Abstract Background With increased scrutiny regarding the cost and safety of health care delivery, there is increasing interest in judicious patient selection for total joint arthroplasty (TJA) ...procedures. It is unknown which comorbidities incur the greatest increase in risk to the patient and cost to the system after TJA. Therefore, this study sought to characterize the association of common preoperative comorbidities with both the risk for postoperative in-hospital complications and the total hospital cost in patients undergoing TJA. Methods A retrospective cohort study was conducted using the National Inpatient Sample. All elective, unilateral, primary or revision total knee or hip arthroplasty procedures in patients aged 40-95 years from 2008 to 2012 were identified. Common preoperative comorbidities were identified with use of clinical comorbidity software. Risk of complication and cost were calculated for each comorbidity. Results A total of 4,323,045 patients were identified. Patient comorbidities increased the risk of major postoperative complications, with the highest risk associated with congestive heart failure (CHF; relative risk RR, 4.402), valvular heart disease (VHD; RR, 3.209), and chronic obstructive pulmonary disease (COPD; RR, 2.813). Likewise, comorbidities increased overall hospital costs, with the largest additional costs associated with coagulopathy (+$3787), CHF (+$3701), and electrolyte disorders (+$3179). The cumulative number of comorbidities was associated with increased risk ( R2 = 0.86) and cost ( R2 = 0.90). Conclusion The findings of our study suggest that greater comorbidity burden is associated with increased risk and cost in TJA. Specifically, this article identifies the patient comorbidities that incur the greatest increase in postoperative complications (CHF, VHD, COPD) and cost (coagulopathy, CHF, electrolyte disorders) after TJA.
BackgroundTotal hip arthroplasty is a commonly performed procedure in the United States and Canada that is associated with a definite risk of postoperative infection. Moreover, diagnosing an ...infection after total hip arthroplasty can present a challenge as there are no preoperative tests that are consistently sensitive and specific for infection in patients who need a revision arthroplasty. The present prospective study was performed to evaluate a variety of investigations for the diagnosis of infection at the site of a previous arthroplasty in order to determine if any combination of diagnostic studies could be used to determine which patients are at risk for a postoperative wound infection. MethodsWe prospectively analyzed the preoperative and intraoperative investigations used for the diagnosis of infection in 178 patients who had a total of 202 revision hip replacements. Clinical data were collected preoperatively. Investigations to determine the presence or absence of infection included a white blood-cell count, measurement of the erythrocyte sedimentation rate, measurement of the level of C-reactive protein, preoperative aspiration of the joint, intraoperative gram-staining and culture of periprosthetic tissue, a white blood-cell count in synovial fluid, and examination of intraoperative frozen sections. Frozen sections were analyzed in a blinded fashion without knowledge of clinical or laboratory data. Patients receiving antibiotics at the time of aspiration or collection of specimens for intraoperative culture were excluded from the analysis of those investigations, regardless of the results of the cultures. A positive result (suggestive of infection) was clearly defined for each of the investigations. ResultsThirty-five hips (17 percent) were determined to be infected on the basis of clinical findings and positive results, according to the defined criteria, of investigations. With inflammatory conditions excluded, the sensitivity, specificity, positive predictive value, and negative predictive value were 0.82, 0.85, 0.58, and 0.95, respectively, for the erythrocyte sedimentation rate and 0.96, 0.92, 0.74, and 0.99, respectively, for the level of C-reactive protein. All patients who had a periprosthetic infection had an elevated erythrocyte sedimentation rate or level of C-reactive protein, but not always both. When patients who were receiving antibiotics were excluded, the results of aspiration of the joint were 0.86 for sensitivity, 0.94 for specificity, 0.67 for the positive predictive value, and 0.98 for the negative predictive value. Intraoperative studies revealed sensitivities, specificities, positive predictive values, and negative predictive values of 0.19, 0.98, 0.63, and 0.89, respectively, for gram-staining of specimens of the most inflamed-appearing tissue; 0.36, 0.99, 0.91, and 0.90, respectively, for the white blood-cell count in synovial fluid; and 0.89, 0.85, 0.52, and 0.98, respectively, for a neutrophil count in synovial fluid of more than 80 percent. The sensitivity, specificity, positive predictive value, and negative predictive value were 0.80, 0.94, 0.74, and 0.96, respectively, for the frozen sections and 0.94, 0.97, 0.77, and 0.99, respectively, for the intraoperative cultures. ConclusionsThe combination of a normal erythrocyte sedimentation rate and C-reactive protein level is reliable for predicting the absence of infection. Aspiration should be used when the erythrocyte sedimentation rate or the C-reactive protein level is elevated or when a clinical suspicion of infection remains. We found the gram stain to be unreliable. Examination of intraoperative frozen sections is useful in equivocal cases or when hematological markers may be falsely elevated because of an inflammatory or other condition.
Background
Two of the more common methods of pain management after TKA are peripheral nerve blocks and intraarticular/periarticular injections. However, we are not aware of any study directly ...comparing the commonly used combination of a continuous femoral block given with a single-shot sciatic block with that of a periarticular injection after TKA.
Questions/purposes
This randomized clinical trial compared a combined femoral and sciatic nerve block with periarticular injection as part of a multimodal pain protocol after total knee arthroplasty with respect to (1) pain; (2) narcotic use; (3) quadriceps function and length of stay; and (4) peripheral nerve complications.
Methods
One hundred sixty patients completed randomization into two treatment arms: (1) peripheral nerve blocks (PNB; n = 79) with an indwelling femoral nerve catheter and a single shot sciatic block; or (2) periarticular injection (PAI; n = 81) using ropivacaine, epinephrine, ketorolac, and morphine. All patients received standardized general anesthesia and oral medications. The primary outcome was postoperative pain, on a 0 to 10 scale, measured on the afternoon of postoperative day 1 (POD 1). Secondary outcomes were narcotic use, quadriceps function, length of stay, and peripheral nerve complications.
Results
Mean pain scores on the afternoon of POD 1 were not different between groups (PNB group: 2.9 SD 2.4; PAI group: 3.0 SD 2.2; 95% confidence interval, −0.8 to 0.6; p = 0.76). Mean pain scores taken at three times points on POD 1 were also similar between groups. Hospital length of stay was shorter for the PAI group (2.44 days SD 0.65 versus 2.84 days SD 1.34 for the PNB group; p = 0.02). Narcotic consumption was higher the day of surgery for the PAI group (PAI group: 11.7 mg morphine equivalents SD 13.1; PNB group: 4.6 mg SD 9.1; p < 0.001), but thereafter, there was no difference. More patients in the PNB group had sequelae of peripheral nerve injury (mainly dysesthesia) at 6-week followup (nine 12% versus one 1%; p = 0.009).
Conclusions
Patients receiving periarticular injections had similar pain scores, shorter lengths of stay, less likelihood of peripheral nerve dysesthesia, but greater narcotic use on the day of surgery compared with patients receiving peripheral nerve blocks. Periarticular injections provide adequate pain relief, are simple to use, and avoid the potential complications associated with nerve blocks.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Breast cancer survivors have known risk factors that might influence the results of total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study evaluated clinical outcomes of patients ...with breast cancer history after primary THA and TKA.
Our total joint registry identified patients with breast cancer history undergoing primary THA (n = 423) and TKA (n = 540). Patients were matched 1:1 based upon age, sex, BMI, procedure (hip or knee), and surgical year to non-breast cancer controls. Mortality, implant survival, and complications were assessed via Kaplan-Meier methods. Clinical outcomes were evaluated via Harris Hip Scores (HHSs) or Knee Society Scores (KSSs). Mean follow-up was six years (2 to 15).
Breast cancer patient survival at five years was 92% (95% confidence interval (CI) 89% to 95%) after THA and 94% (95% CI 92% to 97%) after TKA. Breast and non-breast cancer patients had similar five-year implant survival free of any reoperation or revision after THA (p ≥ 0.412) and TKA (p ≥ 0.271). Breast cancer patients demonstrated significantly lower survival free of any complications after THA (91% vs 96%, respectively; hazard ratio = 2 (95% CI 1.1 to 3.4); p = 0.017). Specifically, the rate of intraoperative fracture was 2.4% vs 1.4%, and venous thromboembolism (VTE) was 1.4% and 0.5% for breast cancer and controls, respectively, after THA. No significant difference was noted in any complications after TKA (p ≥ 0.323). Both breast and non-breast cancer patients experienced similar improvements in HHSs (p = 0.514) and KSSs (p = 0.132).
Breast cancer survivors did not have a significantly increased risk of mortality or reoperation after primary THA and TKA. However, there was a two-fold increased risk of complications after THA, including intraoperative fracture and VTE.
Abstract Background Patella resurfacing is performed in >80% of primary total knee arthroplasties (TKAs) in the United States, yet far fewer patellae are resurfaced internationally. Recent registry ...data have begun to question the long-held belief that patellar resurfacing yields lower revision rates. Multiple current meta-analyses have not shown a difference in patient satisfaction, anterior knee pain, or knee society scores based on patellar resurfacing. Methods We sought to determine how the rates of patellar resurfacing have changed over the past 10 years worldwide (2004-2014). Data were abstracted from the annual reports of 7 national joint registries, literature review, or via direct correspondence with registry administrators. Results Average rates of patellar resurfacing from 2004 to 2014 ranged from 4% (Norway) to 82% (United States). The largest decrease in resurfacing rates was in Sweden (15%-2%), whereas the biggest increase was in Australia (44%-59%). In 2010, only 48,367 of 137,813 (35%) primary TKAs from all registries outside the United States were resurfaced. Meta-analyses have demonstrated no difference in anterior knee pain or satisfaction scores but do consistently report increased revision rates for unresurfaced patellae. Recent Swedish registry data, however, showed a reverse trend toward higher revision rates after resurfacing. Conclusion Despite recent registry data and meta-analyses demonstrating equivalent outcomes among resurfaced and unresurfaced patellae in primary TKA, worldwide trends in patellar resurfacing have changed little over the past decade. Most countries outside the United States continue to resurface a much smaller proportion of patellae.
Abstract Prior studies have reported increased failure rates in obese patients with postoperative limb mal-alignment. This study was undertaken to determine if a relationship exists between ...postoperative limb alignment and BMI in patients undergoing primary TKA performed with mechanical instruments. An IRB-approved retrospective review of 196 knees was undertaken. Limb alignment was determined on full-length, standing, hip-to-ankle x-rays, preoperatively and postoperatively. The effects of gender, side, preoperative mechanical alignment and BMI on postoperative alignment were analyzed via multivariate regression analysis. Both preoperative mechanical limb alignment ( P < 0.001) and BMI ( P = 0.009) had a significant effect on postoperative limb alignment following TKA performed with mechanical instruments.
The use of antibiotic-loaded bone cement is an accepted treatment method for infected joint arthroplasties. It is helpful to separate the use of antibiotic-loaded bone cement as a method of ...prophylaxis as compared with the treatment of an established infection. A low dose of antibiotic-loaded bone cement (< or = 1 g of antibiotic per batch of cement) should be used for prophylaxis, and high-dose antibiotic-loaded bone cement (> 1 g antibiotic per batch of cement) is indicated for treatment. The only commercially available antibiotic-loaded bone cement products are low dose, with the use of tobramycin or gentamicin as an antibiotic selection. High-dose antibiotic-loaded bone cement requires hand mixing by the surgeon to facilitate the use of high dosages and choices of multiple antibiotics. Treatment of infected hip and knee arthroplasties with high-dose antibiotic-loaded bone cement is aided by the use of spacers of various shapes and sizes. These spacers, whether they are static or articulating (mobile), are meant to provide local delivery of antibiotics, stabilization of soft tissues, facilitation of an easier reimplantation, and improved clinical outcomes.
Periprosthetic joint infection (PJI) is a common cause of revision total knee surgery. Although debridement and implant retention (DAIR) has lower success rates in the chronic setting, it is an ...accepted treatment of acute PJI, whether postoperatively or with late hematogenous seeding. There are two broad DAIR strategies: single debridement and planned double debridement. The purpose of this study is to evaluate the cost-effectiveness of single vs double DAIR for acute PJI in total knee arthroplasty.
A decision tree using single or double DAIR as the treatment strategy for acute PJI was constructed. Quality-adjusted life years and costs associated with the two treatment arms were calculated. Treatment success rates, failure rates, and mortality rates were derived from the literature. Medical costs were derived from both the literature and Medicare data. A cost-effectiveness plane was constructed from multiple Monte Carlo trials. A sensitivity analysis identified parameters most influencing the optimal strategy decision.
Double DAIR was the optimal treatment strategy both in terms of the health utility state (82% of trials) and medical cost (97% of trials). Strategy tables demonstrated that as long as the success rate of double debridement is 10% or greater than the success rate of a single debridement, the two-stage protocol is cost-effective.
A double DAIR protocol is more cost-effective than single DAIR from a societal perspective.
Abstract Bone loss represents one of the greatest challenges in revision joint surgery. A retrospective review was conducted of both radiographic and clinical outcomes of eleven patients who ...underwent revision arthroplasty using a long extensively porous coated cylindrical femoral component. All patients' femurs presented with severe proximal femoral bone loss (Paprosky class IIIB and IV). With a mean follow-up of 8 years (2 to 14) we report no femoral revisions and one acetabular revision to a constrained cup secondary to instability. All patients were clinically and radiographically stable. We did not observe any issue with proximal stress shielding or component loosening. The article reports that in patients with severe proximal femoral bone loss, extensively porous-coated non-modular stems are a viable option offering stable and predictable outcomes.
Abstract This systematic review examined whether negative-pressure Charnley-type body exhaust suits (BES) or modern positive-pressure surgical helmet systems (SHS) reduce deep infection rates and/or ...contamination in arthroplasty. For deep infection, four studies (3990 patients) gave adjusted relative risk for deep infection of 0.11 (P = 0.09) against SHS. Five of 7 (71%) studies found less air contamination and 2 of 4 studies (50%) less wound contamination with BES. One of 4 (25%) found less air contamination with SHS and 0 of 1 (0%) less wound contamination. In contrast to BES, modern SHS designs were not shown to reduce contamination or deep infection during arthroplasty.
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