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The Impact of Celiac Disease on Complication Rates After Total Joint Arthroplasty: A Matched Cohort Study

Open AccessPublished:September 20, 2022DOI:https://doi.org/10.1016/j.artd.2022.08.001

      Abstract

      Background

      While many studies have demonstrated increased complication risk after total joint arthroplasty in patients with inflammatory bowel disease, it is unclear if celiac disease is associated with similarly increased risk. The purpose of this study was to analyze if celiac disease is associated with increased postoperative complications following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).

      Methods

      A retrospective cohort study was conducted using the PearlDiver database. Patients with celiac disease who underwent THA (n = 1701) and TKA (n = 3515) were matched 1:3 with controls (THA, n = 5103; TKA, n = 10,545) on age, sex, year of arthroplasty, diabetes mellitus, tobacco use, and obesity. Rates of medical complications within 90 days and joint complications including revision arthroplasty, prosthetic joint infection, periprosthetic fracture, and aseptic loosening within 2 years postoperatively were queried. Complication rates were compared for patients with celiac disease vs controls with multivariable logistic regression.

      Results

      After primary THA, patients with celiac disease exhibited significantly higher rates of acute myocardial infarction within 90 days (2.7% vs 1.9%; odds ratio 1.45; 95% confidence interval 1.01-2.07) and periprosthetic fractures at 2 years postoperatively (1.1% vs 0.5%; odds ratio 2.09; 95% confidence interval 1.14-3.79) than controls. Following primary TKA, patients with celiac disease exhibited higher but statistically comparable complication rates than controls (all P > .05).

      Conclusions

      Celiac disease was associated with significantly higher rates of acute myocardial infarction and periprosthetic fracture after primary THA. Complication rates after primary TKA were similar between the cohorts.

      Level of Evidence

      Level III.

      Keywords

      Introduction

      Total joint arthroplasty (TJA) is a highly successful and cost-effective treatment for end-stage osteoarthritis [
      • Ritter M.A.
      • Albohm M.J.
      • Keating E.M.
      • Faris P.M.
      • Meding J.B.
      Comparative outcomes of total joint arthroplasty.
      ,
      • Kamaruzaman H.
      • Kinghorn P.
      • Oppong R.
      Cost-effectiveness of surgical interventions for the management of osteoarthritis: a systematic review of the literature.
      ]. With a growing and aging population in the United States (U.S.), the annual demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) is projected to grow to 572,000 and 3.48 million procedures, respectively, by 2030 [
      • Kurtz S.
      • Ong K.
      • Lau E.
      • Mowat F.
      • Halpern M.
      Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
      ]. While TJA is generally highly successful, it does carry the risk of serious complications both in-hospital ones and those that arise in the years following the procedure [
      • Pulido L.
      • Parvizi J.
      • Macgibeny M.
      • Sharkey P.F.
      • Purtill J.J.
      • Rothman R.H.
      • et al.
      In hospital complications after total joint arthroplasty.
      ,
      • Meek R.M.D.
      • Norwood T.
      • Smith R.
      • Brenkel I.J.
      • Howie C.R.
      The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement.
      ].
      Celiac disease is a chronic immune-mediated condition triggered by dietary gluten with an estimated prevalence of 1%-2% of the world population and is more common in women by a ratio of 1:1.5-2 [
      • Rodrigo L.
      Celiac disease.
      ,
      • Ludvigsson J.F.
      • Bai J.C.
      • Biagi F.
      • Card T.R.
      • Ciacci C.
      • Ciclitira P.J.
      • et al.
      Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology.
      ]. Celiac disease is characterized by gastrointestinal findings including diarrhea, malabsorption, and weight loss, as well as variable extraintestinal manifestations [
      • Taylor A.K.
      • Lebwohl B.
      • Snyder C.L.
      • Green P.H.
      Celiac disease.
      ]. This condition is treated by implementing a strict, life-long gluten-free diet (GFD), which often eliminates patient symptoms [
      • Rodrigo L.
      Celiac disease.
      ]. As many as 38%-72% of patients with celiac disease have low bone mineral density (BMD) at the time of diagnosis, with improvement to only 9%-47% of patients after treatment with a GFD [
      • Larussa T.
      • Suraci E.
      • Nazionale I.
      • Abenavoli L.
      • Imeneo M.
      • Luzza F.
      Bone mineralization in celiac disease.
      ]. Studies have also demonstrated that celiac disease is associated with deterioration of bone microarchitecture and a significantly higher risk of osteoporotic fractures in affected individuals [
      • Zanchetta M.B.
      • Longobardi V.
      • Bai J.C.
      Bone and celiac disease.
      ]. It has been demonstrated that poor preoperative nutritional status can increase the risk of postoperative complications after TJA, including wound complications and surgical site infections (SSIs) [
      • Greene K.A.
      • Wilde A.H.
      • Stulberg B.N.
      Preoperative nutritional status of total joint patients. Relationship to postoperative wound complications.
      ,
      • Alfargieny R.
      • Bodalal Z.
      • Bendardaf R.
      • El-Fadli M.
      • Langhi S.
      Nutritional status as a predictive marker for surgical site infection in total joint arthroplasty.
      ]. However, it is unclear if celiac disease is associated with an increased risk of complications after TJA. As such, examination of celiac disease as a risk factor for postoperative complications following TJA is needed.
      The purpose of this study was to analyze if celiac disease is associated with increased postoperative medical and joint complications following primary THA and TKA. It was hypothesized that patients with celiac disease would exhibit significantly higher postoperative complication rates than matched controls.

      Material and methods

      Data source and study design

      Patient records were queried from the PearlDiver Mariner database (PearlDiver Inc., Colorado Springs, CO), a commercially available administrative claims database which contains deidentified patient data from the inpatient and outpatient settings. The database contains the medical records of approximately 144 million patients across the U.S. from 2010 through Q3 of 2020 which are collected by an independent data aggregator. This study utilized the “M91Ortho” data set within PearlDiver, which contains a random sample of 91 million patients. All health insurance payors are represented including commercial, private, and government plans. Researchers extract data using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth and Tenth revision (ICD-9/ICD-10), codes. Institutional review board exemption was granted as provided data were deidentified and compliant with the Health Insurance Portability and Accountability Act. No outside funding was received for this study.
      A retrospective cohort study was conducted to investigate if celiac disease is associated with increased complication rates following primary THA and TKA. THA was defined with CPT-27130 and associated ICD-9/10 procedural codes. In order to isolate primary THA, patients with a record of prior hemiarthroplasty, revision surgery, or diagnosis codes reflecting the presence of an artificial hip joint were excluded. Additionally, patients with hip avascular necrosis, pathologic hip fractures, hip infectious processes, or conversion from prior hip surgery (ie, CPT-27132) at the time of the primary THA were excluded. Finally, to ensure that postoperative complications are tied to the index THA, patients with contralateral hemiarthroplasty or THA during the 2-year follow-up were also excluded.
      TKA was defined with CPT-27447 and associated ICD-9/10 procedural codes. In order to include only primary TKA, patients with a record of prior unicompartmental knee arthroplasty, other knee reconstructive procedures, revision arthroplasty, or diagnosis codes reflecting the presence of an artificial knee joint were excluded. Patients with knee infections and distal femur and/or proximal tibia fractures at the time of the primary TKA were also excluded. In order to ensure that postoperative complications are tied to the index TKA, patients who underwent contralateral unicompartmental arthroplasty or TKA during the 2-year follow-up were excluded. To avoid excluding patients who experienced prosthetic joint infection (PJI) and given that codes for TKA (eg, CPT-27447) are used to bill for the second stage of a 2-stage revision TKA for infection, contralateral TKA without concomitant removal of an antibiotic spacer during the follow-up was excluded.
      Subsequently, patients with celiac disease were identified by claims containing relevant ICD-9/ICD-10 diagnosis codes (eg, ICD-9-D-5790, ICD-10-D-K900). In order to limit potential transfer bias due to patients leaving or joining the data set during the study period, only patients with continuous database enrollment for at least 3 months before and 2 years after the index arthroplasty were included. All codes used to define inclusion and exclusion criteria are provided in Appendix A.1.

      Demographic data and clinical characteristics

      Baseline demographic data were obtained for all patient cohorts including age, sex, body mass index (BMI), year of arthroplasty, and U.S. region. BMI data were queried using ICD-9/10 diagnosis codes. Clinical characteristics obtained included indication for THA (hip fracture or elective), length of stay (LOS) during the primary arthroplasty procedure, and the prevalence of diabetes mellitus, tobacco use, and obesity.

      Outcomes

      Rates of medical complications during the index hospital encounter and within 90 days postoperatively were obtained. Medical complications queried included inpatient readmissions, deep vein thrombosis, pulmonary embolism, acute myocardial infarction (MI), acute kidney injury, and blood transfusion. Codes used to define medical complications are outlined in Appendix B.1.
      Joint complications were evaluated at 2 years postoperatively. For THA, specific complications queried included all-cause revision, PJI, prosthetic dislocation, and periprosthetic fracture. All-cause revision THA included revision of the femoral and/or acetabular components, liner exchange, implant removal, and insertion/removal of an antibiotic spacer. Hip PJI was defined as a 2-stage revision for PJI, with the second stage defined as a conversion of prior hip surgery (ie, CPT-27132 and associated ICD-9/10 codes) with concomitant removal of an antibiotic spacer. Codes used to define THA complications are provided in Appendix B.2.
      For TKA, specific complications queried included manipulation under anesthesia and/or lysis of adhesions for knee stiffness, all-cause revision, PJI, aseptic loosening, and periprosthetic fracture. All-cause revision TKA included revision of the femoral and/or tibial components, implant removal, liner exchange, and insertion/removal of an antibiotic spacer. Knee PJI was defined as a 1-stage or 2-stage revision for PJI. Codes used to define TKA complications are provided in Appendix B.3.

      Statistical analysis

      Statistical analyses were performed using the R statistical software (Version 4.1.0; R Project for Statistical Computing, Vienna, Austria) integrated within the PearlDiver software with an α level set to 0.05. In order to reduce confounding bias, exact matching without replacement was performed to generate similar patient cohorts. For both THA and TKA, patients with celiac disease were matched at a 1:3 ratio with controls based on the following parameters: age, sex, year of surgery, diabetes mellitus, tobacco use, and obesity. An a priori power analysis was conducted to determine the minimal sample size required to detect significant differences in complication rates between groups and achieve 80% power. To detect a 1% difference in rates of major postoperative complications between patients with celiac disease and controls, assuming a 1:3 enrollment ratio, a minimum of 1435 patients with celiac disease would be required for the THA and TKA analyses.
      Categorical variables were compared with a chi-square test, and continuous variables were compared with Welch’s t-test or the Mann-Whitney U test. Rates of postoperative complications after primary THA and TKA were compared using multivariable logistic regression adjusting for age, sex, BMI, and U.S. region. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated for each outcome.

      Results

      Study populations

      After applying exclusion criteria, a total of 310,152 patients who underwent primary THA were identified, including 1704 (0.5%) with celiac disease. After 1:3 matching, 1701 celiac disease patients were matched with 5103 controls (Table 1). The 2 cohorts were statistically comparable across all matched parameters, indicating successful matching. LOS (2.61 vs 2.75 days, P = .115) and the proportion of patients undergoing THA for hip fractures (3.7% vs 3.5%, P = .705) were similar between the cohorts. There were significant differences in regional and BMI distribution although BMI data were only available for 14.3% (973/6804) of patients.
      Table 1Baseline demographic data for matched cohorts (matched 1:3).
      CharacteristicsTHATKA
      Celiac disease (n = 1701)Controls (n = 5103)P valueCeliac disease (n = 3515)Controls (n = 10,545)P value
      Age (y), mean ± SD64.72 ± 9.9664.73 ± 9.96.95064.43 ± 8.9664.46 ± 8.96.854
      Female sex, n (%)1243 (73.1)3729 (73.1)12699 (76.8)8097 (76.9)1
      U.S. region, n (%)
       Northeast519 (30.5)1162 (22.8)<.001981 (27.9)2101 (19.9)<.001
       South453 (26.6)1735 (34.0)<.0011087 (30.9)3958 (37.5)<.001
       Midwest464 (27.3)1.390 (27.2)1927 (26.4)2923 (27.7).126
       West263 (15.5)799 (15.7).875507 (14.4)1540 (14.6).813
      BMI, n (%)
      BMI data were available for 15.1% of the celiac disease THA cohort, 14.0% of the control THA cohort, 26.3% of the celiac disease TKA cohort, and 15.6% of the control TKA cohort.
       <30106 (41.2)221 (30.9).004161 (17.4)367 (22.2).031
       30-3557 (22.1)174 (24.3).395154 (16.7)395 (24.0).513
       35-4057 (22.1)174 (24.3).395147 (15.9)395 (24.0)<.001
       >4037 (14.4)147 (20.5).020462 (50.0)491 (29.8).006
      Year of index surgery, n (%)
       2010122 (7.2)366 (7.2)1306 (8.7)918 (8.7)1
       2011168 (9.9)504 (9.9)1397 (11.3)1191 (11.3)1
       2012167 (9.8)501 (9.8)1397 (11.3)1191 (11.3)1
       2013177 (10.4)531 (10.4)1458 (13.0)1374 (13.0)1
       2014235 (13.8)705 (13.8)1441 (12.5)1322 (12.5)1
       2015229 (13.5)687 (13.5)1413 (11.7)1239 (11.7)1
       2016217 (12.8)650 (12.7)1440 (12.5)1320 (12.5)1
       2017216 (12.7)648 (12.7)1365 (10.4)1095 (10.4)1
       2018170 (10.0)510 (10.0)1298 (8.5)894 (8.5)1
      Comorbidities, n (%)
       Diabetes mellitus682 (40.1)2046 (40.1)11667 (47.4)5001 (47.4)1
       Obesity650 (38.2)1949 (38.2)11752 (49.8)5256 (49.8)1
       Tobacco use686 (40.3)2058 (40.3)11299 (37.0)3896 (36.9)1
      Length of stay (d), mean ± SD2.61 ± 1.292.75 ± 2.92.1152.78 ± 1.392.82 ± 1.40.283
      Indication for THA, n (%)
       Hip fracture63 (3.7)177 (3.5).705---
       Elective1638 (96.3)4925 (96.5).705---
      SD, standard deviation.
      Bolded OR (95% CI) / P values indicate statistically significant results.
      a BMI data were available for 15.1% of the celiac disease THA cohort, 14.0% of the control THA cohort, 26.3% of the celiac disease TKA cohort, and 15.6% of the control TKA cohort.
      A total of 630,480 patients who underwent primary TKA were identified, including 3518 (0.6%) with celiac disease. After 1:3 matching, 3515 patients with celiac disease were matched with 10,545 controls. The 2 cohorts were statistically comparable across all matched parameters. LOS was similar between the 2 cohorts (2.78 vs 2.82 days, P = .283). Significant differences in region and BMI data were found although only 18.3% (2572/14,060) of patients had available BMI data.

      Complications after primary THA

      Within 90 days following the primary THA, patients with celiac disease exhibited significantly higher rates of acute MI (2.7% vs 1.9%; OR 1.45; 95% CI 1.01-2.07) (Table 2). All other 90-day medical complications and the overall rate of medical complications were statistically comparable between the groups (all P > .05).
      Table 2Rates of complications after primary THA for patients with celiac disease vs controls.
      ComplicationCeliac disease (n = 1701)Controls (n = 5103)Statistical analysis (reference group, celiac cohort)
      n%n%OR (95% CI)P value
      90 Days
       Any medical complication
      The number of patients with at least one medical or joint complication.
      25114.869913.71.08 (0.92-1.27).355
      DVT110.6290.61.10 (0.52-2.15).804
      PE100.6310.60.93 (0.43-1.84).855
      AKI311.81222.40.76 (0.50-1.13).188
      MI462.7961.91.45 (1.01-2.07).042
      Transfusion1227.23567.01.02 (0.82-1.27).869
      Inpatient readmission1227.23436.71.03 (0.83-1.28).801
      2 Years
       Any joint complication
      The number of patients with at least one medical or joint complication.
      824.81963.81.25 (0.95-1.62).101
      Dislocation281.6771.51.08 (0.68-1.65).747
      Revision THA502.91282.51.18 (0.84-1.64).337
      PJI100.6310.61.01 (0.47-2.01).981
      Aseptic loosening171.0290.61.65 (0.88-3.00).109
      Periprosthetic fracture191.1260.52.09 (1.14-3.79).017
      AKI, acute kidney injury; DVT, deep vein thrombosis; PE, pulmonary embolism.
      Bolded OR (95% CI) / P values indicate statistically significant results.
      a The number of patients with at least one medical or joint complication.
      Within 2 years postoperatively, the rate of periprosthetic fracture was significantly higher in the celiac disease cohort (1.1% vs 0.5%; OR 2.09; 95% CI 1.14-3.79). Rates of all other joint complications were higher among patients with celiac disease, but none achieved statistical significance (all P > .05).

      Complications after primary TKA

      Within 90 days following the primary TKA, the celiac disease cohort exhibited higher but statistically comparable rates of all queried medical complications than controls (Table 3). Rates of all joint complications at the 2-year follow-up visit were also higher for patients with celiac disease, but no differences achieved statistical significance (all P > .05).
      Table 3Rates of complications after primary TKA for patients with celiac disease vs controls.
      ComplicationCeliac disease (n = 3515)Controls (n = 10,545)Statistical analysis (reference group, celiac cohort)
      n%n%OR (95% CI)P value
      90 Days
       Any medical complication
      The number of patients with at least one medical or joint complication.
      43212.3120711.41.07 (0.95-1.20).259
      DVT130.4380.40.83 (0.43-1.50).570
      PE300.91101.00.79 (0.52-1.18).263
      AKI581.72051.90.87 (0.64-1.17).372
      MI752.12252.11.16 (0.88-1.52).291
      Transfusion1765.04424.21.18 (0.98-1.41).074
      Inpatient readmission2226.35905.61.09 (0.93-1.29).306
      2 Years
       Any joint complication
      The number of patients with at least one medical or joint complication.
      2948.48257.81.07 (0.92-1.23).367
      MUA/LoA1875.35044.81.10 (0.92-1.31).294
      Revision TKA1273.63253.11.17 (0.95-1.45).146
      PJI732.11881.81.18 (0.88-1.54).249
      Aseptic loosening250.7560.51.27 (0.77-2.02).337
      Periprosthetic fracture60.2250.20.74 (0.27-1.69).531
      AKI, acute kidney injury; DVT, deep vein thrombosis; LoA, lysis of adhesions; MUA, manipulation under anesthesia; PE, pulmonary embolism.
      a The number of patients with at least one medical or joint complication.

      Discussion

      Compared to matched controls, patients with celiac disease who underwent THA exhibited significantly higher rates of periprosthetic fractures at 2 years postoperatively. These results align with prior literature reporting on the negative impact of celiac disease on BMD and associated increased fragility fracture risk [
      • Zanchetta M.B.
      • Longobardi V.
      • Bai J.C.
      Bone and celiac disease.
      ,
      • Sayar S.
      • Aykut H.
      • Kaya Ö.
      • Kürbüz K.
      • Ak Ç.
      • Gökçen P.
      • et al.
      Bone mineral density screening and the frequency of osteopenia/osteoporosis in Turkish adult patients with celiac disease.
      ,
      • McFarlane X.A.
      • Bhalla A.K.
      • Reeves D.E.
      • Morgan L.M.
      • Robertson D.A.
      Osteoporosis in treated adult coeliac disease.
      ,
      • Walters J.R.
      • Banks L.M.
      • Butcher G.P.
      • Fowler C.R.
      Detection of low bone mineral density by dual energy x ray absorptiometry in unsuspected suboptimally treated coeliac disease.
      ,
      • Meyer D.
      • Stavropolous S.
      • Diamond B.
      • Shane E.
      • Green P.H.
      Osteoporosis in a North American adult population with celiac disease.
      ]. While BMD has been shown to significantly improve with treatment via GFDs, it has not been shown to normalize in all patients [
      • Larussa T.
      • Suraci E.
      • Nazionale I.
      • Abenavoli L.
      • Imeneo M.
      • Luzza F.
      Bone mineralization in celiac disease.
      ,
      • Sayar S.
      • Aykut H.
      • Kaya Ö.
      • Kürbüz K.
      • Ak Ç.
      • Gökçen P.
      • et al.
      Bone mineral density screening and the frequency of osteopenia/osteoporosis in Turkish adult patients with celiac disease.
      ,
      • Walters J.R.
      • Banks L.M.
      • Butcher G.P.
      • Fowler C.R.
      Detection of low bone mineral density by dual energy x ray absorptiometry in unsuspected suboptimally treated coeliac disease.
      ,
      • Meyer D.
      • Stavropolous S.
      • Diamond B.
      • Shane E.
      • Green P.H.
      Osteoporosis in a North American adult population with celiac disease.
      ]. As a result, current guidelines recommend adult patients with celiac disease undergo routine screening with a dual-energy radiograph absorptiometry scan 1 year after the initiation of a GFD [
      American gastroenterological association medical position statement: guidelines on osteoporosis in gastrointestinal diseases, this document presents the official recommendations of the American gastroenterological association (AGA) committee on osteoporosis in gastrointestinal disease. It was approved by the clinical practice committee on September 21, 2002, and by the AGA governing board on November 1, 2002.
      ]. Although not specifically queried in this study, it has also been demonstrated that prior fragility fractures within 3 years of THA increases the risk of periprosthetic fracture postoperatively [
      • Ross A.J.
      • Ross B.J.
      • Lee O.C.
      • Guild G.N.
      • Sherman W.F.
      The impact of prior fragility fractures on complications after total hip arthroplasty: a propensity score-matched cohort study.
      ]. Few analyses have specifically looked at celiac disease and the risk of fragility fracture; future studies investigating this association as it relates to preoperative risk for TJA are warranted [
      • Bianchi M.-L.
      • Bardella M.T.
      Bone in celiac disease.
      ].
      In the present study, patients with celiac disease who underwent THA demonstrated a significantly higher incidence of acute MI within 90 days (2.7% vs 1.9%). The findings are consistent with studies that have documented a nearly 2-fold increase in coronary artery disease in patients with celiac disease relative to controls [
      • Gajulapalli R.D.
      • Pattanshetty D.J.
      Risk of coronary artery disease in celiac disease population.
      ]. Much literature has focused on the etiology of this correlation, with many studies focusing on the effect of the GFD adopted by patients with celiac disease after their initial diagnosis. Although the etiology is not fully understood, increases in total cholesterol and additional cardiovascular risk factors, such as metabolic syndrome and insulin resistance, are consistently noted among patients with celiac disease [
      • Potter M.D.E.
      • Brienesse S.C.
      • Walker M.M.
      • Boyle A.
      • Talley N.J.
      Effect of the gluten-free diet on cardiovascular risk factors in patients with coeliac disease: a systematic review.
      ,
      • Ciccone A.
      • Gabrieli D.
      • Cardinale R.
      • Di Ruscio M.
      • Vernia F.
      • Stefanelli G.
      • et al.
      Metabolic alterations in celiac disease occurring after following a gluten-free diet.
      ,
      • Norsa L.
      • Shamir R.
      • Zevit N.
      • Verduci E.
      • Hartman C.
      • Ghisleni D.
      • et al.
      Cardiovascular disease risk factor profiles in children with celiac disease on gluten-free diets.
      ]. There is evidence that periods of hypertension or hypotension during noncardiac surgery are associated with increased morbidity and postoperative cardiac complications [
      • Biccard B.M.
      • Rodseth R.N.
      What evidence is there for intraoperative predictors of perioperative cardiac outcomes? A systematic review.
      ,
      • Sessler D.I.
      • Bloomstone J.A.
      • Aronson S.
      • Berry C.
      • Gan T.J.
      • Kellum J.A.
      • et al.
      Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery.
      ]. Helwani et al. found that regional anesthesia during THA reduced postoperative cardiovascular and pulmonary complications, as well as SSI and hospital LOS, compared to general anesthesia [
      • Helwani M.A.
      • Avidan M.S.
      • Ben Abdallah A.
      • Kaiser D.J.
      • Clohisy J.C.
      • Hall B.L.
      • et al.
      Effects of regional versus general anesthesia on outcomes after total hip arthroplasty: a retrospective propensity-matched cohort study.
      ]. Thus, special care should be taken with this population intraoperatively, and surgeons may consider spinal epidural anesthesia during THA operations for patients with celiac disease.
      Poor nutritional status in general has been linked to an increased risk of postoperative complications in TJA, and celiac disease is associated with a range of micronutrient deficiencies, including low albumin. Bledsoe et al. demonstrated that patients with celiac disease had a significantly higher rate of low nutrient levels, including albumin, than controls [
      • Bledsoe A.C.
      • King K.S.
      • Larson J.J.
      • Snyder M.
      • Absah I.
      • Choung R.S.
      • et al.
      Micronutrient deficiencies are common in contemporary celiac disease despite lack of overt malabsorption symptoms.
      ]. Alfargieny et al. also demonstrated an increased risk of SSI for patients with low preoperative serum albumin [
      • Alfargieny R.
      • Bodalal Z.
      • Bendardaf R.
      • El-Fadli M.
      • Langhi S.
      Nutritional status as a predictive marker for surgical site infection in total joint arthroplasty.
      ]. In a meta-analysis, Mbagwu et al. reported that low serum albumin was a risk factor for all measured complications in several studies including SSI, pneumonia, LOS, readmission, and septic revision [
      • Mbagwu C.
      • Sloan M.
      • Neuwirth A.L.
      • Charette R.S.
      • Baldwin K.D.
      • Kamath A.F.
      • et al.
      Preoperative albumin, transferrin, and total lymphocyte count as risk markers for postoperative complications after total joint arthroplasty: a systematic review.
      ].
      Rates of both 90-day medical complications and 2-year joint complications were higher among patients with celiac disease than among controls, but none achieved statistical significance. A notable finding in this study was that the rate of periprosthetic fracture after THA was significantly higher in patients with celiac disease than in controls, but rates after TKA were statistically comparable. One possible explanation for the difference observed in periprosthetic fracture rates between THA and TKA is the increasing trend toward the predominant use of uncemented THA [
      • Wyatt M.
      • Hooper G.
      • Frampton C.
      • Rothwell A.
      Survival outcomes of cemented compared to uncemented stems in primary total hip replacement.
      ]. Our data on periprosthetic fractures align with prior studies which have demonstrated that, in general, periprosthetic fractures are more common after THA relative to TKA [
      • Della Rocca G.J.
      • Leung K.S.
      • Pape H.-C.
      Periprosthetic fractures: epidemiology and future projections.
      ]. Prior studies have also demonstrated that postoperative periprosthetic fractures are more common in patients who receive uncemented THA [
      • Abdel M.P.
      • Watts C.D.
      • Houdek M.T.
      • Lewallen D.G.
      • Berry D.J.
      Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: a 40-year experience.
      ,
      • Abdulkarim A.
      • Ellanti P.
      • Motterlini N.
      • Fahey T.
      • O’Byrne J.M.
      Cemented versus uncemented fixation in total hip replacement: a systematic review and meta-analysis of randomized controlled trials.
      ]. One possible contributing factor is that uncemented components rely on osseointegration between bone and the porous implant for fixation of components [
      • Kim J.T.
      • Yoo J.J.
      Implant design in cementless hip arthroplasty.
      ]. As previously discussed, celiac disease has a negative impact on bone health and BMD, and thus, celiac disease likely has a disproportional impact on THA due to the relationship between bone density and complication rates relative to TKA. Surgeons may need to consider using cemented femoral stems for THA in patients with celiac disease due to the associated elevated risk of periprosthetic fracture demonstrated in this study.

      Limitations

      There are several limitations to this study. First, by only evaluating complications within 2 years, this analysis is limited to short-term outcomes. Furthermore, because continuous database enrollment for 2 years after arthroplasty was required for inclusion, patients who died within 2 years after the surgery were excluded. Therefore, these results may not be applicable to patients with high perioperative mortality risk. Additionally, the possibility of coding errors is inherent with any analysis of administrative claims data. However, such instances are rare and made up only 0.7% of Medicare and Medicaid payments in 2021 []. Nonetheless, because this analysis relied on claims data, it is possible that uncharted complications were not captured. Another limitation is that the database does not include information on severity of celiac disease nor the length of time since diagnosis. Additionally, it does not contain information on the treatment status of celiac patients (eg, patients on a GFD). This lack of information limits our ability to understand patients' disease severity, length of disease activity, or treatment status at the time of surgery, and it has been demonstrated that treatment can have important impacts on patients’ bone health, nutritional, and clinical status [
      • Larussa T.
      • Suraci E.
      • Nazionale I.
      • Abenavoli L.
      • Imeneo M.
      • Luzza F.
      Bone mineralization in celiac disease.
      ,
      • McFarlane X.A.
      • Bhalla A.K.
      • Reeves D.E.
      • Morgan L.M.
      • Robertson D.A.
      Osteoporosis in treated adult coeliac disease.
      ,
      • Walters J.R.
      • Banks L.M.
      • Butcher G.P.
      • Fowler C.R.
      Detection of low bone mineral density by dual energy x ray absorptiometry in unsuspected suboptimally treated coeliac disease.
      ,
      • Meyer D.
      • Stavropolous S.
      • Diamond B.
      • Shane E.
      • Green P.H.
      Osteoporosis in a North American adult population with celiac disease.
      ]. The database does not also contain data on patients’ BMD (eg, T-score) which prevented characterization of bone health in the included population. Although rates of all joint complications after TKA were higher in the celiac disease cohort, none achieved statistical significance. In addition, although a large patient database was analyzed, this result may reflect inadequate power; future analyses of larger samples of patients with celiac disease undergoing TKA are warranted. Additionally, it has been demonstrated that ICD-9 codes alone are poor in identifying celiac disease [
      • Tanpowpong P.
      • Broder-Fingert S.
      • Obuch J.C.
      • Rahni D.O.
      • Katz A.J.
      • Leffler D.A.
      • et al.
      Multicenter study on the value of ICD-9-CM codes for case identification of celiac disease.
      ]. Lastly, although exact matching and multivariable regression were used, other confounders that were not matched on or controlled for in the regressions could have influenced the results. BMI data were also not universally available for all included patients, and therefore, the adjustment for BMI was incomplete.

      Conclusion

      Celiac disease was associated with significantly higher rates of acute MI and periprosthetic fractures after THA. While it was also associated with higher complication rates after TKA, none achieved statistical significance. These data suggest that celiac disease is associated with higher risk of poor outcomes following THA, but complication risk following TKA may be similar to the general population. Surgeons may need to consider medical optimization and/or cardiology evaluation prior to the surgery to mitigate the associated increased risk of MI. Surgeons may also consider using cemented femoral stems in at-risk patients with celiac disease due to the associated elevated risk of periprosthetic fracture demonstrated in this study.

      Conflicts of interest

      The authors declare there are no conflicts of interest.
      For full disclosure statements refer to https://doi.org/10.1016/j.artd.2022.08.001.

      Appendix A. Supplementary Data

      Appendix

      Table A.1Codes used to define inclusion/exclusion criteria and other demographic and clinical variables.
      CriteriaCode(s)
      Inclusion criteria
       THACPT-27130, ICD-9-P-8151, ICD-10-P-0SR9019, ICD-10-P-0SR901A, ICD-10-P-0SR901Z, ICD-10-P-0SR9029, ICD-10-P-0SR902A, ICD-10-P-0SR902Z, ICD-10-P-0SR9039, ICD-10-P-0SR903A, ICD-10-P-0SR903Z, ICD-10-P-0SR9049, ICD-10-P-0SR904A, ICD-10-P-0SR904Z, ICD-10-P-0SR9069, ICD-10-P-0SR906A, ICD-10-P-0SR906Z, ICD-10-P-0SR90J9, ICD-10-P-0SR90JA, ICD-10-P-0SR90JZ, ICD-10-P-0SRB019, ICD-10-P-0SRB01A, ICD-10-P-0SRB01Z, ICD-10-P-0SRB029, ICD-10-P-0SRB02A, ICD-10-P-0SRB02Z, ICD-10-P-0SRB039, ICD-10-P-0SRB03A, ICD-10-P-0SRB03Z, ICD-10-P-0SRB049, ICD-10-P-0SRB04A, ICD-10-P-0SRB04Z, ICD-10-P-0SRB069, ICD-10-P-0SRB06A, ICD-10-P-0SRB06Z, ICD-10-P-0SRB0J9, ICD-10-P-0SRB0JA, ICD-10-P-0SRB0JZ
       TKACPT-27447, ICD-9-P-8154, ICD-10-P-0SRC069, ICD-10-P-0SRC06A, ICD-10-P-0SRC06Z, ICD-10-P-0SRC0J9, ICD-10-P-0SRC0JA, ICD-10-P-0SRC0JZ, ICD-10-P-0SRD069, ICD-10-P-0SRD06A, ICD-10-P-0SRD06Z, ICD-10-P-0SRD0J9, ICD-10-P-0SRD0JA, ICD-10-P-0SRD0JZ
       Celiac diseaseICD-9-D-5790, ICD-10-D-K900
      Exclusion criteria
       Prior hip hemiarthroplastyCPT-27125
       Presence of artificial hip jointICD-9-D-V4364, ICD-10-D-Z96641, ICD-10-D-Z96642, ICD-10-D-Z96643, ICD-10-D-Z96649
       Avascular necrosis hipICD-9-D-73342, ICD-10-D-M87051, ICD-10-D-M87052, ICD-10-D-M87059
       Conversion from prior hip surgeryCPT-27132
       Pathologic fracture hipICD-9-D-73314, ICD-9-D-73315, ICD-10-D-M84459A, ICD-10-D-M84559A, ICD-10-D-M84659A
       Septic arthritis hipICD-9-D-71105, ICD-9-D-71106, ICD-9-D-71145, ICD-9-D-71146, ICD-10-D-M00851, ICD-10-D-M00852, ICD-10-D-M00859
       Presence of artificial knee jointICD-9-D-V4365, ICD-10-D-Z96651, ICD-10-D-Z96652, ICD-10-D-Z96653, ICD-10-D-Z96659
       Unicompartmental knee arthroplastyCPT-27446, ICD-10-P-0SRC0L9, ICD-10-P-0SRC0LA, ICD-10-P-0SRC0LZ, ICD-10-P-0SRC0M9, ICD-10-P-0SRC0MA, ICD-10-P-0SRC0MZ, ICD-10-P-0SRD0L9, ICD-10-P-0SRD0LA, ICD-10-P-0SRD0LZ, ICD-10-P-0SRD0M9, ICD-10-P-0SRD0MA, ICD-10-P-0SRD0MZ,
       Revision total knee arthroplastyCPT-27440, CPT-27441, CPT-27442, CPT-27443, CPT-27445, CPT-27446, CPT-27486, CPT-27487, CPT-27488, ICD-9-P-0080, ICD-9-P-0081, ICD-9-P-0082, ICD-9-P-0083, ICD-9-P-0084, ICD-9-P-8155, ICD-9-P-8155, ICD-10-P-0SPC0JZ, ICD-10-P-0SPC0JZ
       Knee infectionICD-9-D-71106, ICD-10-D-M009, ICD-10-D-M00061, ICD-10-D-M00062, ICD-10-D-M00069, ICD-10-D-M00161, ICD-10-D-M00162, ICD-10-D-M00169, ICD-10-D-M00261, ICD-10-D-M00262, ICD-10-D-M00269, ICD-10-D-M00861, ICD-10-D-M00862, ICD-10-D-M00869, ICD-10-D-M01X61, ICD-10-D-M01X62, ICD-10-D-M01X69, ICD-10-D-M01X61, ICD-10-D-M01X62, ICD-10-D-M01X69, ICD-10-D-T8453XA, ICD-10-D-T8453XD, ICD-10-D-T8453XS, ICD-10-D-T8454XA, ICD-10-D-T8454XD, ICD-10-D-T8454X
       Knee fractureCPT-27487, ICD-9-D-82100, ICD-9-D-82110, ICD-9-D-82120, ICD-9-D-82123, ICD-9-D-82129, ICD-9-D-82130, ICD-9-D-82132, ICD-9-D-82133, ICD-9-D-82139, ICD-9-D-73316, ICD-9-D-73393, ICD-9-D-82300, ICD-9-D-82302, ICD-9-D-82310, ICD-9-D-82312, ICD-9-D-82380, ICD-9-D-82382, ICD-9-D-82390, ICD-9-D-82392, ICD-10-D-M84453A, ICD-10-D-M84453A, ICD-10-D-M84453A, ICD-10-D-M84453A, ICD-10-D-M84453A, ICD-10-D-S7290XC, ICD-10-D-S72409A, ICD-10-D-S72453A, ICD-10-D-S72456A, ICD-10-D-S72499A, ICD-10-D-S72409B, ICD-10-D-S72453B, ICD-10-D-M84469A, ICD-10-D-M84369A, ICD-10-D-S82109A, ICD-10-D-S82101A, ICD-10-D-S82831A, ICD-10-D-S82102A, ICD-10-D-S82832A, ICD-10-D-S82109B, ICD-10-D-S82109C, ICD-10-D-S82101B, ICD-10-D-S82831B, ICD-10-D-S82102B, ICD-10-D-S82832B, ICD-10-D-S82201A, ICD-10-D-S82401A, ICD-10-D-S82202A, ICD-10-D-S82402A, ICD-10-D-S82201B, ICD-10-D-S82201C, ICD-10-D-S82401B, ICD-10-D-S82202B, ICD-10-D-S82402B
       Contralateral knee total or unicompartmental arthroplastyICD-10-P-0SRC0L9, ICD-10-P-0SRC0LA, ICD-10-P-0SRC0LZ, ICD-10-P-0SRC0M9, ICD-10-P-0SRC0MA, ICD-10-P-0SRC0MZ, ICD-10-P-0SRD0L9, ICD-10-P-0SRD0LA, ICD-10-P-0SRD0LZ, ICD-10-P-0SRD0M9, ICD-10-P-0SRD0MA, ICD-10-P-0SRD0M
      Other
       Tobacco useICD-9-D-3051, ICD-9-D-V1582, ICD-10-D-F17220, ICD-10-D-F17221, ICD-10-D-F17223, ICD-10-D-F17228, ICD-10-D-F17229, ICD-10-D-F17290, ICD-10-D-F17291, ICD-10-D-F17293, ICD-10-D-F17298, ICD-10-D-F17299, ICD-10-D-Z720
       Diabetes mellitusICD-9-D-24900:ICD-9-D-25099, ICD-9-D-7902, ICD-9-D-79021, ICD-9-D-79022, ICD-9-D-79029, ICD-9-D-7915, ICD-9-D-7916, ICD-10-D-E090:ICD-10-D-E139
       ObesityICD-9-D-2780, ICD-9-D-27800, ICD-9-D-27801, ICD-9-D-27802, ICD-9-D-27803, ICD-10-D-E660:ICD-10-D-E669
      Table B.1Codes used to define medical complications.
      OutcomeCode(s)
      Blood transfusionICD-9-P-9904, ICD-10-P-3023, ICD-10-P-30230AZ, ICD-10-P-30230G0, ICD-10-P- 30230G2, ICD-10-P-30230G3, ICD-10-P-30230G4, ICD-10-P-30230H0, ICD-10-P-30230H1, ICD-10-P- 30230J0, ICD-10-P-30230J1, ICD-10-P-30230K0, ICD-10-P-30230K1, ICD-10-P-30230L0, ICD-10-P-30230L1, ICD- 10-P-30230M0, ICD-10-P-30230M1, ICD-10-P-30230N0, ICD-10-P-30230N1, ICD-10-P-30230P0, ICD-10-P- 30230P1, ICD-10-P-30230Q0, ICD-10-P-30230Q1, ICD-10-P-30230R0, ICD-10-P-30230R1, ICD-10-P- 30230S0, ICD-10-P-30230S1, ICD-10-P-30230T0, ICD-10-P-30230T1, ICD-10-P-30230V0, ICD-10-P- 30230V1, ICD-10-P-30230W0, ICD-10-P-30230W1, ICD-10-P-30230X0, ICD-10-P-30230X2, ICD-10-P- 30230X3, ICD-10-P-30230X4, ICD-10-P-30230Y0, ICD-10-P-30230Y2, ICD-10-P-30230Y3, ICD-10-P- 30230Y4, ICD-10-P-30233AZ, ICD-10-P-30233G0, ICD-10-P-30233G2, ICD-10-P-30233G3, ICD-10-P- 30233G4, ICD-10-P-30233H0, ICD-10-P-30233H1, ICD-10-P-30233J0, ICD-10-P-30233J1, ICD-10-P- 30233K0, ICD-10-P-30233K1, ICD-10-P-30233L0, ICD-10-P-30233L1, ICD-10-P-30233M0, ICD-10-P- 30233M1, ICD-10-P-30233N0, ICD-10-P-30233N1, ICD-10-P-30233P0, ICD-10-P-30233P1, ICD-10-P- 30233Q0, ICD-10-P-30233Q1, ICD-10-P-30233R0, ICD-10-P-30233R1, ICD-10-P-30233S0, ICD-10-P- 30233S1, ICD-10-P-30233T0, ICD-10-P-30233T1, ICD-10-P-30233V0, ICD-10-P-30233V1, ICD-10-P- 30233W0, ICD-10-P-30233W1, ICD-10-P-30233X0, ICD-10-P-30233X2, ICD-10-P-30233X3, ICD-10-P- 30233X4, ICD-10-P-30233Y0, ICD-10-P-30233Y2, ICD-10-P-30233Y3, ICD-10-P-30233Y4, ICD-10-P- 30240AZ, ICD-10-P-30240G0, ICD-10-P-30240G2, ICD-10-P-30240G3, ICD-10-P-30240G4, ICD-10-P- 30240H0, ICD-10-P-30240H1, ICD-10-P-30240J0, ICD-10-P-30240J1, ICD-10-P-30240K0, ICD-10-P- 30240K1, ICD-10-P-30240L0, ICD-10-P-30240L1, ICD-10-P-30240M0, ICD-10-P-30240M1, ICD-10-P- 30240N0, ICD-10-P-30240N1, ICD-10-P-30240P0, ICD-10-P-30240P1, ICD-10-P-30240Q0, ICD-10-P- 30240Q1, ICD-10-P-30240R0, ICD-10-P-30240R1, ICD-10-P-30240S0, ICD-10-P-30240S1, ICD-10-P- 30240T0, ICD-10-P-30240T1, ICD-10-P-30240V0, ICD-10-P-30240V1, ICD-10-P-30240W0, ICD-10-P- 30240W1, ICD-10-P-30240X0, ICD-10-P-30240X2, ICD-10-P-30240X3, ICD-10-P-30240X4, ICD-10-P- 30240Y0, ICD-10-P-30240Y2, ICD-10-P-30240Y3, ICD-10-P-30240Y4, ICD-10-P-30243AZ, ICD-10-P- 30243G0, ICD-10-P-30243G2, ICD-10-P-30243G3, ICD-10-P-30243G4, ICD-10-P-30243H0, ICD-10-P- 30243H1, ICD-10-P-30243J0, ICD-10-P-30243J1, ICD-10-P-30243K0, ICD-10-P-30243K1, ICD-10-P-30243L0, ICD- 10-P-30243L1, ICD-10-P-30243M0, ICD-10-P-30243M1, ICD-10-P-30243N0, ICD-10-P-30243N1, ICD-10-P- 30243P0, ICD-10-P-30243P1, ICD-10-P-30243Q0, ICD-10-P-30243Q1, ICD-10-P-30243R0, ICD-10-P- 30243R1, ICD-10-P-30243S0, ICD-10-P-30243S1, ICD-10-P-30243T0, ICD-10-P-30243T1, ICD-10-P- 30243V0, ICD-10-P-30243V1, ICD-10-P-30243W0, ICD-10-P-30243W1, ICD-10-P-30243X0, ICD-10-P- 30243X2, ICD-10-P-30243X3, ICD-10-P-30243X4, ICD-10-P-30243Y0, ICD-10-P-30243Y2, ICD-10-P- 30243Y3, ICD-10-P-30243Y4, ICD-10-P-30250G0, ICD-10-P-30250G1, ICD-10-P-30250H0, ICD-10-P- 30250H1, ICD-10-P-30250J0, ICD-10-P-30250J1, ICD-10-P-30250K0, ICD-10-P-30250K1, ICD-10-P-30250L0, ICD- 10-P-30250L1, ICD-10-P-30250M0, ICD-10-P-30250M1, ICD-10-P-30250N0, ICD-10-P-30250N1, ICD-10-P- 30250P0, ICD-10-P-30250P1, ICD-10-P-30250Q0, ICD-10-P-30250Q1, ICD-10-P-30250R0, ICD-10-P- 30250R1, ICD-10-P-30250S0, ICD-10-P-30250S1, ICD-10-P-30250T0, ICD-10-P-30250T1, ICD-10-P- 30250V0, ICD-10-P-30250V1, ICD-10-P-30250W0, ICD-10-P-30250W1, ICD-10-P-30250X0, ICD-10-P- 30250X1, ICD-10-P-30250Y0, ICD-10-P-30250Y1, ICD-10-P-30253G0, ICD-10-P-30253G1, ICD-10-P- 30253H0, ICD-10-P-30253H1, ICD-10-P-30253J0, ICD-10-P-30253J1, ICD-10-P-30253K0, ICD-10-P- 30253K1, ICD-10-P-30253L0, ICD-10-P-30253L1, ICD-10-P-30253M0, ICD-10-P-30253M1, ICD-10-P- 30253N0, ICD-10-P-30253N1, ICD-10-P-30253P0, ICD-10-P-30253P1, ICD-10-P-30253Q0, ICD-10-P- 30253Q1, ICD-10-P-30253R0, ICD-10-P-30253R1, ICD-10-P-30253S0, ICD-10-P-30253S1, ICD-10-P- 30253T0, ICD-10-P-30253T1, ICD-10-P-30253V0, ICD-10-P-30253V1, ICD-10-P-30253W0, ICD-10-P- 30253W1, ICD-10-P-30253X0, ICD-10-P-30253X1, ICD-10-P-30253Y0, ICD-10-P-30253Y1, ICD-10-P- 30260G0, ICD-10-P-30260G1, ICD-10-P-30260H0, ICD-10-P-30260H1, ICD-10-P-30260J0, ICD-10-P- 30260J1, ICD-10-P-30260K0, ICD-10-P-30260K1, ICD-10-P-30260L0, ICD-10-P-30260L1, ICD-10-P- 30260M0, ICD-10-P-30260M1, ICD-10-P-30260N0, ICD-10-P-30260N1, ICD-10-P-30260P0, ICD-10-P- 30260P1, ICD-10-P-30260Q0, ICD-10-P-30260Q1, ICD-10-P-30260R0, ICD-10-P-30260R1, ICD-10-P- 30260S0, ICD-10-P-30260S1, ICD-10-P-30260T0, ICD-10-P-30260T1, ICD-10-P-30260V0, ICD-10-P- 30260V1, ICD-10-P-30260W0, ICD-10-P-30260W1, ICD-10-P-30260X0, ICD-10-P-30260X1, ICD-10-P- 30260Y0, ICD-10-P-30260Y1, ICD-10-P-30263G0, ICD-10-P-30263G1, ICD-10-P-30263H0, ICD-10-P- 30263H1, ICD-10-P-30263J0, ICD-10-P-30263J1, ICD-10-P-30263K0, ICD-10-P-30263K1, ICD-10-P-30263L0, ICD- 10-P-30263L1, ICD-10-P-30263M0, ICD-10-P-30263M1, ICD-10-P-30263N0, ICD-10-P-30263N1, ICD-10-P- 30263P0, ICD-10-P-30263P1, ICD-10-P-30263Q0, ICD-10-P-30263Q1, ICD-10-P-30263R0, ICD-10-P- 30263R1, ICD-10-P-30263S0, ICD-10-P-30263S1, ICD-10-P-30263T0, ICD-10-P-30263T1, ICD-10-P- 30263V0, ICD-10-P-30263V1, ICD-10-P-30263W0, ICD-10-P-30263W1, ICD-10-P-30263X0, ICD-10-P-30263X1, ICD-10-P-30263Y0, ICD-10-P-30263Y1, ICD-10-P-30273H1, ICD-10-P-30273J1, ICD-10-P-30273K1, ICD-10-P- 30273L1, ICD-10-P-30273M1, ICD-10-P-30273N1, ICD-10-P-30273P1, ICD-10-P-30273Q1, ICD-10-P- 30273R1, ICD-10-P-30273S1, ICD-10-P-30273T1, ICD-10-P-30273V1, ICD-10-P-30273W1, ICD-10-P- 30277H1, ICD-10-P-30277J1, ICD-10-P-30277K1, ICD-10-P-30277L1, ICD-10-P-30277M1, ICD-10-P- 30277N1, ICD-10-P-30277P1, ICD-10-P-30277Q1, ICD-10-P-30277R1, ICD-10-P-30277S1, ICD-10-P- 30277T1, ICD-10-P-30277V1, ICD-10-P-30277W1, ICD-10-P-30280B1, ICD-10-P-30283B1
      Pulmonary embolismICD-9-D-4151:ICD-9-D-4159, ICD-10-D-I26:ICD-10-D-I269
      Acute kidney injuryICD-9-D-5845, ICD-9-D-5846, ICD-9-D-5847, ICD-9-D-5848, ICD-9-D-5849, ICD-10-D-N17:ICD-10-D-N179
      Myocardial infarctionICD-9-D-410:ICD-9-D-41099, ICD-9-D-412:ICD-9-D-41299, ICD-10-D-I21:ICD-10-D-I2199, ICD-10-D-I22:ICD-10-D-I2299, ICD-10-D-I252
      Deep vein thrombosisICD-9-D-4532, ICD-9-D-4533, ICD-9-D-4534, ICD-9-D-45382, ICD-9-D-45384, ICD-9-D-45385, ICD-9-D-45386, ICD-10-D-I26:ICD-10-D-I2699
      Table B.2Total hip joint complications.
      Code typeCode(s)
      Periprosthetic fractureICD-9-D-99644, ICD-10-D-M9701XA, ICD-10-D-M9702XA, ICD-10-D-T84040A, ICD-10-D-T84041A
      All-cause revision THACPT-27132, CPT-27134, CPT-27137, CPT-27138, CPT-11981, CPT-27091, CPT-20680, ICD-9-P-0070, ICD-9-P-0071, ICD-9-P-0072, ICD-9-P-0073, ICD-9-P-8153, ICD-9-P-8456, ICD-9-P-8457, ICD-10-P-0SW908Z, ICD-10-P-0SW909Z, ICD-10-P-0SW90BZ, ICD-10-P-0SW90JZ, ICD-10-P-0SW938Z, ICD-10-P-0SW93JZ, ICD-10-P-0SW94JZ, ICD-10-P-0SW9X8Z, ICD-10-P-0SW9XJZ, ICD-10-P-0SWA0JZ, ICD-10-P-0SWA4JZ, ICD-10-P-0SWAXJZ, ICD-10-P-0SWB08Z, ICD-10-P-0SWB09Z, ICD-10-P-0SWB0BZ, ICD-10-P-0SWB0JZ, ICD-10-P-0SWB3JZ, ICD-10-P-0SWB48Z, ICD-10-P-0SWB4JZ, ICD-10-P-0SWBX8Z, ICD-10-P-0SWBXJZ, ICD-10-P-0SWE0JZ, ICD-10-P-0SWE4JZ, ICD-10-P-0SWEXJZ, ICD-10-P-0SWR0JZ, ICD-10-P-0SWRXJZ, ICD-10-P-0SWS0JZ, ICD-10-P-0SWS3JZ, ICD-10-P-0SWS4JZ, ICD-10-P-0SWSXJZ
      Hip dislocationICD-9-D-99642, ICD-10-D-T84020A, ICD-10-D-T84021A
      Aseptic looseningICD-9-D-99641, ICD-10-D-T84030A, ICD-10-D-T84031A
      PJI
      Patients with PJI had to have both codes for PJI and revision in order to be included in the PJI group.
      ICD-9-D-99666, ICD-10-D-T8450XA, ICD-10-D-T8459XA
      a Patients with PJI had to have both codes for PJI and revision in order to be included in the PJI group.
      Table B.3Total knee joint complications.
      Code typeCode(s)
      Periprosthetic fractureICD-9-D-99644, ICD-10-D-M9711XA, ICD-10-D-M9712XA, ICD-10-D-T84042A, ICD-10-D-T84043A
      All-cause revision THACPT-27486, CPT-27487, ICD-9-P-0080, ICD-9-P-0081, ICD-9-P-0082, ICD-9-P-0083, ICD-9-P-0084, ICD-10-P-0SWC0JZ, ICD-10-P-0SWD0JZ, ICD-10-P-0SWC0JC, ICD-10-P-0SWCXJZ, ICD-10-P-0SWD0JC, ICD-10-P-0SWV0JZ, ICD-10-P-0SWDXJZ, ICD-10-P-0SWW0JZ, ICD-10-P-0SWC09Z, ICD-10-P-0SWT0JZ, ICD-10-P-0SWD09Z, ICD-10-P-0SWU0JZ, CPT-27488, ICD-9-P-8006, ICD-10-P-0SPC0JZ, ICD-10-P-0SPD0JZ, CPT-11981, ICD-9-P-8456, ICD-10-P-0SHC08Z, ICD-10-P-0SHD08Z, ICD-10-P-0SRC0EZ, ICD-10-P-0SRD0EZ, CPT-27447, ICD-9-P-8154, ICD-10-P-0SRC0J9, ICD-10-P-0SRC0JA, ICD-10-P-0SRC0JZ, ICD-10-P-0SRD0J9, ICD-10-P-0SRD0JA, ICD-10-P-0SRD0JZ, CPT-11982, ICD-9-P-8457, ICD-10-P-0SPC08Z, ICD-10-P-0SPC0EZ, ICD-10-P-0SPD08Z, ICD-10-P-0SPD0EZ
      MUA/LoACPT-27570, CPT-29884
      Aseptic looseningICD-9-D-99641, ICD-10-D-T84032A, ICD-10-D-T84033A
      PJI
      Patients with PJI had to have both codes for PJI and revision in order to be included in the PJI group.
      ICD-9-D-99666, ICD-10-D-M01X61, ICD-10-D-M01X62, ICD-10-D-M01X69, ICD-10-D-T8453XA, ICD-10-D-T8453XD, ICD-10-D-T8453XS, ICD-10-D-T8454XA, ICD-10-D-T8454XD, ICD-10-D-T8454XS
      LoA, lysis of adhesions; MUA, manipulation under anesthesia.
      a Patients with PJI had to have both codes for PJI and revision in order to be included in the PJI group.

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