Study Suggests VHA Joint Replacement Outcomes Are Suboptimal
In 2016, VA Physical Therapy Assistant Shawn Zimmerlee worked with Marine Corps veteran John Houghton in his recovery from recent hip surgery at the Iron Mountain, MI, VAMC. VA photo
ROCHESTER, MI — In most head-to-head comparisons, surgical care at the VHA is found to be as good or better than that provided in the community. That’s why a recent study on joint replacement surgery was so surprising.
A study team led by researchers from Ascension Providence Rochester Hospital in Rochester, MI, compared the short-term outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA) between the VA cohort and the general cohort.
To do that, the authors retrospectively reviewed 10,460 patients with primary THA and TKA from the VA Corporate Data Warehouse. At the same time, a 58,820-member control group was created from the American College of Surgeons—National Surgical Quality Improvement Program database; including were patients with primary THA and TKA over the same time period.
The study then compared length of stay, mortality rates, 30-day complication rates and 30-day readmissions. Results were published late last year in the Journal of the American Academy of Orthopedic Surgeons.1
Researchers found that VHA patients—who were more likely to be men, 93% vs.41%, and to have increased rates of medical comorbidities—had higher rates of short-term complications. “When controlling for demographics and medical comorbidities, VA patients were more likely to have a readmission (P < 0.001), prolonged length of stay > 4 days (P < 0.001) and experience a complication within 30 days (P < 0.001),” the authors wrote.
They added, “Despite controlling for higher rates of medical comorbidities, VA patients undergoing primary THA and TKA had poorer short-term outcomes than the civilian cohort. Additional research is needed to ensure our veteran cohort is appropriately optimized and address the discrepancy with the outcomes of the civilian.”
Now, a variety of VA researchers are taking a close look at what either helps prevent or exacerbates prosthetic joint infection, one of the most serious outcomes of joint arthroplasty.
For example, in a recent study, researchers from the Columbia, SC, VA Health Care System pointed out that statins have a “variety of pleiotropic effects that could be beneficial for patients undertaking total knee or hip arthroplasty. In vitro and in vivo models suggest the beneficial effects of statins through bone formation and modulating proinflammatory cytokines triggered by implant debris. However, statins also exhibit antimicrobial action and may reduce the risk of revision surgery via reducing the risk of infection.”
In light of that information, they explored the relationship between statin use and PJI after total knee or hip arthroplasty. To do that, they conducted a retrospective cohort of VA patients undergoing total knee or hip arthroplasty performed within the Department of Veterans Affairs.
More than 60,000 patients were included in the research beginning in January 2020. The authors reported in the Journal of Arthroplasty that unmatched Cox models revealed during follow-up a statistically significant lower risk of infection for the statin exposed patients (hazard ratio = 0.869; 95% confidence interval = [0.79-0.956]). The matched Cox model results, meanwhile, indicated a statistically significant lower risk of PJI, only in the overall model, for the statin exposed cohort compared with the unexposed cohort (hazard ratio = 0.895, 95% confidence interval = [0.807-0.993]).2
Statins Beneficial
“Our analysis finds some support for the beneficial effects of statins for preventing PJI among patients undergoing total knee or hip arthroplasty,” the researchers concluded.
A study team from the Salt Lake City, UT, VAMC and the University of Utah looked at the issue from the opposite direction. They observed that rates of prosthetic joint infection (PJI) appeared to be elevated among patients with inflammatory arthropathy (IA). Researchers were uncertain, however, whether continuing biologic drugs perioperatively would affect PJI rates.
Their study set out to compare rates of perioperative biologic continuation in IA patients who did and did not develop PJI after primary total joint arthroplasty (TJA).
Researchers retrospectively reviewed all cases of PJI within one year of primary TJA in IA patients on biologic medications. To do that, they pulled 2005 to 2018 records from the VA Corporate Data Warehouse. Matched controls who did not develop PJI after TJA were pulled from the same database.
The study in the Journal of Arthroplasty compared biologics suspension, defined as medication interruption prior to TJA with surgery occurring after the end of the dosing cycle and resumption after wound healing, among cases and controls.3
The authors pointed out that biologic medications were continued through surgery in 35% (9/26) of patients who developed PJI compared to 14% (8/58) of controls (P = 0.031; adjusted odds ratio of 3.46 [1.11-10.78]). They noted that no significant difference existed among 26 cases and 58 controls for age, gender, procedure, body mass index, rates of diabetes or chronic kidney disease, smoking status or preoperative opioid use (all P > 0.05).
“With the limited sample sizes available in this study, we found an association with perioperative continuation of biologic medications and PJI,” the study team concluded. “This data may provide support for current guidelines from the American Association of Hip and Knee Surgeons to withhold biologics before TJA with surgery scheduled at the end of the dosing cycle and medication resumption only after wound healing.”
Another study conducted by researchers from the Southeast Louisiana Veterans Healthcare System, Louisiana State University Health Sciences Center and Tulane University School of Medicine, all in New Orleans, focused on issues around self-reported penicillin allergies in patients undergoing total joint arthroplasty.
Researchers pointed out that concern often results in the use of second-line prophylactic antibiotics, and that a higher risk of prosthetic joint infection (PJI) is associated with suboptimal antibiotics vs first generation cephalosporins. Those antibiotics usually are grouped with other beta-lactam antibiotics such as penicillin for potential allergic reactions.
The study sought to evaluate the economic burden of self-reported penicillin allergies in TJA.
To do that, the study team obtained data from studies reporting true incidence of IgE-mediated penicillin allergies, infection-free survivorship of TJA, and cost of PJI attributed to use of second-line antibiotics. Researchers then calculated the projected cost of preoperative penicillin allergy testing and potentially avoidable PJI associated with second-line antibiotic usage.
Results published in the Journal of Arthroplasty indicated that implementing preoperative penicillin allergy testing would lead to a potential savings of nearly $37 million to payers in the first year based on one-year survivorship. That savings increase to $411.6 million over a 10-year span and $1.18 billion over a 20-year span.4
“Preoperative penicillin allergy testing or risk stratification via thorough history should be implemented as standard of care for patients with self-reported penicillin allergies before TJA and would result in decreased cost of PJI,” the authors concluded.
- Frisch NB, Courtney PM, Darrith B, Copeland LA, Gerlinger TL. Veterans Undergoing Total Hip and Knee Arthroplasty: 30-day Outcomes as Compared to the General Population. J Am Acad Orthop Surg. 2020 Nov 15;28(22):923-929. doi: 10.5435/JAAOS-D-19-00775. PMID: 32004175.
- Sutton SS, Magagnoli JC, Cummings TH, Hardin JW. Statin Exposure and Risk of Prosthetic Joint Infection After Total Knee or Hip Arthroplasty Among U.S. Veterans. J Arthroplasty. 2021 Oct;36(10):3584-3588.e1. doi: 10.1016/j.arth.2021.06.006. Epub 2021 Jun 11. PMID: 34229942.
- Carlson VR, Anderson LA, Lu CC, Sauer BC, Blackburn BE, Gililland JM. Perioperative Continuation of Biologic Medications Increases Odds of Periprosthetic Joint Infection in Patients With Inflammatory Arthropathy. J Arthroplasty. 2021 Jul;36(7):2546-2550. doi: 10.1016/j.arth.2021.02.025. Epub 2021 Feb 13. PMID: 33653628.
- Lee OC, Cheng DC, Paul JL, Ross BJ, Hawkins BJ, Sherman WF. Economic Burden of Patient-Reported Penicillin Allergy on Total Hip and Total Knee Arthroplasty. J Arthroplasty. 2021 Sep; 36(9):3067-3072. doi: 10.1016/j.arth.2021.04.032. Epub 2021 May 4. PMID: 34053750.