The Cumulative Effect of Substance Abuse Disorders and Depression on Postoperative Complications After Primary Total Knee Arthroplasty

Abstract

Background: Substance abuse disorder (SUD), alcohol abuse disorder (AUD), and depression have been identified as independent risk factors for complications after total knee arthroplasty (TKA). However, these mental health disorders are highly co-associated, and their cumulative effect on postoperative complications have not been investigated. Therefore, this study aimed to determine if patients who have more than one mental health disorder (SUD, AUD, or depression) were at an increased risk for postoperative complications following TKA. Methods: A total of 11,403 TKA patients were identified from a prospectively collected institutional database between January 1, 2017 and April 1, 2019. Patients who had depression, SUD, and AUD were separated into 7 mental health subgroups including each of these diagnoses alone and their combined permeations. Patient demographics, body mass indices, medical comorbidities, and 15 postoperative complications were collected. Univariate analyses were performed using independent Student's t-tests. Multivariate analyses were then performed to identify odds ratios (ORs) for mental health disorders subgroups associated with complications. Results: We found a total of 2073 (18%) patients diagnosed with either SUD (4%), AUD (0.6%), or depression (12%). Univariate analyses showed that depression was associated with mechanical failures (P < .001). SUD was associated with periprosthetic joint infection (PJI) (P < .001), wound complications (P ¼ .022), and aseptic loosening (P ¼ .007). AUD was associated with PJI (P < .001) and deep vein thromboses (P ¼ .003). Multivariate analyses found that AUD (OR: 19.419, P < .001) and SUD (OR:3.693, P ¼.010) were independent risk factors for PJI. Compared with SUD alone, patients with depression plus SUD were found to have a 4fold (OR: 13.639, P < .001) and 2-fold (OR:4.401, P ¼ .021) increased risk for PJI and cellulitis, respectively. Conclusions: Patients who had depression, SUD, or AUD were at increased risk for postoperative complications following primary TKA. When patients have more than one mental health diagnosis, their risk for complications was amplified. The results of this study can help identify those patients who are at greater risk of postoperative complications to enable improved preoperative optimization and patient education.

The Association of Alcohol Use Disorder with Perioperative Complications following Primary Total Hip Arthroplasty

“…DSM-V ( The Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition ) defines alcohol use disorder as a constellation of symptoms consisting of dependence and abuse, with the addition of cravings, leading to psycho-social and interpersonal functioning 6) . The negative association of alcohol use disorder following primary total hip arthroplasty (THA) has been demonstrated in previous studies 7 8 9 10 11) .…”

“…Patients with a diagnosis of alcohol use disorder were identified using the codes comprising alcohol abuse (ICD-9: 305.01 and 305.02) and alcohol dependence (ICD-9: 303.91 and 303.92). These codes were chosen for use in the alcohol use disorder cohort as because they have been used in previously published studies 7 20) . In addition, when combined accurately these codes represent alcohol use disorder per the DSM-56).…”

“…Gold et al 7) demonstrated that alcohol use disorder is a significant risk factor for development of peri-prosthetic joint infections (PJIs) and deep vein thromboses following primary total knee arthroplasty. Lavernia and Villa 9) demonstrated that patients with alcohol use disorder had a negative impact on patient reported outcome measurements compared to moderate drinkers or non-drinkers following primary THA.…”

“…However, limitations to the aforementioned study and other studies include coalescence of other psychiatric comorbidities into the study cohort causing difficulty in understanding the relationship of alcohol use disorder following primary THA. Another limitation is that there was no adjusting for additional covariates, which could potentially overestimate the results of analysis of the dependent variables, or that the results are not generalizable to the orthopaedic community 7 9 12) . Thus, with the growing incidence and prevalence of alcohol use disorder with a concomitant exponential increase in the frequency of performance of primary THA procedures worldwide, conduct of studies evaluating the disorder following primary THA is warranted 2 4 13) .…”

Greater Prevalence of Mental Health Conditions in Septic Revision Total Knee Arthroplasty: A Call to Action

“…[17][18][19][20][21][22] Similarly, the risk of surgical complications such as periprosthetic joint infection (PJI), fracture, revision, and extensor mechanism rupture increases as well. 12,23,24 Specifically, the risk of PJI increases 217% at the 90 day postoperative mark when a mental health International Classification of Disease 9th edition (ICD-9) diagnosis code was found in the patients chart. 12 Additionally, opioid use increases the risk of PJI in total joint arthroplasty patients as well as depression and anxiety in chronic pain patients.…”