7 Ways to Improve Joint Surgery Outcomes and Reduce Costs

Selecting the right patients for elective surgeries like joint replacement is essential when operating in a system where patient outcomes are linked to payer reimbursement to physician groups and hospitals.

According to Bryan D. Springer, M.D., an orthopedic surgeon with OrthoCarolina Hip and Knee Center in Charlotte, North Carolina, “bundles have led us to have to practice more medicine than we ever had to in the past.”

He added, “I think I am one step away from having to wear a stethoscope around my neck when I go in to see patients.:

“And I think a lot of it is because our medical colleagues don’t read the same literature we read. How many times do you get a morbidly obese patient sent to you by their [primary] doctor with a note saying we will get your knee replaced first and then you’ll lose the weight. And our literature is pretty overwhelming that that doesn’t happen. So, in order to be successful in a bundle we need to take ownership for our patients.”

He explained that while the Centers for Disease Control and Prevention established guidelines for prevention of surgical site infection (SSI) in 2017, 25 out of 43 areas of concern had no definite recommendation on how to manage patients.

Because of this, orthopedic surgeons should be measuring certain risk factors before agreeing to do the surgery in order to reduce the risk for postoperative infection. Springer suggested that the following seven are important modifiable risk factors.

1. Glycemic Management

The stress surgery puts on a patient’s body is known to antagonize insulin, predisposing patients to hyperglycemia. Springer said that hyperglycemia impairs the ability of leukocyte to thwart infection and puts surgical patients at a greater risk for infection than patients with diabetes.

Springer referred to “Relationship of Hyperglycemia and Surgical-Site Infection in Orthopaedic Surgery” published in the Journal of Bone & Joint Surgery on July 3, 2012, which found that hyperglycemia was an independent risk factor for 30-day surgical-site infection in orthopedic trauma patients without a history of diabetes.

He also mentioned, “Elevated Postoperative Blood Glucose and Preoperative Hemoglobin A1C are associated with Increased Wound Complications Following Total Joint Arthroplasty” published on May 1, 2013, in the Journal of Bone & Joint Surgery which confirmed that patients with a mean postoperative hemoglobin A1C level of >6.7% are at increased risk for wound complications following elective primary total joint arthroplasty.

Springer added that one-third of total joint arthroplasty patients are hyperglycemic which puts them at higher risk for complications and infections. The goal is to maintain the blood glucose level at less than 200. He said that this spike in blood glucose happens whether you are diabetic or not, and that if you checked the glucose levels on all your patients after surgery, you’d be amazed at how high they go.

He recommended using the HgbA1c as a marker of long-term glucose control, saying, “The majority of studies show HgbA1c < 7-8 is when the risk wants to go up and it really depends on where you want to set your threshold risk for those patients. Are you going to deny someone at 7.2 and they have a likelihood of success or set your mark at 8 or a little bit higher?”

“One of the interesting things coming down the pike is serum fructosamine, which can show if your patient has tight glucose control a lot quicker,” he added, referring to the study, “Serum Fructosamine: A Simple and Inexpensive Test for Assessing Preoperative Gylcemic Control,” published in the November 2017 issue of the Journal of Bone & Joint Surgery.

2. Obesity

Springer said, “Obesity is really controversial. It borders on ethical discussions. It is really hard to deal with and we as orthopedic surgeons are not good at it.”

“When sitting down and trying to talk to patients about their weight, we tend to try to punt it back to the medical doctors or really not discuss it all even though the data is pretty compelling looking at the preoperative risks, infection risks and revision rates in patients, particularly the morbidly obese patient. But remember, BMI is a continuous variable, so if you extrapolate out complications and BMI, right as you get heavier, your risk goes up. And that inflection point seems to be around 40.”

Springer shared a few important studies on obesity complications in total knee arthroplasty (TKA). In “Primary Total Knee Arthroplasty in Super-obese Patients: Dramatically Higher Postoperative Complication Rates Even Compared to Revision Surgery,” published in the May, 2015 issue of The Journal of Arthroplasty, super obesity was associated with dramatically increased rates of postoperative complications after TKA compared to non-obese, obese, and morbidly obese patients, as well as those undergoing revision TKA.

In “Obesity and Total Joint Arthroplasty: A Literature Based Review” published in the May 2013 issue of the Journal of Arthroplasty, a workgroup of the American Association of Hip and Knee Surgeons (AAHKS) Evidence Based Committee wrote:

“It is our consensus opinion that consideration should be given to delaying total joint arthroplasty in a patient with a BMI [body mass index] > 40, especially when associated with other co-morbid conditions, such as poorly controlled diabetes or malnutrition.”

There is a lot of literature out there on obesity complications. No fewer than 60 articles have been in peer review literature concerning complications related to obesity and total knee arthroscopy since 2010.

Springer said, “We are not doing these patients a service by saying we are going to lose 55 pounds and then when your BMI is lower than 40 we will operate on you. We need to do more than that.”

He added, “We looked at 289 of our own patients who had end stage OA [osteoarthritis] of the hip or knee (76 hip, 213 knees) and a BMI > 40. And only 9% of the patients got their BMI under 40 and had the total joint arthroplasty.”

“I think in some ways we have to risk-stratify all our patients and take into consideration if a higher risk is worth it for patients whose quality of life would be tremendously changed by the surgery like a patient with destructive [osteoarthritis] of hip and wheelchair bound. It is easy to draw lines in the sand, but we have to take these cases individually.”

3. Malnutrition

When it comes to malnutrition, Singer said that a lot of times you don’t know it is there unless you screen for it. In the study “The Effect of Malnutrition on Patients Undergoing Elective Joint Arthroplasty,” published in the September 2013 issue of the Journal of Arthroplasty, malnutrition was found to be prevalent in patients older than age 55 with a significant increase in post-operative complications. Out of 2,161 elective total hip arthroplasty patients, 8.5% were malnourished and the rate of overall complications in the malnourished group was 12% vs. 2.9% in the patients with the control group (p < 0.0001).

Screening can include:

• Total Lymphocyte Count: <1500 mm³
• Serum Albumin: <3.5 g/dl
• Transferrin Level: < 200 mg/dl

Springer said, “Be aware, especially of that obese patient who is malnourished (high calories/low protein) because those patients are really at high risk of developing complications. It is a clustering effect.”

4. Smoking

Smoking is another important modifiable risk factor, according to Singer. He said, there is no question that smoking and the risks of smoking around the time of surgery is well documented. Systemic effects of smoking and nicotine include:

• Local tissue hypoxia
• Micro-vascular constriction
• Increase carboxyhemoglobin
• Decreased collagen production
• Wound healing
• Decreased T cell function
• Infection

“I find that out of all the modifiable risk factors, this is the hardest thing to quit. How long do you need to quit prior to surgery? Smoking cessation should be 4 to 8 weeks prior. Keep in mind though, that while it decreases complications, it does not normalize. The patient is still at risk as former smoker.”

“It has been shown that quitting smoking is harder than quitting heroin. It is that ingrained in people’s brains and lifestyles. And if you are going to draw a line in the sand, then you better be ready to drop some cases.”

He added that serum cotinine levels which have a half-life of 20 hours can predict smoking within the last week. Levels < 10 ng/mL are consistent with not smoking.

5. Vitamin D

Springer also explained that vitamin D plays a major role in immune system modulation, and that therefore deficiency has been directly related to greater infection risk. In his first year of checking vitamin D routinely, out of 50 patients undergoing total joint arthroplasty, 65% were vitamin D deficient. He said though that it is easily and rapidly correctable unless the patient has an underlying medical condition.

6. Preop screening for MRSA and MSSA

Screening for methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA) is controversial just simply because of the expense and logistics of implementing it, but there is clear evidence that a lot of us are carriers of MSSA.

Molecular DNA studies have shown that a majority of infecting strains are part of patient’s resident nasal flora. About 30% of the population are MSSA carriers and 4% MRSA carriers.

The goal, Springer said, is to decrease the incidence of postoperative S. aureus surgical site infections (SSI) by eliminating S. aureus nasal carriage from the patient prior to surgery, referring to a meta-analysis of 16 studies focusing on total joint arthroplasty, which found nasal decolonization of S. aureus resulted in a 54.6% decrease in the risk of SSI (p <0.001).

7. Management of Anti-Rheumatic Medications

Lastly, Springer mentioned the management of anti-rheumatic medications and pointed to “The American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Anti-rheumatic Medications in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Knee Arthroplasty” which was published in the September 2017 issue of The Journal of Arthroplasty September 2017 issue.

Ultimately, Springer said, that when it comes to infection prevention, it is okay to say no for patient safety. He said in a Rothman Institute study, the 5-year survivorship after a joint infection was less than the 5-year survivorship of 5 of the 6 most diagnosed cancers, so it really hits home with patients.

“We have been developing a patient optimization program at OrthoCarolina, but it is a work in progress. We really need a new paradigm of coordinated care that addresses the total health of the patient.”

Meet Dr. Springer at the Upcoming ICJR South Hip and Knee Course

Springer’s discussion on preoperative patient optimization was originally presented at the International Congress for Joint Reconstruction’s 6th Annual ICJR South Hip and Knee Course in 2018. His presentation is also on the agenda for the 7th Annual ICJR South Hip & Knee Course which will be held June 27-29, 2019 at the Ocean Reef Club in Key Largo, Florida.

The conference is designed for orthopedic surgeons and allied health professionals looking to learn the latest in orthopedic technology, surgical technique and optimum patient care. The course will include current controversies in total knee arthroplasty and total hip arthroplasty, enhanced recovery and outpatient arthroplasty, and perioperative patient management.

To register, click here.