Abstract
Background
It has been noted in the literature that there are increased complication rates following total hip arthroplasty (THA) in patients with chronic kidney disease (CKD) or end stage renal disease (ESRD). However, there is little data directly comparing outcomes in patients undergoing THA for osteoarthritis (OA) versus ESRD or CKD with OA. The objective of this study is to illustrate the risk of developing postoperative complications after THA in the CKD and ESRD populations by stage of disease when compared to a control group (OA) and thus better equip orthopaedic providers in the care of these patients.
Methods
The National Inpatient Sample (NIS) was utilized to identify patients undergoing elective THA from 2006 to 2015 with OA, ESRD, and CKD. The prevalence of preoperative comorbidities and the incidence of numerous postoperative complications broken into categories were examined.
Results
Between 2006 and 2015 the NIS database reported 4,350,961 patients diagnosed with OA, 8355 diagnosed with ESRD, and 104,313 diagnosed with CKD undergoing THA. The incidence of wound hematoma (2.5% vs. 0.8%; p < .0001), wound infection (0.7% vs. 0.4%; p = .0319), cardiac (1.3% vs. 0.6%; p = .0067), urinary (3.9% vs. 2.0%; p < .0001), and pulmonary complications (2.2% vs. 0.5%; p < .0001) occurred more frequently in patients with OA and ESRD when compared to only OA patients. For patients with OA and CKD, stages 3–5 saw at least half of the complication categories occur at significantly higher rates than OA patients.
Conclusion
This study shows that patients with ESRD and CKD have increased rates of complications after THA. This study's specific breakdown by stage and complication can benefit orthopaedic surgeons and practitioners in realistic pre and postoperative planning and provides data that could benefit decision making on bundled reimbursement for this specific patient population, as providers could better account for the postoperative complications noted above and their associated costs.
Keywords: Hip arthroplasty, Perioperative morbidity, Chronic kidney disease, Outcomes, Osteoarthritis
Highlights
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Patients with ESRD and CKD stages 3–5 have increased rates of complications when undergoing total hip arthroplasty.
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Patients with ESRD and CKD stages 3-5 have increased rates of preoperative comorbidities when undergoing total hip arthroplasty.
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Data presented in this study can benefit decision making in bundled reimbursement for this patient population.
1. Introduction
Total hip arthroplasty (THA) is among the most frequent orthopaedic procedures performed in the United States annually. Overwhelmingly, the most frequent indication for the operation is osteoarthritis (OA), with osteonecrosis and rheumatoid arthritis next on the list.1 Over 400,000 primary THA procedures are expected to occur in 2022.2 Additionally, demand in the near future for hip replacement is forecasted to increase substantially due to an increasing elderly population and increased public awareness of the improved quality of life resulting from the procedure.3,4 With the ever-changing landscape of elective THA operations in the United States, it is of increasing importance that orthopaedic surgeons distinguish patient risk factors which may contribute to post-operative complications. Several risk factors have previously been documented in the literature, including obesity, chronic kidney disease (CKD), rheumatologic disease, and diabetes mellitus.5, 6, 7
One of the more prevalent risk factors in patients undergoing primary THA is CKD. In fact, it has been documented that 6.1% of patients undergoing THA will have some stage of CKD.8 This number will continue to rise as the incidence of patients with end stage renal disease (ESRD) is expected to increase by 11–18% by 2030.9 Renal disease is a critical risk factor, which has previously been linked to several postoperative complications following THA.10, 11, 12 These patients often have multiple comorbidities and greater postoperative morbidity. The majority of previous studies documented in the literature focus on patients with ESRD requiring dialysis or transplant undergoing THA. This has created a paucity of literature data depicting the complications of patients with earlier stages of CKD. It is well documented that CKD is an independent risk factor for negative surgical outcomes; however, more specific data is needed particularly regarding CKD stages and their association with THA.8,13,14
Up to this point, there is limited data directly comparing patients with OA and various stages of CKD versus patients with OA undergoing THA. A way to reliably and effectively evaluate the relationship between the 2 populations is to utilize the National Inpatient Sample (NIS), whose data encompasses the entire United States, represents all payer statuses, and includes data over several years which develops a large enough sample to create statistical significance. This database has shown to be effective in analyzing risk factors, comorbidities, and outcomes associated with total joint arthroplasty.15,16 The aim of this study is to utilize the NIS to investigate if there is a difference in complication rates or comorbidities between patients with CKD undergoing THA and patients with OA undergoing THA. Specifically, the complications under investigation include wound seroma, wound infection, dislocation, urinary complications, cardiac complications, and pulmonary complications.
2. Material and methods
The NIS data from 2006 through the third quarter of 2015 was selected for analysis. We omitted fourth quarter data from 2015 because of the changeover from ICD-9 to ICD-10. In this study, we utilized ICD-9 codes and Clinical Classifications Software (CCS) codes to find and include our groups of interest and specific diagnoses. We did not exclude any patients who were identified from the ICD-9 and CCS codes. CCS codes were developed by the HCUP to provide a way of condensing procedures and diagnoses into categories. This was accomplished by gathering individual ICD-9-CM and CPT codes into general diagnosis and procedure groups to assist statistical analysis and reporting. The following ICD-9 codes were used: end stage renal disease (585.6), osteonecrosis (733.4), wound seroma or hematoma (998.1), wound infection (996.6 and 998.5), dislocation (835 and 996.42), cardiac complications (997.1), urinary complications (584.5–584.9 and 997.5), pulmonary complications (518.81–518.85 and 997.3), and overall surgical complications (998.9). The CCS code used for the primary THA procedure was 153. We selected the CCS codes for the OA diagnosis 203. In this study, we delineated ESRD as a separate entity from CKD stage 5 based on commencement of maintenance dialysis or transplantation.17 Patients with only ESRD and OA codes were included in this study. This data was analyzed year by year within the desired variables. Additionally, we used the Elixhauser Comorbidity Software, which is a tool that identifies 29 of the most frequently listed medical comorbidities within the NIS database for further comparison and identification of pertinent differences.
Detailed summaries of the complications and comorbidities experienced by patients undergoing THA were analyzed as a whole and by patients with CKD and OA versus patients with OA and no CKD. Proportions of complications by stage were compared utilizing Rao-Scott chi square tests, with post-hoc comparisons by individual CKD stage (versus the OA-only group) adjusted via Bonferroni corrections to control the experiment-wise Type-I error rate. Additionally, a weighted logistic regression model accounting for survey design variables was performed to obtain the odds ratio of complications per each increase in CKD stage (from 0 to stage 1, stage 1 to stage 2, etc.). For the pre-specified complications, sampling weights were used to produce national estimates. Statistical significance was set at a P-value of <.05.
3. Results
Between the years 2006 and 2015, the NIS database accounted for 4,350,961 THA procedures in patients with OA and 8355 procedures in patients with ESRD. Based on the Rao-Scott chi-square tests the following complications were found to occur at a statistically significantly higher rate in patients with ESRD and OA vs OA (Table 1): wound seroma or hematoma (2.5% vs 0.8%; p < .0001), wound infection (0.7% vs 0.4%; p = .0319), cardiac complications (1.3% vs 0.6%; p = .0067), urinary complications (3.9% vs 2.0%; p < .0001), and pulmonary complications (2.2% vs 0.5%; p < .0001). When stratified based on CKD stage, the Rao-Scott chi-square tests show that all complication rates were significantly higher in all stages of CKD with OA when compared to the OA-only group (Table 2).
Table 1.
Complication rates following THA for ESRD (dialysis-dependent) within OA.
| Complication | ESRD + OA (N = 8,355a) | OA alone (N = 4,246,648a) | P-Value |
|---|---|---|---|
| Wound seroma or hematoma | 210 (2.5%) | 32491 (0.8%) | <0.0001 |
| Wound infection | 60 (0.7%) | 15044 (0.4%) | 0.0319 |
| Dislocation | 92 (1.1%) | 32392 (0.8%) | 0.1553 |
| Cardiac complications | 106 (1.3%) | 27224 (0.6%) | 0.0067 |
| Urinary complications | 327 (3.9%) | 85854 (2.0%) | <0.0001 |
| Pulmonary complications | 180 (2.2%) | 21631 (0.5%) | <0.0001 |
Sample size based on weighted frequencies.
Table 2.
Complications by CKD stage within OA.
| Complication | OA alone (N = 4,246,648a) | Stage 1 (eGFR> 90 mL/min/1.73 m2) (N = 2176) | Stage 2 (eGFR 60–89 mL/min/1.73 m2) (N = 13,458) | Stage 3 (eGFR 30–59 mL/min/1.73 m2) (N = 69,601) | Stage 4 (eGFR 15–29 mL/min/1.73 m2) (N = 9907) | Stage 5 (eGFR< 15 mL/min/1.73 m2) (N = 817) | P-Valueb |
|---|---|---|---|---|---|---|---|
| Wound seroma or hematoma | 32491 (0.8%) | 20 (0.9%) | 74 (0.5%) | 752 (1.1%) | 178 (1.8%) | 20 (2.4%) | 0.0001 |
| Wound infection | 15044 (0.4%) | 5 (0.2%) | 94 (0.7%) | 323 (0.5%) | 54 (0.5%) | 0 (0.0%) | <0.0001 |
| Dislocation | 32392 (0.8%) | 41 (1.9%) | 163 (1.2%) | 889 (1.3%) | 175 (1.8%) | 10 (1.2%) | <0.0001 |
| Cardiac complications | 27224 (0.6%) | 27 (1.3%) | 97 (0.7%) | 856 (1.2%) | 113 (1.1%) | 4 (0.5%) | <0.0001 |
| Urinary complications | 85854 (2.0%) | 192 (8.8%) | 1507 (11.2%) | 11996 (17.2%) | 3036 (30.6%) | 210 (25.7%) | <0.0001 |
| Pulmonary complications | 21631 (0.5%) | 8 (0.4%) | 307 (2.3%) | 1243 (1.8%) | 268 (2.7%) | 30 (3.7%) | <0.0001 |
Sample size based on weighted frequencies, rounded to the nearest whole integer.
p-value from Rao-Scott chi-square test adjusted for sampling weights and design.
With Bonferroni correction, however, CKD 3–5 showed statistically significant increases in more of the previously listed complications than CKD stages 1 and 2 (Table 3). CKD stage 3 specifically showed increased rates of all complications except wound infection. Only urinary complications (8.8% vs. 2.0%; p < .0001) occurred significantly more frequently for CKD stage 1, and urinary (11.2% vs. 2.0%; p < .0001) and pulmonary (2.3% vs. 0.5%; p < .0001) complications were significantly more frequent for CKD stage 2.
Table 3.
Complications by each CKD stage with OA vs. OA alone (Bonferroni adjusted).
| Complication | Stage 1 (eGFR> 90 mL/min/1.73 m2) (N = 2176) | Stage 2 (eGFR 60–89 mL/min/1.73 m2) (N = 13,458) | Stage 3 (eGFR 30–59 mL/min/1.73 m2) (N = 69,601) | Stage 4 (eGFR 15–29 mL/min/1.73 m2) (N = 9907) | Stage 5 (eGFR< 15 mL/min/1.73 m2) (N = 817) |
|---|---|---|---|---|---|
| Wound seroma or hematoma | 1.0000 | 1.0000 | 0.0145 | 0.0010 | 0.4940 |
| Wound infection | 1.0000 | 0.3471 | 0.5908 | 1.0000 | <.0001 |
| Dislocation | 0.6821 | 0.5071 | <.0001 | 0.0449 | 1.0000 |
| Cardiac complications | 1.0000 | 1.0000 | <.0001 | 0.2766 | 1.0000 |
| Urinary complications | <.0001 | <.0001 | <.0001 | <.0001 | <.0001 |
| Pulmonary complications | 1.0000 | <.0001 | <.0001 | <.0001 | 0.0002 |
Patients with ESRD exhibited significantly higher prevalence of each comorbidity listed (Table 5): congestive heart failure, valvular disease, pulmonary circulation disease, peripheral vascular disease, hypertension, paralysis, other neurological disorders, chronic pulmonary disease, diabetes without chronic complications, diabetes with chronic complications, renal failure, liver disease, acquired immune deficiency syndrome, lymphoma, metastatic cancer, coagulopathy, weight loss, fluid and electrolyte disorders, chronic blood loss anemia, deficiency anemias, drug abuse, and psychoses.
Table 5.
Comorbidities associated with ESRD (dialysis-dependent) among OA patients undergoing THA.
| Comorbidity | ESRD + OA (N = 8,355a) | OA alone (N = 4,246,648a) | P-Value |
|---|---|---|---|
| Congestive heart failure | 1551 (18.6%) | 104854 (2.5%) | <0.0001 |
| Valvular disease | 735 (8.8%) | 166793 (3.9%) | <0.0001 |
| Pulmonary circulation disease | 297 (3.6%) | 34678 (0.8%) | <0.0001 |
| Peripheral vascular disease | 783 (9.4%) | 94376 (2.2%) | <0.0001 |
| Hypertension | 7730 (92.5%) | 2499692 (58.9%) | <0.0001 |
| Paralysis | 103 (1.2%) | 14454 (0.3%) | <0.0001 |
| Other neurological disorders | 619 (7.4%) | 160148 (3.8%) | <0.0001 |
| Chronic pulmonary disease | 1468 (17.6%) | 583334 (13.7%) | 0.0008 |
| Diabetes w/o chronic complications | 1896 (22.7%) | 547530 (12.9%) | <0.0001 |
| Diabetes w/chronic complications | 1177 (14.1%) | 41155 (1.0%) | <0.0001 |
| Hypothyroidism | 1374 (16.4%) | 572713 (13.5%) | 0.0127 |
| Renal failure | 8355 (100.0%) | 89558 (2.1%) | <0.0001 |
| Liver disease | 294 (3.5%) | 40063 (0.9%) | <0.0001 |
| Peptic ulcer Disease x bleeding | 10 (0.1%) | 654 (0.0%) | 0.0158 |
| Acquired immune deficiency syndrome | 50 (0.6%) | 3756 (0.1%) | <0.0001 |
| Lymphoma | 121 (1.5%) | 13337 (0.3%) | <0.0001 |
| Metastatic cancer | 0 (0.0%) | 6508 (0.2%) | <0.0001 |
| Solid tumor w/out metastasis | 34 (0.4%) | 18746 (0.4%) | 0.8679 |
| Rheumatoid arthritis/collagen vas | 612 (7.3%) | 157261 (3.7%) | <0.0001 |
| Coagulopathy | 671 (8.0%) | 90060 (2.1%) | <0.0001 |
| Obesity | 739 (8.9%) | 647089 (15.2%) | <0.0001 |
| Weight loss | 266 (3.2%) | 21096 (0.5%) | <0.0001 |
| Fluid and electrolyte disorders | 2324 (27.8%) | 368114 (8.7%) | <0.0001 |
| Chronic blood loss anemia | 242 (2.9%) | 73370 (1.7%) | 0.0106 |
| Deficiency Anemias | 4871 (58.3%) | 558656 (13.2%) | <0.0001 |
| Alcohol abuse | 37 (0.4%) | 62195 (1.5%) | 0.0036 |
| Drug abuse | 104 (1.2%) | 28901 (0.7%) | 0.0464 |
| Psychoses | 295 (3.5%) | 78170 (1.8%) | 0.0003 |
| Depression | 895 (10.7%) | 480056 (11.3%) | 0.5718 |
Sample size based on weighted frequencies.
All complications had significantly higher odds of occurrence with increased CKD stage (Table 4). Furthermore, urinary complications had the highest rate of increase per CKD stage, with an estimated 115% increase in the odds of occurrence with each higher stage (OR 2.15; 95% CI 2.11–2.20; p < .0001). Descriptively, rates of urinary complications peaked in patients with CKD stage 4 and OA, while pulmonary complications and wound hematoma/seroma steadily increased with peak occurrence in CKD stage 5 (Fig. 1).
Table 4.
Logistic model for complications by increasing CKD stage.
| Complication | ORa | 95% LCLa | 95% UCLa | P-value |
|---|---|---|---|---|
| Wound seroma or hematoma | 1.14 | 1.07 | 1.22 | <.0001 |
| Wound infection | 1.11 | 1.01 | 1.22 | 0.0265 |
| Dislocation | 1.20 | 1.13 | 1.28 | <.0001 |
| Cardiac complications | 1.21 | 1.13 | 1.30 | <.0001 |
| Urinary complications | 2.15 | 2.11 | 2.20 | <.0001 |
| Pulmonary complications | 1.55 | 1.47 | 1.63 | <.0001 |
OR = Odds Ratio, LCL = Lower Confidence Limit, UCL = Upper Confidence Limit.
Fig. 1.
Complication occurrence (% of cases) by CKD stage, stratified by complication type
Fig. 1 shows the rate of complications postoperatively in patients with CKD and OA group. Urinary complications were found to be the most frequently occurring complication in each stage. Stage 0 refers to control patients (OA only).
4. Discussion
In this study, the incidence of postoperative complications and the prevalence of preoperative comorbidities were compared between patients with a diagnosis of OA only and kidney disease with OA who underwent THA. Our findings demonstrate a statistically significant increase in the rates of wound hematoma, wound infection, dislocation, cardiac complications, urinary complications and pulmonary complications in patients with ESRD or CKD stage 3, with a mix of complications significantly associated with CKD stages 2, 4, and 5. Urinary complications occurred at significantly higher rates in all CKD stages as well as ESRD. Additionally, we found a higher prevalence of a host of comorbidities in the kidney disease cohort. We believe this is the first study to quantitatively highlight the hypothesized disparities in surgical outcomes and preoperative comorbidities between patients with OA, ESRD, and CKD stages 1–5 utilizing the NIS database.
CKD has been described as a risk factor for perioperative complication and mortality.8,13,14 This is likely multifactorial in cause and associated with their decreased ability to manage electrolytes, erythropoietin production, calcium homeostasis, and blood pressure. Furthermore, hemodialysis has been implicated as a risk factor for complications. Ottesen et al. found that patients receiving dialysis more frequently experienced adverse event, reoperation, readmission, and mortality.18
A strength of our paper is the ability of our data from a high-powered and appropriately representative database in the NIS to examine post-operative complications in patients who underwent THA with renal disease on a sliding scale from CKD stage 1 to ESRD. Additionally, the generalizability of our results is augmented by the differing hospital settings and vast number of participating surgeons with an overall wide spectrum of experience. Many papers in the literature previously solely examined ESRD in the setting of THA.10,19, 20, 21 A few studies have also looked at the stages of CKD broken down by stage in the setting of THA.8,22 However, we believe our study is the first of its kind to directly evaluate CKD by stage and ESRD to OA. The comparative nature of this study to OA is a strong point, because it may help with physician preoperative decision making. This is because they can evaluate the complication rates for each stage of CKD compared to their general OA patient population, and then provide more informed counseling and risk stratification.
Our study demonstrates a significant, positive correlation between CKD stage and complication rates. CKD stage 1 only had a significant increased rate of urinary complications. CKD 2 showed a rise in urinary and pulmonary complications when compared to OA. Once patients reached CKD stage 3 up to ESRD, there was a significant increase in at least half of complication categories (Table 1, Table 3), marking a shift from CKD stage 1, with only urinary complications being elevated, and CKD stage 2, with urinary and pulmonary complications occurring more frequently. Warren et al. performed a database study which showed data similar to ours in that once eGFR <60 (CKD Stage 3), the major complication rate and mortality drastically increases.23 Additionally, Antoniak et al. performed a database study which showed once a patient's eGFR is < 44 (CKD Stage 3b), the major complication rate increases at a linear rate. Our data is mostly consistent with these previous studies, but it is bolstered with a full spectrum of renal disease and comorbidity data.
Classically, surgical approaches have been found to impact outcomes for THA, specifically in relation to dislocation. However, this has recently been brought into contention by a recent large-scale review of the literature revealing no association between approach and dislocation rates.24 Due to the absence of documented approach of this database study, we were unable to analyze approaches. However, overall, we found a significant increase in dislocation in patients with CKD stages 3 and 4.
In addition to the direct impact on renal function, CKD patients are affected by associated conditions such as diabetes mellitus, hypertension, anemia, and weakened immune system. These all have been demonstrated to increase rates of complications with patients undergoing THA.25, 26, 27, 28 In addition, patients with renal disease may have associated characteristics that effect outcomes that are more difficult to quantify. Coresh et al. found that potentially modifiable factors such as lower socioeconomic status, poor glycemic/blood pressure control, and suboptimal health behaviors represented 80% of CKD prevalence disparities.29
Another important consideration during preoperative planning for patients with CKD is the potential for acute deterioration in renal function or AKI postoperatively. In the literature, there are multiple studies demonstrating the increased incidence of AKI following total joint arthroplasty (TJA).30, 31, 32 Takeshita et al. were able to identify diabetes mellitus and preoperative NSAIDs as controllable risk factors for AKI following TJA. Limiting NSAIDs and controlling blood glucose via HbA1c testing should be contemplated in the preoperative period to reduce the rates of kidney injury postoperatively.33 Jiang et al. noted other perioperative risk factors for AKI being increased body mass index, use of angiotensin II receptor blockers, and angiotensin converting enzyme inhibitors.32
In our study, we found that renal disease patients undergoing THA had a heightened rate of urinary complications (Table 1, Table 2, Table 3, Table 4). We believe there are multiple potential factors that could be contributing to this finding. One important factor is diabetes mellitus, which our data demonstrated to occur significantly more frequently in ESRD patients. Diabetes is well documented in the literature to be associated with urinary tract infections.34, 35, 36 Tourret et al. found that urinary tract infections occur anywhere from 1.5 to 4 times more frequently in diabetic patients compared to the overall population.37 When looking at TJA specifically, diabetes has been illustrated multiple times as an independent factor for increased risk of urinary tract complications in the postoperative time period.38, 39, 40
The prevalence of these comorbidities with respect to patients with ESRD was higher: congestive heart failure, valvular disease, pulmonary circulation disease, peripheral vascular disease, hypertension, paralysis, other neurological disorders, chronic pulmonary disease, diabetes without chronic complications, diabetes with chronic complications, renal failure, liver disease, acquired immune deficiency syndrome, lymphoma, metastatic cancer, coagulopathy, weight loss, fluid and electrolyte disorders, chronic blood loss anemia, deficiency anemias, drug abuse, and psychosis. These must be considered simultaneously while assessing complication rates, as many of them have been previously linked to hospital readmission.25
The importance of this information is multifactorial, with preoperative counseling and planning at the forefront. This study illustrates that patients with renal disease have an amplified risk for complications and can be stratified by CKD level, which could serve patients in their understanding of risk to proceed with elective joint replacement or to simply understand expected postoperative course. The importance of this information is underlined by the rising nature of renal disease and the overall rising incidence of THA as management for hip pathology. Furthermore, as bundle payments use information such as comorbidities in the evaluation of risk for complications and adjusted bundled payment, this study could serve as objective evidence of the heightened risk for complication increasing from CKD stage 1–5. For example, there was an increased risk of urinary complications from an expected frequency of 2.0% in the OA-only group, to 8.8% in CKD 1, to 25.7% in CKD 5. This could be useful in the consideration of payment modifiers for the comprehensive Care for Joint Replacement Model in this specific payment population. In their review of bundled payment systems with respect to total joint arthroplasty, McLawhorn and Buller noted that implementation of this model created $522,389 worth of value for a hospital system over the course of 271 patient episodes, and in another 3-year study, the authors saw a 20% decrease in 90-day cost over the study duration along with decreased length-of-stay and postoperative complications.41 Orthopaedic providers in bundled payment systems may find this study useful to save money and increase quality of care by knowing what complications to look for in renal disease patients of any stage undergoing THA.
Finally, this study further highlights the role of medical management and multidisciplinary care in conjunction with orthopaedic surgery. As CKD may be difficult to manage, understanding risk stratification among stages of CKD, dialysis, and renal transplantation will serve patients who would benefit in THA.
Our study is limited in the following ways. Mainly, we relied on a large national database. A large database could potentially have data entry errors which would lead to bias in our results. Additionally, we were restricted to examining perioperative complications in this study. Postoperative functional information and survivorship data were not available in the database. This is due to the inpatient specific quality of the NIS database.
Stage 3 CKD patients with OA experienced significantly higher rates of all but one category of complications assessed for in this study (Table 3). A possible explanation for this outcome could be a lack of medical surveillance in patients with lower stages of CKD when compared to patients with advanced renal disease and those on hemodialysis. Further research to determine the etiology of this finding would be beneficial.
5. Conclusion
This study demonstrates that patients with ESRD and CKD 3–5 have increased rates of complications and preoperative comorbidities. This information can benefit orthopaedic surgeons and practitioners in preoperative and postoperative planning and counseling. Furthermore, this study provides data that could benefit decision making on bundled reimbursement for this particular patient population.
Funding/sponsorship
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Institutional ethical committee approval
This study met Institutional Review Board criteria for exemption from full review due to the absence of patient identifiers and the blinded nature of the National Inpatient Sample database.
Authors contribution
Jake Fox: Writing- Original draft preparation, Data curation, Writing- Review & Editing.
Grayson Domingue: Investigation, Writing- Original draft preparation.
Christian DeMaio: Writing- Review & Editing, Resources.
Bryan Brockman: Visualization, Writing- Review & Editing.
Kimberly Malloy: Software, Validation, Formal analysis, Methodology.
Rishi Thakral: Supervision, Conceptualization, Methodology, Writing- Review & Editing.
Declaration of competing interest
None.
Acknowledgements
Justin Dvorak, PhD, for his work in additional statistical analyses.
Footnotes
Work Completed: Department of Orthopaedic Surgery and Rehabilitation, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, AAT-3400, Oklahoma City, OK, 73104, USA.
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