Chief Cushie ~MaryO~ Posted June 16, 2023 Chief Cushie Report Share Posted June 16, 2023 I'm glad I didn't know this before my recent knee surgery! Abstract Background Cushing’s syndrome (CS) is a disorder characterized by exposure to supraphysiologic levels of glucocorticoids. The purpose of this study was to evaluate the association between CS and postoperative complication rates following total joint arthroplasty (TJA). Methods Patients diagnosed with CS undergoing TJA for degenerative etiologies were identified from a large national database and matched 1:5 to a control cohort using propensity scoring. Propensity score matching resulted in 1,059 total hip arthroplasty (THA) patients with CS matched to 5,295 control THA patients and 1,561 total knee arthroplasty (TKA) patients with CS matched to 7,805 control TKA patients. Rates of medical complications occurring within 90 days of TJA and surgical-related complications occurring within 1 year of TJA were compared using odds ratios. Results The THA patients with CS had higher incidences of pulmonary embolism (Odds Ratio (OR) 2.21, P=0.0026), urinary tract infection (OR 1.29, P=0.0417), pneumonia (OR 1.58, P=0.0071), sepsis (OR 1.89, P=0.0134), periprosthetic joint infection (OR 1.45, P=0.0109), and all-cause revision surgery (OR 1.54, P=0.0036). The TKA patients with CS had significantly higher incidences of urinary tract infection (OR 1.34, P=0.0044), pneumonia (OR 1.62, P=0.0042), and dislocation (OR 2.43, P=0.0049) and a lower incidence of manipulation under anesthesia (MUA) (OR 0.63, P=0.0027). Conclusion Cushing’s syndrome is associated with early medical- and surgical-related complications following TJA and a reduced incidence of MUA following TKA. Introduction Cushing’s syndrome (CS) is characterized by exposure to supraphysiologic levels of glucocorticoids, whether endogenous or exogenous. Chronic exposure to hypercortisolism can lead to the development of comorbidities known to be risk factors for complications following total joint arthroplasty (TJA) including obesity, hypertension, diabetes, hyperlipidemia, and cerebrovascular disease.[1,2] Hypercortisolism is also a known risk factor for the development of osteonecrosis, and there have been several case reports of this disease being caused by endogenous production of corticosteroids.[3, 4, 5, 6, 7, 8] It can therefore be expected that the incidence of arthroplasty procedures among CS patients is likely higher than the general population. It is important to identify and understand patient specific risk factors for complications following TJA. There has been a major push recently to investigate the association between uncommon disorders and complication rates following TJA in order to risk stratify, counsel, and optimize these patients appropriately.[9, 10, 11, 12, 13, 14, 15] The typical clinical features of CS include increased central adiposity, purple striae, thin skin, fatigue, and proximal atrophy of the upper and lower limbs.[16,17] The most common etiology of endogenous CS is overproduction of adrenocorticotropic hormone (ACTH) from a pituitary adenoma, although ACTH-independent forms of CS may be caused by overproduction of glucocorticoids from the adrenal glands.[2] First-line laboratory tests for the diagnosis of CS include 24-hour urinary free cortisol, late night salivary cortisol, and the dexamethasone suppression test to determine if the negative feedback of the hypothalamic-pituitary-adrenal axis is functioning appropriately.[16] Hypercortisolism associated with CS is known to have a deleterious effect on bone health by decreasing osteoblast function and increasing bone resorption and has been associated with decreased bone mineral density at various sites in the femur including Ward’s triangle, the femoral neck, and the greater trochanter.[18] The effect of these changes in physiology on outcomes following TJA remains unclear. There are few prior case reports describing arthroplasty procedures for CS patients,[3, 4, 5] with one case report of total hip arthroplasty (THA) for femoral head osteonecrosis complicated by pulmonary thromboembolism requiring a 10-day admission to the ICU.[3] However, no large scale studies to date have investigated complication rates following TJA within this patient population. It is therefore important to better understand the risks associated with this pathology. The purpose of this study was to evaluate the association between CS and postoperative complication rates following TJA. We hypothesized that patients who have CS would have increased incidences of early medical- and surgical-related complications. Section snippets Methods This is a retrospective cohort study utilizing the commercially available M151Ortho database via PearlDiver (PearlDiver Inc., Colorado Springs, Colorado). This database contains deidentified records for 151 million patients in the United States in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Patient records were queried using International Classification of Diseases (ICD) codes and Current Procedural Terminology (CPT) codes. This study was deemed exempt from Results The THA patients who had CS had significantly higher 90-day incidences of PE (OR 2.21, P=0.0026), UTI (OR 1.29, P=0.0417), pneumonia (OR 1.58, P=0.0071), and sepsis (OR 1.89, P=0.0134) (Table 2). The TKA patients who had CS had significantly higher 90-day incidences of UTI (OR 1.34, P=0.0044) and pneumonia (OR 1.62, P=0.0042) (Table 3). Regarding surgical-related complications, CS patients undergoing THA had significantly higher incidences of PJI (OR 1.45, P=0.0109) and all-cause revision Discussion This study revealed that patients who have CS are at increased risk of developing early postoperative complications following TJA. Understanding this risk profile is important for accurate shared decision making between CS patients and their clinicians. Interestingly, CS seems to influence rates of instability and stiffness following TKA as patients in the test cohort were more likely to sustain a dislocation and less likely to undergo MUA. Rates of infectious medical complications including Conclusion Cushing’s syndrome is associated with an increased risk of early infectious complications following TJA including UTI, pneumonia, sepsis, and hip PJI and an increased incidence of dislocation following TKA. Interestingly, CS appears to be protective against arthrofibrosis as patients who have CS had lower incidences of MUA following TKA. Clinicians may be guided by this study to accurately risk stratify and counsel patients with CS prior to undergoing TJA. References (29) A. Lacroix et al. Cushing’s syndrome Lancet (2015) H.G. Moore Total Joint Arthroplasty in Patients With Achondroplasia: Comparison of 90-Day Adverse Events and 5-Year Implant Survival Arthroplast Today (2021) M.J. Gouzoulis et al. Hidradenitis Suppurativa Leads to Increased Risk of Wound-Related Complications following Total Joint Arthroplasty Arthroplast Today (2022) H.G. Moore Total Hip Arthroplasty in Patients With Cerebral Palsy: A Matched Comparison of 90-Day Adverse Events and 5-Year Implant Survival J. Arthroplasty (2021) M.W. Cole et al. The Impact of Celiac Disease on Complication Rates After Total Joint Arthroplasty: A Matched Cohort Study Arthroplast Today (2022) M.R. Mercier et al. Outcomes Following Total Hip Arthroplasty in Patients With Postpolio Syndrome: A Matched Cohort Analysis J. Arthroplasty (2022) M. Barbot et al. Cushing’s syndrome: Overview of clinical presentation, diagnostic tools and complications Best Pract. Res. Clin. Endocrinol. Metab (2020) E. Salt Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis Semin. Arthritis Rheum (2017) R. Gandhi Predictive risk factors for stiff knees in total knee arthroplasty J. Arthroplasty (2006) P.E. Scranton Management of knee pain and stiffness after total knee arthroplasty J. Arthroplasty (2001) From https://www.sciencedirect.com/science/article/abs/pii/S0883540323006484 1 Quote Link to comment Share on other sites More sharing options...
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