Total Joint Arthroplasty in a Safety Net Hospital: Substance Abuse and Other Factors Affecting Outcomes

From the 2018 HVPAA National Conference

Harry Jergesen (UCSF Orthopaedic Surgery), Hao-hua Wu (UCSF Orthopaedic Surgery), Zach Thielen (Hoag Institute), Jay Roever (UCSF Orthopaedic Surgery), Toure Vashon (UCSF Orthopaedic Surgery), Paul Yi (Johns Hopkins Department of Radiology)


Although total joint arthroplasty (TJA) is one of the most efficacious and cost-effective procedures in all of orthopaedic surgery, and medicine, in general, TJA outcomes and patient risk factors for post-TJA complications have not been studied in detail in safety net hospital settings.


This study examines the relationship between selected risk factors and short-term complications in such a population, including a subgroup with treated substance abuse.


This retrospective cohort study contains 486 consecutive patients following primary hip and knee arthroplasty. 103 of these had a history of substance abuse, and completed a one-year sobriety pathway preoperatively. Primary outcomes included the presence of any complication, deep infection, and reoperation. Bivariable analyses were used to identify predictors of these outcomes, and a multivariate analysis to identify independent risk factors.


Adverse outcomes occurred in younger patients and those with higher rates of substance abuse, HIV and HCV infection, mental illness, and medical co-morbidities. Substance abuse alone was not an independent risk factor.  HIV and HCV infection were independent risk factors for overall postoperative complications. In the substance abuse subgroup, with its higher prevalence of risk factors, complications were more frequent (31.1% vs. 16.4%, p<.01), particularly deep infections (5.8% vs. 1.8%, p=0.037).


Specific risk factors were associated with short-term complications in safety-net arthroplasty patients. Despite having completed a preoperative sobriety pathway, substance abuse patients had more complications than did others. However, substance abuse alone was not an independent risk factor for adverse surgical outcomes. Other factors, notably HCV infection, more common in patients with substance abuse, were most closely associated with adverse outcomes.

Implications for the Patient

Patients with substance abuse and HCV infection are at high-risk for adverse outcomes after TJA in the safety net hospital population. Improving the surgical outcomes for these patients represents a potential high-value area for improvement as more patients receive health insurance in the USA under new healthcare policies.

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