Abstract Background Adverse local tissue reactions (ALTR) and periprosthetic joint infection (PJI) can occur after metal-on-metal (MOM) total hip arthroplasty (THA), both potentially generating ...purulent synovial fluid (SF) and elevated white cell count. This makes it difficult to distinguish between diagnoses; therefore, we evaluated leukocyte esterase (LE) strip test’s reliability in ruling out PJI in ALTR revision THA. Methods and Materials 61 patients with ALTRs and an LE strip test were evaluated, excluding 15 cases with SF metallic debris. LE strip tests were classified -/trace, +(mildly positive), and ++(strongly positive). Results LE strip tests were ++, +, -/trace in 8 patients (13.1%), 14 (23.0%), and 39 (63.9%), respectively. Means and ranges of SF white cell count and polymorphonuclear percentage were 1,291.4 (0-10886 cells/uL), and 46.1% (0%-94%), respectively. Conclusion ++ LE strip test,in conjunction with preoperative workups, reliably rules out infection in 92.9% of patients undergoing THA revision secondary to ALTR.
Abstract Background Venous thromboembolism (VTE) is a potentially preventable and costly complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The in-hospital incidence ...and economic burden of VTE following total joint arthroplasty (TJA) in the United States is unknown. The aim of this study was to examine this issue. Methods The Nationwide Inpatient Sample was used to estimate the total number of THA, TKA, and VTE events using International Classification of Diseases, Ninth Revision procedure codes from years 2002 to 2011. The rate of in-hospital deep vein thrombosis (DVT) and pulmonary embolism (PE), associated length of hospitalization, and current and projected in-hospital charges were obtained. Results Revision arthroplasties had higher rates of in-hospital VTE compared to primary TJAs (2.5% vs 1.6%, P < .0001). Among primary TJAs, the median rate of in-hospital VTE was 0.59% (0.55%-0.63%) for primary THA and 1.01% (0.94%-1.08%) for primary TKA. Revision THAs developed more VTE events compared to revision TKAs (1.35% 1.25%-1.46% vs 1.16% 1.07%-1.26%). Patients with a VTE have longer hospitalizations (median primary TKA: 7 vs 3; median primary THA: 6 vs 3, P < .0001). The overall rate of VTE decreased over the last decade; however, the PE rates have remained relatively constant. Moreover, the associated costs with VTE events have increased significantly over the last decade. Conclusion Based on the analysis of the Nationwide Inpatient Sample database, the rate of in-hospital DVT following TJA appears to have declined over the last decade while the incidence of PE has remained constant. This may indicate that the current recommendations by the American Academy of Orthopaedic Surgeons for VTE prophylaxis are adequate for preventing DVT without increasing the rate of PE or that institutional screening and reporting of DVT has been reduced because DVTs became a “never” event.
Abstract Background Underweight (UW) patients undergoing total hip arthroplasty have exhibited higher complication rates, including infection and transfusion. No study to our knowledge has evaluated ...UW total knee arthroplasty (TKA) patients. We, therefore, conducted a study to investigate if these patients are at increased risk for complications, including infection and transfusion. Methods A case-control study was conducted using a prospectively collected institutional database. Twenty-seven TKA patients were identified as UW (body mass index BMI < 18.5 kg/m2 ) from 2000-2012 and were matched for age, gender, date of surgery, age-adjusted Charlson comorbidity index, rheumatoid arthritis, and diabetes. These patients were compared to 81 normal weight patients (BMI 18.5-24 kg/m2 ). Demographic variables were compared, along with wound complications, surgical site infection (SSI), blistering, deep vein thrombosis, pulmonary embolism, transfusion, revision, flexion contracture, hematoma formation, and patellar clunk. Results The average BMI was 17.1 kg/m2 (range 12.8-18.4) for UW and 23.0 kg/m2 (range 19.0-25.0) for normal weight patients ( P < .001). UW TKA patients were more likely to develop SSIs (3/27, 11.1% vs 0/81, 0.0%, P = .01) and were more likely to require transfusions (odds ratio = 3.4, confidence interval 1.3-9.1; P = .02). Conclusions Our study demonstrates that UW TKA patients have a higher likelihood of developing SSI and requiring blood transfusions. The specific reasons are unclear, but we conjecture that it may be related to decreased wound healing capabilities and low preoperative hemoglobin. Investigation of local tissue coverage and hematologic status may be beneficial in this patient population to prevent SSI. Based on the results of this study, a prospective evaluation of these factors should be undertaken.
Abstract Background Total hip arthroplasty (THA) is one of the most successful orthopedic surgeries performed in the last 50 years. However, controversies still exist between conducting 1- or 2-stage ...bilateral THA. Methods Using PubMed, Ovid, Embase, and Cochrane library databases, we searched for papers written between January 1995 and October 2015 that contained the following search terms: “one-stage or two-stage” or “simultaneous or staged,” and “hip” and “arthroplasty or replacement.” A meta-analysis was conducted with the collected pooled data about major and minor systemic complications, surgical complications, and other perioperative data associated with 1- and 2-stage bilateral THA. Statistical analysis was performed by the Mantel-Haenszel method, and the fixed effect model was used to analyze data. Results There were 13 studies with 17,762 patients who underwent 1-stage bilateral THA and 46,147 patients who underwent 2-stage bilateral THA. One-stage bilateral THA had a lower risk of major systemic complications, less deep venous thrombosis, and shorter operative time compared with 2-stage bilateral THA. There were no significant differences in death, pulmonary embolism, cardiovascular complication, infections, minor complications, and other surgical complications between procedures. Conclusion One-stage bilateral THA was superior to 2-stage bilateral THA in terms of major systemic complication, deep venous thrombosis, and surgical time compared with 2-stage bilateral THA. However, this study does not encourage performing 1-stage over 2-stage bilateral THA. Higher evidence level studies are necessary for further analysis.
Abstract Introduction While periprosthetic joint infection (PJI) has a huge impact on patient function and health, only a few studies have investigated its impact on mortality. The purpose of this ...large-scale study was to 1) determine the rate and trends of in-hospital mortality for PJI and 2) compare the in-hospital mortality rate of patients with PJI and those undergoing revision arthroplasty for aseptic failure and patients undergoing other non-orthopedic major surgical procedures. Methods Data from the Nationwide Inpatient Sample (NIS) from 2002 to 2010 were analyzed to determine the risk of in-hospital mortality for PJI patients compared with aseptic revision arthroplasty. The Elixhauser comorbidity index was used to obtain patient comorbidities. Multiple logistic regression analyses were used to examine if PJI and other patient-related factors were associated with mortality. Results PJI was associated with an increased risk (odds ratio OR 2.05, p<0.0001) of in-hospital mortality (0.77%) compared with aseptic revisions (0.38%). The in-hospital mortality rate of revision total hip arthroplasties with PJI was higher than those for interventional coronary procedures (1.22%, 95% confidence interval CI 1.20-1.24), cholecystectomy (1.13%, 95% CI 1.11-1.15), kidney transplant (0.70%, 95% CI 0.61-0.79) and carotid surgery (0.89%, 95% CI 0.86-0.93). Discussion Patients undergoing treatment for PJI have a two-fold increase in in-hospital mortality for each surgical admission compared to aseptic revisions. Considering that PJI cases often have multiple admissions and that this analysis is by surgical admission, the risk of mortality will accumulate for every additional surgery. Surgeons should be cognizant of the potentially fatal outcome of PJI and the importance of infection control to reduce the risk of mortality.
Abstract Background There is continued controversy regarding the optimal venous thromboembolism (VTE) prophylaxis, particularly for total joint arthroplasty (TJA) patients at higher risk. The purpose ...of this study was to compare the efficacy of aspirin (ASA) to warfarin in patients with higher risk of VTE. Methods This retrospective study examined 30,270 patients who received ASA or warfarin for VTE prophylaxis after TJA. Using a previously developed risk stratification model, patients were classified into low or high VTE risk categories. Postoperative 90-day VTE, periprosthetic joint infection (PJI), gastrointestinal complications, and mortality were recorded. Results The incidences of VTE, PJI, and mortality were higher in patients receiving warfarin compared to ASA. In multivariate analysis, warfarin was an independent risk factor for VTE, PJI, and mortality in the higher risk VTE patients ( P < .001). There was no significant difference in gastrointestinal complications between groups. Conclusion Our study demonstrates that ASA is as effective as and safer than warfarin for VTE prophylaxis after TJA, even in patients at higher risk of VTE.
The Fate of Unmatched Orthopaedic Applicants Michael M. Kheir, MD; Timothy L. Tan, MD; Alexander J. Rondon, MD, MBA ...
JB & JS open access,
06/2020, Volume:
5, Issue:
2
Journal Article
Peer reviewed
Open access
Introduction:. Orthopaedic surgery residency has become increasingly competitive for medical school applicants with at least one in five applicants not matching annually. For unmatched applicants, ...the new application cycle is a perplexing and disconcerting period, where unique decisions must be addressed by the applicant. We aimed to investigate the risk factors and outcomes of unmatched orthopaedic applicants. Methods:. This was a retrospective study using a survey-based questionnaire administered electronically to medical students annually from 2016 to 2019 immediately after match day. Applicant responses totaled 934 completed surveys, of which 81 identified themselves as unmatched from the previous year and reapplied for a subsequent cycle. Variables collected through the survey included demographics, United States Medical Licensing Examination scores, Electronic Residency Application Service application characteristics, and interim year pursuits. A univariate analysis was performed with an alpha level of 0.05 denoting statistical significance. Results:. Overall, 58.0% of unmatched applicants subsequently matched into an orthopaedic residency. Applicants who pursued a research year or surgical internship after initially not matching had a subsequent match rate of 52.1% and 64.0%, respectively (p = 0.46). Of those who matched, 19.1% were Alpha Omega Alpha (AOA) compared with 2.9% in the unmatched group (p = 0.04). When stratified by gender, 83.3% of women matched subsequently compared with 50.8% of men (p = 0.02). There were no differences in Step 1 scores (242.5 vs. 240.7, p = 0.60), Step 2 clinical knowledge (CK) scores (248.3 vs. 244.5, p = 0.60), or the number of publications (15.6 vs. 10.9, p = 0.25) between applicants who matched or did not match, respectively. Discussion:. Our findings demonstrate that most orthopaedic applicants matched during their subsequent attempt. Women and those with AOA status had a significantly higher match rate than their counterparts. There was no difference in outcomes between those who pursued a research year or surgical internship, Step 1 or 2CK scores, or the number of publications. Further study is warranted to properly analyze risk factors for not matching on a subsequent attempt. Level of Evidence:. Prognostic Level IV.
Abstract Background Failure of 2-stage exchange arthroplasty for the management of periprosthetic joint infection (PJI) poses a major clinical challenge. There is a paucity of information regarding ...the outcomes of further surgical intervention in these patients. Thus, we aim to report the clinical outcomes of subsequent surgery for a failed prior 2-stage exchange arthroplasty. Methods Our institutional database was used to identify 60 patients (42 knees and 18 hips), with a failed prior 2-stage exchange, who underwent further surgical intervention between 1998 and 2012, and had a minimum 2-year follow-up. A retrospective review was performed to extract relevant clinical information, including mortality, microbiology, and subsequent surgeries. Musculoskeletal Infection Society criteria were used to define PJI, and treatment success was defined using Delphi criteria. Results Irrigation and debridement (I&D) was performed after a failed 2-stage exchange in 61.7% of patients; 56.8% subsequently failed. Forty patients underwent an intended second 2-stage exchange; 6 cases required a spacer exchange. Reimplantation occurred only in 65% of cases, and 61.6% had infection controlled. The 14 cases that were not reimplanted resulted in 6 retained spacers, 5 amputations, 2 PJI-related mortalities, and 1 arthrodesis. Conclusion Further surgical intervention after a failed prior 2-stage exchange arthroplasty has poor outcomes. Although I&D has a high failure rate, many patients who are deemed candidates for a second 2-stage exchange either do not undergo reimplantation or fail after reimplantation. The management of PJI clearly remains imperfect, and there is a dire need for further innovations that may improve the care of these patients.
Abstract Background In total joint arthroplasty (TJA) literature, there is a paucity of large cohort studies comparing chronic kidney disease (CKD) and end-stage renal disease (ESRD) vs non-CKD/ESRD ...patients. Thus, the purposes of this study were (1) to identify inhospital complications and mortality in CKD/ESRD and non-CKD/ESRD patients and (2) compare inhospital complications and mortality between dialysis and renal transplantation patients undergoing TJA. Methods We queried the Nationwide Inpatient Sample database for patients with and without diagnosis of CKD/ESRD and those with a renal transplant or on dialysis undergoing primary or revision total knee or hip arthroplasty from 2007 to 2011. Patient comorbidities were identified using the Elixhauser comorbidity index. International Classification of Diseases, Ninth Revision , codes were used to identify postoperative surgical site infections (SSIs), wound complications, deep vein thrombosis, and transfusions. Results Chronic kidney disease/ESRD was associated with greater risk of SSIs (odds ratio OR, 1.4; P < .001), wound complications (OR, 1.1; P = .01), transfusions (OR, 1.6; P < .001), deep vein thrombosis (OR, 1.4; P = .03), and mortality (OR, 2.1; P < .001) than non-CKD/ESRD patients. Dialysis patients had higher rates of SSI, wound complications, transfusions, and mortality compared to renal transplant patients. Conclusion Chronic kidney disease/ESRD patients had a greater risk of SSIs and wound complications compared to those without renal disease, and the risk of these complications was even greater in CKD/ESRD patients receiving dialysis. These findings emphasize the importance of counseling CKD patients about higher potential complications after TJA, and dialysis patients may be encouraged to undergo renal transplantation before TJA.
Abstract Background context Vertebral artery injuries (VAIs) are rare but serious complications of cervical spine surgery, with the potential to cause catastrophic bleeding, permanent neurologic ...impairment, and even death. The present literature regarding incidence of this complication largely comprises a single surgeon or small multicenter case series. Purpose We sought to gather a large sample of high-volume surgeons to adequately characterize the incidence and risk factors for VAI, management strategies used, and patient outcomes after VAI. Study design The study was constructed as a cross-sectional study comprising all cervical spine patients operated on by the members of the international Cervical Spine Research Society (CSRS). Patient sample All patients who have undergone cervical spine surgery by a current member of CSRS as of the spring of 2012. Outcome measures For each surgeon surveyed, we collected self-reported measures to include the number of cervical cases performed in the surgeon's career, the number of VAIs encountered, the stage of the case during which the injury occurred, the management strategies used, and the overall patient outcome after injury. Methods An anonymous 10-question web-based survey was distributed to the members of the CSRS. Statistical analysis was performed using Student t tests for numerical outcomes and chi-squared analysis for categorical variables. Results One hundred forty-one CSRS members (of 195 total, 72%) responded to the survey, accounting for a total of 163,324 cervical spine surgeries performed. The overall incidence of VAI was 0.07% (111/163,324). Posterior instrumentation of the upper cervical spine (32.4%), anterior corpectomy (23.4%), and posterior exposure of the cervical spine (11.7%) were the most common stages of the case to result in an injury to the vertebral artery. Discectomy (9%) and anterior exposure of the spine (7.2%) were also common time points for an arterial injury. One-fifth (22/111) of all VAI involved an anomalous course of the vertebral artery. The most common management of VAI was by direct tamponade. The outcomes of VAIs included no permanent sequelae in 90% of patients, permanent neurologic sequelae in 5.5%, and death in 4.5%. Surgeons at academic and private centers had nearly identical rates of VAIs. However, surgeons who had performed 300 or fewer cervical spine surgeries in their career had a VAI incidence of 0.33% compared with 0.06% in those with greater than 300 lifetime cases (p=.028). Conclusions The overall incidence of VAI during cervical spine surgery reported from this survey was 0.07%. Less experienced surgeons had a higher rate of VAI compared with their more experienced peers. The results of VAI are highly variable, resulting in no permanent harm most of the time; however, permanent neurologic injury or death occur in 10% of cases.
PDF
