Preoperative Optimization in Total Joint Arthroplasty. Infection risk and health effect. Cooperation of hospital and primary health care.

Abstract

Lower extremity total joint arthroplasty (TJA) reduces pain and improves quality of life in individuals with end-stage osteoarthritis, with the majority of cases achieving long-lasting, favorable outcomes. However, infectious complications at the surgical site can be devastating and costly for both patients and society, requiring repeated surgeries and prolonged antibiotic treatment, and they are associated with increased morbidity and mortality. This has led to growing interest in preoperative optimization programs aimed at improving modifiable risk factors for infection, such as obesity, diabetes, anemia, malnutrition, smoking, and physical inactivity. These programs vary in design and scope, and most are retrospective. Little has been published about their efficacy. The aim of this project was to implement and evaluate a structured preoperative optimization pathway to reduce infectious and general complications after TJA and to assess its impact on patient health overall.

Methods This was a prospective case control study examining a multifactorial optimization process coordinated between hospital and primary health care. Patients in the control group were already on the TJA waiting list and had received conventional preoperative preparation. They were included one week before surgery. Patients in the intervention group were enrolled during a visit at the outpatient orthopedic clinic after referral from primary health care 6 –12 months before surgery. Initial assessment included blood tests and BMI recording, followed by a primary health care visit within three weeks for review and management. Patients with BMI ≥ 40 were referred to a clinical nutritionist, and those with vitamin D < 50 nmol/L were advised to take supplements. Malnutrition risk was also assessed. One week before surgery, both groups underwent blood tests and BMI measurements and completed a questionnaire regarding preoperative preparation. Both groups then received the same follow-up. Data collected included demographics, surgery details, comorbidities (ASA physical status classification), laboratory values, transfusions, hospital stay length, complications, and mortality. Superficial surgical site infections (SSIs), periprosthetic joint infections (PJIs), reoperations, new diagnoses, postoperative health events, and Emergency Room (ER) visits and hospital/Intensive Care Unit (ICU) admissions were recorded.

Results The control group consisted of 738 of 744 consenting patients included in the study one week before operation. Operations took place between August 2018 and September 2020. The intervention arm consisted of 746 of 1,010 consenting patients included at a median of 307 days before operation. Operations in this group took place between march 2019 and december 2022, with 259 exclusions in cases in which patients declined surgery when offered. Surgery took place during the COVID-19 pandemic in 5% of cases in the control group versus 77% in the intervention group. The initial results came from the control group as patients in this group underwent surgery earlier. These results revealed an association between obesity and dysglycemia/diabetes and superficial SSI, suggesting potential benefits of risk factor modification. The optimization process within the intervention group resulted in improvement in patient engagement and in metrics such as weight, anemia, HbA1c, and vitamin D. The baseline characteristics of the two groups one week before operation were similar except that the intervention group had substantially more comorbidities (ASA class 3-4, 32% versus 23%). Despite having more comorbidities, the intervention group presented lower rates of superficial SSI at 6 weeks post-op when adjusted for age, sex, and ASA class (OR 0.64, 95% CI 0.42–0.97). Overall surgical site complications were also lower (11.3% vs. 15.7%; difference 4.5%, 95% CI -8.0 to -1.0). At one year, superficial SSI was less common in the intervention group (5.9% vs. 7.9%, HR 0.67, 95% CI 0.45–1.01), though this finding was not statistically significant. In the control group, elevated BMI (≥ 30) and HbA1c (≥ 42 mmol/mol) were associated with superficial SSI, but this association was not observed in the intervention group. At three years, PJI was more common in the intervention group (2.0% versus 1.1%, HR 1.80, 95% CI 0.76–4.30), though the difference between groups was not significant. Most PJIs developed from superficial SSI (80% in the intervention group and 88% in the control group), with 95% of the superficial SSIs in the intervention group and 98% in the control group occurring within six weeks. Progression from superficial SSI to PJI was more common in the intervention group (27.3%) compared to the control group (12.1%). At three years, there was no significant difference between the groups regarding new health-related diagnosis and events nor mortality.

Conclusion A structured preoperative optimization pathway improved modifiable risk factors and reduced short-term superficial SSIs and surgical site complications. However, it did not significantly affect long-term rates of SSIs, PJIs, or overall health and mortality. External factors, such as the COVID-19 pandemic and transfer of TJA to other facilities, may have influenced results. These findings highlight the need for prospective studies on optimization programs and further evaluation of organizational and practice changes in patient care.