Orthopedics

Feature Article 

Dual Diagnosis and Total Hip Arthroplasty

Mitchell R. Klement, MD; Brian T. Nickel, MD; Abiram Bala, MD; Colin T. Penrose, MD; Cynthia L. Green, PhD; Samuel S. Wellman, MD; Michael P. Bolognesi, MD; Thorsten M. Seyler, MD, PhD

Abstract

The co-occurrence of a mental illness and a substance abuse disorder (SUD) is common and has been referred to as a “dual diagnosis” (DD). Although studies have independently investigated mental illness alone and SUD alone, few have examined the effects of these entities combined on complications. A search of the Medicare database from 2005 to 2012 identified 2000 DD patients who underwent total hip arthroplasty (THA). They were compared with 86,976 patients with mental illness only and 590,689 controls (no mental illness or SUD). Medical comorbidities and postoperative complications at 30-day, 90-day, and minimum 2-year time points were analyzed. There was a significant increase (P<.001) in 7 (53.8%) of 13 recorded postoperative medical complications, including acute renal failure (odds ratio [OR], 1.78), postoperative anemia (OR, 1.31), and blood transfusion (OR, 1.24), at the 90-day time point. In addition, there was a statistically significant increase overall in periprosthetic infection (periprosthetic joint infection OR, 4.30; P<.001), periprosthetic fracture (OR, 2.80; P<.001), dislocation (OR, 6.38; P<.001), and the need for THA revision (OR, 3.58; P<.001). When compared with patients with mental illness only, DD patients remained at significantly (P<.001) increased risk for 90-day and overall postoperative surgical complications, including dislocation, periprosthetic joint infection, and THA revision. Patients with a DD were at significant risk for perioperative complications compared with both control patients and patients with mental illness only. Studies investigating only psychiatric disease or only SUD may miss a vulnerable cohort. Further investigation is needed to exactly define to what extent DD amplifies complication rates. [Orthopedics. 2018; 41(3):e321–e327.]

Abstract

The co-occurrence of a mental illness and a substance abuse disorder (SUD) is common and has been referred to as a “dual diagnosis” (DD). Although studies have independently investigated mental illness alone and SUD alone, few have examined the effects of these entities combined on complications. A search of the Medicare database from 2005 to 2012 identified 2000 DD patients who underwent total hip arthroplasty (THA). They were compared with 86,976 patients with mental illness only and 590,689 controls (no mental illness or SUD). Medical comorbidities and postoperative complications at 30-day, 90-day, and minimum 2-year time points were analyzed. There was a significant increase (P<.001) in 7 (53.8%) of 13 recorded postoperative medical complications, including acute renal failure (odds ratio [OR], 1.78), postoperative anemia (OR, 1.31), and blood transfusion (OR, 1.24), at the 90-day time point. In addition, there was a statistically significant increase overall in periprosthetic infection (periprosthetic joint infection OR, 4.30; P<.001), periprosthetic fracture (OR, 2.80; P<.001), dislocation (OR, 6.38; P<.001), and the need for THA revision (OR, 3.58; P<.001). When compared with patients with mental illness only, DD patients remained at significantly (P<.001) increased risk for 90-day and overall postoperative surgical complications, including dislocation, periprosthetic joint infection, and THA revision. Patients with a DD were at significant risk for perioperative complications compared with both control patients and patients with mental illness only. Studies investigating only psychiatric disease or only SUD may miss a vulnerable cohort. Further investigation is needed to exactly define to what extent DD amplifies complication rates. [Orthopedics. 2018; 41(3):e321–e327.]

Psychiatric diseases in patients undergoing total hip arthroplasty (THA) have been associated with increased perioperative morbidity and mortality.1–4 Furthermore, it is estimated that as many as 50% of patients with a psychiatric disease may also have a concomitant substance abuse disorder (SUD).5 Forty-one percent of those with a lifetime SUD will also have a lifetime history of at least 1 mental disorder, according to the National Comorbidity Survey.6 Substance abuse independently has been linked to inferior outcomes in THA7,8 and may confound existing studies investigating psychiatric disease alone. The coexistence of a psychiatric disease and substance abuse is called a “dual diagnosis” (DD).

Individuals with a DD have interacting chronic, remitting, and relapsing conditions that exacerbate and intensify one another, causing a superordinate condition more severe than the sum of its parts.9 As a result, individuals with a DD, compared with individuals with either problem alone, have increased symptoms, higher prevalence of physical health problems, more noncompliance with all health care regimens, more frequent relapses and hospitalizations, more treatment complications, and more problems with self-care, violence, and homelessness.5

Many studies have investigated the effect of either psychiatric disease or substance abuse on complications after THA, but there are currently no studies investigating the role of DD in THA. Before the impact of psychiatric disease can be truly appreciated in the THA population, the close association with SUD must be investigated, as patients with a DD have more severe, persistent, and treatment-resistant psychiatric and substance disorders.10 The purpose of this study was to evaluate the effect of DD on medical and surgical complication profiles after THA. Both control patients and patients with mental illness only were compared with DD patients.

Materials and Methods

This study was exempt from institutional review board approval because a public database was used and no protected health information was included. Pearl-Diver technologies (PearlDiver Inc, Colorado Springs, Colorado) was used to search 100% of the Medicare database from 2005 to 2012 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and Current Procedural Terminology (CPT) codes. All patients who underwent primary THA (ICD-9-CM code V43.64 and CPT code 27130) with psychiatric disease (bipolar, ICD-9-CM codes 296.0, 296.40-296.89; depression, ICD-9-CM codes 296.2–296.3; schizophrenia, ICD-9-CM codes 295.00–295.95) and SUD (alcohol, ICD-9-CM code 305.00; opioids, ICD-9-CM code 305.50; sedative, ICD-9-CM code 305.40; cocaine, ICD-9-CM code 305.60; cannabis, ICD-9-CM code 305.20) during the study period with minimum 2-year follow-up were included. The control group consisted of patients who underwent THA and did not carry a diagnosis of psychiatric disease and/or SUD. The ICD-9-CM and CPT codes were also used to determine rates of various postoperative complications that occurred within 30 days, within 90 days, and within final time point (overall) with minimum 2-year follow-up. The comorbidities of the various groups were identified and recorded based on the Elixhauser comorbidity index.11

Non-missing data were summarized using counts and percentages. If the frequency within an individual category was 10 or less, then the exact count was not made available by design of PearlDiver technologies; the authors imputed a value of 5 in these rare incidences. The frequencies of the DD patients were compared with those of both the control patients (no history of psychiatric disease or SUD) and the patients with mental illness only at 30 days, 90 days, and overall (minimum 2-year follow-up). The result was presented as odds ratio (OR) with 95% confidence interval (CI) for each comorbidity using the chi-square test within both table format and forest plots. Expected cell counts of less than 5 were observed within only 1 complication (osteolysis/polywear), and the result obtained using the chi-square test compared with Fisher's exact test did not change the interpretation of results. Thus, chi-square tests were used for all comparisons. P≤.05 indicated statistical significance. SAS version 9.4 software (SAS Institute, Inc, Cary, North Carolina) was used for all analyses.

The DD cohort was compared with a cohort of patients with psychiatric disease only to isolate the effects of the addition of a coexisting SUD. The cohort of patients with psychiatric disease only and these methods have been previously described.4

Results

The search identified 2000 patients with a DD, 86,976 patients with psychiatric disease only, and 590,689 control patients (no psychiatric disease or SUD). Patients with a DD were more likely to be younger (age <65 years; OR, 77.48; P<.001), male (OR, 2.13; P<.001), and more medically complex (significant increase in 28 of 29 Elixhauser comorbidities; P<.01) compared with control patients. Dual diagnosis patients remained more likely to be younger (age <65 years; OR, 6.62), male (OR, 4.24), and more medically complex (significant increase in 27 of 29 Elixhauser comorbidities; P<.05).

Within 30 days after surgery, the DD cohort had a significant increase in 7 (53.8%) of 13 recorded medical complications, including respiratory failure (OR, 2.57; P<.001), pneumonia (OR, 2.41; P<.001), sepsis or systemic inflammatory response syndrome (OR, 2.46; P<.001), acute renal failure (OR, 1.57; P<.001), postoperative anemia (OR, 1.29; P<.001), and the need for blood transfusion (OR, 1.22; P<.001), compared with control patients (Table 1). Within 90 days after surgery, the same medical complications remained significant (Figure 1). There were no differences observed at either time point regarding heart failure, deep venous thrombosis, pulmonary embolism, or stroke; however, there was a statistically significant decrease in myocardial infarction and arrhythmia (Figure 1, Table 1).

Medical and Surgical Complications Within the 30-Day Time Point

Table 1:

Medical and Surgical Complications Within the 30-Day Time Point

Postoperative medical complications within 90 days. Abbreviations: LCL, lower confidence limit; OR, odds ratio; PD, psychiatric disease only; SIRS, systemic inflammatory response syndrome; UCL, upper confidence limit.

Figure 1:

Postoperative medical complications within 90 days. Abbreviations: LCL, lower confidence limit; OR, odds ratio; PD, psychiatric disease only; SIRS, systemic inflammatory response syndrome; UCL, upper confidence limit.

Regarding surgical complications, there was a significant increase in 8 (80%) of 10 recorded complications, including dislocation (OR, 7.66; P<.001), bleeding complications (OR, 1.81; P<.001), cellulitis/seroma (OR, 3.65; P<.001), and wound complications (OR, 3.70; P<.001), at 30 days. The same surgical complications were significantly increased at 90 days and overall (minimum 2-year follow-up). At the overall time point, there was a significant increase in periprosthetic infection (OR, 4.30; P<.001), the need for irrigation and debridement (OR, 4.35; P<.001), dislocation (OR, 6.38; P<.001), periprosthetic fracture (OR, 2.80; P<.001), and THA revision (OR, 3.58; P<.001) (Figure 2).

Postoperative surgical complications at overall time point comparing dual diagnosis cohort with control cohort. Abbreviations: I&D, irrigation and debridement; LCL, lower confidence limit; OR, odds ratio; PD, psychiatric disease only; THA, total hip arthroplasty; UCL, upper confidence limit.

Figure 2:

Postoperative surgical complications at overall time point comparing dual diagnosis cohort with control cohort. Abbreviations: I&D, irrigation and debridement; LCL, lower confidence limit; OR, odds ratio; PD, psychiatric disease only; THA, total hip arthroplasty; UCL, upper confidence limit.

Finally, when compared with patients with psychiatric disease only, patients with a DD had significantly fewer medical complications, including myocardial infarction, heart failure, arrhythmia with atrial fibrillation, stroke, and the need for blood transfusion, at 30 days postoperatively (Table 2). Despite this, DD patients had significantly more surgical complications, including periprosthetic infection, cellulitis/seroma, dislocation, wound complications, the need for arthrotomy/irrigation and debridement, and any cause revision, at 30 days (Table 2). This increase in surgical complications remained statistically significant at the overall time point as well. All complications, with the exception of osteolysis/polywear, were increased at the final follow-up (Figure 3). The addition of a SUD to an existing psychiatric disease nearly doubled the rate of arthrotomy/irrigation and debridement, any cause revision, and dislocation at the final follow-up (Figure 3). The addition of a SUD led to a significant increase in infection (Figure 4).

Medical and Surgical Complications Within the 30-Day Time Point Comparing the Dual Diagnosis Group With the Psychiatric Disease Only Group

Table 2:

Medical and Surgical Complications Within the 30-Day Time Point Comparing the Dual Diagnosis Group With the Psychiatric Disease Only Group

Postoperative surgical complications at overall time point comparing dual diagnosis cohort with psychiatric disease only (PD) cohort. Abbreviations: I&D, irrigation and debridement; LCL, lower confidence limit; OR, odds ratio; THA, total hip arthroplasty; UCL, upper confidence limit.

Figure 3:

Postoperative surgical complications at overall time point comparing dual diagnosis cohort with psychiatric disease only (PD) cohort. Abbreviations: I&D, irrigation and debridement; LCL, lower confidence limit; OR, odds ratio; THA, total hip arthroplasty; UCL, upper confidence limit.

Bar graph comparing periprosthetic infection rates at all time points between dual diagnosis (far right) cohort, psychiatric disease only (PD) cohort (middle), and control cohort (far left). All differences between all groups were significant (P<.05).

Figure 4:

Bar graph comparing periprosthetic infection rates at all time points between dual diagnosis (far right) cohort, psychiatric disease only (PD) cohort (middle), and control cohort (far left). All differences between all groups were significant (P<.05).

Discussion

Since the development of the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, and its multiaxial system, the term dual diagnosis has been commonly used within the fields of mental health, psychiatry, and addiction medicine to describe the co-occurrence of a SUD and a psychiatric disorder.12,13 The psychiatric disorder usually manifests before the SUD. Regardless of the order, their co-occurrence is not infrequent, with an estimated 2.2% to 3.3%14 of the general US population having a DD.

The complexity of DD would certainly explain the increased medical complications seen in this study. It is well established that patients with psychiatric disease alone have an increased risk of developing comorbidities such as cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer, making their preexisting psychiatric disease more severe.15–18 These patients also have lower use of medical care, reduced adherence to treatments for chronic diseases, and higher risks of adverse health outcomes.18 These factors, coupled with the increased risk of drug and alcohol use, could certainly explain the increased medical complications in this group compared with the general population.

The results of this study are similar to those of previous studies. Best et al,8 using the National Hospital Discharge Survey database, found an increased risk of general medical complications (OR, 1.30) among patients who misused alcohol. Best et al7 also used the National Hospital Discharge Survey database to examine drug misuse, finding higher odds of postoperative infection, anemia, convulsions, osteomyelitis, and blood transfusion. However, these studies were limited to data available only during in-patient hospitalization. Yu et al19 studied complications in patients with substance abuse, finding high rates of postoperative substance withdrawal delirium and psychosis (46%), late complications (25%), and loss to follow-up (27%). Yu et al19 described these patients as having unexpected perioperative psychotic episodes, poor compliance, and a tendency to not follow medical advice after surgery.19 Although these patients have more medical complications compared with the general population, they appear to have fewer medical complications compared with the psychiatric disease only cohort. The etiology for this has yet to be determined and warrants further investigation.

Perhaps the most striking finding of this study was the drastic increase in the odds of the recorded surgical complications in the DD cohort compared with both the control cohort and the psychiatric disease only cohort. The authors previously reported an increased odds of these same surgical complications in a psychiatric disease only cohort when compared with a control group4; however, in the current study, these odds were further increased when a coexisting SUD was present. Psychiatric disease2,20 and drug abuse21 have been associated with increased risk of infection due to dysregulation of the immune system with the former22 and the risk of bacteremia with the latter, accounting for the increased odds of irrigation and debridement and periprosthetic joint infection in the current study. Furthermore, both psychiatric disease23,24 and alcoholism25,26 are risk factors for osteoporosis and falls. This combination places patients with a DD at extreme risk of dislocation and periprosthetic fracture. In the current study, patients were most at risk for dislocation across all time points (30-day OR, 7.66; 90-day OR, 5.66; overall OR, 4.44). Given these factors, it is not surprising that the risk of THA revision was increased at the overall time point (minimum 2-year follow-up), although the exact etiologies for revision were not reported.

Although there is much literature on psychiatric disease and drug abuse, few if any studies have investigated the effects of these combined diagnoses on complications after THA. In previous studies, although multivariable regression analysis has been useful for eliminating potential confounding variables, it may not appropriately capture the synergistic interactions seen in DD.

Strengths of the current study included the use of a large national database to combine a variety of psychiatric and substance abuse disorders and generate large patient cohorts for analysis. Also, this is the first large database study on DD extending complication analysis beyond discharge and into the global period and short-term follow-up.

Limitations of this study included its retrospective nature and the lack of specific patient data (eg, DD duration, pharmacologic treatment, counseling history, and psychotherapy). Without this information and the ability to perform multivariable analysis, it is difficult to prove causation of the complications reported. Rather, this study served to identify a cohort of patients potentially at risk to determine if further study is warranted. The Medicare database relies on the accuracy of coding. Two studies showed high validity when Medicare THA primary and revision data were compared with manual charts.27,28 Further, the database does not contain information regarding the technical aspects of the THA, components, or radiographic measurements, which may be relevant to complications such as dislocation and osteolysis.

Conclusion

Dual diagnosis significantly increases medical and surgical complications after primary THA. With the exception of osteolysis/polywear, patients with a DD had at least 3 times the odds of having dislocation, periprosthetic joint infection, fracture, irrigation and debridement, or the need for revision compared with control patients. The synergistic effect of psychiatric disease and SUD is poorly understood in this population and merits further investigation. Patients presenting with SUD or mental health disorders need to be screened for the presence of DD and treatment needs to be initiated. Further analysis is needed to determine the most effective screening tool and treatment pathways to reduce the complications reported in this article.

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Medical and Surgical Complications Within the 30-Day Time Point

ComplicationIncidence in Control PatientsPatients With a Dual Diagnosis

IncidenceOdds Ratio95% Confidence IntervalP
Medical
  Myocardial infarction1.89%1.00%0.520.34–0.81.003
  Heart failure5.62%6.60%1.191.00–1.42.057
  Arrhythmia without atrial fibrillation7.50%5.45%0.710.59–0.86.001
  Arrhythmia with atrial fibrillation16.30%9.15%0.520.44–0.60<.001
  Respiratory failure0.83%2.10%2.571.89–3.49<.001
  Deep venous thrombosis2.34%2.90%1.250.96–1.62.099
  Pulmonary embolism0.79%1.05%1.330.87–2.05.191
  Stroke0.67%0.70%1.050.62–1.78.859
  Pneumonia2.14%5.00%2.411.97–2.95<.001
  Sepsis/systemic inflammatory response syndrome0.89%2.15%2.461.81–3.30<.001
  Acute renal failure3.14%4.85%1.571.28–1.93<.001
  Postoperative anemia28.92%34.35%1.291.17–1.41<.001
  Blood transfusion30.46%34.85%1.221.11–1.34<.001
Surgical
  Bleeding complications2.11%3.75%1.811.43–2.28<.001
  Periprosthetic infection0.67%3.35%5.164.04–6.60<.001
  Cellulitis or seroma1.98%6.85%3.653.06–4.34<.001
  Dislocation0.98%4.70%7.665.77–10.18<.001
  Periprosthetic fracture0.51%1.30%2.561.73–3.77<.001
  Osteolysis/polywear0.04%0.00%0-.367
  Wound complications0.46%1.70%3.702.63–5.21<.001
  Vascular/neuro injury0.29%0.001%0.860.36–2.06.728
  Total hip arthroplasty revision1.08%3.70%3.512.78–4.44<.001
  Arthrotomy/irrigation and debridement0.57%1.75%3.102.22–4.34<.001

Medical and Surgical Complications Within the 30-Day Time Point Comparing the Dual Diagnosis Group With the Psychiatric Disease Only Group

ComplicationIncidence in Control PatientsIncidence in Patients With Psychiatric Disease OnlyPatients With a Dual Diagnosis

IncidenceOdds Ratio95% Confidence IntervalP
Medical
  Myocardial infarction1.89%1.93%1.00%0.510.33–0.80.003
  Heart failure5.62%9.18%6.60%0.700.59–0.84<.001
  Arrhythmia without atrial fibrillation7.50%7.33%5.45%0.730.60–0.86.729
  Arrhythmia with atrial fibrillation16.30%15.90%9.15%0.530.45–0.62<.001
  Respiratory failure0.83%1.83%2.10%1.150.84–1.57.377
  Deep venous thrombosis2.34%2.96%2.90%0.980.75–1.30.884
  Pulmonary embolism0.79%1.09%1.05%0.960.62–1.49.965
  Stroke0.67%1.20%0.70%0.580.34–0.99.043
  Pneumonia2.14%4.13%5.00%1.221.00–1.50.054
  Sepsis/systemic inflammatory response syndrome0.89%1.78%2.15%1.210.89–1.65.218
  Acute renal failure3.14%5.04%4.85%0.960.78–1.18.702
  Postoperative anemia28.92%35.75%34.35%0.940.86–1.03.196
  Blood transfusion30.46%37.21%34.85%0.900.82–1.00.030
Surgical
  Bleeding complications2.11%3.01%3.75%1.231.00–1.59.054
  Periprosthetic infection0.67%1.66%3.35%2.101.60–2.62<.001
  Cellulitis or seroma1.98%4.02%6.85%1.760.47–2.10<.001
  Dislocation0.98%2.39%4.70%2.852.13–3.80<.001
  Periprosthetic fracture0.51%1.18%1.30%1.100.64–1.63.619
  Osteolysis/polywear0.04%0.06%0.00%0.00-.279
  Wound complications0.46%1.08%1.70%1.581.12–2.23.009
  Vascular/neuro injury0.29%0.30%0.001%0.820.34–2.00.673
  Total hip arthroplasty revision1.08%2.29%3.70%1.641.30–2.08<.001
  Arthrotomy/irrigation and debridement0.57%1.14%1.75%1.551.10–2.17<.001
Authors

The authors are from the Department of Orthopaedic Surgery (MRK, BTN, CTP, SSW, MPB, TMS), Duke University Medical Center, and the Department of Biostatistics and Bioinformatics (CLG), Duke University, Durham, North Carolina; and the Department of Orthopedic Surgery (AB), Stanford University Medical Center, Redwood City, California.

Drs Klement, Nickel, Bala, Penrose, and Green have no relevant financial relationships to disclose. Dr Wellman is a paid consultant for Total Joint Orthopedics and has received grants from Stryker, Zimmer Biomet, and DePuy. Dr Bolognesi is a paid consultant for Kinamed and Total Joint Orthopedics; has received resident educational support from Stryker, Smith & Nephew, Zimmer Biomet, DePuy Synthes, Medtronic, DJO, MicroPort, and Exactech; has received a grant from DePuy Synthes; is on the speaker's bureau of Pacira; receives royalties from Biomet, Zimmer, and Total Joint Orthopedics; and holds stock in Total Joint Orthopedics and Amedica. Dr Seyler is a paid consultant for Total Joint Orthopedics.

Correspondence should be addressed to: Mitchell R. Klement, MD, Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC 27710 ( Mitchell.klement@dm.duke.edu).

Received: March 23, 2017
Accepted: December 15, 2017
Posted Online: February 19, 2018

10.3928/01477447-20180213-09

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