Abstract
Background
Controversy continues regarding the optimal timing of surgery for patients with symptomatic bilateral degenerative knee arthritis who are not considered eligible for same-day bilateral TKA (BTKA).
Questions/purposes
We compared (1) 30-day mortality; (2) rates of in-hospital complications; and (3) blood transfusion rates between patients undergoing same-admission staged BTKA and patients undergoing BTKA staged within 1 year in a highly specialized center where specific guidelines have been implemented for same-day BTKA patient selection.
Methods
We analyzed institutional data for 149 patients undergoing same-admission staged and 1557 patients undergoing staged BTKA diagnosed with bilateral knee idiopathic osteoarthritis from 1998 to 2011. Although patients in both groups presented with bilateral knee disease, same-admission staged patients had more medical comorbidities and did not qualify for same-day BTKA. Specifically, patients with coronary artery disease with inducible ischemia, congestive heart failure, advanced chronic obstructive pulmonary disease, uncontrolled diabetes, peripheral vascular disease, renal failure, morbid obesity, history of venous thromboembolism, or those who were older than 75 years were not considered eligible for same-day BTKA. Patient demographics and Deyo comorbidity index were tabulated. The groups were similar in age, but same-admission staged patients were more likely to be male and had a higher overall comorbidity burden. The complications were categorized into systemic (medical) and local (orthopaedic). Furthermore, the systemic complications were subcategorized into major (required complex surgical or medical intervention or were deemed life-threatening) and minor (necessitated additional observation or required medical treatment), depending on their severity. Regression models were conducted to examine the association between surgery type and development of complications.
Results
There was no difference in 30-day mortality between the groups (0% versus 0.06%; p = 0.754). There was no difference in the local complication rates (0.7% versus 0.8%; p = 1.000). However, multivariable regression analysis adjusting for age, sex, and Deyo comorbidity index showed that same-admission staged patients were three and two times more likely than staged to develop a minor (odds ratio [OR], 3.02; 95% confidence interval [CI], 1.25–3.25; p = 0.004) and major (OR, 2.02; 95% CI, 2.09–4.37; p < 0.001) complication, respectively. The same-admission group experienced more acute postoperative anemia (11% versus 3%; p < 0.001) and blood transfusions (93% versus 54%; p < 0.001).
Conclusions
These results suggest that patients who are not appropriate candidates for same-day BTKA as a result of increased overall comorbidity burden may be better served by undergoing staged BTKA within 1 year rather than same-admission staged because of the associated higher perioperative morbidity observed in the same-admission BTKA group.
Level of Evidence
Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Introduction
Many patients who present with symptomatic bilateral knee osteoarthritis elect to undergo bilateral TKA (BTKA) [24]. In 2007, approximately 7% of all TKAs performed in the United States were same-day bilateral (under a single anesthetic session) [10] and 15% staged BTKAs (two sequential unilateral TKAs performed within 1 year) [1]. It has been postulated that same-day BTKA results in greater pathophysiological insult than that from separate unilateral procedures [18, 25]. Although controversy still persists regarding the safety of same-day BTKA [12, 13, 17, 23, 27], large institutional series have shown that same-day BTKA can be performed safely without increased perioperative morbidity and mortality compared with staged BTKA if a selective preoperative screening process for same-day BTKA candidates is used [11, 13, 14, 19]. When a BTKA candidate is not considered eligible for same-day BTKA, treatment options include same-admission staged BTKA (managed as separate procedures during a single hospitalization) or staged BTKA during two separate hospitalizations, usually performed within 1 year [25, 26]. Same-admission staged BTKA has been used as a treatment option with the intent to reduce the perioperative complication rate compared with same-day BTKA. However, the few studies reporting on this approach have conflicting results, possibly as a result of differences in study design and patient selection process [5, 6, 15, 28].
The purpose of this study was to compare the (1) 30-day mortality; (2) rates of in-hospital complications; and (3) blood transfusion rates between patients undergoing same-admission staged BTKA and patients undergoing BTKA staged within 1 year in a highly specialized center for total joint arthroplasty where specific guidelines have been implemented for same-day BTKA patient selection.
Materials and Methods
Data Collection
We performed a review of a large computerized patient database based on hospital discharge data to identify admissions with an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code for primary TKA (81.54) from 1998 through 2011. This study included patients with idiopathic osteoarthritis who underwent staged BTKA within 1 year. Patients who had both TKAs during a single hospital admission were classified as having same-admission staged BTKA, whereas patients undergoing two TKAs during separate hospitalizations within 1 year were classified as having staged BTKA. This study was approved by our institutional review board.
Administrative data collected for this study consisted of ICD-9-CM [7] diagnosis and procedure codes, patient characteristics, and hospital length of stay. Patient characteristics included age, sex, and race (white, black, Hispanic, other, and unknown). Patient comorbidity burden was evaluated using the Deyo modification of the Charlson Comorbidity Score for administrative diagnoses codes [4]. Additional comorbidity indicators were created for hypertension, diabetes mellitus, obesity, hypercholesterolemia, pulmonary disease, renal disease, coronary artery disease (CAD), congestive heart failure (CHF), sleep apnea, pulmonary hypertension, liver disease, and coagulopathy (Appendix 1) [7].
Outcomes of interest identified using ICD-9-CM diagnosis and procedure codes [7] included in-hospital complications, classified as local, minor or major, and blood transfusions. Local (orthopaedic) complications included peripheral nerve and vascular injuries, hemorrhage, hematoma, or seroma complicating the procedure, accidental puncture or laceration during the procedure, and disruption and nonhealing of the surgical wound; they were identified using codes for complications of surgical and medical care (956.XX, 997.XX-998.XX). The list of specific local complications and ICD-9-CM codes are provided (Appendix 1).
An additional 19 acute systemic complications were identified using ICD-9-CM codes [7] (Appendix 1) and classified as minor or major. Minor complications included those that necessitated additional observation or required medical treatment: (1) hypotension; (2) syncope and collapse; (3) tachycardia; (4) delirium; (5) urinary tract infection; (6) urinary retention; (7) superficial incisional surgical site infections and cellulitis; (8) paralytic ileus; and (9) pleural effusion. Complications were considered major if they required complex surgical or medical intervention or if they were deemed life-threatening or resulted in functional impairment; they included (1) central nervous system infarction (ischemic stroke); (2) pulmonary compromise; (3) sepsis; (4) shock/cardiorespiratory arrest; (5) acute myocardial infarction (MI); (6) major cardiac (except MI); (7) pneumonia; (8) pulmonary embolism (PE); (9) deep vein thrombosis; and (10) deep periprosthetic infection.
Thirty-day mortality was determined by submitting protected information for the study subjects to the Social Security Death Index (SSDI) to obtain patient survivorship information through September 2012. Patient medical records were reviewed to verify infections identified by ICD-9-CM coding and determine 30-day mortality for patients not matched to the SSDI.
Study Population
Between January 1998 and December 2011, there were 1706 patients with idiopathic osteoarthritis who underwent bilateral TKA: 149 patients undergoing same-admission staged BTKA and 1557 patients undergoing staged BTKA with a mean interval between procedures of 6.5 days (range, 1–14 days) and 205.5 days (range, 6–365 days), respectively. The selection process for same-day or staged BTKA was based on the comorbidity profile of the candidates and surgeon’s decision. Patients with substantial cardiopulmonary or other serious comorbidities generally underwent staged procedures after receiving medical clearance from an internist. Specifically, CAD with inducible ischemia, CHF, advanced chronic obstructive pulmonary disease, uncontrolled diabetes, peripheral vascular disease, renal failure, morbid obesity, history of venous thromboembolism, and age > 75 years were considered contraindications for same-day BTKA. If the preoperative workup concluded that the patient was not deemed an appropriate candidate for same-day BTKA but presented with major bilateral knee deformities requiring simultaneous correction—for accelerated postoperative rehabilitation—the same-admission staged approach was recommended to the patient. If the patient had recovered without any systemic or local complications and was medically stable postoperatively after the first knee, the second knee was replaced during the same hospitalization, typically 5 to 7 days later. If the patient declined to proceed with same-admission staged BTKA or experienced a major complication postoperatively after the first knee, the patient underwent TKA on the contralateral side at a later date within 1 year from the index procedure [13, 29].
Same-admission staged patients were the same age as separate-admission staged patients (71 [range, 39–87] versus 70 [range, 25–92] years; p = 0.078) but were more likely to be male (52% versus 34%; p < 0.001), obese (38% versus 30%; p = 0.032), and had a higher overall comorbidity burden (1 [range, 0–7] versus 0 [range, 0–9]; p = 0.002). They were more likely to have pulmonary disease (18% versus 12%; p = 0.054) and CAD (30% versus 19%; p = 0.002) (Table 1).
Table 1.
Demographics and comorbidity profile of the bilateral TKA cohorts
| Variable | Same-admission staged (n = 149) | Staged (n = 1557) | p value |
|---|---|---|---|
| Age (years), median (range) | 71.3 (38.5–86.6) | 69.7 (25.2–91.5) | 0.078 |
| Race, number (%) | |||
| White | 127 (85.2) | 1252 (80.4) | |
| Black | 11 (7.4) | 123 (7.9) | |
| Hispanic | 3 (2.0) | 70 (4.5) | 0.495 |
| Other | 8 (5.4) | 111(7.1) | |
| Unknown | 0 (0) | 1 (0.1) | |
| Female sex, number (%) | 72 (48.3) | 1023 (65.7) | < 0.001 |
| Charlson-Deyo Index, median (range) | 1 (0–7) | 0 (0–9) | 0.002 |
| Comorbidities, number (%) | |||
| Hypertension | 93 (62.4) | 1035 (66.5) | 0.320 |
| Diabetes | 29 (19.5) | 238 (15.3) | 0.193 |
| Hypercholesteremia | 64 (42.9) | 669 (43) | 1.000 |
| Obesity | 57 (38.3) | 461 (29.6) | 0.032 |
| Pulmonary disease | 27 (18.1) | 193 (12.4) | 0.054 |
| Renal disease | 5 (3.4) | 33 (2.1) | 0.374 |
| Coronary artery disease | 44 (29.5) | 293 (18.8) | 0.002 |
| Congestive heart failure | 7 (4.7) | 32 (2.1) | 0.075 |
| Sleep apnea | 6 (4.0) | 49 (3.1) | 0.473 |
| Pulmonary hypertension | 5 (3.4) | 40 (2.6) | 0.588 |
| Liver disease | 0 (0.0) | 0 (0.0) | N/A |
| Coagulopathy | 0 (0) | 6 (0.4) | 1.000 |
N/A = not applicable.
Statistical Analysis
Descriptive statistics were calculated to examine patient characteristics and outcomes of interest by procedure type. Medians and ranges are reported for continuous variables, whereas categorical variables are summarized with frequencies and percentages. Between-group comparisons were performed using the Wilcoxon rank-sum test for continuous variables and the chi-square test or Fisher’s exact test for categorical variables. Based on the results of the univariate analyses, multivariable logistic regression modeling, adjusting for patient characteristics, were developed to examine the association between surgery type and development of (1) any minor complication; and (2) any major complication. Statistical significance was set at p < 0.05. All analyses were performed using SAS software Version 9.3 (SAS Institute, Inc, Cary, NC, USA).
Results
There was no difference in 30-day mortality rate between the same-admission staged and staged BTKA patients (zero of 149 [0%] versus one of 1557 [0.06%]; p = 0.754).
There was no difference in the percentage of any local complication (one of 149 [0.7%] versus 12 of 1557 [0.8%]; p = 1.000) among the groups (Table 2). However, there was a difference in the percentage of any minor (Table 3) or major (Table 4) complication between the BTKA groups. Multivariable regression analysis adjusting for age, sex, and Deyo comorbidity index showed that same-admission staged patients were three and two times more likely than staged to develop a minor (odds ratio [OR], 3.02; 95% confidence interval [CI], 1.25–3.25; p = 0.004) (Table 5) and major (OR, 2.02; 95% CI, 2.09–4.37; p < 0.001) (Table 6) complication, respectively.
Table 2.
Local complication rates in the bilateral TKA groups
| Variable | Same-admission staged (n = 149) | Staged (n = 1557) | p value | ||
|---|---|---|---|---|---|
| Number | Percent | Number | Percent | ||
| Any local complication | 1 | 0.7 | 12 | 0.8 | 1.000 |
| Peripheral nerve injuries | 0 | 0 | 0 | 0 | N/A |
| Peripheral vascular complications | 1 | 0.7 | 3 | 0.9 | 0.306 |
| Hemorrhage complicating a procedure | 0 | 0 | 0 | 0 | N/A |
| Hematoma complicating a procedure | 0 | 0 | 4 | 0.26 | 1.000 |
| Seroma complicating a procedure | 0 | 0 | 1 | 0.1 | 1.000 |
| Accidental puncture or laceration during a procedure | 0 | 0 | 3 | 0.2 | 1.000 |
| Disruption of operative wound | 0 | 0 | 0 | 0 | N/A |
| Disruption of internal operation wound | 0 | 0 | 0 | 0 | N/A |
| Disruption of external operation wound | 0 | 0 | 2 | 0.1 | 1.000 |
| Nonhealing surgical wound | 0 | 0 | 1 | 0.1 | 1.000 |
N/A = not applicable.
Table 3.
Minor complication rates in bilateral TKA groups
| Variable | Same-admission staged (n = 149) | Staged (n = 1557) | p value | ||
|---|---|---|---|---|---|
| Number | Percent | Number | Percent | ||
| Any minor complication | 53 | 35.6 | 243 | 15.6 | < 0.001 |
| Hypotension | 10 | 6.7 | 26 | 1.7 | 0.001 |
| Syncope and collapse | 9 | 6.0 | 27 | 1.7 | 0.003 |
| Tachycardia | 4 | 2.7 | 57 | 3.7 | 0.816 |
| Delirium | 1 | 0.7 | 19 | 1.2 | 1.000 |
| Urinary tract infection | 19 | 12.8 | 77 | 5.0 | 0.001 |
| Urinary retention | 2 | 1.3 | 11 | 0.7 | 0.316 |
| Superficial incisional surgical site infection and cellulitis* | 6 | 4.0 | 21 | 1.4 | 0.002 |
| Paralytic ileus | 15 | 10.1 | 48 | 3.1 | < 0.001 |
| Pleural effusion | 2 | 1.3 | 6 | 0.4 | 0.206 |
* In-hospital infections are included only.
Table 4.
Major complication rates in the bilateral TKA groups
| Variables | Same-admission staged (n = 149) | Staged (n = 1557) | p value | ||
|---|---|---|---|---|---|
| Number | Percent | Number | Percent | ||
| Any major complication | 24 | 16.1 | 140 | 9.0 | 0.008 |
| Central nervous system (infarction complication) | 0 | 0 | 0 | 0 | N/A |
| Pulmonary compromise | 9 | 6.0 | 55 | 3.5 | 0.170 |
| Sepsis | 0 | 0 | 2 | 0.1 | 1.000 |
| Shock/cardiorespiratory arrest | 0 | 0 | 1 | 0.1 | 1.000 |
| Acute myocardial infarction | 1 | 0.7 | 2 | 0.1 | 0.240 |
| Cardiac complications* | 3 | 2.0 | 18 | 1.7 | 0.421 |
| Pneumonia | 0 | 0 | 4 | 0.3 | 1.000 |
| Pulmonary embolism | 4 | 2.7 | 9 | 0.6 | 0.021 |
| Deep vein thrombosis | 11 | 7.4 | 59 | 3.8 | 0.048 |
| Deep periprosthetic infection | 0 | 0 | 0 | 0 | N/A |
* Except acute myocardial infarction; N/A = not applicable.
Table 5.
Odds ratios from the multivariable logistic regression model examining risk of minor complication
| Variable | OR | Lower CL | Upper CL | p value |
|---|---|---|---|---|
| Age | 1.01 | 0.99 | 1.03 | 0.058 |
| Female versus male | 1.29 | 0.98 | 1.69 | 0.073 |
| Charlson-Deyo comorbidity score | 1.13 | 1.02 | 1.26 | 0.022 |
| Same-admission staged versus staged | 3.02 | 2.09 | 4.37 | < 0.001 |
OR = odds ratio; CL = confidence level.
Table 6.
Odds ratios from the multivariable logistic regression model examining risk of major complication
| Variable | OR | Lower CL | Upper CL | p value |
|---|---|---|---|---|
| Age | 1.01 | 0.99 | 1.03 | 0.426 |
| Female versus male | 1.43 | 1 | 2.04 | 0.05 |
| Charlson-Deyo comorbidity score | 1.10 | 0.96 | 1.25 | 0.187 |
| Same-admission staged versus staged | 2.02 | 1.25 | 3.25 | 0.004 |
OR = odds ratio; CL = confidence level.
Patients undergoing staged BTKA were associated with a lower incidence of acute posthemorrhagic anemia (16 of 149 [10.7%] versus 42 of 1557 [2.7%]; p < 0.001), blood transfusion (835 of 1557 [54%] versus 139 of 149 [93%]; p < 0.001), and allogeneic blood transfusion (250 of 1557 [16%] versus 96 of 149 [64%]; p < 0.001) compared with the same-admission staged patients (Table 7).
Table 7.
Procedure time, blood transfusion rates, length of stay, discharge disposition, and need for mechanical ventilation for both bilateral TKA cohorts (analysis per patient)
| Variable | Same-admission staged (n = 149) | Staged (n = 1557) | p value |
|---|---|---|---|
| Procedure time (minutes), median (range)* | 262.5 (188–371) | 260 (163–670) | 0.295 |
| Acute posthemorrhagic anemia, number (%) | 16 (10.7) | 42 (2.7) | < 0.001 |
| Blood transfusion, number (%) | 139 (93.3) | 835 (53.6) | < 0.001 |
| Allogeneic blood transfusion, number (%) | 96 (64.4) | 250 (16.1) | < 0.001 |
| Length of stay (days), median (range) | 11 (4–29) | 9 (2–35) | < 0.001 |
| Discharge disposition | |||
| Rehabilitation center, number (%) | 126 (84.6) | 714 (45.9) | |
| Higher level of care (intensive care unit), number (%) | 1 (0.7) | 19 (1.2) | < 0.001 |
| Other (eg, home), number (%) | 22 (14.8) | 824 (52.9) | |
| Mechanical ventilation, number (%) | 2 (1.3) | 10 (0.6) | 0.897 |
* Procedure time was recorded in 82 of 149 same-admission staged and 1071 of 1557 staged bilateral TKA cases.
Discussion
It is common practice to perform bilateral procedures separately with an interval of several weeks to months. Despite higher blood loss, risk for cardiopulmonary complications, and overall higher physiologic insult compared with staged procedures, recent studies have suggested that same-day BTKA can be performed safely in appropriately selected patients with perioperative complication rates no higher, or even lower, than staged bilateral procedures [11, 13, 14, 19, 26]. Same-day BTKA (either simultaneously or sequentially) is considered when severe bilateral knee deformity and symptomatology, certain patient expectations, or socioeconomic pressures are present [6, 8, 20, 25]. In such situations, and when the patient is not considered medically eligible for same-day BTKA, same-admission staged BTKA, although representing a compromise, may be considered as a treatment option. However, few studies have approached this controversial approach [5, 6, 15, 28]. Thus, we compared 30-day mortality, in-hospital complications rates, and blood transfusion rates between same-admission staged and staged-within 1 year BTKA at a high-volume institution where specific guidelines have been implemented encouraging same-day BTKA in younger and healthier patients.
Our study has several important limitations. First, selection bias is an important issue. Some patients may have refused to undergo same-admission staged BTKA for medical reasons because the perioperative complication risk may have been considered too high. In addition, the selection process for same-day and consequently for both staged BTKA groups may have been altered over the study period because of socioeconomic, patient-related factors and change in patients’ expectations and demands. Therefore, any change in the decision-making process may have affected the perioperative outcomes for both staged groups. However, in our cohort, same-admission staged patients were similar in age and diagnosis but were associated with higher overall comorbidity burden predisposing them potentially to higher risk for perioperative adverse events compared with the staged group. To address this dissimilarity at baseline, we performed a multivariate regression analysis adjusting for age, sex, and Deyo comorbidity index and found that same-admission staged patients were three and two times more likely to develop a minor and major complication, respectively, underlining the significant effect of surgery type on perioperative outcomes. Second, another limiting factor is the bias associated with the retrospective nature of our study. Specifically, the study timeframe is very long; many elements of care have changed, and there is no way to know with certainty whether these changes would have affected the study groups. Furthermore, length of stay and discharge to a rehabilitation center have decreased over the study period, and those trends would influence the groups dissimilarly. Nevertheless, some key aspects in the perioperative care, including anesthetic technique, surveillance, and pain management, have not changed over time and, therefore, our study may provide valid information on outcomes associated with the management of patients undergoing BTKA. The present analysis presents a single institution’s experience, from 1998 to 2011, encompassing 1710 patients and 3420 TKAs and no patients were lost to 30-day followup. This large series may provide a more accurate estimate of low-incidence outcomes surrounding BTKA than various prospective studies that are limited in sample size. Third, we used ICD-9 coding and SSDI to identify comorbidities, complications, and provide complete 30-day followup. It is possible that coding errors may have occurred. Nevertheless, ICD-9-CM coding has been widely used in multiple studies lately and has been accepted as a valid method to identify and analyze perioperative events [2, 3, 30]. Finally, same-admission BTKAs were not performed in the same proportions over time. This may reflect the change in the decision-making process across the study period, and more specifically the decrease in trend may imply the associated higher perioperative morbidity.
We found no difference in mortality between same-admission staged BTKA and mortality among patients whose BTKAs were staged several months apart. Our results are consistent with the findings of published studies comparing perioperative mortality between same-admission staged and staged BTKAs [5, 6, 28].
In our cohort, the local complication rate was similar among the groups. However, same-admission staged patients were more likely to develop any minor or major complication compared with staged patients. Sliva et al. [28] reported, in a series of 332 consecutive patients undergoing BTKA, that the odds of a patient developing a minor complication was 2.64 times greater in the staged than in the same-admission staged 4 to 7 days apart group. A possible explanation for this difference may be that in our study, the same-admission group was associated with higher overall comorbidity burden compared with the staged group in contrast to the study of Sliva et al. [28] in which patients in both staged groups were matched for age and comorbidity. However, we performed a multivariate regression analysis adjusting for age, sex, and Deyo comorbidity index and found that same-admission staged patients were three and two times more likely to develop a minor and major complication, respectively, underlining the significant effect of surgery type on perioperative outcomes in our cohort. Specifically, the higher incidence of cardiac (hypotension, syncope, and collapse) and thromboembolic (PE and deep vein thrombosis) events in the same-admission staged group compared with the staged group may be justified by the greater prevalence of male sex, CAD, and pulmonary disease, all of which have been found to be independent risk factors for perioperative morbidity and mortality after unilateral or BTKA [9, 14, 16, 19]. The extended hospital stay may explain the higher in-hospital infection rate in the same-admission staged cohort, because large institutional series have shown that longer hospitalization is a significant predictor for prosthetic joint infection [21, 22]. Same-admission staged BTKA was performed with a mean interval between procedures of 6.5 days in our study in comparison to the study of Sliva et al. [28] in which the average interval was 4.5 days. When further examining the effect of time interval between BTKAs performed during the same hospitalization, Wu et al. [31] reported a similar incidence of major (acute MI, PE, etc) and minor complications (transient hypotension or low SpO2) throughout hospitalization when procedures were performed 2 (n = 46) or 7 days (n = 33) apart. In addition, no significant difference in the occurrence of the investigated complications was found between the first and second operations in both groups. However, authors pointed out that the lack of power secondary to their small sample size of 79 patients was a major limitation.
The frequency of acute posthemorrhagic anemia and blood transfusion was higher in the same-admission staged BTKA group. Our results are in line with the findings of Sliva et al. [28] who reported that 54% of the patients undergoing same-day sequential BTKA, 58% of the patients undergoing staggered BTKA performed 4 to 7 days apart (average, 4.5 days) during a single hospitalization, and 17% of the staged spaced an average of 70.5 weeks apart (range, 1.6–270.9 weeks) required allogeneic or autologous blood transfusion, respectively [28]. The increased need for blood transfusion in the patients undergoing same-admission staged BTKA compared with patients undergoing simultaneous BTKA has been supported as well by a nationally representative data analysis of 43,350 patients undergoing BTKA from 1998 to 2006 [15].
In summary, despite the theoretical advantage of less physiological insult and potential for assessing the patient’s response to the first operation before proceeding with the second side, patients undergoing same-admission staged BTKA were associated with increased perioperative morbidity compared with staged within 1 year BTKA. Our results suggest that for patients who are not appropriate candidates for same-day BTKA based on a selective preoperative screening process in a high-volume subspecialty setting, it is preferable to undergo the procedure as a staged intervention over 1 year and avoid same-admission staged BTKA because of a higher frequency of perioperative adverse events. Same-admission staged BTKA should be performed with caution when the orthopaedic need for simultaneous correction of deformity prevails over the medical safety. However, because of the baseline dissimilarity in comorbidity profile between the groups, our study may offer pilot data for larger, multicenter prospective studies that control for this key issue.
Acknowledgments
We thank Andres Gleich MBA, Christopher Ferrandina BA, and David Staum BA, for their contribution in the data management.
Appendix 1
ICD-9-CM diagnosis codes used in the study
| Variables | ICD-9 codes |
|---|---|
| Mechanical ventilation | 93.90, 96.70, 96.71 |
| Blood transfusion | 99.02, 99.03, 99.04, 99.05, 99.06, 99.07, 99.09 |
| Acute posthemorrhagic anemia | 285.1 |
| Osteoarthritis | 715.16 |
| Inflammatory arthritis | 099.3, 136.1, 446.0, 446.4, 446.5, 446.7, 44.76, 696.0, 701.0, 710.0, 710.1, 710.2, 710.3, 710.4, 710.8, 710.9, 711.1X*, 713.1, 713.3, 714.0, 714.2, 714.3, 714.9, 720.0X, 725 |
| Comorbidities | |
| Hypertension | 401.9, 402.90, 403.9X |
| Diabetes | 250.X |
| Hypercholesteremia | 272.0 |
| Obesity | 278.0X |
| Pulmonary disease | 490, 491.X, 492.X, 493.X, 494.0, 496 |
| Renal disease | 403.9X, 585.9 |
| Coronary artery disease | 416.0, 416.8 |
| Congestive heart failure | 428.0, 428.31 |
| Sleep apnea | 780.57 |
| Pulmonary hypertension | 416.0, 416.8 |
| Liver disease | 571.0, 573.0, 576.8 |
| Coagulopathy | 286.X |
| Local complications | |
| Injury to peripheral nerve(s) of pelvic girdle and lower limb | 956.X |
| Peripheral vascular complications | 997.2 |
| Hemorrhage complicating a procedure | 998.11 |
| Hematoma complicating a procedure | 998.12 |
| Seroma complicating a procedure | 998.13 |
| Accidental puncture or laceration during a procedure | 998.2 |
| Disruption of operative wound | 998.3 |
| Disruption of internal operation wound | 998.31 |
| Disruption of external operation wound | 998.32 |
| Nonhealing surgical wound | 998.83 |
| Minor complications | |
| Hypotension | 458.2, 458.29, 458.9 |
| Syncope and collapse | 780.2 |
| Tachycardia | 785.0 |
| Delirium | 292.81, 293.0, 293.1 |
| Urinary tract infection | 599.0 |
| Urinary retention | 788.2X |
| Postoperative infection and cellulitis | 998.5X, 999.3X, 682.6 |
| Paralytic ileus | 560.1 |
| Pleural effusion | 511.9 |
| Major complications | |
| Central nervous system infarction | 997.01, 997.02 |
| Pulmonary compromise | 518.X, 997.3X |
| Sepsis | 038.X, 785.52, 785.59, 790.7, 995.91, 995.92, 998.0 |
| Shock/cardiorespiratory arrest | 427.5, 799.1 |
| Acute myocardial infarction | 410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91 |
| Cardiac complications | 997.1X |
| Pneumonia | 480.X, 481, 482.X, 483.X, 485, 486, 487.0, 507.0 |
| Pulmonary embolism | 415.11, 415.12, 415.19 |
| Embolism/thrombosis—deep vein thrombosis | 453.8, 453.41, 453.42 |
* An X indicates that the variable includes all codes starting with the numbers preceding the X.; ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification.
Footnotes
Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
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