Is the Parkinson Disease Diagnosis-to-Surgery Interval Associated With 5-year Vascular and Periprosthetic Outcomes After TKA? A Nationwide Large-database Study.

BACKGROUND: Because populations in many countries are aging, a number of large database studies have reported more patients with Parkinson disease undergoing TKA, and the risk of complications after surgery is greater in this population. Because Parkinson disease-related autonomic dysfunction, medication changes, mobility loss, and frailty may evolve after diagnosis, the diagnosis-to-TKA interval could identify clinically different vascular and periprosthetic risk profiles and help guide counseling and selective preoperative assessment; however, 5-year endpoint-specific risks remain insufficiently characterized.

QUESTIONS/PURPOSES: (1) Is Parkinson disease diagnosed before TKA associated with higher 5-year risks of vascular events and periprosthetic complications after TKA? (2) How do these associations appear when patients with Parkinson disease diagnosed before TKA are grouped by a pragmatic 5-year diagnosis-to-TKA interval?

METHODS: Using the National Health Insurance Service (NHIS) database of South Korea, we identified patients who underwent unilateral TKA between January 2010 and December 2018, with follow-up available through December 2023 to allow assessment of 5-year postoperative outcomes. The database links procedure, diagnosis, prescription, and health-screening data at the individual level, allowing assessment of 5-year vascular and periprosthetic outcomes. Patients with < 5 years of follow-up or preexisting cardiovascular or cerebrovascular disease were excluded to focus on incident postoperative vascular events. The unmatched analytic cohort included 287,075 patients without Parkinson disease and 20,728 patients with Parkinson disease diagnosed before TKA, including 16,877 diagnosed ≤ 5 years before TKA and 3851 diagnosed > 5 years before TKA. All patients in these unmatched groups had at least 5 years of follow-up by design. Parkinson disease was defined by diagnostic codes and prescriptions for Parkinson disease-related medications. Each group of patients diagnosed with Parkinson disease before TKA was propensity score-matched 1:1 to the group of patients without Parkinson disease, yielding 20,707 matched pairs for all patients with Parkinson disease before TKA, 16,860 matched pairs for those diagnosed ≤ 5 years before TKA, and 3848 matched pairs for those diagnosed > 5 years before TKA. After matching, age, sex, comorbidity, health behaviors, dyslipidemia, and year of surgery were balanced. Outcomes were analyzed using Cox regression models, with prespecified time-window analyses to describe temporal patterns in adjusted associations.

RESULTS: After adjustment for age, sex, Charlson comorbidity index, smoking, alcohol use, physical activity, dyslipidemia, and year of surgery, Parkinson disease diagnosed before TKA was associated with a slightly higher 5-year adjusted hazard of cerebrovascular events (adjusted HR 1.11 [95% confidence interval (CI) 1.07 to 1.16]; p < 0.001) but not with cardiovascular events, periprosthetic fracture, or PJI. Among patients with Parkinson disease diagnosed ≤ 5 years before TKA, cardiovascular events (adjusted HR 1.05 [95% CI 1.01 to 1.10]; p = 0.02) and cerebrovascular events (adjusted HR 1.14 [95% CI 1.09 to 1.18]; p < 0.001) were associated with slightly higher adjusted hazards than in matched patients without Parkinson disease. These associations were not observed in patients with Parkinson disease diagnosed > 5 years before TKA. Time-window analyses in patients diagnosed ≤ 5 years before TKA showed a small early inverse association for cardiovascular events at 6 months and a small positive association by 5 years. Periprosthetic fracture and periprosthetic joint infection were not increased across interval subgroups.

CONCLUSION: These findings should not be interpreted as supporting routine cardiovascular or cerebrovascular screening solely because a patient has Parkinson disease. Rather, Parkinson disease status and the diagnosis-to-TKA interval may help surgeons counsel patients and identify selected individuals who warrant multidisciplinary perioperative assessment of vascular risk factors, autonomic symptoms, blood pressure instability, and Parkinson disease medication management. Future studies should incorporate clinical Parkinson disease severity, frailty, mobility, and competing mortality to improve absolute risk prediction and identify patients who may benefit from additional preoperative medical review.

LEVEL OF EVIDENCE: Level III, therapeutic study.