BOSTON – Hip and knee joint replacement surgeries are among the most commonly performed surgical procedures in the United States, with about 300,000 and 800,000 hip and knee surgeries performed each year, respectively. Known as total joint arthroplasty (TJA), joint replacement surgery is an effective and successful procedure to eliminate pain and improve quality of life for patients with disabling arthritis.
Though rare, post-operative complications leading to hospital readmission and surgical revision can be painful for patients and are costly for both patients and healthcare systems. A recent duo of studies led by clinician-researchers at New England Baptist Hospital (NEBH), part of Beth Israel Lahey Health, explored patient-related variables that could be used to predict and potentially modify adverse outcomes for patients undergoing total joint arthroplasty.
Researchers Find Total Joint Replacement May Outweigh the Risks for Patients Who Are Unhoused
In a recent issue of the Journal of the American Academy of Orthopedic Surgeons, NEBH physician-researchers evaluated outcomes of patients who underwent total hip or total knee arthroplasty while unhoused. One of the first to analyze outcomes for this population treated at an urban, academic, safety net hospital, the study found that – with careful pre-operative planning and post-operative support – the quality of life-enhancing benefits of total joint replacement can outweigh potential risks posed by the unique challenges of patients who are experiencing homelessness.
“Housing status is a key determinant of health and is linked with imbalanced access to care, including frequent use of acute care and lack of regular follow-up for chronic conditions, such as arthritis and joint pain,” said corresponding author Eric L. Smith, MD, FOAO, chief of arthroplasty at NEBH. “While total joint replacement has been shown to improve quality of life, surgeons often hesitate to perform elective surgeries on patients who are experiencing homelessness, but outcomes in this population remain poorly understood.”
Smith and colleagues retrospectively reviewed 442 patients who underwent unilateral knee or hip replacement surgery between June 2016 and August 2017, with a minimum follow-up period of two years. Of these 442 patients, 28 self-reported as being unhoused. The patients who were unhoused were markedly younger, tended to be male, and more often struggled with substance misuse, including tobacco, alcohol and illicit drugs.
The researchers found no significant difference between the two groups in getting to clinical follow-up visits, with 11 percent of unhoused patients missing visits compared to 12 percent of housed patients. However, patients who were unhoused were more than 15 times more likely to have an Emergency Department visit within 90 days of the procedure compared to housed patients.
Similarly, while the two groups also did not significantly differ in hospital readmission or revision surgery, prosthetic joint infections were more common among unhoused patients and were the primary reason for hospital readmission or revision surgery among this group.
“The findings of this study underscore that unhoused patients who undergo total joint arthroplasty still experience unique challenges compared with the general patient population,” said Smith. “We believe the best way to manage these challenges lies in a collaborative, support system. With careful preoperative optimization and collaborative support, the benefits of total joint arthroplasty may outweigh the risk of poor outcomes.”
Limited Health Literacy Is Linked to Worse Pre-Operative Status and Surgical Outcomes for Patients Undergoing Elective Shoulder Arthroplasty
In the Journal of Shoulder and Elbow Surgery, Andrew Jawa, MD, chief of the Division of Shoulder Arthroplasty at NEBH, and colleagues evaluated the effects of limited health literacy on perioperative outcomes in patients undergoing shoulder arthroplasty. The team found that patients with limited health literacy have worse function, worse pain control and experience prolonged hospital stays following shoulder surgery than people with higher levels of health literacy.
“Patients with limited health literacy may have difficulty understanding and acting upon medical information, placing them at risk for potential misuse of health services and adverse outcomes,” said Jawa, who is senior author of the paper. “Our study found that limited health literacy affects about a quarter of patients undergoing elective shoulder arthroplasty and, given its association with several adverse outcomes, it is an important factor to consider for postoperative planning.”
Jawa and colleagues retrospectively identified 230 patients who underwent one of two kinds of shoulder arthroplasty between January 2018 and May 2021 from a single surgeon registry. The health literacy of each patient was assessed using a validated screening tool that asked questions like, “How confident are you filling out medical forms by yourself?” and “How often do you have someone help you read hospital materials?”
Overall, 25 percent of patients were classified as having limited health literacy. Limited health literacy was linked to greater preoperative symptom severity, including higher rates of opioid use, more self-reported allergies and worse pain. Patients with limited health literacy also experienced significantly longer hospital stays, though they did not differ in terms of hospitalization costs.
“The burgeoning demand and costs associated with shoulder arthroplasty require concerted efforts to optimize resource allocation in the postoperative setting,” said Jawa. “Health literacy represents a domain which may provide an opportunity to achieve this goal while simultaneously addressing a barrier to equitable care.”
Smith’s co-authors included Ruijia Niu, MPH, and Christopher Fang, MD, of BIDMC; Cameron Egan, MD, of Massachusetts General Hospital; Nneoma Duru of Boston University School of Medicine; Maxwell C. Alley, MD, and David M. Freccero, MD, of Boston Medical Center.
None of the authors or any immediate family member has received anything of value from of has stock or stock options held in a commercial or institution related directly or indirectly to the subject of this article.
Jawa’s co-author’s included first author Richard Puzzitiello, MD, now at Tufts Medical Center; Eileen M. Colliton, MD, Michael A. Moverman, MD, and Jacob M. Kirsch, MD, of NEBH; Daniel Swanson, BS, Paul A. Hart, BS, and Edward Allen, BS of Boston Sports and Shoulder Center; Mariano E. Menendez, MD, of Rush University Medical Center.
No funding was disclosed by the authors. Andrew Jawa is a board/committee member of the American Academy of Orthopaedic Surgeons and the American Shoulder and Elbow Surgeons Society; he is a member of the editorial/governing board of the Journal of Shoulder and Elbow Surgery; he reports IP royalties, stock/stock options from Ignite Orthopaedics; and paid consultant, paid presenter/speaker fees, and research support from personal fees from DJO Global.
New England Baptist Hospital (NEBH) is the premier regional provider for orthopedic surgery and the treatment of musculoskeletal diseases and disorders. NEBH has been nationally recognized for high patient satisfaction and leadership in quality and clinical outcomes. NEBH is a teaching affiliate of Tufts University School of Medicine and conducts teaching programs in collaboration with Harvard Medical School. NEBH has been the official hospital of the Boston Celtics for over 30 years.
New England Baptist Hospital is part of Beth Israel Lahey Health, a new health care system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, more than 4,800 physicians and 36,000 employees in a shared mission to expand access to great care and advance the science and practice of medicine through groundbreaking research and education.