Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2024 Jun 1.
Published in final edited form as: Musculoskeletal Care. 2022 Dec 19;21(2):576–581. doi: 10.1002/msc.1724

Limited English Proficiency Correlates with Postoperative Complications after Knee Arthroplasty

Kevin H Nguyen a, Chloe Sales a, Pablo Suarez a, Alicia Fernandez b, Derek T Ward c, Solmaz P Manuel d,*
PMCID: PMC10272016  NIHMSID: NIHMS1859709  PMID: 36536487

INTRODUCTION

Total knee arthroplasty (TKA) has been consistently found to improve patients’ symptoms, pain scores, and quality of life (Carr et al., 2012; Dailiana et al., 2015; Heath et al., 2021). Partly as a result, TKAs are among the most commonly performed procedures in the United States and with an aging population and rising rates of obesity, TKA volume is expected to increase. Postoperative complications after TKA, however, may adversely affect outcomes. One study of more than 15,000 TKAs in the American College of Surgeons National Surgical Quality Improvement Program found that 5.5% of TKA cases have a complication within 30 days (Belmont et al., 2014).

Disparities in postoperative outcomes after total joint arthroplasty among non-white minority populations have been well documented. (Johnson & Hunter, 2014; Kremers et al., 2015; Singh et al., 2014; Sloan et al., 2018). Compared to majority populations, racial and ethnic minority groups are at increased risk of postoperative complications and readmission after TKA (Adelani et al., 2018; Blum & Ibrahim, 2012; Goodman et al., 2016). These healthcare disparities may be mediated in part by language barriers faced by patients with limited English proficiency (LEP). Studies have found that patients with LEP undergoing lower extremity joint arthroplasty face longer lengths of hospital stay and higher hospitalization costs (Bernstein et al., 2020; Manuel et al., 2022). These studies did not explore the association between LEP status and risk of postoperative complications after lower extremity arthroplasty procedures.

In order to explore whether postoperative TKA complications correlate with LEP status and longer lengths of hospital stay, we compared the rates of complications after TKA between patients with LEP and patients who are English proficient (EP) at a large academic medical center.

METHODS

Study Participants

This was a retrospective cohort study of elective TKA patients ≥18 years of age between January 2013 and December 2021 from a single academic medical center serving an ethnically and linguistically diverse urban center. All TKA surgeries were performed by one of five high volume specialists in the academic institution’s orthopedic surgery service. Cases that were urgent or emergent were excluded from this study. A single patient who died during the hospitalization was also excluded from the study. Institutional review board approval was granted with waiver of consent.

Study Design

The primary predictor variable was English proficiency status, where having LEP was defined as self-reporting a primary language other than English. Primary outcome variables were rates of postoperative complications after TKA, as defined by the Centers for Medicare and Medicaid Services (CMS) (Complication Measure Overview, 2022). Rates of postoperative complications were obtained from patients’ electronic health records. Complications analyzed included 30-day deep vein thrombosis (DVT), 30-day venous thromboembolism (VTE), 90-day surgical site infection, 7-day pneumonia, 7-day sepsis, and 1-day encephalopathy. Arthroplasty specific complications included periprosthetic fracture, implant fracture, instability, implant loosening, and stiffness.

Demographic and perioperative data were obtained from patients’ electronic health records. These variables included age, self-reported gender, self-reported race/ethnicity, self-reported primary spoken language, American Society of Anesthesiologists (ASA) physical status, smoking status, and body mass index (BMI). Race/ethnicity was categorized as non-Hispanic white, Hispanic/Latinx, Asian-American and Pacific Islander (AAPI), Black, Indigenous, multiracial, or not-reported. These racial and ethnicity categories are socially-defined and do not reflect biologically or genetically distinct groups (Flanagin et al., 2021). Primary language spoken was categorized as English, Spanish, Chinese (Mandarin or Cantonese), Russian, or other non-English languages.

Statistical Tests

Comparisons of baseline characteristics, perioperative metrics, and postoperative complication rates between EP and LEP patients were performed using t-test for continuous variables and Fisher’s exact test for categorical variables. Multivariable logistic regression modelling was used to calculate adjusted odds ratios of having a postoperative complication. Calculated odds ratios were adjusted for covariates chosen a prior based on prior arthroplasty literature, including age, patient-reported gender, BMI, ASA physical status, smoking status, and length of hospitalization (Gronbeck et al., 2019; Ko et al., 2021). Race/ethnicity were excluded from the regression model due to high collinearity between race/ethnicity categories with English proficiency status. All statistical analyses were performed using Stata version 16.1. The reporting of this study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (Elm et al., 2007).

RESULTS

A total of 3450 TKA cases were performed between January 2013 and December 2021. 9.2% (316) of the patients were classified as having LEP. Among patients with LEP, 41.8% (132) self-identified as AAPI and 35.1% (111) self-identified as Hispanic/Latinx. Compared to EP patients, LEP patients were older (71 ± 10 years vs 65 ± 10 years, p<.001) and more likely to be female (72% vs 59%, p<.001). Patients with LEP had longer lengths of hospitalization (mean: 2.8 ± 2.1 days vs 2.3 ± 1.7 days, p<.001) (Table 1).

Table 1.

Patient demographics and baseline characteristics by English proficiency

Total Knee Arthroplasty Patients (N=3450) English Proficient (n=3134) Limited English Proficiency (n=316) P value
Gender, % Female (n) a 60% (2068) 59% (1840) 72% (228) <.001
Age, years (SD) b 66 (10) 65 (10) 71 (10) <.001
Race/Ethnicity, % (n) a <.001
 Non-Hispanic white 63.6% (2195) 68.9% (2160) 11.1 % (35)
 Hispanic/Latinx 10.7% (370) 8.3% (259) 35.1% (111)
 AAPI 10.6% (365) 7.4% (233) 41.8% (132)
 Black 7.9% (274) 8.7% (273) 0.3% (1)
 Indigenous 0.6% (22) 0.7% (22) 0.0% (0)
 Multiracial 4.4% (151) 3.6% (114) 11.7% (37)
 Not reported 2.1% (73) 2.3% (73) 0.0% (0)
Language Spoken, % (n) a <.001
 English 90.8% (3134) 100% (3134) 0% (0)
 Spanish 3.3% (115) 0% (0) 36.4% (115)
 Chinese 2.8% (95) 0% (0) 30.1% (95)
 Russian 0.7% (25) 0% (0) 7.9% (25)
 Other Non-English 2.3% (81) 0% (0) 25.6% (81)
ASA Physical Status, % (n) a .07
 ASA 1 4.1% (140) 4.3% (135) 1.6% (5)
 ASA 2 67.5% (2322) 67.5% (2109) 67.6% (213)
 ASA 3 28.2% (969) 27.9% (872) 30.8% (97)
 ASA 4 0.2% (7) 0.2% (7) 0% (0)
BMI, kg/m2 (SD) b 30 (6) 30 (6) 30 (5) 1.0
Length of Stay, days (SD) b 2.3 (1.8) 2.3 (1.7) 2.8 (2.1) <.001
Open in a new tab

Data are presented as mean (SD) for continuous variables and %(n) for categorical variables.

a

Fisher’s exact test

b

Two sample t-test.

Abbreviations: AAPI, Asian American & Pacific Islander; ASA, American Society of Anesthesiologists; BMI, body mass index.

Overall, rates of postoperative complications ranged from 0.1% for 1-day encephalopathy to 3.6% for 90-day surgical site infection. When comparing rates of postoperative complications between LEP and EP patients, LEP patients had higher rates of 30-day DVT (2.5% vs 0.8%, p=.01), 30-day VTE (3.8% vs 1.9%, p=.03), and 7-day pneumonia (1.3% vs 0.3%, p=.02). There were no significant differences in rates of 90-day surgical sites infections, 7-day sepsis, 1-day encephalopathy or in rates of arthroplasty specific complications (Figure 1). Multivariable logistic regressions adjusted for age, gender, BMI, ASA physical status, smoking status, and length of hospitalization found that patients with LEP had higher rates of 30-day postoperative DVT (aOR: 2.84, CI:1.19–6.79, p=.02) and 30-day VTE (aOR: 2.10 CI:1.06–4.12, p=.03) when compared to their EP counterparts (Figure 2).

Figure 1.

Figure 1.

Open in a new tab

Comparing Postoperative Complication Rates Based on English Proficiency Status after Knee Arthroplasty. Statistical significance of differences in complications rates were calculated using Fisher’s exact test. Abbreviations: DVT, deep vein thrombosis; VTE, venous thromboembolism. Symbols: *p<.05

Figure 2.

Figure 2.

Open in a new tab

Adjusted Odds Ratios of LEP patients relative to EP patients for Complications after Knee Arthroplasty.

*Odds ratios were adjusted for age, patient-reported gender, body mass index, American Society of Anesthesiologists physical status, smoking status and length of hospitalization. Abbreviations: LEP, limited English proficiency; EP, English proficient; DVT, deep vein thrombosis; VTE, venous thromboembolism.

DISCUSSION

This study examined the relationship between English language proficiency and postoperative complication rates for patients undergoing elective TKA and found that LEP patients had increased rates of 30-day DVT and 30-day VTE.

Although prior studies have identified that racial and ethnic minority patients undergoing lower extremity arthroplasty have higher risks of immediate postoperative complications, this is the first study to suggest that language barriers may also be associated with these healthcare disparities after arthroplasty procedures (Amen et al., 2020; Pierce et al., 2015). While these findings are novel for the field of orthopedics, LEP status has been previously associated with higher rates of harmful adverse events for hospitalized patients and increased risk of postoperative complications after cardiac surgery and neurosurgery; the majority of these postoperative complications were hypothesized to be related to communication errors (Divi et al., 2007; Tang et al., 2016; Witt et al., 2021).

While our data does not shed light as to why patients with LEP may have increased rates of postoperative DVT and VTE, the literature offers some potential clues. Surgical LEP patients have been found to have poorer pain assessment and management, compared to EP patients (Jimenez et al., 2012, 2014; Plancarte et al., 2021). Inadequate pain control may prolong time to first mobilization for LEP patients, increasing their risk of developing a postoperative DVT and VTE. Not only do these complications increase risk of poorer postoperative recovery and patient mortality, but they may require extended hospitalizations for inpatient management. Therefore, these higher rates of postoperative complications may contribute to our study’s findings that arthroplasty patients with LEP have longer lengths of hospitalization, which is also consistent with prior studies and further highlights the self-perpetuating nature and high cost of healthcare disparities for patients with LEP (Bernstein et al., 2020; John-Baptiste et al., 2004; Manuel et al., 2022).

Our study did not find any significant differences in rates of arthroplasty specific complications including periprosthetic fracture, implant fracture, instability, implant loosening, and stiffness. This suggests that surgical technique was mostly consistent between LEP and EP patients and that the observed disparities in postoperative complications likely arise from differences in postoperative, rather than intraoperative, management and may be related to communication barriers.

We highlight multiple limitations of this study. First, while the electronic health records are a reliable database for postoperative complications, our study design cannot offer insight into specific mediators of these complications, including some potential clinical confounders. The aim of future projects will be to obtain qualitative data from stakeholders, including patients, surgeons, and perioperative staff on how language barriers may contribute to adverse outcomes for LEP patients. We only examined data from a single academic institution; future studies should examine complication reports from multiple sites to assess external validity. However, larger national databases lack data on primary patient language, limiting our ability to study outcomes for patients with LEP. Finally, we grouped all LEP patients; nursing and provider capacity in distinct languages may vary, as might the level of English proficiency of the patients themselves.

CONCLUSIONS

In this retrospective cohort study of over 3,400 elective knee arthroplasty cases, patients with limited English proficiency were more likely to experience postoperative deep vein thromboses and venous thromboembolism when compared to English proficient patients, even after controlling for confounding factors.

Acknowledgements:

The authors thank Dr. Nancy Hills from the University of California, San Francisco Clinical and Translational Science Institute for her assistance and expertise with the statistical methods that were utilized in this study.

Funding:

This research was supported by grant funding from the Hellman Family Foundation and the UCSF Department of Anesthesiology Patricia Sanders Research Award. This project was also supported by the UCSF Summer Explore Research Fellowship grant, National Center for Advancing Translational Sciences, and National Institutes of Health (NIH) through UCSF-CTSI Grant Number UL1 TR001872. Dr Fernandez’s contribution to the research reported in this publication was supported by NIH K24DK102057. The content of this research is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Conflicts of Interest: DTW has received consulting stipends from Depuy (Johnson & Johnson) and there are no other conflicts to report.

REFERENCES

  1. Adelani MA, Keller MR, Barrack RL, & Olsen MA (2018). The Impact of Hospital Volume on Racial Differences in Complications, Readmissions, and Emergency Department Visits Following Total Joint Arthroplasty. The Journal of Arthroplasty, 33(2), 309–315.e20. 10.1016/j.arth.2017.09.034 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Amen TB, Varady NH, Rajaee S, & Chen AF (2020). Persistent Racial Disparities in Utilization Rates and Perioperative Metrics in Total Joint Arthroplasty in the U.S.: A Comprehensive Analysis of Trends from 2006 to 2015. JBJS, 102(9), 811–820. 10.2106/JBJS.19.01194 [DOI] [PubMed] [Google Scholar]
  3. Anis HK, Sodhi N, Coste M, Ehiorobo JO, Newman JM, Garbarino LJ, Gold P, Freund B, Piuzzi N, & Mont MA (2019). A comparison of peri-operative outcomes between elective and non-elective total hip arthroplasties. Annals of Translational Medicine, 7(4), 78. 10.21037/atm.2019.01.64 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Belmont PJJ, Goodman GP, Waterman BR, Bader JO, & Schoenfeld AJ (2014). Thirty-Day Postoperative Complications and Mortality Following Total Knee Arthroplasty: Incidence and Risk Factors Among a National Sample of 15,321 Patients. JBJS, 96(1), 20–26. 10.2106/JBJS.M.00018 [DOI] [PubMed] [Google Scholar]
  5. Bernstein JA, Sharan M, Lygrisse KA, & Lajam CM (2020). The Need for an Interpreter Increases Length of Stay and Influences Postoperative Disposition Following Primary Total Joint Arthroplasty. The Journal of Arthroplasty, 35(9), 2405–2409. 10.1016/j.arth.2020.04.083 [DOI] [PubMed] [Google Scholar]
  6. Blum MA, & Ibrahim SA (2012). Race/Ethnicity and Use of Elective Joint Replacement in the Management of End-Stage Knee/Hip Osteoarthritis: A Review of the Literature. Clinics in Geriatric Medicine, 28(3), 521–532. 10.1016/j.cger.2012.05.002 [DOI] [PubMed] [Google Scholar]
  7. Carr AJ, Robertsson O, Graves S, Price AJ, Arden NK, Judge A, & Beard DJ (2012). Knee replacement. The Lancet, 379(9823), 1331–1340. 10.1016/S0140-6736(11)60752-6 [DOI] [PubMed] [Google Scholar]
  8. Complication Measure Overview. (n.d.). Retrieved July 11, 2022, from https://qualitynet.cms.gov/inpatient/measures/complication
  9. Dailiana ZH, Papakostidou I, Varitimidis S, Liaropoulos L, Zintzaras E, Karachalios T, Michelinakis E, & Malizos KN (2015). Patient-reported quality of life after primary major joint arthroplasty: A prospective comparison of hip and knee arthroplasty. BMC Musculoskeletal Disorders, 16(1), 366. 10.1186/s12891-015-0814-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Divi C, Koss RG, Schmaltz SP, & Loeb JM (2007). Language proficiency and adverse events in US hospitals: A pilot study. International Journal for Quality in Health Care, 19(2), 60–67. 10.1093/intqhc/mzl069 [DOI] [PubMed] [Google Scholar]
  11. Elm E. von, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, & Vandenbroucke JP (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. The Lancet, 370(9596), 1453–1457. 10.1016/S0140-6736(07)61602-X [DOI] [PubMed] [Google Scholar]
  12. Flanagin A, Frey T, Christiansen SL, & Bauchner H (2021). The Reporting of Race and Ethnicity in Medical and Science Journals: Comments Invited. JAMA, 325(11), 1049–1052. 10.1001/jama.2021.2104 [DOI] [PubMed] [Google Scholar]
  13. Goodman SM, Parks ML, McHugh K, Fields K, Smethurst R, Figgie MP, & Bass AR (2016). Disparities in Outcomes for African Americans and Whites Undergoing Total Knee Arthroplasty: A Systematic Literature Review. The Journal of Rheumatology, 43(4), 765–770. 10.3899/jrheum.150950 [DOI] [PubMed] [Google Scholar]
  14. Gronbeck C, Cote MP, Lieberman JR, & Halawi MJ (2019). Risk stratification in primary total joint arthroplasty: The current state of knowledge. Arthroplasty Today, 5(1), 126–131. 10.1016/j.artd.2018.10.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Heath EL, Ackerman IN, Cashman K, Lorimer M, Graves SE, & Harris IA (2021). Patient-reported outcomes after hip and knee arthroplasty. Bone & Joint Open, 2(6), 422–432. 10.1302/2633-1462.26.BJO-2021-0053.R1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Jimenez N, Jackson DL, Zhou C, Ayala NC, & Ebel BE (2014). Postoperative pain management in children, parental English proficiency, and access to interpretation. Hospital Pediatrics, 4(1), 23–30. 10.1542/hpeds.2013-0031 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Jimenez N, Moreno G, Leng M, Buchwald D, & Morales LS (2012). Patient-reported quality of pain treatment and use of interpreters in spanish-speaking patients hospitalized for obstetric and gynecological care. Journal of General Internal Medicine, 27(12), 1602–1608. 10.1007/s11606-012-2154-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. John-Baptiste A, Naglie G, Tomlinson G, Alibhai SMH, Etchells E, Cheung A, Kapral M, Gold WL, Abrams H, Bacchus M, & Krahn M (2004). The effect of English language proficiency on length of stay and in-hospital mortality. Journal of General Internal Medicine, 19(3), 221–228. 10.1111/j.1525-1497.2004.21205.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Johnson VL, & Hunter DJ (2014). The epidemiology of osteoarthritis. Best Practice & Research Clinical Rheumatology, 28(1), 5–15. 10.1016/j.berh.2014.01.004 [DOI] [PubMed] [Google Scholar]
  20. Ko M-S, Choi C-H, Yoon H-K, Yoo J-H, Oh H-C, Lee J-H, & Park S-H (2021). Risk factors of postoperative complications following total knee arthroplasty in Korea: A nationwide retrospective cohort study. Medicine, 100(48), e28052. 10.1097/MD.0000000000028052 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Kremers HM, Larson D, Crowson C, Kremers W, Washington R, Steiner C, Jiranek W, & Berry D (2015). Prevalence of Total Hip and Knee Replacement in the United States. The Journal of Bone and Joint Surgery. American Volume. 10.2106/JBJS.N.01141 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Le Manach Y, Collins G, Bhandari M, Bessissow A, Boddaert J, Khiami F, Chaudhry H, De Beer J, Riou B, Landais P, Winemaker M, Boudemaghe T, & Devereaux PJ (2015). Outcomes After Hip Fracture Surgery Compared With Elective Total Hip Replacement. JAMA, 314(11), 1159–1166. 10.1001/jama.2015.10842 [DOI] [PubMed] [Google Scholar]
  23. Manuel SP, Nguyen K, Karliner LS, Ward DT, & Fernandez A (2022). Association of English Language Proficiency With Hospitalization Cost, Length of Stay, Disposition Location, and Readmission Following Total Joint Arthroplasty. JAMA Network Open, 5(3), e221842. 10.1001/jamanetworkopen.2022.1842 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Ngai KM, Grudzen CR, Lee R, Tong VY, Richardson LD, & Fernandez A (2016). The Association between Limited English Proficiency and Unplanned Emergency Department Revisit within 72 hours. Annals of Emergency Medicine, 68(2), 213–221. 10.1016/j.annemergmed.2016.02.042 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Pierce TP, Elmallah RK, Lavernia CJ, Chen AF, Harwin SF, Thomas CM, & Mont MA (2015). Racial Disparities in Lower Extremity Arthroplasty Outcomes and Use. Orthopedics, 38(12), e1139–e1146. 10.3928/01477447-20151123-05 [DOI] [PubMed] [Google Scholar]
  26. Plancarte CA, Hametz P, & Southern WN (2021). Association Between English Proficiency and Timing of Analgesia Administration After Surgery. Hospital Pediatrics, 11(11), 1199–1204. 10.1542/hpeds.2020-005766 [DOI] [PubMed] [Google Scholar]
  27. Singh JA, Lu X, Rosenthal GE, Ibrahim S, & Cram P (2014). Racial Disparities in Knee and Hip Total Joint Arthroplasty: An 18-year Analysis of National Medicare Data. Annals of the Rheumatic Diseases, 73(12), 2107–2115. 10.1136/annrheumdis-2013-203494 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Sloan M, Premkumar A, & Sheth NP (2018). Projected Volume of Primary Total Joint Arthroplasty in the U.S., 2014 to 2030. JBJS, 100(17), 1455–1460. 10.2106/JBJS.17.01617 [DOI] [PubMed] [Google Scholar]
  29. Tang EW, Go J, Kwok A, Leung B, Lauck S, Wong ST, Taipale PG, & Ratner PA (2016). The relationship between language proficiency and surgical length of stay following cardiac bypass surgery. European Journal of Cardiovascular Nursing, 15(6), 438–446. 10.1177/1474515115596645 [DOI] [PubMed] [Google Scholar]
  30. Witt EE, Eruchalu CN, Dey T, Bates DW, Goodwin CR, & Ortega G (2021). The role of patient primary language in access to brain tumor resection: Evaluating emergent admission and hospital volume. Journal of Cancer Policy, 30, 100306. 10.1016/j.jcpo.2021.100306 [DOI] [PubMed] [Google Scholar]

RESOURCES