Monday, April 7, 2014

Younger age, comorbidities, race, hospital volume are associated with higher revision risk - the 4Ps

Younger Age Is Associated with a Higher Risk of Early Periprosthetic Joint Infection and Aseptic Mechanical Failure After Total Knee Arthroplasty

These authors used the California Patient Discharge Database 2005-2009 to determine whether the incidence of early periprosthetic joint infection requiring revision knee surgery is significantly different in patients younger than fifty years of age compared with older patients following primary unilateral total knee arthroplasty.

At one year, 
0.82% of all 120,538 primary total knee arthroplasties had undergone revision due to periprosthetic joint infection and 
1.15% had undergone revision due to aseptic mechanical failure. 

In patients younger than fifty years of age  
1.36% had for revision due to periprosthetic joint infection and
3.49% had revision due to aseptic mechanical failure. 

The risk of periprosthetic joint infection was almost twice as high in patients younger than fifty years of age (odds ratio = 1.81, 95% confidence interval = 1.33 to 2.47) compared with patients sixty-five years of age or older.
The risk of aseptic mechanical failure was almost five times higher in patients younger than fifty years of age (odds ratio = 4.66, 95% confidence interval = 3.77 to 5.76).
The lowest risks of infection and mechanical failure were in patients over 65 years of age. Black patients had a statistically increased risk of infection and aseptic mechanical failure. The comorbidities of anemia, heart failure, pulmonary obstructive disease, depression, diabetes, obesity, peripheral vascular disease, and psychosis all were associated with the risk of infection and mechanical failure.

Comment: There are at least five possible reasons for the increased failure rate (septic or aseptic) in younger patients: (1) greater activity levels placing increased loads on the joint, (2) increased longevity, (3) more complex diagnoses (this study found a  higher prevalence of secondary (e.g., posttraumatic)
osteoarthritis in younger patients compared with primary osteoarthritis in older patients), (4) the temptation to use "innovative" but less well proven approaches to arthroplasty in younger patients, and
(5) greater expectations leading to patient demand for revision if expectations are not met.

But in addition to age, this study also emphasizes the importance of other factors, such as comobidities and hospital volume, in the risk of failure.

So, again, it comes down to the 4Ps:
the problem - primary osteoarthritis or secondary arthritis
the patient - age, comorbidities, race, gender
the procedure - type of arthroplasty, surgical approach, fixation, rehabilitation
the provider -  surgeon and hospital experience.

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