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U.S. Minority Groups Have Worse Outcomes Than White Patients After Revision Total Hip and Knee Joint Arthroplasty

Key findings

  • This retrospective study of 4,424 adults evaluated the utilization of revision total hip or total knee arthroplasty (TJA) by minority racial/ethnic groups in the U.S. and the potential effect of race/ethnicity on outcomes
  • Between 2010 and 2017, 10.2% of patients undergoing primary TJA at Massachusetts General Hospital were African American people, 5.1% were Latinx people and 3.7% were Asian people; the respective figures for revision TJA were 4.2%, 1.6% and 1.2%
  • African Americans had significantly longer hospital stays and higher 30-day readmission rates than white people, and both African American and Latinx people had significantly higher postoperative infection rates
  • BMI was higher for African Americans and Latinx people than white people, and diabetes was more common among African American people, demonstrating the need to optimize preoperative medical comorbidities before revision arthroplasty

It's been widely reported that racial and ethnic groups that are minorities in the U.S. have not only less access to primary hip and knee total joint arthroplasty (TJA) than white patients do, but also experience poorer postoperative outcomes. The latter include greater postoperative pain, longer hospital stays, more 90-day hospital readmissions and inferior postoperative function.

Now, Christian Klemt, PhD, research fellow, Anand Padmanabha, MD, arthroplasty fellow, Young-Min Kwon, MD, PhD, director of the Bioengineering Laboratory and the vice chair of clinical research in Department of Orthopaedic Surgery at Massachusetts General Hospital, and colleagues in the Bioengineering Lab, have investigated similar issues surrounding revision TJA. In The Journal of Arthroplasty, they report that utilization of revision TJA by racial/ethnic minorities is even worse than for primary TJA, and a number of post-revision outcomes are significantly worse for racial/ethnic minorities than for white patients.

Study Cohort

The retrospective analysis included 4,424 consecutive adults who underwent revision TJA between 2010 and 2017 and had at least two years of follow-up. Based on how they self-identified, they were categorized as non-Hispanic white (93%), non-Hispanic Black or African American (4.2%), Latinx (1.6%) or Asian (1.2%).

Patients who reported being Native American or mixed-race were excluded because of small sample sizes.

Utilization of TJA

During the study period, 16,431 patients underwent primary hip and knee TJA. Of these, 81.0% were white people, 10.2% were African American people, 5.1% were Latinx people and 3.7% were Asian people.

Thus, the prevalence of underutilization of TJA by minority racial/ethnic groups seems to increase between primary and revision procedures.

Demographics and Comorbidities

There were significant differences between racial/ethnic groups in:

  • Body mass index—higher for African American and Latinx people than white people
  • American Society of Anesthesiology Physical Status Classification System (ASA) score—worse for African American people than white people and better for Asian people than white people
  • Insurance status—all three minority groups were more likely than white people to be uninsured
  • Diabetes—more common among African American people than white people

Higher BMI and higher prevalence of diabetes have been associated with increased risk of periprosthetic joint infection, and diabetes has been linked to other post-TJA complications, including increased length of hospital stay and higher re-revision rates.

Post-revision Complications

  • African American people had significantly longer hospital stays, higher 30-day readmission rates and higher postoperative infection rates than white people
  • Latinx people had significantly higher postoperative infection rates than white people
  • Asian people had significantly higher re-revision rates than white people, perhaps because of the deep knee flexion and squatting that is more common among Asian people

Considerations for Orthopaedic Surgeons

The study findings demonstrate an underutilization of revision TJA by ethnic minority groups, suggesting that disparities in access to orthopedic surgery increase from primary to revision surgery despite higher failure rates of minority ethnic groups reported after primary TJA surgery. In addition, inferior postoperative outcomes were associated with African American and Latinx patients, when compared to white patients, with African American people demonstrating the highest risk of postoperative complications.

The findings of increased rates of postoperative complications in racial/ethnic minority groups compared with white people demonstrate the need to optimize preoperative medical comorbidities before revision arthroplasty.

Learn more about the Bioengineering Lab at Mass General

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