Abstract Studies conflict regarding the impact of psychiatric illnesses including depression, anxiety, dementia and schizophrenia on perioperative outcomes following total hip (THA) and knee ...arthroplasty (TKA). Psychiatric comorbidity incidence, in-hospital adverse events, discharge disposition, and mortality were assessed for THA or TKA patients between 1990 and 2007 using the US National Hospital Discharge Survey. A cohort representative of 8,379,490 patients was identified and analyzed using multivariable regression analysis. Diagnoses of depression, dementia and schizophrenia were associated with increased odds of adverse events ( P < 0.001). Schizophrenia and depression were associated with higher odds of perioperative blood transfusion ( P < 0.001). All psychiatric comorbidities were associated with higher odds of non-routine discharge ( P < 0.001). Diagnosis of dementia was associated with higher in-hospital mortality ( P < 0.001).
A shift toward a value-driven health-care model has made prospective collection of patient-reported outcome measures (PROMs) inextricably tied to measuring the success of orthopaedic surgery and ...patient satisfaction. While progress has been made in optimizing the utilization of PROM data, including establishing appropriate PROMs for a procedure and determining the clinical importance of unique tools, if these PROMs are not accurately analyzed and reported, a proportion of patients who do not reach the clinical thresholds may go unnoticed. Furthermore, parameters are unclear for setting a statistically and clinically important PROM threshold along with a minimum period for follow-up data collection.In this forum, we walk through simulated data sets modeling PROMs with the example of total joint arthroplasty. We discuss how the commonly used method of reporting PROMs by mean change can overestimate the treatment effects for the cohort as a whole and fail to capture distinct populations that are below a clinically relevant threshold. We demonstrate that when a study's outcome is PROMs, clinical importance should be reported using clinical thresholds such as the minimum clinically important difference (MCID), the smallest change in the treatment outcome that a patient perceives as beneficial, and the patient acceptable symptom state (PASS), the highest level of symptoms beyond which a patient considers himself or herself well. Finally, we propose a standardized reporting of PROMs that incorporates both the MCID and the PASS, and introduce a "clinical relevance ratio," which relies on a clinically relevant threshold to dichotomize outcomes and reports the number of patients achieving clinical importance at a given time point divided by the total number of patients included in the study. Unlike other common PROM-reporting approaches, the clinical relevance ratio is not skewed by patients who are lost to follow-up with increased time.
Background
Frozen section histology is widely used to aid in the diagnosis of periprosthetic joint infection at the second stage of revision arthroplasty, although there are limited data regarding ...its utility. Moreover, there is no definitive method to assess control of infection at the time of reimplantation. Because failure of a two-stage revision can have serious consequences, it is important to identify the cases that might fail and defer reimplantation if necessary. Thus, a reliable test providing information about the control of infection and risk of subsequent failure is necessary.
Questions/purposes
(1) At second-stage reimplantation surgery, what is the diagnostic accuracy of frozen sections as compared with the Musculoskeletal Infection Society (MSIS) as the gold standard? (2) What are the diagnostic accuracy parameters for the MSIS criteria and frozen sections in predicting failure of reimplantation? (3) Do positive MSIS criteria or frozen section at the time of reimplantation increase the risk of subsequent failure?
Methods
A total of 97 patients undergoing the second stage of revision total hip arthroplasty or total knee arthroplasty in 2013 for a diagnosis of periprosthetic joint infection (PJI) were considered eligible for the study. Of these, 11 had incomplete MSIS criteria and seven lacked 1-year followup, leaving 79 patients (38 knees and 41 hips) available for analysis. At the time of reimplantation, frozen section results were compared with modified MSIS criteria as the gold standard in detecting infection. Subsequently, success or failure of reimplantation was defined by (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention for infection after reimplantation surgery; and (3) no occurrence of PJI-related mortality; and diagnostic parameters in predicting treatment failure were calculated for both the modified MSIS criteria and frozen sections.
Results
At the time of second-stage reimplantation surgery, frozen section is useful in ruling in infection, where the specificity is 94% (95% confidence interval CI, 89%–99%); however, there is less utility in ruling out infection, because sensitivity is only 50% (CI, 13%–88%). Both the MSIS criteria and frozen sections have high specificity for ruling in failure of reimplantation (MSIS criteria specificity: 96% CI, 91%–100%; frozen section: 95% CI, 88%–100%), but screening capabilities are limited (MSIS sensitivity: 26% CI, 9%–44%; frozen section: 22% CI, 9%–29%). Positive MSIS criteria at the time of reimplantation were a risk factor for subsequent failure (hazard ratio HR, 5.22 1.64–16.62, p = 0.005), whereas positive frozen section was not (HR, 1.16 0.15–8.86, p = 0.883).
Conclusions
On the basis of our results, both frozen section and MSIS are recommended at the time of the second stage of revision arthroplasty. Both frozen section and modified MSIS criteria had limited screening capabilities to identify failure, although both demonstrated high specificity. MSIS criteria should be evaluated at the second stage of revision arthroplasty because performing reimplantation in a joint that is positive for infection significantly increases the risk for subsequent failure.
Level of Evidence
Level III, diagnostic study.
Continuous wound drainage after arthroplasty can lead to the development of a periprosthetic joint infection. Closed incisional negative pressure wound therapy (ciNPWT) has been reported to help ...alleviate drainage and other wound complications. The purpose of this prospective randomized controlled trial is to compare the use of ciNPWT with our standard of care dressing in revision arthroplasty patients who were at high risk to develop wound complications.
A total of 160 patients undergoing elective revision arthroplasty were prospectively randomized to receive either ciNPWT or a silver-impregnated occlusive dressing after surgery in a single institution. Patients were included if they had at least 1 risk factor for developing wound complication(s): wound complication, readmission, and reoperation rates were collected at 2, 4, and 12 weeks postoperatively.
The postoperative wound complication rate was significantly higher in the control cohort compared to the ciNPWT cohort (19 23.8% vs 8 10.1%, P = .022). There was no significant difference between the control and ciNPWT cohorts in terms of readmissions (19 23.8% vs 16 20.3%, P = .595). Reoperation rate was higher in controls compared to ciNPWT patients (10 12.5% vs 2 2.5%, P = .017). After adjusting for the history of a prior periprosthetic joint infection and inflammatory arthritis, the ciNPWT cohort had a significantly decreased wound complication rate (odds ratio 0.28, 95% confidence interval 0.11-0.68).
ciNPWT may decrease the rate of postoperative wound complications in patients who are at an increased risk of such wound issues after revision arthroplasty.
Prescription-drug abuse has strained US healthcare. While several investigations highlight an association between opioid use and adverse postoperative outcomes, similar associations with nonopioid ...prescription-drugs remain under-studied. Furthermore, patients’ underlying prescription drug use patterns remain poorly characterized. This perspective details such obstacles which hinder translating literature-reported findings into practice.
Background The clinical benefit of chronic suppression with oral antibiotics as a salvage treatment for periprosthetic joint infection is unclear. The purpose of this study was to compare ...infection-free prosthetic survival rates between patients who received chronic oral antibiotics and those who did not following irrigation and debridement with polyethylene exchange or two-stage revision for periprosthetic joint infection. Methods We reviewed the records on all irrigation and debridement procedures with polyethylene exchange and two-stage revisions performed at our institution from 1996 to 2010 for hip or knee periprosthetic joint infection. Of 625 patients treated with a total of 655 eligible revisions, ninety-two received chronic oral antibiotics for a minimum of six months and were eligible for inclusion in our study. These patients were compared with a matched cohort (ratio of 1:3) who did not receive chronic oral antibiotics. Results The five-year infection-free prosthetic survival rate was 68.5% (95% confidence interval CI = 59.2% to 79.3%) for the antibiotic-suppression group and 41.1% (95% CI = 34.9% to 48.5%) for the non-suppression group (hazard ratio HR = 0.63, p = 0.008). Stratification by the type of surgery and the infecting organism showed a higher five-year survival rate for the patients in the suppression group who underwent irrigation and debridement with polyethylene exchange (64.7%) compared with those in the non-suppression group who underwent irrigation and debridement with polyethylene exchange (30.4%, p < 0.0001) and a higher five-year survival rate for the patients in the suppression group who had a Staphylococcus aureus infection (57.4%) compared with those in the non-suppression group who had a Staphylococcus aureus infection (40.1%, p = 0.047). Conclusions Chronic suppression with oral antibiotics increased the infection-free prosthetic survival rate following surgical treatment for periprosthetic joint infection. Patients who underwent irrigation and debridement with polyethylene exchange and those who had a Staphylococcus aureus infection had the greatest benefit. Level of Evidence Therapeutic Level III . See the Instructions for Authors for a complete description of levels of evidence.
The purpose of this study is to identify factors affecting operative times and to evaluate the associations of operative times with prosthetic joint infections (PJIs) and surgical site infections ...(SSIs) in primary total knee arthroplasty.
A total of 11,840 primary total knee arthroplasties with a mean 2-year post-operative follow-up were studied. Operative times were analyzed both as categorical and continuous variables. Associations with PJIs and SSIs were evaluated with univariate and multivariate analyses to adjust for gender, age, body mass index, Charlson Comorbidity Index, year of surgery, antibiotic cement use, and hospital/surgeon volume.
The longest cases (>121 minutes) were associated with patients who were younger (P < .001) and had a higher body mass index (P < .001). PJI rates were higher in cases >121 minutes (1.4%) compared to those <85 minutes (0.3%, P < .001). SSI rates were also highest (3.8%) in cases >121 minutes (P < .001). Cases complicated by PJIs (135 ± 47 minutes) had longer mean operative times compared to non-infected cases (105 ± 32 minutes, P < .001). Patients with subsequent SSIs also had longer mean operative times (P < .001). Multivariate analyses revealed an 18% increased risk for PJIs and an 11% increased risk for SSIs for every 15-minute increase in operative time.
Identifying risk factors for infection that are as easily measurable and modifiable as procedure duration can aid in risk-stratifying post-operative surveillance. This study demonstrated that longer operative times were an independent predisposing factor for both PJIs and SSIs even after accounting for patient and procedure-related factors.
MINI-ABSTRACTPatient-reported outcome measures are increasingly important in the era of value-based healthcare. We use the example of total joint arthroplasty to demonstrate how current reporting ...measures may hide poorer outcomes. There is thus a need for a standardized approach in reporting patient-reported outcome measure tied to clinically relevant thresholds.
Abstract Background The current gold standard to diagnose periprosthetic joint infection (PJI)—the Musculoskeletal Infection Society (MSIS) criteria, requires a battery of tests, the results of which ...may not be available at the time of decision-making. Thus, surgeons often rely on intraoperative frozen section histology. However, the accuracy of frozen sections has not been determined when matched for the MSIS criteria. We aimed to (1) assess the value of intraoperative histology in the diagnosis of PJI and (2) evaluate discrepancy rate between frozen and permanent section analysis. Methods A retrospective review of patients who underwent revision total hip or total knee arthroplasty for either PJI or mechanical failure in 2013 was conducted. Two hundred procedures where tissue samples for frozen sections had been collected were identified and included into the study. Results of frozen sections were compared to the modified MSIS criteria. Discrepancy rate between frozen and permanent sections was also calculated. Results Frozen sections had sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 73.7% (95% confidence interval CI, 59.7%-87.7%), 98.8% (95% CI, 97.1%-100.0%), 94.1% (95% CI, 90.6%-97.6%), 93.3.4% (95% CI, 84.4%-100.0%), 94.0% (95% CI, 90.7%-97.3%), respectively. There were 10 discrepancies between the results of frozen and permanent sections (N = 421 samples), thereby yielding 97.6% concordance. Conclusion When matched to the MSIS criteria, intraoperative frozen section histology yields a high specificity, positive predictive value, negative predictive value, accuracy, and moderate sensitivity. The discrepancy rate between frozen and permanent sections is low and both demonstrate good approximation of MSIS criteria.
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