Failure to Optimize Before Total Knee Arthroplasty: Which Modifiable Risk Factor is the Most Dangerous?

Area of Science:

• Orthopedic Surgery
• Patient Safety
• Surgical Outcomes

Background:

• Complications following total knee arthroplasty (TKA) significantly impact patient outcomes.
• Surgeons face accountability in value-based care models for TKA complications.
• Optimizing modifiable risk factors preoperatively is crucial for improving TKA success rates.

Purpose of the Study:

• To assess the impact of failing to optimize key modifiable risk factors in patients undergoing TKA.
• To identify specific risk factors that most significantly influence postoperative outcomes after TKA.
• To provide evidence supporting enhanced preoperative optimization protocols for TKA patients.

Main Methods:

• Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program database (2017-2018).
• Patients undergoing TKA were categorized as optimized or non-optimized based on body mass index (<40kg/m²), albumin (>3.5g/dL), smoking status, and diabetes status.
• Analysis of 30-day readmission, infection, general complications, and mortality rates between the groups.

Main Results:

• Out of 84,315 TKA patients, 31.6% were not optimized. Non-optimized patients had significantly higher rates of readmission (5% vs 3%), infection (2% vs 1%), general complications (8% vs 5%), and mortality (0.35% vs 0.1%).
• Factors including high BMI (>40kg/m²), low albumin (<3.5g/dL), smoking, and insulin-dependent diabetes were all linked to increased postoperative complications.
• Hypoalbuminemia (<3.5g/dL) was identified as a particularly strong predictor, with 3.7-fold higher odds of infection and 7.2-fold higher odds of 30-day mortality.

Conclusions:

• Despite established knowledge, surgeons continue to operate on non-optimized patients undergoing TKA.
• Hypoalbuminemia emerged as the most potent modifiable risk factor impacting all evaluated postoperative complications.
• Preoperative nutritional optimization, particularly addressing albumin levels, requires heightened clinical attention to improve TKA outcomes.