, observed that all participants had at least 1 complication, infection being the most likely. In that same study, they reported a 29% inhospital mortality rate postoperatively. Regarding TKA specifically, Ponnusamy et al Table 3 Common Primary Indications for Revision Arthroplasty in Hemodialysis-Dependent Patients. Indication
ICD-9-CM
TKA (%)
THA (%)
Periprosthetic infection Other acquired deformities Other mechanical complications
996.66 739.6 996.49, 996.47, 996,77 996.41 996.42 996.44 996.43
432 (46.5) 197 (21.2) 98 (10.5)
59 (6.9) 56 (6.6) 119 (14.0)
Mechanical loosening Dislocation of prosthetic joint Periprosthetic fracture Broken prosthetic joint implant
59 35 18 16
(6.3) (3.8) (1.9) (1.7)
109 206 174 32
(12.8) (24.3) (20.5) (3.8)
ICD, International Classification of Diseases, Ninth Revision, Clinical Modification; TKA, total knee arthroplasty; THA, total hip arthroplasty.
[22] determined that HDD patients had a significantly higher inpatient mortality (0.92% vs 0.10%) and greater overall complication rate (12.485 vs 5.0%) vs controls. Focusing on THA, Sunday et al, Lieberman et al, and Sakalkale et al [5,8,9] all reported worsened mortality for HDD patients following primary THA, often due to an infectious etiology. In more recent literature, Lieu et al and Fukunishi et al [10,23] found that while HDD individuals have improved mortality rate, LOS, and complications than in the past, they still remain inferior to their renally healthy counterparts. Given the evidence that exists for outcomes in HDD patients, the potential benefits of joint arthroplasty should be heavily scrutinized before the intervention is offered to this patient population. Other comorbid medical conditions that commonly coexist with chronic kidney disease and hemodialysis dependence have been independently linked to worse prognosis following joint arthroplasty. Several studies exist that elucidate which of these commonly concomitant comorbidities may confound revision hip arthroplasty outcome [13e15,17,24]. In a systematic review of 13,722 THA patients, Haynes et al demonstrated that obesity was significantly associated with earlier THA intervention as well as increased perioperative complications [25]. Diabetes has been associated with longer LOS and increased cost following a hip and knee arthroplasty as compared to their nondiabetic counterparts [13,26]. Tobacco and alcohol consumption, congestive heart failure, COPD, and peripheral vascular disease have all been documented in the literature to increase perioperative complications associated with hip and knee arthroplasty [14e16,27,28]. These studies demonstrating the independent effect of these comorbid conditions highlight the importance of controlling for their incidence when analyzing the HDD patients. Miric et al [7] demonstrated that HDD patients had significantly higher rates of diabetes, congestive heart failure, valvular disease, alcohol abuse, peripheral vascular disease, and hypertension. They controlled for those comorbid conditions and, as in the present study, demonstrated increased risk of surgical site infections, 90-day readmission, and all-cause mortality postoperatively. Given the efforts made to control for commonly concomitant comorbidities, the authors of the present study believe that the results reported here should reflect HDD’s true and isolated effects on revision joint arthroplasty outcomes. The primary advantage of the present study is its large sample size. This investigation is the largest study to date that explores the outcomes following revision joint arthroplasty among HDD patients. Additionally, to the best knowledge of the authors, this is the only study that specifically investigates revision joint arthroplasty among HDD patients. It is important to note there are a number of similar studies in primary joint arthroplasty in hemodialysis patients [4,5,8,9]. HDD patients have several comorbid conditions that could confound the effect of HD on postrevision outcome. As such, another advantage of this study is the matching of pertinent demographic factors and comorbidities to isolate the independent effect of HD on outcome following revision joint arthroplasty. While the Medicare data include records from over 51 million unique patients, this study has a number of limitations. Our findings rely heavily on the accuracy of the entry of data into both the patients’ medical records and the database itself [29]. Studies have reported low sensitivity for identifying prior comorbid diagnoses [30]. Also, our study did not investigate peritoneal dialysis, the more accessible counterpart to hemodialysis, and its association with mortality after revision joint arthroplasty [31]. While our follow-up time was considered a strength and is longer than most contemporaneous studies, a longer follow-up time would more effectively characterize the long-term prognosis and outcome following revision joint arthroplasty in HDD patients. Furthermore, the outcomes measured in this study could be broadeneddadditional outcome parameters used in other studies like incidence of
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complications like deep vein thrombosis and need for transfusions, re-revision rate, use of a quantitative joint rating scale like the Harris Hip Score (HHS), among others to better characterize the complications and outcomes of these HDD patients [22,32]. Additionally, the major medical complications analyzed in this study is not all encompassing and, hence, did not include other pertinent complications such as cardiac arrhythmias, cardiomyopathies, protein-calorie malnutrition, renal osteodystrophy, and other intradialytic complications that have been shown to increase morbidity and mortality among HDD patients [33]. Conclusion Hemodialysis is a significant risk factor for increased LOS, mean total cost, hospital readmission, septicemia, and mortality following revision joint arthroplasty. Joint specialist should be aware and prepared for these complications, which should facilitate better preoperative and postoperative planning, as well as patient counseling regarding the risks and benefits of revision joint arthroplasty in HDD patients. References [1] Karachalios T, Komnos G, Koutalos A. Total hip arthroplasty. EFORT Open Rev 2018;3:232e9. https://doi.org/10.1302/2058-5241.3.170068. [2] Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet 2019;393:647e54. https://doi.org/10.1016/S0140-6736(18)31665-9. [3] Lachiewicz PF, Soileau ES. Changing indications for revision total hip arthroplasty. J Surg Orthop Adv 2005;14:82e4. [4] Patterson JT, Tillinghast K, Ward D. Dialysis dependence predicts complications, intensive care unit care, length of stay, and skilled nursing needs in elective primary total knee and hip arthroplasty. J Arthroplasty 2018;33: 2263e7. https://doi.org/10.1016/j.arth.2018.02.035. [5] Lieberman JR, Fuchs MD, Haas SB, Garvin KL, Goldstock L, Gupta R, et al. Hip arthroplasty in patients with chronic renal failure. J Arthroplasty 1995;10: 191e5. https://doi.org/10.1016/S0883-5403(05)80126-3. [6] Debarge R, Pibarot V, Guyen O, Vaz G, Carret JP, Bejui-Hugues J. [Total hip arthroplasty in patients with chronic renal failure transplant or dialysis]. Rev Chir Orthop Reparatrice Appar Mot 2007;93:222e7. [7] Miric A, Inacio MCS, Namba RS. The effect of chronic kidney disease on total hip arthroplasty. J Arthroplasty 2014;29:1225e30. https://doi.org/10.1016/ j.arth.2013.12.031. [8] Sunday JM, Guille JT, Torg JS. Complications of joint arthroplasty in patients with end-stage renal disease on hemodialysis. Clin Orthop Relat Res 2002;397:350e5. [9] Sakalkale DP, Hozack WJ, Rothman RH. Total hip arthroplasty in patients on long-term renal dialysis. J Arthroplasty 1999;14:571e5. https://doi.org/ 10.1016/S0883-5403(99)90079-7. [10] Fukunishi S, Fukui T, Nishio S, Imamura F, Yoh K, Yoshiya S. Results of total hip arthroplasty for dialysis arthropathy in long-term hemodialysis patients. J Orthop Sci 2009;14:285e91. https://doi.org/10.1007/s00776-009-1330-2. [11] Torres PU, Bover J, Mazzaferro S, Vernejoul MC de, Cohen-Solal M. When, how, and why a bone biopsy should be performed in patients with chronic kidney disease. Semin Nephrol 2014;34:612e25. https://doi.org/10.1016/ j.semnephrol.2014.09.004. [12] Crawford R, Athanasou NA. Beta 2-microglobulin amyloid deposition in hip revision arthroplasty tissues. Histopathology 1998;33:479e84.
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[13] Akiboye F, Rayman G. Management of hyperglycemia and diabetes in orthopedic surgery. Curr Diab Rep 2017;17:13. https://doi.org/10.1007/s11892017-0839-6. [14] Cullen MW, Gullerud RE, Larson DR, Melton LJ, Huddleston JM. Impact of heart failure on hip fracture outcomes: a population-based study. J Hosp Med 2011;6:507e12. https://doi.org/10.1002/jhm.918. [15] Klasan A, Dworschak P, Heyse TJ, Ruchholtz S, Alter P, Vogelmeier CF, et al. COPD as a risk factor of the complications in lower limb arthroplasty: a patient-matched study. Int J Chron Obstruct Pulmon Dis 2018;13:2495e9. https://doi.org/10.2147/COPD.S161577. [16] Singh JA, Lewallen DG. Medical comorbidity is associated with persistent index hip pain after primary THA. Pain Med 2013;14:1222e9. https://doi.org/ 10.1111/pme.12153. [17] Ahmed AA, Mooar PA, Kleiner M, Torg JS, Miyamoto CT. Hypertensive patients show delayed wound healing following total hip arthroplasty. PLoS One 2011;6:e23224. https://doi.org/10.1371/journal.pone.0023224. [18] Yen S-H, Chen J-H, Lu Y-D, Wang J-W. Perioperative complications of total knee arthroplasty in dialysis patients. J Arthroplasty 2018;33:872e7. https:// doi.org/10.1016/j.arth.2017.09.058. [19] Tay KS, Lo NN, Yeo SJ, Chia SL, Tay DKJ, Chin PL. Revision total knee arthroplasty: causes and outcomes. Ann Acad Med Singap 2013;42:178e83. [20] Sethi D, Gower PE. Dialysis arthropathy, beta 2-microglobulin and the effect of dialyser membrane. Nephrol Dial Transpl 1988;3:768e72. [21] Harris WH. The problem is osteolysis. Clin Orthop Relat Res 1995;311:46e53. [22] Ponnusamy K, Jain A, Thakkar S, Sterling R, Skolasky R, Khanuja H. Inpatient mortality and morbidity for dialysis-dependent patients undergoing primary total hip or knee arthroplasty. J Bone Joint Surg 2015;97:1326e32. https:// doi.org/10.2106/JBJS.N.01301. [23] Lieu D, Harris IA, Naylor JM, Mittal R. Review article: total hip replacement in haemodialysis or renal transplant patients. J Orthop Surg (Hong Kong) 2014;22:393e8. https://doi.org/10.1177/230949901402200325. [24] Sahota S, Lovecchio F, Harold RE, Beal MD, Manning DW. The effect of smoking on thirty-day postoperative complications after total joint arthroplasty: a propensity score-matched analysis. J Arthroplasty 2018;33:30e5. https://doi.org/10.1016/j.arth.2017.07.037. [25] Haynes J, Nam D, Barrack RL. Obesity in total hip arthroplasty: does it make a difference? Bone Joint J 2017;99-B(1 Supple A):31e6. https://doi.org/10.1302/ 0301-620X.99B1.BJJ-2016-0346.R1. [26] Shohat N, Goswami K, Tarabichi M, Sterbis E, Tan TL, Parvizi J. All patients should be screened for diabetes before total joint arthroplasty. J Arthroplasty 2018;33:2057e61. https://doi.org/10.1016/j.arth.2018.02.047. [27] Kapadia BH, Issa K, Pivec R, Bonutti PM, Mont MA. Tobacco use may be associated with increased revision and complication rates following total hip arthroplasty. J Arthroplasty 2014;29:777e80. https://doi.org/10.1016/ j.arth.2013.08.023. [28] Regan EA, Radcliff TA, Henderson WG, Cowper Ripley DC, Maciejewski ML, Vogel WB, et al. Improving hip fractures outcomes for COPD patients. COPD 2013;10:11e9. https://doi.org/10.3109/15412555.2012.723072. [29] Agniel D, Kohane IS, Weber GM. Biases in electronic health record data due to processes within the healthcare system: retrospective observational study. BMJ 2018;361:k1479. https://doi.org/10.1136/bmj.k1479. [30] Samuel AM, Lukasiewicz AM, Webb ML, Bohl DD, Basques BA, Davis KA, et al. ICD-9 diagnosis codes have poor sensitivity for identification of preexisting comorbidities in traumatic fracture patients: a study of the National Trauma Data Bank. J Trauma Acute Care Surg 2015;79:622e30. https://doi.org/ 10.1097/TA.0000000000000805. [31] Walker RC, Howard K, Morton RL. Home hemodialysis: a comprehensive review of patient-centered and economic considerations. Clinicoecon Outcomes Res 2017;9:149e61. https://doi.org/10.2147/CEOR.S69340. [32] Nilsdotter A, Bremander A. Measures of hip function and symptoms: Harris Hip Score (HHS), Hip Disability and Osteoarthritis Outcome Score (HOOS), Oxford Hip Score (OHS), Lequesne Index of Severity for Osteoarthritis of the Hip (LISOH), and American Academy of Orthopedic Surgeons (AAOS) Hip and Knee Questionnaire. Arthritis Care Res (Hoboken) 2011;63(Suppl 11):S200e7. https://doi.org/10.1002/acr.20549. [33] Himmelfarb J. Hemodialysis complications. Am J Kidney Dis 2005;45: 1122e31.
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Outcomes Following Revision Joint Arthroplasty Among Hemodialysis-Dependent Patients Lawal A. Labaran, BS a, Sean Sequeira, BS a, Surajudeen A. Bolarinwa, MD a, Jomar Aryee, BS a, Samuel R. Montgomery Jr, BS a, Eugene Nwankwo, BS b, Emanuel Haug, MD a, Joshua Bell, MD a, Quanjun Cui, MD a, * a b
Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA Department of Orthopaedic Surgery, Texas Tech University, Lubbock, TX
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 August 2019 Received in revised form 6 October 2019 Accepted 21 October 2019 Available online xxx
Background: Hemodialysis (HD) dependence is known to impact the integrity of bone and has long been associated with metabolic bone disease and other adverse events postoperatively. The aim of this study is to analyze postoperative outcomes following revision hip and knee arthroplasty in hemodialysisdependent (HDD) patients and to characterize the common indications for revision procedures among this patient population. Methods: A total of 1779 HDD patients who underwent a revision joint arthroplasty (930 revision total knee arthroplasty [TKA] and 849 revision total hip arthroplasty [THA]) between 2005 and 2014 were identified from a retrospective database review. Our resulting study groups of revision TKA and THA HDD patients were compared to their respective matched control groups for hospital length of stay (LOS), 90day mean total cost, hospital readmission, and other major medical and surgical complications. Results: HD was significantly associated with increased LOS (7.7 ± 8.3 vs 4.8 ± 4.5; P < .001), mean 90day total cost ($47,478 ± $33,413 vs $24,286 ± $21,472; P < .001), hospital readmission (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.96-2.58; P < .001), septicemia (OR, 3.18; 95% CI, 2.70-3.74; P < .001), postoperative infection (OR, 1.72; 95% CI, 1.50-1.98; P < .001), and mortality (OR, 3.99; 95% CI, 3.12-5.06; P < .001) following revision TKA. Among revision THA patients, HD was associated with increased LOS (9.4 ± 9.5 vs 5.7 ± 5.7; P < .001), mean 90-day total cost ($40,182 ± $27,082 vs $26,519 ± $22,856; P < .001), hospital readmission (OR, 2.33; 95% CI, 2.02-2.68; P < .001), septicemia (OR, 3.61; 95% CI, 3.05-4.27; P < .001), and mortality (OR, 3.55; 95% CI, 2.86-4.37; P < .001). Conclusion: HD remains a significant risk factor for increased LOS, mean total cost, hospital readmission, septicemia, and mortality following revision joint arthroplasty. Published by Elsevier Inc.
Keywords: revision joint arthroplasty revision TKA/THA hemodialysis complications end-stage renal disease dialysis
Total hip (THA) and total knee arthroplasty (TKA) are increasingly common procedures that have wide patient demographics and surgical indication profiles. First performed in the early 1960s, THAs historically had good outcomes, had manageable complications, and provided patients with the retention of their prosthesis for up to15-20 years [1,2]. Similarly, TKAs are among the most
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2019.10.041. * Reprint requests: Quanjun Cui, MD, Department of Orthopaedic Surgery, University of Virginia, 400 Ray C Hunt Drive, Charlottesville, VA, 22908. https://doi.org/10.1016/j.arth.2019.10.041 0883-5403/Published by Elsevier Inc.
efficacious surgeries for those with refractory knee pain for both cost and outcomes [3]. While often successful, common causes of revision joint arthroplasty include wear, loosening, dislocation, infection, and fracture [4,5]. Although complications have progressively been reduced and long-term outcomes have improved, there still exist several areas of further investigation and optimization. Certain patient demographics, namely chronic renal disease patients, have demonstrated higher rates of complications and poorer outcomes associated with joint arthroplasties and revisions [6,7]. While chronic renal disease patients have been extensively studied in terms of their capacity to achieve successful THA and TKAs, literature on revision joint arthroplasty in hemodialysis (HD) patients is less well documented [5,8e10]. Hemodialysis patients
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comprise of a prominent fraction of joint arthroplasty candidates, a correlation that has multiple hypotheses as to its pathogenesis. One etiology can be traced to HD patients’ high rates of renal osteodystrophy. Renal osteodystrophy results in abnormal (high or low) bone turnover and increases the risk of skeletal fractures, reduces quality of life, and worsens clinical outcomes [11]. A second hypothesis is that beta 2-microglobulin amyloid deposition in periprosthetic tissues contributes to primary and revision joint arthroplasty [12]. Typically, patients on HD also have a number of comorbidities that contribute to worsened outcomes and complication rates as well as obscure hemodialysis’ true effect on revision joint arthroplasty outcomes. In terms of diabetes, the most common cause of chronic kidney disease in the United States, unregulated chronic hyperglycemia, can result in increased incidence of surgical site infections, deep periprosthetic infections, length of stay (LOS), and morbidity [13]. In fact, the presence of diabetes mellitus, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), congestive heart failure, and peripheral vascular disease has all been demonstrated as poor prognostic indicators of joint arthroplasty outcomes and complication rates [13e17]. Due to increased longevity for hemodialysis-dependent (HDD) patients from improved HD mortality and outcomes, an increasing number of HDD patients tend to accumulate more wear, loosening, dislocation, infection, and fracture, prompting repeat surgical intervention for revision. Although few joint arthroplasties require revision, HDD patients are more likely to require a revision joint arthroplasty prompting extensive research in surgical indications, outcomes, and complications for this unique set of patients undergoing revision arthroplasty [18]. The aims of this study are to analyze outcomes following revision joint arthroplasty among HDD patients and to identify the common indications for revision arthroplasty in this patient population. Methods Data Source A retrospective database review was conducted, using the commercially available PearlDiver Patient Records Database (www. pearldiverinc.com; PearlDiver Inc, Colorado Springs, CO), which contains all Medicare patient records from 2005 to 2014, searchable by International Classification of Diseases (ICD), Current Procedural Terminology, and Diagnosis-Related Group codes among others. Queried data are de-identified and Health Insurance Portability and Accountability Act compliant; therefore, institutional review board approval was waived for this study. Study Population All Medicare patients from the years of 2005 to 2014 who underwent revision TKA (ICD-9-CM: 00.80, 00.81, 00.82, 00.83, 00.84, and 81.55) were queried. Patients 85 years or older and those with a preexisting diagnosis of lower extremity neoplasm involving the hip or knee joints (ICD-9-CM: 171.3, 173.70, 173.79, 215.3, 216.7, 213.7, and 170.7) were excluded from the study. This was repeated in a separate query for patients who underwent revision THA (ICD9-CM: 00.70, 00.71, 00.72, 00.73, and 81.53). The resulting groups were further divided into the resulting populations: those who were identified as HDD (ICD-9-D-V420, ICD-9-P-556.9) before revision arthroplasty and those with no history of HDD. Revision arthroplasty patients and corresponding controls were then matched based on age, sex, obesity, tobacco use, alcohol use, diabetes mellitus, peripheral vascular disease, congestive heart failure, COPD, hypertension, and hyperlipidemia.
Postoperative Outcome Following Revision Joint Arthroplasty in HDD Patients Revision TKA and THA groups were then compared to their respective controls for LOS, 90-day mean total cost, 90-day readmission rates, and 90-day major medical complications including pulmonary embolism, cardiovascular accident, myocardial infarction, pneumonia, and venous thromboembolism. In addition, 1year postoperative outcomes including septicemia, infection, and mortality rates were compared. Primary Indications for Revision Joint Arthroplasty in HDD Patients The primary diagnosis at the time of respective revision arthroplasty was queried. The following diagnoses were evaluated: periprosthetic infection/inflammation, other acquired deformities such as valgus and varus deformities, other mechanical complications (not otherwise specified), mechanical loosening, dislocation of prosthetic joint, periprosthetic fracture, and broken prosthetic joint implant. Statistical Analysis Both groups’ baseline demographics and preexisting comorbidities were compared using Pearson’s chi-square analysis. Pearson’s chi-squared analysis was then used to compare rates of septicemia, infection, mortality, readmission, and major medical complications between both study groups and their respective matched controls. Multivariate logistical regression was applied to determine the isolated effect HDD had on all postoperative outcomes following revision TKA and THA. This was adjusted for age, sex, morbid obesity, tobacco use, alcohol use, and preexisting identified comorbidities as covariates. LOS and 90-day hospital cost was compared using Student t-test. A linear regression was calculated to determine independent effect of HDD on LOS adjusted using previously mentioned covariates. All statistical analyses were performed using R Project for Statistical Computing. Significance was determined for P values <.05. Results Patient Demographics and Comorbidities In total, 930 and 849 HDD patients who underwent a revision TKA and THA, respectively, were identified. Also, 18,359 revision TKA and 16,596 revision THA matched control patients were selected. Following a matched selection of the control groups, there were no significant differences in demographic factors and preexisting comorbidities. An increase in the Charlson Comorbidity Index was noted in both the HDD patients undergoing revision TKA (9.62 ± 2.96 vs 7.00 ± 2.99; P < .001) and those undergoing revision THA (9.2 ± 3.3 vs 6.6 ± 3.2; P < .001; Table 1). Postoperative Outcome Following Revision Joint Arthroplasty Among Hemodialysis Patients Revision Knee Arthroplasty Within the revision TKA population, HDD was associated with increased rates of 90-day hospital readmission (42.4% vs 23.7%; odds ratio [OR], 2.25, 95% confidence interval [CI], 1.96-2.58; P < .001) and greater LOS (7.7 ± 8.3 days vs 4.8 ± 4.5 days; P < .001). Following an adjusted linear regression, HDD independently increased LOS by approximately 2.26 days (P < .001). And 90-day mean total cost was also significantly higher ($47,478 ± $33,413 vs $24,286 ± $21,472; P < .001) among HDD patients undergoing
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Table 1 Patient Demographics. Total Numbers
Age (y) <65 65-69 70-74 75-79 80-84 Male sex Obesity (BMI > 30 kg/m2) Tobacco use Alcohol abuse CCI Comorbidities Diabetes mellitus Peripheral vascular disease Congestive heart failure COPD Hypertension Hyperlipidemia
Revision TKA
P Value
Hemodialysis 930 (%)
Matched Control 18,359 (%)
280 (30.1) 175 (18.8) 211 (22.7) 162 (17.4) 102 (11.0) 401 (43.1) 409 (44.0) 359 (38.6) 25 (2.7) 9.62 ± 2.96
5419 (29.5) 3334 (18.2) 4170 (22.7) 3381 (18.4) 2055 (11.2) 7879 (42.9) 8055 (43.9) 7059 (38.4) 444 (2.4) 7.00 ± 2.99
678 195 570 496 756 922
13,432 3821 11,211 9779 14,988 18,210
Revision THA
P Value
Hemodialysis 849 (%)
Matched Control 16,596 (%)
.930 .978 .953 .680 <.001
316 (37.2) 125 (14.7) 151 (17.8) 143 (16.8) 114 (13.4) 425 (50.1) 165 (19.4) 341 (40.2) 48 (5.7) 9.2 ± 3.3
6074 (36.6) 2343 (14.1) 2962 (17.8) 2851 (17.2) 2366 (14.3) 8332 (50.2) 3179 (19.2) 6632 (40.0) 861 (5.2) 6.6 ± 3.2
.962 .875 .935 .606 <.001
.891 .942 .918 .995 1.000 .823
494 154 433 409 834 593
9656 2869 8388 7974 16,308 11,589
1.000 .553 .822 .971 1.000 1.000
.934
(72.9) (21.0) (61.3) (53.3) (81.3) (99.1)
(73.2) (20.8) (61.1) (53.3) (81.6) (99.2)
.946
(58.2) (18.1) (51.0) (48.2) (98.2) (69.8)
(58.2) (17.2) (50.5) (48.0) (98.3) (69.8)
TKA, total knee arthroplasty; THA, total hip arthroplasty; BMI, body mass index; CCI, Charlson Comorbidity Index; COPD, chronic obstructive pulmonary disease.
revision compared to controls. HDD was also an independent predictor of septicemia (24.2% vs 8.6%; OR, 3.18; 95% CI, 2.70-3.74; P < .001), infection (37.8% vs 25.3%; OR, 1.72; 95% CI, 1.50-1.98; P < .001), and mortality (9.7% vs 2.4%; OR, 3.99; 95% CI, 3.12-5.06; P < .001) within 1 year compared to non-HDD patients. No significant difference was seen in 90-day major medical complications including pulmonary embolism, venous thromboembolism, myocardial infarction, cardiovascular accident, and pneumonia (11.7% vs 11.0%; P ¼ .510) between HDD and non-HDD patients (Table 2). Revision Hip Arthroplasty Within the revision THA population, HDD was associated with increased rates of 90-day hospital readmission (46.4% vs 26.4%; OR, 2.33; 95% CI, 2.02-2.68; P < .001) and greater LOS (9.4 ± 9.5 days vs 5.7 ± 5.7 days; P < .001). Likewise, following a linear regression, HDD independently increased LOS by about 2.73 days (P < .001). And 90-day mean total cost ($40,182 ± $27,082 vs $26,519
± $22,856; P < .001) was also significantly higher in the HDD patients undergoing revision compared to controls. HDD was also an independent predictor of septicemia (25.6% vs 8.2%; OR, 3.61; 95% CI, 3.05-4.27; P < .001) and mortality (14.4% vs 4.1%; OR, 3.55; 95% CI, 2.86-4.37; P < .001) within 1 year compared to non-HDD patients. No significant difference was seen in 90-day major medical complications (13.8% vs 12.1%; P ¼ .159) and 1-year infection rates (19.7% vs 18.5%; P ¼ .404) between HDD and non-HDD patients (Table 2). Primary Indications for Revision Arthroplasty Among Hemodialysis Patients Among HDD patients undergoing revision TKA, the most common preoperative diagnoses were periprosthetic infection and/or inflammation (46.5%), acquired deformities of the knee joint (21.2%), other mechanical complications (10.5%), mechanical loosening (6.3%), dislocation (3.8%), periprosthetic fracture (1.9%), and
Table 2 Postoperative Outcome Following Revision Knee Arthroplasty in Hemodialysis-Dependent Patients. TKA
Length of stay (d) 90-d Mean total cost 90-d Readmission 90-d Major medical complications 1-y Septicemia 1-y Infection 1-y Mortality
Hemodialysis 930 (%)
Matched Control 18,359 (%)
P Value
Adjusted OR (95% CI)
7.7 ± 8.3 $47,478 ± $33,413 394 (42.4) 109 (11.7) 225 (24.2) 352 (37.8) 90 (9.7)
4.8 ± 4.5 $24,286 ± $21,472 4382 (23.7) 2014 (11.0) 1575 (8.6) 4642 (25.3) 440 (2.4)
<.001 <.001 <.001 .510 <.001 <.001 <.001
2.26 d 2.25 1.00 3.18 1.72 3.99
Hemodialysis 849 (%)
Matched Control 16,596 (%)
P Value
Adjusted OR (95% CI)
9.4 þ 9.5 $40,182 ± $27,082 394 (46.4) 117 (13.8) 218 (25.6) 167 (19.7) 122 (14.4)
5.7 ± 5.7 $26,519 ± $22,856 4376 (26.4) 2008 (12.1) 1366 (8.2) 3065 (18.5) 679 (4.1)
<.001 <.001 <.001 .159 <.001 .404 <.001
2.73 d 2.33 1.06 3.61 1.05 3.55
(1.71-2.81)a (1.96-2.58) (0.81-1.23) (2.70-3.74) (1.50-1.98) (3.12-5.06)
P Value <.001 d <.001 .987 <.001 <.001 <.001
THA
Length of stay (d) 90-d Mean total cost 90-d Readmission 90-d Major medical complications 1-y Septicemia 1-y Infection 1-y Mortality
TKA, total knee arthroplasty; THA, total hip arthroplasty; OR, odds ratio; CI, confidence interval. a Adjust linear regression coefficient (b).
(2.14-3.33)a (2.02-2.68) (0.86-1.30) (3.05-4.27) (0.88-1.25) (2.86-4.37)
P Value <.001 d <.001 .549 <.001 .564 <.001
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broken prosthetic joint implant (1.7%). The most common indications for revision THA among HDD were dislocation of prosthetic hip joint (24.3%), periprosthetic infection (20.5), other mechanical complications (14.0%), mechanical loosening (12.8%), periprosthetic fracture (6.9%), acquired deformity of hip joint (6.6), and broken prosthetic hip implant (3.8%; Table 3). Discussion Hip and knee arthroplasties are some of the most common orthopedic procedures worldwide today for refractory joint pain from end-stage osteoarthritis. The incidence will only grow as life expectancy and normal “wear-and-tear” on the joints continue to rise. While arthroplasty often provides lifetime improvement in pain and activities of daily living, complications like wear, loosening, dislocation, infection, and fracture often necessitate revision joint arthroplasty [3,19]. HDD patients with THA and TKA are not spared, and in fact, due to the nature of their disease may be more predisposed to having indications for revision surgery. In this study, HD was associated with increased LOS, 90-day cost, 90-day readmission, septicemia, and 1-year mortality following both revision TKA and THA. Additionally, dislocation and periprosthetic infections were the most common indications for revision THA and TKA among HDD patients. Etiology of the poor outcome of joint arthroplasty among HDD cannot be overlooked. In patients with chronic kidney disease, beta-2 microglobulin has been hypothesized to be at least contributory, if not the main factor, behind this patient populations’ poor outcomes [20]. The increase in beta-2 microglobulin produces a dialysis arthropathy that exerts detrimental effects on the health of native and prosthetic joints often producing indications for primary arthroplasty and, occasionally, revision arthroplasty. Crawford and Athanasou [12] studied the histopathologic, radiographic, and clinical effects of dialysis arthropathy on patients who had primary THA. It was determined that beta-2 microglobulin was present in 60% of cases with large amyloid deposits in collagenous connective tissue. Subsequently, Crawford and Athanasou hypothesized that wear particles, namely beta-2 microglobulin, can migrate through small fissures to the bone-implant interface, inducing aseptic loosening and acting as a nidus for infection. Harris [21] postulated that it was the mounted macrophage response that elicited prostaglandin, proteases, and other inflammatory cytokines to navigate to the site, causing aseptic loosening. Results obtained in this study align well with the existing literature that has demonstrated that HDD patients generally have a greater morbidity and mortality associated with hip and knee arthroplasty. Sunday et al [8], in their small retrospective study evaluating joint arthroplasty in HDD patients, observed that all participants had at least 1 complication, infection being the most likely. In that same study, they reported a 29% inhospital mortality rate postoperatively. Regarding TKA specifically, Ponnusamy et al Table 3 Common Primary Indications for Revision Arthroplasty in Hemodialysis-Dependent Patients. Indication
ICD-9-CM
TKA (%)
THA (%)
Periprosthetic infection Other acquired deformities Other mechanical complications
996.66 739.6 996.49, 996.47, 996,77 996.41 996.42 996.44 996.43
432 (46.5) 197 (21.2) 98 (10.5)
59 (6.9) 56 (6.6) 119 (14.0)
Mechanical loosening Dislocation of prosthetic joint Periprosthetic fracture Broken prosthetic joint implant
59 35 18 16
(6.3) (3.8) (1.9) (1.7)
109 206 174 32
(12.8) (24.3) (20.5) (3.8)
ICD, International Classification of Diseases, Ninth Revision, Clinical Modification; TKA, total knee arthroplasty; THA, total hip arthroplasty.
[22] determined that HDD patients had a significantly higher inpatient mortality (0.92% vs 0.10%) and greater overall complication rate (12.485 vs 5.0%) vs controls. Focusing on THA, Sunday et al, Lieberman et al, and Sakalkale et al [5,8,9] all reported worsened mortality for HDD patients following primary THA, often due to an infectious etiology. In more recent literature, Lieu et al and Fukunishi et al [10,23] found that while HDD individuals have improved mortality rate, LOS, and complications than in the past, they still remain inferior to their renally healthy counterparts. Given the evidence that exists for outcomes in HDD patients, the potential benefits of joint arthroplasty should be heavily scrutinized before the intervention is offered to this patient population. Other comorbid medical conditions that commonly coexist with chronic kidney disease and hemodialysis dependence have been independently linked to worse prognosis following joint arthroplasty. Several studies exist that elucidate which of these commonly concomitant comorbidities may confound revision hip arthroplasty outcome [13e15,17,24]. In a systematic review of 13,722 THA patients, Haynes et al demonstrated that obesity was significantly associated with earlier THA intervention as well as increased perioperative complications [25]. Diabetes has been associated with longer LOS and increased cost following a hip and knee arthroplasty as compared to their nondiabetic counterparts [13,26]. Tobacco and alcohol consumption, congestive heart failure, COPD, and peripheral vascular disease have all been documented in the literature to increase perioperative complications associated with hip and knee arthroplasty [14e16,27,28]. These studies demonstrating the independent effect of these comorbid conditions highlight the importance of controlling for their incidence when analyzing the HDD patients. Miric et al [7] demonstrated that HDD patients had significantly higher rates of diabetes, congestive heart failure, valvular disease, alcohol abuse, peripheral vascular disease, and hypertension. They controlled for those comorbid conditions and, as in the present study, demonstrated increased risk of surgical site infections, 90-day readmission, and all-cause mortality postoperatively. Given the efforts made to control for commonly concomitant comorbidities, the authors of the present study believe that the results reported here should reflect HDD’s true and isolated effects on revision joint arthroplasty outcomes. The primary advantage of the present study is its large sample size. This investigation is the largest study to date that explores the outcomes following revision joint arthroplasty among HDD patients. Additionally, to the best knowledge of the authors, this is the only study that specifically investigates revision joint arthroplasty among HDD patients. It is important to note there are a number of similar studies in primary joint arthroplasty in hemodialysis patients [4,5,8,9]. HDD patients have several comorbid conditions that could confound the effect of HD on postrevision outcome. As such, another advantage of this study is the matching of pertinent demographic factors and comorbidities to isolate the independent effect of HD on outcome following revision joint arthroplasty. While the Medicare data include records from over 51 million unique patients, this study has a number of limitations. Our findings rely heavily on the accuracy of the entry of data into both the patients’ medical records and the database itself [29]. Studies have reported low sensitivity for identifying prior comorbid diagnoses [30]. Also, our study did not investigate peritoneal dialysis, the more accessible counterpart to hemodialysis, and its association with mortality after revision joint arthroplasty [31]. While our follow-up time was considered a strength and is longer than most contemporaneous studies, a longer follow-up time would more effectively characterize the long-term prognosis and outcome following revision joint arthroplasty in HDD patients. Furthermore, the outcomes measured in this study could be broadeneddadditional outcome parameters used in other studies like incidence of
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complications like deep vein thrombosis and need for transfusions, re-revision rate, use of a quantitative joint rating scale like the Harris Hip Score (HHS), among others to better characterize the complications and outcomes of these HDD patients [22,32]. Additionally, the major medical complications analyzed in this study is not all encompassing and, hence, did not include other pertinent complications such as cardiac arrhythmias, cardiomyopathies, protein-calorie malnutrition, renal osteodystrophy, and other intradialytic complications that have been shown to increase morbidity and mortality among HDD patients [33]. Conclusion Hemodialysis is a significant risk factor for increased LOS, mean total cost, hospital readmission, septicemia, and mortality following revision joint arthroplasty. Joint specialist should be aware and prepared for these complications, which should facilitate better preoperative and postoperative planning, as well as patient counseling regarding the risks and benefits of revision joint arthroplasty in HDD patients. References [1] Karachalios T, Komnos G, Koutalos A. Total hip arthroplasty. EFORT Open Rev 2018;3:232e9. https://doi.org/10.1302/2058-5241.3.170068. [2] Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 15 years of follow-up. Lancet 2019;393:647e54. https://doi.org/10.1016/S0140-6736(18)31665-9. [3] Lachiewicz PF, Soileau ES. Changing indications for revision total hip arthroplasty. J Surg Orthop Adv 2005;14:82e4. [4] Patterson JT, Tillinghast K, Ward D. Dialysis dependence predicts complications, intensive care unit care, length of stay, and skilled nursing needs in elective primary total knee and hip arthroplasty. J Arthroplasty 2018;33: 2263e7. https://doi.org/10.1016/j.arth.2018.02.035. [5] Lieberman JR, Fuchs MD, Haas SB, Garvin KL, Goldstock L, Gupta R, et al. Hip arthroplasty in patients with chronic renal failure. J Arthroplasty 1995;10: 191e5. https://doi.org/10.1016/S0883-5403(05)80126-3. [6] Debarge R, Pibarot V, Guyen O, Vaz G, Carret JP, Bejui-Hugues J. [Total hip arthroplasty in patients with chronic renal failure transplant or dialysis]. Rev Chir Orthop Reparatrice Appar Mot 2007;93:222e7. [7] Miric A, Inacio MCS, Namba RS. The effect of chronic kidney disease on total hip arthroplasty. J Arthroplasty 2014;29:1225e30. https://doi.org/10.1016/ j.arth.2013.12.031. [8] Sunday JM, Guille JT, Torg JS. Complications of joint arthroplasty in patients with end-stage renal disease on hemodialysis. Clin Orthop Relat Res 2002;397:350e5. [9] Sakalkale DP, Hozack WJ, Rothman RH. Total hip arthroplasty in patients on long-term renal dialysis. J Arthroplasty 1999;14:571e5. https://doi.org/ 10.1016/S0883-5403(99)90079-7. [10] Fukunishi S, Fukui T, Nishio S, Imamura F, Yoh K, Yoshiya S. Results of total hip arthroplasty for dialysis arthropathy in long-term hemodialysis patients. J Orthop Sci 2009;14:285e91. https://doi.org/10.1007/s00776-009-1330-2. [11] Torres PU, Bover J, Mazzaferro S, Vernejoul MC de, Cohen-Solal M. When, how, and why a bone biopsy should be performed in patients with chronic kidney disease. Semin Nephrol 2014;34:612e25. https://doi.org/10.1016/ j.semnephrol.2014.09.004. [12] Crawford R, Athanasou NA. Beta 2-microglobulin amyloid deposition in hip revision arthroplasty tissues. Histopathology 1998;33:479e84.
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