Abstract Recently, the government has moved towards public reporting of 30-day readmission rates after elective primary total knee (TKA) and total hip arthroplasty (THA). We identified 11,814 and ...8105 patients who underwent primary TKA and THA from the 2011 ACS NSQIP. Overall readmission rates within 30-days of surgery were 4.6% for TKA and 4.2% for THA. Complications associated with readmission were predominantly wound infections, sepsis, thromboembolic, cardiac, and respiratory related. In TKA, multivariate analysis identified age ( P = 0.002), male gender ( P = 0.03), cancer history ( P = 0.008), elevated BUN ( P = 0.002), a bleeding disorder ( P < 0.001) and high ASA class ( P < 0.001) as predictors of readmission. In THA, obesity ( P = 0.008), steroid use ( P = 0.037), a bleeding disorder ( P = 0.002), dependent functional status ( P = 0.022), and high ASA class ( P < 0.001) predicted readmission. Understanding characteristics associated with readmission will be essential for equitable patient risk stratification.
The United States is in the midst of an opioid epidemic. Little is known about perioperative opioid use for total knee arthroplasty (TKA). The purpose of this study was to identify rates of ...preoperative opioid use, evaluate postoperative trends and identify risk factors for prolonged use after TKA.
Patients who underwent primary TKA from 2007-2014 were identified within the Humana database. Postoperative opioid use was measured by monthly prescription refill rates. A preoperative opioid user (OU) was defined by history of opioid prescription within 3 months prior to TKA and a non-opioid user (NOU) was defined by no history of prior opioid use. Rates of opioid use were trended monthly for one year postoperatively for all cohorts.
73,959 TKA patients were analyzed and 23,532 patients (31.2%) were OU. OU increased from 30.1% in 2007 to 39.3% in 2014 (P < .001). Preoperative opioid use was the strongest predictor for prolonged opioid use following TKA, with OU filling significantly more opioid prescriptions than NOU at every time point analyzed. Younger age, female sex and other intrinsic factors were found to significantly increase the rate of opioid refilling following TKA throughout the postoperative year.
Approximately one-third of TKA patients use opioids within 3 months prior to surgery and this percentage has increased over 9% during the years included in this study. Preoperative opioid use was most predictive of increased refills of opioids following TKA. However, other intrinsic patient characteristics were also predictive of prolonged opioid use.
Abstract The authors assessed the incidence of and risk factors associated with 30-day surgical site infections (SSIs) following primary (p) and revision (r) THA and TKA. In total, 23,128 primary and ...2170 revision TJAs were identified between 2005 and 2010 in the ACS NSQIP database. The 30-day SSI rates, overall and deep, were 1.1 and 0.1% for pTKA, 1.18 and 0.4% for pTHA, 1.68 and 0.7% for rTKA, and 2.9 and 1.7% for rTHA. After primary TJA, independent risk factors were BMI > 40, hypertension, prolonged operative time, electrolyte disturbance and previous infection, and after revision TJA, dyspnea and bleeding disorder were risk factors. This study should help provide benchmark data for SSI following TJA.
Spinal anesthesia has been associated with lower postoperative rates of deep-vein thrombosis, a shorter operative time, and less blood loss when compared with general anesthesia. The purpose of the ...present study was to identify differences in thirty-day perioperative morbidity and mortality between anesthesia choices among patients undergoing total knee arthroplasty.
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was searched to identify patients who underwent primary total knee arthroplasty between 2005 and 2010. Complications that occurred within thirty days after the procedure in patients who had been managed with either general or spinal anesthesia were identified. Patient characteristics, thirty-day complication rates, and mortality were compared. Multivariate logistic regression identified predictors of thirty-day morbidity, and stratified propensity scores were used to adjust for selection bias.
The database search identified 14,052 cases of primary total knee arthroplasty; 6030 (42.9%) were performed with the patient under spinal anesthesia and 8022 (57.1%) were performed with the patient under general anesthesia. The spinal anesthesia group had a lower unadjusted frequency of superficial wound infections (0.68% versus 0.92%; p = 0.0003), blood transfusions (5.02% versus 6.07%; p = 0.0086), and overall complications (10.72% versus 12.34%; p = 0.0032). The length of surgery (ninety-six versus 100 minutes; p < 0.0001) and the length of hospital stay (3.45 versus 3.77 days; p < 0.0001) were shorter in the spinal anesthesia group. After adjustment for potential confounders, the overall likelihood of complications was significantly higher in association with general anesthesia (odds ratio, 1.129; 95% confidence interval, 1.004 to 1.269). Patients with the highest number of preoperative comorbidities, as defined by propensity score-matched quintiles, demonstrated a significant difference between the groups with regard to the short-term complication rate (11.63% versus 15.28%; p = 0.0152). Age, female sex, black race, elevated creatinine, American Society of Anesthesiologists class, operative time, and anesthetic choice were all independent risk factors of short-term complication after total knee arthroplasty.
Patients undergoing total knee arthroplasty who were managed with general anesthesia had a small but significant increase in the risk of complications as compared with patients who were managed with spinal anesthesia; the difference was greatest for patients with multiple comorbidities. Surgeons who perform knee arthroplasty may consider spinal anesthesia for patients with comorbidities.
Total joint arthroplasty is the most frequently performed orthopaedic procedure in the United States. The purpose of the present study was to identify differences in thirty-day morbidity and ...mortality following primary total hip and total knee arthroplasty according to smoking status and pack-year history of smoking.
We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who had undergone primary total hip or total knee arthroplasty between 2006 and 2012. Patients were stratified by smoking status and pack-year history of smoking. Thirty-day rates of mortality, wound complications, and total complications were compared with use of univariate and multivariate analyses.
We identified 78,191 patients who had undergone primary total hip or total knee arthroplasty. Of these, 81.8% (63,971) were nonsmokers, 7.9% (6158) were former smokers, and 10.3% (8062) were current smokers. Current smokers had a higher rate of wound complications (1.8%) compared with former smokers and nonsmokers (1.3% and 1.1%, respectively; p < 0.001). Former smokers had a higher rate of total complications (6.9%) compared with current smokers and nonsmokers (5.9% and 5.4%, respectively; p < 0.001). Multivariate analysis identified current smokers as being at increased risk of wound complications (odds ratio OR, 1.47; 95% confidence interval CI, 1.21 to 1.78), particularly deep wound infection, while both current smokers (OR, 1.18; 95% CI, 1.06 to 1.31) and former smokers (OR, 1.20; 95% CI, 1.08 to 1.34) were at increased total complication risk. Increasing pack-year history of smoking resulted in increasing total complication risk.
On the basis of our findings, current smokers have an increased risk of wound complications and both current and former smokers have an increased total complication risk following total hip or total knee arthroplasty.
Death of the Lewinnek “Safe Zone” Dorr, Lawrence D.; Callaghan, John J.
The Journal of arthroplasty,
January 2019, 2019-01-00, 20190101, Letnik:
34, Številka:
1
Journal Article
Background
Positioning of total hip bearings involves tradeoffs, because cup orientations most favorable in terms of stability are not necessarily ideal in terms of reduction of contact stress and ...wear potential. Previous studies and models have not addressed these potentially competing considerations for optimal total hip arthroplasty (THA) function.
Questions/purposes
We therefore asked if component positioning in total hips could be addressed in terms of balancing bearing surface wear and stability. Specifically, we sought to identify acetabular component inclination and anteversion orientation, which simultaneously resulted in minimal wear while maximizing construct stability, for several permutations of femoral head diameter and femoral stem anteversion.
Methods
A validated metal-on-metal THA finite element (FE) model was used in this investigation. Five dislocation-prone motions as well as gait were considered as were permutations of femoral anteversion (0°–30°), femoral head diameter (32–48 mm), cup inclination (25°–75°), and cup anteversion (0°–50°), resulting in 4320 distinct FE simulations. A novel metric was developed to identify a range of favorable cup orientations (so-called “landing zone”) by considering both surface wear and component stability.
Results
When considering both wear and stability with equal weight, ideal cup position was more restrictive than the historically defined safe zone and was substantially more sensitive to cup anteversion than to inclination. Ideal acetabular positioning varied with both femoral head diameter and femoral version. In general, ideal cup inclination decreased with increased head diameter (approximately 0.5° per millimeter increase in head diameter). Additionally, ideal inclination increased with increased values of femoral anteversion (approximately 0.3° per degree increase in stem anteversion). Conversely, ideal cup anteversion increased with increased femoral head diameter (0.3° per millimeter increase) and decreased with increased femoral stem anteversion (approximately 0.3° per degree increase). Regressions demonstrated strong correlations between optimal cup inclination versus head diameter (Pearson’s r = −0.88), between optimal cup inclination versus femoral anteversion (r = 0.96), between optimal cup anteversion versus head diameter (r = 0.99), and between optimal cup anteversion and femoral anteversion (r = −0.98). For a 36-mm cup with a 20° anteverted stem, the ideal cup orientation was 46° ± 12° inclination and 15° ± 4° anteversion.
Conclusions
The range of cup orientations that maximized stability and minimized wear (so-called “landing zone”) was substantially smaller than historical guidelines and specifically did not increase with increased head size, challenging the presumption that larger heads are more forgiving. In particular, when the cup is oriented to improve not only stability, but also wear in the model, there was little or no added stability achieved by the use of larger femoral heads. Additionally, ideal cup positioning was more sensitive to cup anteversion than to inclination.
Clinical Relevance
Positioning THA bearings involves tradeoffs regarding stability and long-term bearing wear. Cup positions most favorable to minimization of wear such as low inclination and elevated anteversion were detrimental in terms of construct stability. Orientations were identified that best balanced the competing considerations of wear and stability.
ABSTRACT
Musculoskeletal infections (MSKI) remain the bane of orthopedic surgery, and result in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis, and ...treatment has remained largely unchanged over the last 50 years, a 2nd International Consensus Meeting on Musculoskeletal Infection (ICM 2018, https://icmphilly.com) was completed. Questions pertaining to all areas of MSKI were extensively researched to prepare recommendations, which were discussed and voted on by the delegates using the Delphi methodology. The questions, including the General Assembly (GA) results, have been published (GA questions). However, as critical outcomes include: (i) incidence and cost data that substantiate the problems, and (ii) establishment of research priorities; an ICM 2018 research workgroup (RW) was assembled to accomplish these tasks. Here, we present the result of the RW consensus on the current and projected incidence of infection, and the costs per patient, for all orthopedic subspecialties, which range from 0.1% to 30%, and $17,000 to $150,000. The RW also identified the most important research questions. The Delphi methodology was utilized to initially derive four objective criteria to define a subset of the 164 GA questions that are high priority for future research. Thirty‐eight questions (23% of all GA questions) achieved the requisite > 70% agreement vote, and are highlighted in this Consensus article within six thematic categories: acute versus chronic infection, host immunity, antibiotics, diagnosis, research caveats, and modifiable factors. Finally, the RW emphasizes that without appropriate funding to address these high priority research questions, a 3rd ICM on MSKI to address similar issues at greater cost is inevitable.
Abstract Background Increased operative time has been associated with increased complications following TJA. The purpose of the present study was to investigate the effect of operative time on ...short-term complications following TJA while also identifying patient and operative factors associated with prolonged operative times. Methods The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2011-2013 to identify all patients who underwent primary total hip or knee arthroplasty. Patients were stratified by operative time, and 30-day morbidity and mortality data compared using univariate and multivariable analyses. Results We identified 99,444 patients who underwent primary TJA. The overall incidence of complications following TJA was 4.9%. Overall complications were increased in patients with operative times >120 minutes (5.9%) as compared to patients with operative times <60 minutes or 60-120 minutes (4.6% and 4.8%, respectively; p<0.001). Wound complications, including surgical site infection, were also increased for procedures lasting >120 minutes. In a multivariable analysis, operative time exceeding 120 minutes remained an independent predictor of any complication and wound complication, with each 30-minute increase in operative time beyond 120 minutes further increasing risk. Patient age ≤65 years, male sex, black race, BMI ≥ 30 kg/m2 , and an ASA classification of 3 or 4 all predicted operative times >120 minutes. Conclusions We found that operative time >120 minutes was associated with increased short-term morbidity and mortality following primary TJA. Younger age, male sex, black race, obesity, and increased comorbidity were risk factors for operative time exceeding 120 minutes.
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