Given the high prevalence of psychiatric illness in the total joint arthroplasty (TJA) population, relatively little is known about how these two conditions affect each other. Therefore, the purpose of this study is to evaluate the role of major psychiatric illness on patient specific outcomes after TJA. We hypothesize that patients with major psychiatric illnesses will report inferior outcomes and have more complications after TJA compared to those without any psychiatric illness.

We matched and compared two cohorts of patients undergoing TJA from a prospectively collected database registry, which included those with and without a major psychiatric disorder. Major psychiatric disorder was identified in the registry database by determining if patients had been formally diagnosed with any of the following conditions: bipolar disorder, major personality disorder, chronic mental health diagnoses, depression, or schizophrenia. Primary outcomes of interest included patient specific outcomes measured using the WOMAC or EQ5D. Secondary outcomes included complications, infections, hospital length of stay, 30-day readmission rates and final discharge destination.

In total we included 1828 TJAs (1000 THAs, 828 TKAs). In terms of the primary outcome, both the THA experimental group (37.80 ± 17.91 vs. 40.74 ± 19.3, p=0.023) and TKA experimental group (43.38 ± 18.41 vs 45.45 ± 20.07, p=0.050) had significantly lower preoperative WOMAC scores compared to their respective control groups. At the 3-month period both the THA experimental group (76.74 ± 16.94 vs. 79.16 ± 16.19, p=0.036) and TKA experimental group (71.09 ± 18.64 vs. 75.92 ± 16.22, p=0) again had significantly lower 3-month postoperative WOMAC score. Clinical outcomes at the 1-year mark were similar for both groups in terms of WOMAC and EQ5D. Patients with psychiatric illness were more likely to have increased LOS and non-routine discharge from hospital. In the THA subset, the experimental group had an increased LOS by 1.43 days (p=0.0028), in the TKA subset, the experimental group had an increased LOS by 0.77 days (p= 0.050). In terms of non-routine discharge, the THA experimental group was discharged home 86.9% of the time compared to the control group at 91.8% (p=0.024). In the TKA subset, the experimental group was discharged home 87.6% of the time compared to the control group at 92% (p=0.022). There were no other differences between the two subsets in regards to transfusions, 30-day readmissions, infections, mechanical adverse events, and medical complications.

In conclusion, our results demonstrate that psychiatric illness can result in worse outcomes in the early perioperative period after TJA, although outcomes are equivalent 1 year postoperatively. Patients with psychiatric illness can be expected to gain significant improvements in outcome after surgery that are comparable to a baseline population without psychiatric illness. Nonetheless, patients with psychiatric illness are at increased risk of delayed discharge and non-routine discharge. As such, they may require personalized care post-operatively, and should be counseled accordingly. Based on our results, psychiatric illness should not be an impediment to proceeding with TJA.

Limited strong data exists in current literature comparing the 90-day morbidity and mortality following general or spinal anesthetic in patients who underwent total hip or knee arthroplasty, especially between matched cohorts. Because of this, there continues to be an ongoing debate regarding the risks and benefits of using general versus spinal anesthetic for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) for end-stage osteoarthritis.

The Alberta Bone and Joint Health Institute (ABJHI) database was searched to identify all patients who underwent either primary THA or TKA between April 2005 and December 2015. Those identified were matched 1:1 based on age, sex, type of joint replacement (THA or TKA), American Society of Anesthesiologists (ASA) score, and anesthetic type. Patients were stratified into two groups based on whether they received a general anesthesia (GA) or a spinal anesthesia (SA) at the time of their index surgery. Perioperative complications (medical events, mechanical events, deep infection, need for blood transfusion), length of stay (LOS), 30-day readmission, and 90-day mortality were compared between cohorts.

Included in this study are 5,580 patients who underwent THA and 7,712 patient who underwent TKA. All were successfully matched based on similar categorical criteria (THA, 2,790 matched-pairs, TKA, 3,856 matched-pairs). Following stratifications of cohorts, no statistical differences were appreciated between patient baseline demographics. Patients who underwent GA showed a trend towards higher 90-day mortality, however no statistical differences were found between anesthetic type on rates of 90-day mortality following either THA or TKA (THA, p = 0.290, TKA, p = 0.291). Considering this, patients who underwent THA with SA experienced fewer 90-day complications (medical events, p = 0.022, mechanical events, p = 0.017), needed fewer blood transfusions (p < 0 .001), and required shorter LOS (p = 0.038). Moreover, patient who underwent TKA with SA had fewer blood transfusion (p < 0 .001), 30-day readmission rates (p = 0.011), and fewer deep infections (p = 0.030) that required additional surgery compared to those in the GA cohort. Regardless of surgery performed, patients in the SA cohorts were more commonly discharged home without requiring additional support (i.e. home care).

General anesthesia during THA and TKA appears to be associated with increased 90-day morbidity and more frequent need for allogenic blood transfusion. No statistical difference in 90-day mortality is reported between cohorts for either THA or TKA, yet a trend is appreciated favoring SA. Surgeons who commonly perform these surgeries should consider the added benefits of spinal anesthesia for those patients who are candidates.