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The use of preoperative continuous positive airway pressure in patients with obstructive sleep apnea following total hip arthroplasty: A propensity score matched analysis
, Daniel Hameeda, Jeremy A. Dubina, Sandeep S. Bainsa, Craig Shulb, Michael Monta, Ronald E. Delanoisa,
∗Corresponding author: Ronald E. Delanois. delanois@me.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Obstructive sleep apnea (OSA) impacts approximately 936 million individuals globally and is known to complicate post-surgical recovery, particularly after total hip arthroplasty (THA). While continuous positive airway pressure (CPAP) is commonly recommended for managing OSA, its effect on THA recovery remains uncertain. The study aimed to assess the impact of CPAP use on post-THA outcomes in patients with OSA, focusing on medical complications and periprosthetic joint infection (PJI) at 90 days and 1 year.
A national, all-payer database was utilized to identify patients undergoing primary THA between 2010 and 2021. Patients with OSA were stratified based on CPAP use through propensity score matching. Three matched groups were formed: OSA without CPAP, OSA with CPAP, and no OSA. Medical and surgical complications were assessed at 90 days and 1 year post-THA.
Patients with OSA using CPAP exhibited more baseline comorbidities than those without CPAP. CPAP use was associated with inferior outcomes, including higher odds of PJI, wound complications, and venous thromboembolism at 90 days and 1 year post-THA. These trends were consistent even after adjusting for confounders.
CPAP use, indicative of severe OSA, was linked to worse post-THA outcomes, emphasizing the importance of recognizing OSA severity preoperatively. The study does not advocate for or against CPAP use but underscores the heightened risk in this patient population, guiding clinicians in tailoring perioperative strategies and counseling patients about potential risks.
1 Introduction
Continuous positive airway pressure (CPAP) is a widely recommended treatment for obstructive sleep apnea (OSA); however, its influence on recovery post total hip arthroplasty (THA) remains uncertain.1 Given that nearly 25 % of American men experience OSA, it becomes crucial to ascertain whether CPAP can enhance surgical outcomes. Globally, OSA affects a staggering 936 million individuals, with 33.9 % of U.S. men and 17.4 % of women diagnosed.1 OSA is linked to increased mortality and adverse health effects, including cardiovascular disease, cerebrovascular events, and diabetes.2 Patients with OSA face a heightened risk of complications post total joint arthroplasty (TJA), encompassing thromboembolic events, transfusions, thrombocytopenia, as well as respiratory, cardiac, and digestive issues.3–6
CPAP is the primary OSA treatment, providing airflow to the lungs, maintaining positive end-expiratory pressure, reducing atelectasis, enhancing alveolar surface area, improving ventilation/perfusion matching, and augmenting oxygenation.7 Despite extensive research on the impact of preoperative CPAP in various surgeries, such as cardiac procedures, its exploration in the context of THA is less comprehensive.8 The American Society of Anesthesiologists advocates for preoperative screening for undiagnosed OSA, initiating CPAP pre-surgery, and monitoring postoperative patients with sleep apnea.9,10 However, a recent study on CPAP use in THA patients discovered that OSA patients on CPAP faced increased risks of medical complications, periprosthetic fracture, osteolysis, aseptic loosening, and dislocation.11 This discrepancy underscores the necessity for nuanced consideration and further investigation into CPAP's role in THA to refine preoperative protocols and optimize patient outcomes.
Due to the existing controversy in the evidence and limited data on preoperative CPAP use in OSA patients undergoing THA, our study sought to determine the rates of (1) medical complications (venous thromboembolism (VTE), pulmonary embolism (PE), wound complications, transfusions, and cardiac arrest) and (2) periprosthetic joint infection (PJI) at 90 days and 1 year in OSA patients, comparing those with and without CPAP use following THA.
2 Methods
2.1 Database selection
We conducted a thorough analysis utilizing a nationwide, multi-payer dataset (PearlDiver, Colorado Springs, Colorado), comprising over 120 million records in compliance with Health Insurance Portability and Accountability Act regulations across all U.S. states and territories. Recognized as one of the largest repositories of healthcare information, this dataset facilitates longitudinal patient tracking. Patient cohorts and baseline demographic information were identified using International Classification of Diseases (ICD) 10 procedural and diagnostic codes, along with Current Procedural Terminology (CPT) codes. Due to the retrospective study's involvement with patient-protected data, it obtained an exemption from institutional review board scrutiny.
2.2 Patient selection
Our focus was on individuals undergoing total hip arthroplasty (THA) between January 1, 2010, and October 31, 2021 (n = 1.97 million). Among them, we identified patients with a history of sleep apnea (n = 77,979) and categorized them based on CPAP use. To address confounding variables, a propensity score match analysis was conducted, pairing patients based on body mass index (BMI), age, gender, Charlson comorbidity index (CCI), tobacco and alcohol consumption, and diabetes. This resulted in the creation of three comparable groups: 1) sleep apnea patients without CPAP use (n = 48,737) matched with those using CPAP (n = 48,737), 2) non-sleep apnea patients (n = 44,965) matched with sleep apnea patients using CPAP (n = 44,965), and 3) non-sleep apnea patients (n = 44,965) matched with sleep apnea patients not using CPAP (n = 44,965).
2.3 Outcomes of interest
THA revisions were identified through CPT codes and associated ICD 10 procedure codes. Considered demographics included patient gender, age, alcohol consumption, CCI>3, cancer, chronic kidney disease (CKD), congestive heart failure, depression, diabetes mellitus, hypothyroidism, rheumatoid arthritis, obesity, and tobacco use at the time of surgery. Data on periprosthetic joint infections (PJIs), surgical site infections (SSI), aseptic revision, periprosthetic fracture (PPFx), and dislocation at 90-days, one-year, and two-year intervals were collected using CPT and ICD-10 diagnosis codes. PJIs were defined as prosthetic infections leading to joint revision. Additionally, medical complications such as cardiac arrest, stroke, pulmonary embolism, transfusion, venous thromboembolism, and wound complications at 90-days, 1-year, and 2-years were identified using ICD-10 and CPT codes.
2.4 Patient demographics
When comparing the sleep apnea cohort not using CPAP to those using CPAP, the latter were somewhat younger (average age: 59.0 vs. 62.0 years, p < 0.001) and included a higher proportion of women (42.7 % vs. 41.7 %, p = 0.002). Furthermore, the sleep apnea group contained a larger fraction of patients diagnosed with various comorbidities and risk factors. Interestingly, the proportion of patients with cancer was somewhat lower in the sleep apnea group than the non-sleep apnea group (18.5 % vs. 19.1 %, p = 0.041). Finally, the sleep apnea group contained a marginally larger fraction of patients with rheumatoid arthritis (6.2 % vs. 5.1 %, p < 0.001) (See Table 1).
| Sleep Apnea without CPAP n = 44,965 (%) | Sleep Apnea with CPAP n = 44,965 (%) | p-value | |
| Age (SD) | 62 (9.53) | 59 (8.85) | <0.001 |
| Sex | 0.002 | ||
| Female | 18,752 (41.70) | 19,216 (42.73) | |
| Male | 26,213 (58.29) | 25,749 (57.26) | |
| Alcohol Abuse | 2934 (6.52) | 4043 (8.99) | <0.001 |
| CCI >3 | 4226 (9.40) | 4198 (9.34) | <0.001 |
| CHF | 3913 (8.70) | 5374 (11.95) | <0.001 |
| Cancer | 8572 (19.06) | 8332 (18.53) | 0.041 |
| CKD | 8891 (19.77) | 10,125 (22.52) | <0.001 |
| Depression | 18,840 (41.89) | 22,550 (50.15) | <0.001 |
| Diabetes | 21,272 (47.31) | 25,518 (56.75) | <0.001 |
| F&E Disorder | 14,414 (32.06) | 17,453(38.81) | <0.001 |
| HTN | 38,956 (86.64) | 40,232 (89.47) | <0.001 |
| Hypothyroidism | 12,875 (28.63) | 13,586 (30.21) | <0.001 |
| RA | 2296 (5.11) | 2793 (6.21) | <0.001 |
| Obesity | 29,725 (66.11) | 36,666 (81.54) | <0.001 |
| Tobacco Use | 19,961 (44.39) | 23,201 (51.59) | <0.001 |
In comparing the sleep apnea group using CPAP with those who had no history of sleep apnea, the ages were comparable (60.0 vs. 60.0, p = 0.287), as was the proportion of women (42.6 % vs. 42.4 %, p = 0.448). Higher proportions of patients had various comorbidities and risk factors in the sleep apnea group using CPAP. Similarly, in comparison to the group with no sleep apnea history, the sleep apnea group without CPAP had similar age (62.0 vs. 62.0, p = 0.865) and a comparable proportion of women (41.7 % vs. 39.4 %, p = 0.802). The sleep apnea group without CPAP use had more patients with specific comorbidities and risk factors (See Tables 2 and 3).
| No Sleep Apnea n = 48,737 (%) | Sleep Apnea with CPAP n = 48,737 (%) | p-value | |
| Age (SD) | 60 (9.89) | 60 (9.24) | 0.287 |
| Sex | 0.448 | ||
| Female | 20,775 (42.63) | 20,657 (42.38) | |
| Male | 27,962 (57.37) | 28,080 (57.62) | |
| Alcohol Abuse | 4091 (8.39) | 4103 (8.42) | 0.899 |
| CCI >3 | 4448 (9.13) | 4585 (9.41) | <0.001 |
| CHF | 2302 (4.72) | 5770 (11.84) | <0.001 |
| Cancer | 7291 (14.96) | 9349 (19.18) | <0.001 |
| CKD | 6278 (12.88) | 10,993 (22.56) | <0.001 |
| Depression | 17,752 (36.42) | 23,863 (48.96) | <0.001 |
| Diabetes | 24,884 (51.06) | 26,202 (53.76) | <0.001 |
| F&E Disorder | 14,363 (29.47) | 18,700 (48.27) | <0.001 |
| HTN | 38,456(79.09) | 43,393 (89.04) | <0.001 |
| Hypothyroidism | 12,632 (25.92) | 14,673 (30.11) | <0.001 |
| RA | 2733 (5.61) | 2974 (6.10) | 0.001 |
| Obesity | 36,536 (74.96) | 36,861 (75.63) | 0.016 |
| Tobacco Use | 23,794 (48.82) | 24,108 (49.46) | 0.045 |
| No Sleep Apnea n = 44,965 (%) | Sleep Apnea without CPAP n = 44,965 (%) | p-value | |
| Age (SD) | 62 (9.77) | 62 (9.53) | 0.865 |
| Sex | 0.802 | ||
| Female | 18,714 (39.39) | 18,752 (41.70) | |
| Male | 26,251 (58.38) | 26,213 (58.29) | |
| Alcohol Abuse | 2813 (6.25) | 2934 (6.53) | 0.102 |
| CHF | 2320 (5.16) | 3913 (8.70) | <0.001 |
| CCI >3 | 3967 (8.82) | 4226 (9.40) | <0.001 |
| Cancer | 7563 (16.82) | 8572 (19.06) | <0.001 |
| CKD | 6286 (13.98) | 8891 (19.77) | <0.001 |
| Depression | 15,692 (34.89) | 18,840 (41.89) | <0.001 |
| Diabetes | 20,902 (46.48) | 21,272 (47.31) | 0.014 |
| F&E Disorder | 13,354 (29.69) | 14,414 (32.06) | <0.001 |
| HTN | 35,953 (79.95) | 38,956 (86.64) | <0.001 |
| Hypothyroidism | 12,033 (26.76) | 12,875 (28.63) | <0.001 |
| RA | 2497 (5.55) | 2296 (5.11) | 0.003 |
| Obesity | 29,628 (65.89) | 29,725 (66.11) | 0.499 |
| Tobacco Use | 19,946 (44.35) | 19,961 (44.39) | 0.925 |
2.5 Statistical analysis
Age and other continuous variables underwent comparison through Student's t-tests. Bivariate analyses employed Chi-square tests to assess categorical variables, including specific demographics, comorbidities, and complications. Propensity score matching, with a 1:1 ratio, was implemented to ensure comparable patient groups for a comprehensive evaluation of complications and minimize potential confounding bias. All statistical analyses were conducted using R Studio within the Statistic Department of the University of Auckland, Auckland, New Zealand, with statistical significance set at p < 0.05.
3 Results
3.1 Sleep apnea without CPAP verses with CPAP
In patients with sleep apnea, a distinction was observed between those who utilized continuous positive airway pressure (CPAP) and those who didn't. Within the first 90 days post-operation, sleep apnea patients who utilized CPAP had increased rates of blood transfusion (0.96 % vs. 1.31 %, p < 0.001), pulmonary embolism (0.18 % vs. 0.28 %, p = 0.003), ventricular tachycardia (0.75 % vs. 1.08 %, p < 0.001), wound complications (1.72 % vs. 2.13 %, p < 0.001), periprosthetic joint infection (0.78 % vs. 0.95 %, p = 0.006), and surgical site infection (1.28 % vs. 1.68 %, p < 0.001). These disparities persisted at the 1-year mark, particularly for periprosthetic joint infection (0.93 % vs. 1.15 %, p = 0.001) and surgical site infection (1.61 % vs. 2.12 %, p < 0.001). By the 2-year mark, these two complications continued to show significant differences, with rates of 1.00 % vs. 1.23 % for PJI (p < 0.001) and 1.87 % vs. 2.53 % for SSI (p < 0.001), while other outcomes like aseptic revision and dislocation remained consistent across both groups (see Table 4).
| Sleep Apnea without CPAP n = 44,965 (%) | Sleep Apnea with CPAP n = 44,965 (%) | p-value | |
| 90-day Complications | |||
| Aseptic revision | 175 (0.38) | 194 (0.43) | 0.347 |
| Blood transfusion | 436 (0.96) | 592 (1.31) | <0.001 |
| Cardiac Arrest | 55 (0.12) | 65 (0.14) | 0.411 |
| Stroke | 348 (0.77) | 373 (0.82) | 0.370 |
| PE | 82 (0.18) | 126 (0.28) | 0.003 |
| VT | 341 (0.75) | 487 (1.08) | <0.001 |
| WC | 776 (1.72) | 960 (2.13) | <0.001 |
| PJI | 353 (0.78) | 430 (0.95) | 0.006 |
| SSI | 580 (1.28) | 757 (1.68) | <0.001 |
| Dislocation | 88 (0.19) | 105 (0.23) | 0.249 |
| 1-year Complications | |||
| Aseptic revision | 318 (0.70) | 345 (0.76) | 0.311 |
| PJI | 419 (0.93) | 519 (1.15) | 0.001 |
| SSI | 726 (1.61) | 995 (2.12) | <0.001 |
| 2-year Complications | |||
| Aseptic revision | 381 (0.84) | 431 (0.95) | 0.084 |
| PJI | 452 (1.00) | 557 (1.23) | <0.001 |
| SSI | 841 (1.87) | 1140 (2.53) | <0.001 |
| Dislocation | 113 (0.25) | 141 (0.31) | 0.090 |
Table 7 further elaborates on these findings, presenting odds ratios (OR) for post-operative complications. For the initial 90 days post-operation, sleep apnea patients using CPAP demonstrated increased odds for complications such as blood transfusion (OR: 1.36, 95 % CI: 1.20–1.54), cardiac arrest (OR: 1.18, 95 % CI: 0.83–1.69), pulmonary embolism (OR: 1.54, 95 % CI: 1.16–2.03), ventricular tachycardia (OR: 1.43, 95 % CI: 1.25–1.65), wound complications (OR: 1.24, 95 % CI: 1.13–1.37), periprosthetic joint infection (OR: 1.22, 95 % CI: 1.06–1.41), and surgical site infection (OR: 1.31, 95 % CI: 1.18–1.46). This trend continued at the 1-year and 2-year marks, with notably elevated odds for periprosthetic joint infection (OR: 1.24 and 1.23, respectively) and surgical site infection (OR: 1.38 and 1.36, respectively).
3.2 No sleep apnea verses with sleep apnea with CPAP
Within 90 days post-operation, those using CPAP demonstrated heightened rates in cardiac arrest (0.14 % vs. 0.07 %, p = 0.002), stroke (0.85 % vs. 0.49 %, p < 0.001), ventricular tachycardia (VT) (1.08 % vs. 0.55 %, p < 0.001), wound complications (WC) (2.08 % vs. 1.37 %, p < 0.001), periprosthetic joint infection (PJI) (0.92 % vs. 0.655 %, p < 0.001), and surgical site infection (SSI) (1.62 % vs. 1.27 %, p < 0.001). By the 1-year milestone, the disparities in PJI (1.11 % vs. 0.82 %, p < 0.001) and SSI (2.12 % vs. 1.60 %, p < 0.001) remained evident. At the 2-year juncture, PJI (1.19 % vs. 0.89 %, p < 0.001) and SSI (2.44 % vs. 1.85 %, p < 0.001) continued to show significant differences. However, outcomes like aseptic revision and dislocation maintained consistent rates across both groups (see Table 5).
| No Sleep Apnea n = 48,737 (%) | Sleep Apnea with CPAP n = 48,737 (%) | p-value | |
| 90-day Complications | |||
| Aseptic revision | 190 (0.39) | 204 (0.42) | 0.511 |
| Blood transfusion | 603 (1.24) | 624 (1.28) | 0.566 |
| Cardiac Arrest | 37 (0.07) | 70 (0.14) | 0.002 |
| Stroke | 241 (0.49) | 415 (0.85) | <0.001 |
| PE | 117 (0.24) | 135 (0.27) | 0.284 |
| VT | 270 (0.55) | 525 (1.08) | <0.001 |
| WC | 667 (1.37) | 1007 (2.08) | <0.001 |
| PJI | 317 (0.655) | 446 (0.92) | <0.001 |
| SSI | 618 (1.27) | 784 (1.62) | <0.001 |
| Dislocation | 112 (0.23) | 113 (0.23) | 1.000 |
| 1-year Complications | |||
| Aseptic revision | 373 (0.77) | 364 (0.75) | 0.767 |
| PJI | 397 (0.82) | 538 (1.11) | <0.001 |
| SSI | 776 (1.60) | 1030 (2.12) | <0.001 |
| 2-year Complications | |||
| Aseptic revision | 491 (1.01) | 453 (0.93) | 0.226 |
| PJI | 433 (0.89) | 578 (1.19) | <0.001 |
| SSI | 896 (1.85) | 1181 (2.44) | <0.001 |
Further, Table 7 highlights the odds ratios (OR) for post-operative complications among sleep apnea patients using CPAP. For the initial 90 days post-operation, these patients showed elevated odds for complications such as cardiac arrest (OR: 1.89, 95 % CI: 1.27–2.82), stroke (OR: 1.72, 95 % CI: 1.47–2.03), VT (OR: 1.95, 95 % CI: 1.69–2.26), WC (OR: 1.52, 95 % CI: 1.38–1.68), PJI (OR: 1.41, 95 % CI: 1.22–1.63), and SSI (OR: 1.27, 95 % CI: 1.14–1.42). By the 1-year and 2-year marks, the odds for PJI and SSI remained significantly elevated for those using CPAP (see Table 5).
3.3 No sleep apnea verses with sleep apnea without CPAP
Table 6 provides a bivariate analysis of post-operative outcomes, contrasting patients without sleep apnea to those with sleep apnea who did not utilize continuous positive airway pressure (CPAP). At the 90-day post-operative mark, there were significant differences in the rates of blood transfusion (1.24 % vs. 0.96 %, p < 0.001), stroke (0.55 % vs. 0.77 %, p < 0.001), ventricular tachycardia (VT) (0.54 % vs. 0.75 %, p < 0.001), wound complications (WC) (1.21 % vs. 1.72 %, p < 0.001), periprosthetic joint infection (PJI) (0.55 % vs. 0.78 %, p < 0.001), and surgical site infection (SSI) (1.13 % vs. 1.28 %, p = 0.033). By the 1-year interval, there were notable differences in the rates of PJI (0.71 % vs. 0.93 %, p < 0.001) and SSI (1.42 % vs. 1.61 %, p = 0.020). At the 2-year post-operative period, significant disparities were observed in the rates of aseptic revision (1.00 % vs. 0.84 %, p = 0.016), PJI (0.78 % vs. 1.01 %, p < 0.001), and SSI (1.68 % vs. 1.87 %, p = 0.038). Other outcomes, such as cardiac arrest and dislocation, showed no statistically significant differences between the two groups at the various time points (Table 6).
| No Sleep Apnea n = 44,965 (%) | Sleep Apnea without CPAP n = 44,965 (%) | p-value | |
| 90-day Complications | |||
| Aseptic revision | 178 (0.39) | 175 (0.38) | 0.915 |
| Blood transfusion | 559 (1.24) | 436 (0.96) | <0.001 |
| Cardiac Arrest | 41 (0.09) | 55 (0.12) | 0.184 |
| Stroke | 251 (0.55) | 348 (0.77) | <0.001 |
| PE | 109 (0.24) | 82 (0.18) | 0.060 |
| VT | 245 (0.54) | 341 (0.75) | <0.001 |
| WC | 548 (1.21) | 776 (1.72) | <0.001 |
| PJI | 251 (0.55) | 353 (0.78) | <0.001 |
| SSI | 509 (1.13) | 580 (1.28) | 0.033 |
| Dislocation | 96 (0.21) | 88 (0.19) | 0.606 |
| 1-year Complications | |||
| Aseptic revision | 344 (0.76) | 318 (0.70) | 0.329 |
| PJI | 321 (0.71) | 419 (0.93) | <0.001 |
| SSI | 640 (1.42) | 726 (1.61) | 0.020 |
| 2-year Complications | |||
| Aseptic revision | 451 (1.00) | 381 (0.84) | 0.016 |
| PJI | 353 (0.78) | 452 (1.01) | <0.001 |
| SSI | 758 (1.68) | 841 (1.87) | 0.038 |
| Sleep Apnea with CPAPa | Sleep Apnea without CPAPa | |||
| OR | 95 % CI | OR | 95 % CI | |
| 90-day Complications | ||||
| Aseptic revision | 1.07 | 0.88–1.31 | 0.98 | 0.79–1.21 |
| Blood Transfusion | 1.03 | 0.92–1.16 | 0.77 | 0.68–0.88 |
| Cardiac Arrest | 1.89 | 1.27–2.82 | 1.34 | 0.90–2.01 |
| Stroke | 1.72 | 1.47–2.03 | 1.39 | 1.18–1.64 |
| PE | 1.15 | 0.90–1.48 | 0.75 | 0.56–1.00 |
| VT | 1.95 | 1.69–2.26 | 1.39 | 1.18–1.63 |
| WC | 1.52 | 1.38–1.68 | 1.42 | 1.27–1.59 |
| PJI | 1.41 | 1.22–1.63 | 1.41 | 1.20–1.66 |
| SSI | 1.27 | 1.14–1.42 | 1.14 | 1.01–1.29 |
| Dislocation | 1.01 | 0.78–1.31 | 0.91 | 0.68–1.22 |
| 1-year Complications | ||||
| Aseptic revision | 0.98 | 0.84–1.13 | 0.92 | 0.79–1.07 |
| PJI | 1.36 | 1.19–1.55 | 1.31 | 1.13–1.51 |
| SSI | 1.33 | 1.21–1.47 | 1.14 | 1.02–1.27 |
| 2-year Complications | ||||
| Aseptic revision | 0.92 | 0.81–1.05 | 0.84 | 0.73–0.96 |
| PJI | 1.34 | 1.18–1.52 | 1.28 | 1.11–1.47 |
| SSI | 1.33 | 1.21–1.45 | 1.11 | 1.01–1.23 |
| Dislocation | b | b | b | b |
Additionally, sleep apnea patients not on CPAP demonstrated heightened odds for complications such as stroke (OR: 1.39, 95 % CI: 1.18–1.64), VT (OR: 1.39, 95 % CI: 1.18–1.63), WC (OR: 1.42, 95 % CI: 1.27–1.59), and PJI (OR: 1.41, 95 % CI: 1.20–1.66). By the end of the first and second years, these patients continued to show increased odds for PJI and SSI (see Table 7)
4 Discussion
Sleep apnea, a prevalent and potentially severe sleep disorder, has garnered significant attention for its potential impact on post-operative outcomes. Although continuous positive airway pressure (CPAP) is a standard therapeutic approach for sleep apnea, ongoing debates surround its implications for post-operative complications. Our comprehensive study delved into this area, contrasting the post-operative outcomes of sleep apnea patients using CPAP with those not using CPAP and individuals without the disorder. Within the initial 90 days post-operation, sleep apnea patients on CPAP exhibited elevated complications, including cardiac arrest, stroke, and wound issues, compared to their counterparts not using CPAP. This trend persisted up to the 2-year mark, particularly concerning periprosthetic joint infection (PJI) and surgical site infection (SSI). However, outcomes such as aseptic revision and dislocation showed consistency across both groups. Furthermore, even among sleep apnea patients without CPAP, heightened risks for complications like stroke and ventricular tachycardia persisted two years post-operation. Our results suggest that sleep apnea, whether managed with CPAP or not, appears to influence post-operative outcomes, emphasizing the critical importance of thorough pre-operative assessments and tailored perioperative care for this specific patient population. The increased risks associated with CPAP usage warrant further investigation to refine and optimize patient care strategies in this context.
Numerous prior investigations have identified OSA as an independent risk factor for various orthopedic procedures, including both primary and revision total joint arthroplasty (TJA). Over a decade of research on TJA revealed that sleep apnea correlated with a heightened 90-day risk for multiple medical and surgery-related complications, as well as increased hospital utilization. Similar studies have indicated that OSA is linked with an escalated risk of in-hospital mortality and wound-related complications post-revision joint arthroplasty. Furthermore, OSA patients have been identified as having a higher likelihood of requiring transfusions and experiencing thromboembolic complications, potentially due to elevated levels of coagulation factors. This surge in prothrombotic agents might also elucidate the amplified risk of cardiovascular issues, including myocardial infarction and stroke. Our research echoes these findings, highlighting that sleep apnea patients using CPAP face a greater risk of cardiovascular, thromboembolic, and medical complications compared to those not on CPAP. We hypothesize that patients with sleep apnea on CPAP likely represent a subset with more pronounced and active disease, offering a potential avenue for clinicians and surgeons to better assess risk in OSA patients during the preoperative phase.
Our findings align with existing research, indicating that patients with sleep apnea, especially those using CPAP pre-operatively, encounter increased complications post-total hip arthroplasty (THA). This pattern is not only apparent immediately after surgery but also extends up to two years post-operation. Sleep apnea introduces various pathophysiological changes, including elevated protein levels, diminished natural killer cells, and the triggering of inflammatory markers, all of which can lead to adverse outcomes. Notably, our study emphasizes the elevated risks of post-operative complications in sleep apnea patients, such as periprosthetic joint infection (PJI) and surgical site infection (SSI), regardless of CPAP usage. Historically, the link between sleep apnea and metabolic bone diseases has been associated with inadequate oxygen delivery, affecting bone cell development and maturation. For example, a study by Chen et al. revealed that those with sleep apnea were 2.7 times more likely to develop osteoporosis. Beyond impacting bone health, reduced oxygenation can weaken the immune system, potentially heightening the risk of infections like PJI and SSI. Other research points to sleep apnea amplifying surgical risks due to mechanisms like protein cascade activation, vascular anomalies, and increased inflammatory reactions. This combination of weakened immunity and vascular challenges might be pivotal in the heightened post-surgical infection rates observed in sleep apnea patients.
Our study, while comprehensive, acknowledges certain limitations. Relying on a large-scale administrative insurance database necessitates accurate data entry and coding for diagnoses, comorbidities, and procedures. Recent research indicates that inaccuracies in such databases are typically below 1 %. Additionally, the ICD-10 diagnosis codes used do not capture the severity of sleep apnea, limiting our ability to delve into how varying severities of OSA might influence postoperative complications related to THA. Another limitation is that the coding system doesn't provide insights into patients' compliance with their CPAP usage, which could affect the broader applicability of our conclusions. While we didn't account for all potential comorbidities that could influence sleep apnea outcomes, it's worth noting that the severity of sleep apnea, if included, might offer deeper insights into the interplay between sleep apnea and CPAP usage, beyond the assumption that CPAP is primarily used for severe cases. Despite these limitations, our research stands out due to its extensive propensity-matched analysis, comparing THA outcomes in sleep apnea patients with and without CPAP, and contrasting these with outcomes in patients without sleep apnea.
This research holds significant implications for surgeons and clinicians overseeing patients with OSA who use CPAP machines and are slated for THA. Our results indicate that patients utilizing CPAP machines face a heightened risk of early medical and surgical complications post-THA. While CPAP usage might often be indicative of more severe OSA cases, our study offers a clearer understanding of the magnitude of risk associated with this specific subset of OSA patients. While CPAP undoubtedly offers essential medical advantages, our findings emphasize the need for enhanced preoperative and perioperative counseling and optimization for these patients. This is crucial to mitigate their elevated risk of medical and surgical complications, as evidenced by our study.
5 Conclusion
Our research indicates that individuals with obstructive sleep apnea (OSA) using continuous positive airway pressure (CPAP) face heightened risks of medical complications within the first 90 days, surgical complications extending up to one year, and increased healthcare utilization compared to OSA patients who are not actively using CPAP. These findings are crucial for making well-informed decisions during preoperative and perioperative stages, providing valuable guidance for counseling high-risk patients before and during THA.
Funding
None.
Patient consent
No patient consent needed due to retrospective nature and public database.
Ethical approval
IRB exemption due to retrospective nature and public database.
Data availability
Available in a respository upon request.
CRediT authorship contribution statement
Brittany Oster: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Daniel Hameed: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Jeremy A. Dubin: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Sandeep S. Bains: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Craig Shul: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Michael Mont: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Ronald E. Delanois: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.
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