Periarticular injection of liposomal bupivacaine has been adopted as part of multimodal pain management after total knee arthroplasty (TKA).
In this prospective, randomized clinical trial, we ...enrolled 162 patients undergoing primary TKA in a single institution between January 2014 and May 2015. Eighty-seven patients were randomized to liposomal bupivacaine (experimental group), and 75 patients were randomized to free bupivacaine (control group). All patients received spinal anesthesia and otherwise identical surgical approaches, pain management, and rehabilitation protocols. Outcomes evaluated include the patient-reported visual analog pain scores, narcotic consumption, and narcotic-related side effects (Brief Pain Inventory) within 96 hours after surgery as well as functional outcomes using the Knee Society Score and the Short-Form 12 measured preoperatively and at 4-6 weeks after surgery.
There were no statistically significant differences between the groups in terms of postoperative daily pain scores, narcotic consumption (by-day and overall), or narcotic-related side effects. There were no statistically significant differences between the groups in terms of surgical (P = .76) and medical complications or length of hospital stay (P = .35). There were no statistically significant differences in satisfaction between the groups (P = .56) or between the groups in postoperative Knee Society Score (P = .53) and the Short-Form 12 at 4-6 weeks (P = .82, P = .66).
As part of multimodal pain management protocol, periarticular injection of liposomal bupivacaine compared with bupivacaine HCl did not result in any clinically or statistically significant improvement of the measured outcomes following TKA.
Abstract Total joint arthroplasty is a safe and successful procedure. However, numerous complications may present after elective arthroplasty. This study prospectively collected data on systemic and ...local in hospital complications after 15 383 joint arthroplasties, which included 8230 total hip arthroplasties and 7153 total knee arthroplasties. In general, the incidence of complications was higher after knee arthroplasty, simultaneous bilateral surgery, and revision surgery. There were 22 (0.16%) deaths in this cohort. We identified 486 major systemic complications, the most common was pulmonary embolism (152), followed by tachyarrhythmia (92) and acute myocardial infarction (36). There were 109 major local complications, including 16 vascular injuries, 29 peripheral nerve injuries, 25 periprosthetic fractures, and 18 dislocations. Total joint arthroplasty, despite its success, can be associated with rare serious and life-threatening complications. This study provides a baseline of complications that can occur after elective joint arthroplasty.
Total joint arthroplasty is a large and growing part of the U.S. Medicare budget, drawing attention to how much providers are paid for their services. The purpose of this study was to examine the ...variables that affect total joint arthroplasty reimbursement. Along with standard economic variables, we include unique health-care variables. Given the focus on value in the Affordable Care Act, the model examines the relationship of the quality of care to total joint arthroplasty reimbursement. We hoped to find that reimbursement patterns reward quality and reflect standard economic principles.
Multivariable regression was performed to identify variables that correlate with Medicare reimbursement for total joint arthroplasty. Inpatient charge or reimbursement data on Medicare reimbursements were available for 2,750 hospitals with at least 10 discharges for uncomplicated total joint arthroplasty from the Centers for Medicare & Medicaid Services (CMS) for fiscal year 2011. Reimbursement variability was examined by using the Dartmouth Atlas to group institutions into hospital referral regions and hospital service areas. Independent variables were taken from the Dartmouth Atlas, CMS, the WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) Rural Health Research Center, and the United States Census.
There were 427,207 total joint arthroplasties identified, with a weighted mean reimbursement of $14,324.84 (range, $9,103 to $38,686). Nationally, the coefficient of variation for reimbursements was 0.19. The regression model accounted for 52.5% of reimbursement variation among providers. The total joint arthroplasty provider volume (p < 0.001) and patient satisfaction (p < 0.001) were negatively correlated with reimbursement. Government ownership of a hospital (p < 0.001) and higher Medicare costs (p < 0.001) correlated positively with reimbursement.
Medicare reimbursements for total joint arthroplasty are highly variable. Greater reimbursement was associated with lower patient volume, lower patient satisfaction, a healthier patient population, and government ownership of a hospital. As value-based reimbursement provisions of the Affordable Care Act are implemented, there will be dramatic changes in total joint arthroplasty reimbursements. To meet these changes, providers should expect qualities such as high patient volume, willingness to care for sicker patient populations, patient satisfaction, safe outcomes, and procedural demand to correlate with their reimbursement.
Practicing orthopaedic surgeons and hospital administrators should be aware of discrepancies in inpatient reimbursement for total joint arthroplasty from Medicare. Furthermore, these discrepancies are not associated with typical economic factors. These findings warrant further investigation and collaboration between policymakers and providers to develop value-based reimbursement.
Abstract Although persistent drainage and hematoma formation are recognized risk factors for the development of periprosthetic infection, it is not known if excess anticoagulation is a predisposing ...factor. We conducted a 2 to 1 case-control study with 78 cases who underwent revision for septic failure. The controls underwent the same index procedure but did not develop consequent infection. Patient comorbidities, medications, intraoperative, and postoperative factors were compared. Postoperative wound complications including development of hematoma and wound drainage were significant risk factors for periprosthetic infection. A mean international normalized ratio of greater than 1.5 was found to be more prevalent in patients who developed postoperative wound complications and subsequent periprosthetic infection. Cautious anticoagulation to prevent hematoma formation and/or wound drainage is critical to prevent periprosthetic infection and its undesirable consequences.
Abstract Background Intraoperative fractures during total hip arthroplasty (THA) are more common when using cementless stems. The purpose of this study was to investigate the impact of a new shorter ...second-generation cementless, tapered wedge stem with improved proximal femoral fit in reducing the incidence of intraoperative fracture. Methods A retrospective study was conducted on primary THA cases performed at a single institution using a first-generation or second-generation cementless stem from 2006-2016. All intraoperative femur fractures were identified, as well as early 30-day postoperative periprosthetic femur fractures, which could represent non-displaced intraoperative fractures that were initially missed. Risk for intraoperative femur fracture was analyzed using logistic regression, accounting for demographic covariates and surgeon. Results Of 6,473 primary THA performed with a cementless, tapered wedge stem during the study period, 3,126 utilized a first-generation stem and 3,347 utilized a second-generation stem. The incidence of intraoperative fracture was 1.79% for first-generation stems and 0.24% for second-generation stems, representing a 7.5-fold reduction of risk for fracture. After accounting for covariates, the odds of intraoperative fracture were 0.33 using the second-generation stem relative to the first-generation stem (p=0.01). However, there was no significant difference in the odds of early 30-day postoperative fractures using the second-generation stem (odds ratio 0.93, p=0.56). Conclusion A new second-generation cementless stem resulted in a 7.5-fold decrease in the incidence of intraoperative femur fracture compared to the preceding stem.
Abstract Background Preventing surgical site infection (SSI) after total joint arthroplasty (TJA) is a high priority and is partly linked to the efficacy of surgical site preparation solutions (SPSs) ...in reducing the number of pathogens on the skin before incision. The aim of this study is to investigate the effectiveness of SRS reapplication after draping to reduce the incidence of SSI after TJA. Methods Six hundred patients undergoing primary TJA between 2010 and 2011 at a single institution were recruited and randomly assigned to one of 2 groups. The patients in the intervention group (n = 300) received SPS that included alcohol and povidone-iodine before draping and an additional SPS by iodine povacrylex and isopropyl alcohol before application of the final adhesive drape, whereas the patients in the control group (n = 300) received a single SPS with alcohol and povidone-iodine before draping. Randomization was performed by an opaque envelope, and the rates of SSI and blistering were compared between groups. Results Five seventy-seven patients completed the study and were included in the final analysis. There was a significant reduction in the incidence of superficial SSI for the intervention group (1.8%, 5 of 283) compared to the control group (6.5%, 19 of 294, P = .02). There were 2 (0.7%, 2 of 294) deep incisional SSIs in the control group, and 2 (0.7%, 2 of 283) organ-space SSIs in the intervention group ( P = 1.00). In addition, skin blistering was lower in the intervention group (3.5%, 10 of 283) vs the control group (6.5%, 19 of 294), but this difference also did not reach statistical significance ( P = .13). Conclusion Reapplication of an SPS after draping and before the application of iodophor-impregnated incisive draping resulted in a significant reduction in the rate of SSI in patients undergoing elective TJA.
Background
In recent years, a number of alternative bearing surfaces, such as ceramic on ceramic, are being used in THA. Squeaking after THA is a recently recognized complication; however, its ...incidence is unknown.
Questions/purposes
Find the incidence of squeaking; when it ensues; activities associated to squeaking; its natural history, and outcome of revisions for squeaking.
Methods
A prospective observational study between 2002 and 2007; yield 1486 ceramic-on-ceramic THA performed at our institution. All patients were followed up by office visits or by phone, to obtain information regarding squeaking, pain and function. Minimum followup was 2.5 years (mean, 5.5 years; range, 2.5–7.9 years).
Results
Ninety-five of the 1486 hips (6%) developed squeaking after THA, 39 females (44%) and 49 males (56%) with an average age of 49.9 years. Squeaking began on average 19.7 months after surgery but not associated with pain or functional impairment in any patient. Squeaking could be heard during walking (38%), ascending stairs (24%), bending forward (21%), and other activities (18%), was constant in 26% of the patients and intermittent in 74%. The intensity and frequency remained similar over time in 70% of the patients.
Conclusions
Squeaking is a real phenomenon that occurred in about 6% of our patients. The etiology for this problem remains elusive and is likely to be multifactorial in nature. Squeaking, when developed, does not seem to be self-limited and persists in the majority. Nine patients underwent revision arthroplasty for squeaking. No fractures or other implant-related issues were observed.
Level of Evidence
Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Abstract The purpose is to determine the incidence and timing of pulmonary embolism for patients receiving warfarin for thrombo-prophylaxis following total joint arthroplasty (TJA). Current ...guidelines for duration of prophylaxis are nonspecific. Chemical prophylaxis carries the risk of bleeding and associated periprosthetic joint infection. We retrospectively studied 26,415 primary and revision TJA cases performed at our institution between 2000 and 2010. The overall 90-day rate of symptomatic PE was 1.07%. Fatal PE rate was 0.02%. Out of 283 documented symptomatic PE cases, 81% occurred within three postoperative days, 89% within one postoperative week, and 94% within two postoperative weeks. The risk of symptomatic PE appears to be highest during the first week after TJA. Efforts must be made to minimize risk during this period.
Background
Squeaking is reportedly a complication in patients having ceramic-on-ceramic total hip implants. The etiology remains unknown and multifactorial with recent studies suggesting a ...relationship between the audible squeak and implant design. When we evaluated our ceramic-on-ceramic cohort, we noticed squeaking primarily in patients receiving an acetabular system designed with an elevated titanium rim.
Objectives/purposes
We therefore (1) determined the incidence of squeaking among four different ceramic-on-ceramic bearing surfaces used for THA at our institution; (2) evaluated the association between different acetabular designs and the incidence of squeaking; and (3) assessed other potential variables associated with squeaking.
Methods
We retrospectively reviewed 1507 patients having a ceramic-on-ceramic THA between 2002 and 2009; we separately analyzed those receiving an acetabular system with and without an elevated titanium rim. Data were collected through phone-administered questionnaires and retrospective reviews of patient charts for intraoperative findings, followup reports, demographic information, and radiographic findings.
Results
Squeaking occurred in 92 of the 1507 patients (6%). All 92 patients with squeaking received an elevated rim design (1291 patients) or an incidence of 7% with that design. We found no association between squeaking and any other examined factors.
Conclusion
Our findings complement the theory from in vitro studies suggesting that neck impingement on the elevated titanium rim is the probable cause of the increased frequency of squeaking with this design.
Level of Evidence
Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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