Incidence, Risk Factors, and Sources of Sepsis Following Total Joint Arthroplasty

Moving Beyond Systemic Inflammatory Response Syndrome and Bacteremia: Are Modern Critical Care Calculators Useful in Predicting Debridement, Antibiotics, and Implant Retention Treatment Outcomes in Periprosthetic Joint Infection?

BACKGROUND

In critically ill periprosthetic joint infection (PJI) patients, surgeons need to balance the need for aggressive, definitive treatment against the health state of a potentially unstable patient. A clear understanding of the association between treatment outcomes and assessment scores for sepsis would benefit clinical decision-making in these urgent cases. The current study evaluates the effect of critical illness on debridement, antibiotics, and implant retention (DAIR) outcomes, as defined by systemic inflammatory response syndrome (SIRS) and, for the first time, by contemporary markers quick sequential organ failure assessment (qSOFA) and Modified Early Warning Score (MEWS).

METHODS

We retrospectively identified 253 patients who underwent DAIR for PJI at a single institution between 2017 and 2021. The SIRS, qSOFA, and MEWS scores were calculated based on variables on admission. A DAIR treatment failure, defined as reoperation or mortality, was measured at 90 days and two years. Univariate analysis was used to determine the association between elevated critical care scores and DAIR failure.

RESULTS

The DAIR treatment success was 59% at two years, with hip procedures and Charlson comorbidity index ≥ one independently associated with higher odds of DAIR failure. There were 43 patients (16%) who presented with SIRS; however, only four (2%) had positive qSOFA scores. Neither SIRS nor qSOFA was predictive of DAIR failure. Only for knees, elevated MEWS scores were predictive of 90-day DAIR failure (P = 0.019).

CONCLUSIONS

Over one in six patients undergoing DAIR for PJI presented with SIRS, while only one in 50 had a positive qSOFA. The SIRS and qSOFA scores were not predictive of DAIR failure. Elevated MEWS scores were associated with DAIR failure at 90 days postoperatively in knee PJIs only and should be confirmed in a larger cohort. Our results suggest that SIRS is not predictive of DAIR outcomes, possibly because it overestimates the proportion of critically ill patients.

Medical- and Implant-Related Complications Following Total Joint Arthroplasty in Patients Who Have Chronic Lymphocytic Leukemia

BACKGROUND

Chronic lymphocytic leukemia (CLL) is highly prevalent in the total joint arthroplasty age group but has not been properly evaluated. This study aimed to assess the following: 1) 90-day medical complications, 2) implant-related complications, 3) healthcare utilization, and 4) time to revision in CLL and non-CLL total joint arthroplasty.

METHODS

The CLL cases undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) were identified using diagnostic and procedural codes. The CLL TKA and THA patients were matched in a 1:5 ratio, with controls based on demographics and comorbidities. The outcomes included 90-day medical complications, 2-year implant complications, length of stay, 90-day readmission, and time to revision.

RESULTS

The CLL TKA patients had significantly higher odds of 90-day medical complications compared to controls, notably pneumonia (OR [odds ratio], 9.2; CI [confidence interval], 7.1 to 12.0; P < 0.001) and myocardial infarction (OR, 5.5; CI, 3.9 to 7.9; P < 0.001). Similarly, CLL THA patients had greater odds of 90-day medical complications, especially pneumonia (OR 10.0; CI 8.2 to 12.2; P < 0.001) and acute kidney injury (OR 6.3; CI 5.1 to 7.8; P < 0.001). The CLL TKA patients faced higher odds of periprosthetic fracture, mechanical loosening, and prosthetic joint infection, while THA patients had increased periprosthetic fractures. Revisions occurred earlier for THA than TKA (337 ± 547 versus 643 ± 774 days). The CLL patients had longer length of stay(TKA: 5.9 ± 6.5 versus 3.1 ± 1.6 days; P < 0.001) (THA: 6.3 ± 12.9 versus 3.0 ± 2.4; P < 0.001) and higher 90-day readmission rates (OR, 1.3; CI, 1.1 to 1.5, P < 0.001).

CONCLUSIONS

Orthopaedic surgeons should consider CLL status for informed patient counseling and complications mitigation.

Incidence, predictors, and outcomes of sepsis in revision total hip arthroplasty (rTHA)

INTRODUCTION

Revision total hip arthroplasty (rTHA) is increasingly common, with sepsis being a serious but rare complication. Sepsis rates in rTHA vary widely, and understanding risk factors is crucial for improving outcomes. This study aims to evaluate the incidence of sepsis following rTHA and identify preoperative and intraoperative predictors.

METHODS

A retrospective observational study using the ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database analyzed 12,966 rTHA patients (2016-2021). Predictors of sepsis were identified through univariate and multivariate analysis, including demographic, comorbid, and surgical factors. The primary endpoint was identifying sepsis predictors; secondary endpoints included sepsis incidence across patient groups.

RESULTS

In a cohort of 12,966 patients undergoing revision total hip arthroplasty, the incidence of sepsis was 1.9% (251 patients). Preoperative factors associated with increased sepsis incidence included diabetes (2.6%), smoking (2.9%), dyspnea (3.7%), severe chronic obstructive pulmonary disease (COPD) (3.5%), dialysis (5.3%), open wounds (9.5%), steroid use (3.1%), partial/total dependence (3.5%), and American society of anesthesiologists (ASA) III-IV status (2.7%). Multivariate analysis identified several predictors of sepsis, including age (OR + 0.02 per year), total operation time (OR -0.004 per minute), open wounds (OR 3.6), severe COPD (OR 1.9), transfusion within 72 h (OR 3.3), dyspnea (OR 8.1), and emergent cases (OR 3.4). The sepsis group had higher adverse outcomes, including a 30-day mortality rate of 0.8% (vs. 0.22% in non-septic patients), higher rates of deep vein thrombosis (2.8% vs. 0.7%), pulmonary embolism (1.6% vs. 0.5%), stroke (0.8% vs. 0.2%), and acute renal failure (1.2% vs. 0.1%), all with significant p-values and higher odds ratios.

CONCLUSION

Sepsis after rTHA is a significant complication. Predictors include age, open wounds, COPD, dyspnea, and transfusions. Identifying at-risk patients can improve prevention and management strategies to enhance patient outcomes.

Effect of Antiseptic Irrigation Solutions on Primary Human Knee Fibroblasts Cultured in Human Platelet Lysate

BACKGROUND

Native and periprosthetic joint infections are devastating conditions fraught with patient morbidity and mortality. Aseptic and septic joints are often debrided and irrigated to decrease bacterial loads when preventing or treating infection. However, the effect of clinically used irrigation solutions on the native cellular components of the synovial joint is unknown.

METHODS

Patients consented, and their suprapatellar knee tissue was surgically excised for fibroblast isolation. Cultured knee fibroblasts were treated with normal saline for three minutes or one of the following experimental solutions: acetic acid, chlorhexidine-gluconate, Dakin's solution, hydrogen peroxide, or povidone-iodine. The exposure time for the antiseptic solutions was one and three minutes. At 24 hours after irrigation treatment, metabolic activity was measured via MTS [3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium] activity assay, and deoxyribonucleic acid content was assessed by Hoechst staining as a surrogate for cell number. Phase-contrast imaging elucidated proliferation potential, progressive cell loss, and cell morphology over a 5-day period. All experiments were repeated in triplicate.

RESULTS

All experimental antiseptic irrigation solutions, regardless of application time, caused a significant reduction in metabolic activity and DNA content, indicating extensive cell death. Phase-contrast imaging showed halted cellular proliferation, progressive cell loss, and distinct changes in cellular morphology, indicating decreased cellular viability and progressive cell death.

CONCLUSIONS

All antiseptic irrigation solutions investigated in this study were severely cytotoxic to human knee fibroblasts regardless of their chemical composition. The concentrations of these solutions are commonly used in orthopaedic surgery. Although these solutions have high bactericidal properties, it may be beneficial to use them in combination at lower doses to retain their effect on bacteria while remaining benign to native synovial cells.

Efficacy and Safety of Dual vs Single Antibiotic-Loaded Cement in Bone Fracture Management: A Systematic Review and Meta-Analysis

Bone fractures often require arthroplasty, which carries the risk of surgical site infections (SSIs) and prosthetic joint infections (PJIs). Antibiotic-loaded bone cement (ALBC) is commonly used to reduce these risks. Dual antibiotic-loaded cement (DALC) has been proposed as a more effective option compared to single antibiotic-loaded cement (SALC). This systematic review and meta-analysis aimed to compare the efficacy and safety of DALC and SALC in preventing infections and related outcomes in arthroplasty. We conducted a systematic review and meta-analysis comparing DALC and SALC in patients undergoing hip or knee arthroplasty for fractures. The primary outcome was infection rate (SSI and PJI), with secondary outcomes including re-revision rates and mortality. Databases searched included PubMed, Cochrane Library, Scopus, and Google Scholar. Data synthesis was performed using Review Manager Software (RevMan 5.4, Cochrane Methods, London, UK), and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Nine studies comprising 55,672 patients were included. Eight studies focused on hip arthroplasty, and four included knee surgeries. In hip arthroplasty, DALC significantly reduced infection rates compared to SALC (OR, 0.64; 95% CI, 0.49 to 0.83; P = 0.001), with moderate heterogeneity (I² = 52%). However, no significant difference was found in knee arthroplasty (OR, 1.21; 95% CI, 0.87 to 1.70; P = 0.26). Overall, DALC showed a significant reduction in infection rates (OR, 0.81; 95% CI, 0.66 to 1.00; P = 0.05). DALC also significantly reduced deep surgical site infections in hip surgeries (OR, 0.46; 95% CI, 0.33 to 0.66; P < 0.001). No significant differences were observed in re-revision rates for either hip or knee arthroplasty. Mortality rates were also not significantly different between DALC and SALC. DALC appears to reduce infection rates, particularly in hip arthroplasty, compared to SALC. However, no significant differences were found in re-revision or mortality rates. These findings suggest that DALC may offer better prophylaxis in hip surgeries, but further research is needed to explore its broader benefits and cost-effectiveness.

Do modifiable patient factors increase the risk of postoperative complications after total joint arthroplasty?

INTRODUCTION

Numerous studies demonstrate that modifiable lifestyle risk factors can influence patient outcomes including survivability, quality of life, and postoperative complications following orthopaedic surgery. The purpose of this study was to determine the impact of modifiable lifestyle risk factors on postoperative medical and surgical complications following a total joint arthroplasty (TJA) in a large national healthcare system.

METHODS

A retrospective chart review of a large national health system database was performed to identify patients who underwent TJA between 2017 and 2021. TJA included total knee arthroplasty, total hip arthroplasty, and total shoulder arthroplasty. Modifiable lifestyle risk factors were defined as tobacco use, narcotic drug abuse, hypertension, and diabetes mellitus. Postoperative medical complications and postoperative surgical complications were collected. Logistic regression and odds ratio point estimate analysis were conducted to assess for associations between postoperative complications and modifiable lifestyle risk factors.

RESULTS

Of the 16,940 patients identified, the mean age was 71 years, mean BMI was 29.7 kg/m2, and 62% were women. We found that 3.5% had used narcotics, 8.7% were past or current smokers, 24% had diabetes, and 61% had hypertension; in addition, 5.4% experienced postoperative medical complications and 6.4% experienced postoperative surgical complications. Patients who used narcotics were 90% more likely to have postoperative complications (p < 0.0001) and 105% more likely to experience prosthetic complications (p < 0.0001). Similarly, patients with tobacco use were 65% more likely to have postoperative complications (p < 0.0001) and 27% more likely to experience prosthetic complications.

CONCLUSIONS

Our results demonstrate critical rates of increased postoperative medical and surgical complications after TJA for patients with narcotic abuse, tobacco use, or diabetes mellitus. Furthermore, adopting preoperative interventions and optimization programs informed by our findings on specific modifiable risk factors could aid orthopaedic surgeons in optimizing patient health.

LEVEL OF EVIDENCE

III; Retrospective study.

Causal relationships between lung cancer and sepsis: a genetic correlation and multivariate mendelian randomization analysis

Background

Former research has emphasized a correlation between lung cancer (LC) and sepsis, but the causative link remains unclear.

Method

This study used univariate Mendelian Randomization (MR) to explore the causal relationship between LC, its subtypes, and sepsis. Linkage Disequilibrium Score (LDSC) regression was used to calculate genetic correlations. Multivariate MR was applied to investigate the role of seven confounding factors. The primary method utilized was inverse-variance-weighted (IVW), supplemented by sensitivity analyses to assess directionality, heterogeneity, and result robustness.

Results

LDSC analysis revealed a significant genetic correlation between LC and sepsis (genetic correlation = 0.325, p = 0.014). Following false discovery rate (FDR) correction, strong evidence suggested that genetically predicted LC (OR = 1.172, 95% CI 1.083-1.269, p = 8.29 × 10-5, P fdr = 2.49 × 10-4), squamous cell lung carcinoma (OR = 1.098, 95% CI 1.021-1.181, p = 0.012, P fdr = 0.012), and lung adenocarcinoma (OR = 1.098, 95% CI 1.024-1.178, p = 0.009, P fdr = 0.012) are linked to an increased incidence of sepsis. Suggestive evidence was also found for small cell lung carcinoma (Wald ratio: OR = 1.156, 95% CI 1.047-1.277, p = 0.004) in relation to sepsis. The multivariate MR suggested that the partial impact of all LC subtypes on sepsis might be mediated through body mass index. Reverse analysis did not find a causal relationship (p > 0.05 and P fdr > 0.05).

Conclusion

The study suggests a causative link between LC and increased sepsis risk, underscoring the need for integrated sepsis management in LC patients.

Systemic Inflammatory Response Syndrome and Prosthetic Joint Infection

BACKGROUND

The development of systemic inflammatory response syndrome (SIRS) criteria leads to increased mortality. Little is known about development of SIRS in patients who have prosthetic joint infection (PJI). We aimed to determine the incidence, risk factors, clinical outcomes, and causative organisms in patients who develop SIRS with PJI.

METHODS

We retrospectively identified 655 patients (321 men, 334 women; 382 total hip, 273 total knee) who have hip or knee PJI at 1 institution between July 1, 2015 and December 31, 2020. We formed 2 groups: patients who have SIRS alert (PJI + SIRS) and patients who do not have SIRS alert (PJI). We analyzed clinical outcomes, comorbidities, and operating room culture results.

RESULTS

Of 655 patients, 63 developed SIRS with PJI (9.6%). Intensive care unit (ICU) admission rates (27.0 versus. 6.9%, P < .001) and length of stay (7.7 versus. 5.6 days, P = .003) were greater in PJI + SIRS. At 2 years, reoperation (36.5 versus. 22.3%, P = .01) and mortality rates (17.5 versus. 8.8%, P = .03) were greater in PJI + SIRS. Risk factors included deficiency anemia (P = .001), blood loss anemia (P = .013), uncomplicated diabetes (P = .006), diabetes with complication (P = .001), electrolyte disorder (P < .00001), neurological disorder (P = .0001), paralysis (P = .026), renal failure (P = .005), and peptic ulcer disease (P = .004). Staphylococcus aureus more commonly speciated on tissue cultures in PJI + SIRS (P = .002).

CONCLUSION

The incidence of SIRS is 10% among patients who have PJI. Development of PJI + SIRS is associated with increased lengths of stay, ICU admissions, and 2-year reoperation and mortality rates. Identifying certain comorbidities can stratify patients' risk of developing PJI + SIRS.

Graphic type differentiation of cell count data for diagnosis of early and late periprosthetic joint infection: A new method

BACKGROUND

Graphic type differentiation of cell count data of synovial aspirates is a new method for the diagnosis of early and late periprosthetic joint infection.

OBJECTIVE

The aim of the study was to analyse if the same 6 LMNE-types can be differentiated in the new Yumizen H500 cell counter as it was the case for the old cell counter ABX Pentra XL 80 of previous publications, to verify if the erythrocyte and thrombocyte curves of the new device give additional information and to calculate the difference of cell count in LMNE-type I and III (with abrasion) in the cell counter and in the manual counting chamber (Neubauer improved).

METHODS

450 aspirates of 152 total hip arthroplasties and 298 knee arthroplasties obtained for the diagnosis of periprosthetic joint infection were analysed with the Yumizen H500.

RESULTS

All LMNE-matrices of the 450 aspirates could assigned to one of the six LMNE-types. There were 76 LMNE-type I, 72 LMNE-type II, 14 LMNE-type III, 241 LMNE-type IV, 36 LMNE-type V and 12 LMNE-type VI. The erythrocyte and thrombocyte distribution curves were very helpful for differentiation of hematoma and infection. The cell count in the manual counting procedure was lower than in the cell counter: for the LMNE-type I (abrasion type) the median of the difference was 925/μL (median) and for the LMNE-type III (combined type of infection and abrasion) 3570/μL (median).

CONCLUSION

The described graphic type differentiation is a new and helpful method for differentiation of hematoma and early PJI as well as abrasion and late PJI.

Thirty-Day Mortality and Complication Rates in Total Joint Arthroplasty After a Recent COVID-19 Diagnosis: A Retrospective Cohort in the National COVID Cohort Collaborative (N3C)

BACKGROUND

The risk of postoperative complications in patients who had a positive COVID-19 test prior to a total joint arthroplasty (TJA) is unknown. The purpose of this investigation was to study the complications and mortality associated with a recent COVID-19 diagnosis prior to TJA.

METHODS

Patients undergoing primary and revision total hip arthroplasties (THAs) or total knee arthroplasties (TKAs) were identified using the National COVID Cohort Collaborative (N3C) Data Enclave. Patients were divided into a COVID-19-positive group (positive polymerase chain reaction [PCR] test, clinical diagnosis, or positive antibody test) and a COVID-19-negative group, and the time from diagnosis was noted. There was no differentiation between severity or acuity of illness available. The postoperative complications reviewed included venous thromboembolism, pneumonia, acute myocardial infarction, readmission rates, and 30-day mortality rates.

RESULTS

A total of 85,047 patients who underwent elective TJA were included in this study, and 3,516 patients (4.13%) had had a recent positive COVID-19 diagnosis. Patients diagnosed with COVID-19 at 2 weeks prior to TJA were at increased risk of pneumonia (odds ratio [OR], 2.46), acute myocardial infarction (OR, 2.90), sepsis within 90 days (OR, 2.63), and 30-day mortality (OR, 10.61).

CONCLUSIONS

Patients with a recent COVID-19 diagnosis prior to TJA are at greater risk of postoperative complications including 30-day mortality. Our analysis presents critical data that should be considered prior to TJA in patients recently diagnosed with COVID-19.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Positive COVID-19 Diagnosis Following Primary Elective Total Joint Arthroplasty: Increased Complication and Mortality Rates

BACKGROUND

This study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19.

METHODS

A large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]).

RESULTS

Of patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately.

CONCLUSION

Patients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.

Super-obese patients are associated with significant infection burden after total hip arthroplasty

INTRODUCTION

Over ⅓ of the population in the United State is obese (body mass index [BMI] >30 kg/m2), with an increasing proportion being morbidly obese (BMI >40 kg/m2). As the obesity rate climbs, an increasing number have entered the super-obese category (BMI >50 kg/m2), theoretically increasing risk for complications after total hip arthroplasty (THA). This study compared complications in non-obese, obese, morbidly obese, and super-obese patients undergoing THA. We specifically assessed: (1) 1- and 2-year peri-prosthetic joint infection (PJI) rates; (2) complication rates; as well as (3) 1- and 2-year revision rates.

METHODS

A database review identified patients undergoing primary THA from 01 January 2010 to 31 December 2019. Patients were stratified based on the presence of International Classification of Diseases, 9th and 10th revision diagnosis codes of non-obese (BMI <30 kg/m2) (n = 8680), obese (BMI <40 kg/m2) (n = 12,443), morbidly obese (BMI <50 kg/m2) (n = 5250), and super-obese (BMI >50 kg/m2) (n = 814) prior to THA. Complication rates at 90 days, 1 year, and 2 years were compared across groups.

RESULTS

At all time points, super-obese patients were associated with higher rates of PJI, even when compared to morbidly obese patients. Complications such as sepsis, venous thrombo-embolism, and revision surgeries were found in higher numbers in super-obese as well as morbidly obese patients, compared to obese and non-obese patients.

CONCLUSIONS

This study provides large-scale analyses demonstrating the association between super-obese and morbidly obese patients and higher infection rates, as well as complications, following THA. Importantly, the association of PJI is highest among super-obese patients, even when compared to morbidly obese patients. Attaining a BMI <40 kg/m2 prior to surgery may be an important goal discussed with patients to lower the chance of postoperative infections.

The Influence of Patient Sex on Outcomes Following One-Stage and Two-Stage Revision for Periprosthetic Joint Infection in Total Joint Arthroplasty

Although females have a higher rate of primary total joint arthroplasty (TJA), males have a higher rate of revision. The literature lacks studies examining the relationship between sex and outcomes following single and two-stage exchange for periprosthetic joint infection (PJI). The purpose of this study was to examine if differences exist in outcomes following revision for chronic PJI between sexes. A retrospective review was performed on all patients with an MSIS confirmed PJI who underwent a single or two-stage exchange at our institution from January 2010 to January 2021. Patient demographics, comorbidity characteristics, and outcomes were collected and compared between males and females. The primary outcome variable was disease-free survival at 1 year following definitive revision. Multivariable logistic regression analysis was performed to determine risk factors for failure. Of the 470 patients meeting final eligibility criteria, 250 were male and 226 were female (2 males and 4 females had a joint infection of either the contralateral side or a different joint and were treated as separate records). Of the patients in the cohort, 80% of the males (200/250) and 80% of the females (181/226) were found to be disease-free at 1-year follow-up (p > 0.99). Multivariable logistic regression analysis showed that nicotine use and diabetes, but not sex, were significant predictors of failure. Our study did not find a relationship between sex and outcome of revision for PJI. Further research is required to determine whether differences exist between males and females in the expression of PJI and outcomes following treatment.

A Low Rate of Periprosthetic Infections after Aseptic Knee Prosthesis Revision Using Dual-Antibiotic-Impregnated Bone Cement

AIM

The incidence of periprosthetic joint infections (PJI) following aseptic knee revision arthroplasty lies between 3% and 7.5%. The aim of this study was to verify the hypothesis that the use of dual-antibiotic-impregnated cement in knee revision arthroplasty leads to a lower rate of periprosthetic joint infections.

METHODS

We retrospectively reviewed 403 aseptic revision knee arthroplasties performed between January 2013 and March 2021 (148 revisions of a unicompartmental prosthesis, 188 revisions of a bicondylar total knee arthroplasty (TKA), 41 revisions of an axis-guided prosthesis, and 26 revisions of only one component of a surface replacement prosthesis). The bone cement Copal G+C (Heraeus Medical, Wertheim, Germany) with two antibiotics-gentamycin and clindamycin-was used for the fixation of the new implant. The follow-up period was 53.4 ± 27.9 (4.0-115.0) months.

RESULTS

Five patients suffered from PJI within follow-up (1.2%). The revision rate for any reason was 8.7%. Survival for any reason was significantly different between the types of revision (p = 0.026, Log-Rank-test), with lower survival rates after more complex surgical procedures. The 5-year survival rate with regard to revision for any reason was 91.3% [88.2-94.4%] and with regard to revision for PJI 98.2% [98.7-99.9%], respectively.

CONCLUSION

The use of the dual-antibiotic-impregnated bone cement Copal G+C results in a lower rate of periprosthetic infections after aseptic knee prosthesis replacement than that reported in published prosthesis revisions using only one antibiotic in the bone cement.

Investigation of the effect of rifampicin resistance and risk factors on recovery rates after DAIR procedure in patients with prosthetic joint infection

BACKGROUND

Rifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favourable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing debridement, antibiotics and implant retention (DAIR).

METHODS

We reviewed medical records and microbiology reports of 67 patients (37 males and 30 females) undergoing DAIR due to PJI between 2014 and 2021. Patient-related factors, co-morbidities and microbiological reports were collected and reviewed. Forty-four patients had hip, 21 had knee, 1 had shoulder and 1 had elbow joint infection. Obtained data were statistically analysed with a logistic regression model.

RESULTS

Rifampicin-sensitive organism was isolated in 47 cases. Recovery rate was 72.3% in the sensitive and 76.9% in the resistant group. We found no significant effect of rifampicin resistance on the probability of recovery. Age and diabetes mellitus showed negative clinical impact on recovery. Staphylococcus aureus and coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (66.6% of the isolates) and Gram-negative rods in the resistant group (65.2%).

CONCLUSIONS

Based on our results, higher age and diabetes mellitus may have a clinically relevant negative impact on clinical outcome, however, this effect was not statistically significant. This may be due to the limited number of patients included in this study. We observed no clinically relevant effect of rifampicin-resistance, sex and body mass index (BMI) on recovery rates among patients undergoing DAIR due to PJI.

The relationship of C-reaktif protein level after knee artroplasty with gender difference and type of artroplasty

PURPOSE

It was aimed to reveal the relationship between CRP level after knee arthroplasty and gender difference and arthroplasty type.

METHODS

Preoperative and postoperative (1st and 7th day, 1st and 3rd months) CRP values of the patients who underwent TKA or UKA were examined. The data were compared by categorizing them into primary male-female, secondary TKA-UKA groups.

RESULTS

967 patients were included in the study (151 male, 685 female in the TKA group and 25 male, 106 female in the UKA group) In the TKA group, the mean age was 67.38 in males and 65.54 in females. In the UKA group, the mean age was 58.72 in males and 57,63 in females. CRP values were found to be statistically significantly lower in females compared to males in the preoperative period, postoperative 1st and 3rd months in patients who underwent TKA (p < .05). In the UKA group, it was found to be significantly lower in females in the preoperative period and at the postoperative 3rd month, p < .05). When the CRP values and their effect on the course of arthroplasty were evaluated according to the type of arthroplasty, there was no significant difference between the CRP values of the preoperative patients (p = .686). In addition, in the comparison made on the postoperative 1st day, 1st week, 1st month, and 3rd month, CRP values of the patient who underwent UKA were found to be significantly lower (p < .05). When analyzed separately by arthroplasty type, postoperative CRP values decreased to normal limits in 96.3% of patients who underwent TKA and 98.5% of patients who underwent UKA in the third month.

CONCLUSIONS

Our study showed that the uncomplicated course of CRP after TKA and UKA is gender-specific, and higher CRP values are observed in males than in females. The UKA group exhibited significantly lower postoperative CRP levels than the TKA group.

Short-Term Indwelling Foley Catheters Do Not Reduce the Risk of Postoperative Urinary Retention in Uncomplicated Primary THA and TKA: A Randomized Controlled Trial

BACKGROUND

The purpose of this randomized controlled trial was to determine whether a short-term Foley catheter (inserted in the operating room and removed upon arrival to the orthopaedic floor) would reduce the risk of postoperative urinary retention (POUR) in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA).

METHODS

Three hundred and eighty-eight patients undergoing inpatient primary TKA (n = 228) or THA (n = 160) with spinal anesthesia were randomized to receive a short-term Foley catheter (n = 194) or no Foley (n = 194). There were 143 male and 245 female patients. The primary outcome was POUR, defined as requiring ≥2 straight catheterizations or the placement of an indwelling urinary catheter when indicated by retention of ≥450 mL on bladder scans. Secondary outcomes included urinary tract infections (UTIs) within 3 weeks and the need for ≥1 straight catheterization. A power analysis determined that 194 patients per group were required to detect a 7% minimal clinically important difference in POUR rates at 80% power and alpha of 0.05. Intention-to-treat and as-treated analyses were performed (2 patients received the non-allocated treatment). Outcomes were compared between the groups using univariate and multivariate analyses, with alpha < 0.05.

RESULTS

Nine patients developed POUR: 4 in the short-term Foley group and 5 in the control group (2.1% versus 2.6%; p = 1.00). Of those who developed POUR, 8 were male and 1 was female (88.9% versus 11.1%; p = 0.002). Twenty-four patients required ≥1 straight catheterization: 10 in the Foley group and 14 in the control group (5.2% versus 7.2%; p = 0.40). Four patients developed UTIs: 3 in the Foley group and 1 in the control group (1.5% versus 0.5%; p = 0.62) on intention-to-treat analysis, and 4 in the Foley group and none in the control group (2.1% versus 0.0%; p = 0.12) on as-treated analysis.

CONCLUSIONS

The use of a short-term Foley catheter inserted in the operating room and removed on arrival to the orthopaedic floor does not decrease the rate of POUR.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Impact of Chronic Obstructive Pulmonary Disease on Outcomes After Total Joint Arthroplasty: A Meta-analysis and Systematic Review

Background

Comorbid chronic obstructive pulmonary disease (COPD) is increasingly common and may have an adverse impact on outcomes in patients undergoing total joint arthroplasty (TJA) of lower extremity. The purpose of this meta-analysis is to compare the postoperative complications between COPD and non-COPD patients undergoing primary TJA including total hip and knee arthroplasty.

Methods

PubMed, EMBASE, and Cochrane Library were systematically searched for relevant studies published before December 2021. Postoperative outcomes were compared between patients with COPD versus those without COPD as controls. The outcomes were mortality, re-admission, pulmonary, cardiac, renal, thromboembolic complications, surgical site infection (SSI), periprosthetic joint infection (PJI), and sepsis.

Results

A total of 1,002,779 patients from nine studies were finally included in this meta-analysis. Patients with COPD had an increased risk of mortality (OR [odds ratio] = 1.69, 95% confidence interval [CI] 1.42-2.02), re-admission (OR = 1.54, 95% CI 1.38-1.71), pulmonary complications (OR = 2.73, 95% CI 2.26-3.30), cardiac complications (OR = 1.40, 95% CI 1.15-1.69), thromboembolic complications (OR = 1.21, 95% CI 1.15-1.28), renal complications (OR = 1.50, 95% CI 1.14-1.26), SSI (OR = 1.23, 95% CI 1.18-1.30), PJI (OR = 1.26, 95% CI 1.15-1.38), and sepsis (OR = 1.36, 95% CI 1.22-1.52).

Conclusion

Patients with comorbid COPD showed an increased risk of mortality and postoperative complications following TJA compared with patients without COPD. Therefore, orthopedic surgeons can use the study to adequately educate these potential complications when obtaining informed consent. Furthermore, preoperative evaluation and medical optimization are crucial to minimizing postoperative complications from arising in this difficult-to-treat population.

Level of evidence

Level III.

Registration

None.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-022-00794-2.

Debridement, antibiotics and implant retention for prosthetic joint infection: comparison of outcomes between total hip arthroplasty and hip resurfacing

INTRODUCTION

The management of prosthetic joint infection (PJI) has been widely studied in the context of total hip arthroplasty (THA). However, the outcomes of debridement, antibiotics and implant retention (DAIR) for PJI have never been compared between hip resurfacing arthroplasty (HRA) and THA. This led us to carry out a retrospective case-control study comparing the surgical treatment of post-operative infections between HRA and THA to determine the infection remission rate and the medium-term functional outcomes.

METHODS

This single-centre case-control study analysed 3056 HRA cases of which 13 patients had a PJI treated by DAIR. These patients were age-matched with 15 infected THA hips treated by DAIR and modular component exchange (controls). Their survival (no recurrence of the infection) was compared and factors that could affect the success of the DAIR were explored: sex, body mass index, age at surgery, presence of haematoma, type of bacteria present and antibiotic therapy.

RESULTS

At a mean follow-up of five years (2-7), the infection control rate was significantly higher in the HRA group (100% [13/13]) than in the THA group (67% [10/15]) (p = 0.044). More patients in the THA group had undergone early DAIR (< 30 days) (73% [11/15]) than in the HRA group (54% [7/13]). There was no significant difference between the two groups in the ASA score, presence of comorbidities, body mass index and duration of the initial arthroplasty procedure. At the review, the Oxford-12 score of 17/60 (12-28) was better in the HRA group than the score of 25/60 (12-40) in the THA group (p = 0.004).

CONCLUSION

DAIR, no matter the time frame, is a viable therapeutic option for infection control after HRA.

Movement is Life-Optimizing Patient Access to Total Joint Arthroplasty: Smoking Cessation Disparities

Currently, 13.7% of the adult American population smokes cigarettes. Although rates of cigarette smoking have decreased over time, those of e-cigarette usage have increased. Smoking rates are highest in American Indians/Alaskan Natives and adults whose highest education level is a General Educational Development certificate, who live in rural American areas, and who have an annual household income of less than $35,000. After arthroplasty, smoking is linked to impaired wound healing, superficial and deep wound infections, and aseptic loosening. Patients who smoke should be strongly encouraged to stop and be supported with smoking cessation programs. Monitoring smoking cessation with cotinine levels may be inaccurate because variations have been noted in race, ethnicity, and sex. Confirmation of cessation as a hard stop to surgery could increase existing healthcare disparities. The role of the surgeon in encouraging patients to stop smoking, at least temporarily, before total joint arthroplasty cannot be overemphasized.

Associations between smoking and clinical outcomes after total hip and knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Smoking increases risk of several complications after total hip or knee arthroplasty (THA/TKA), so we systematically reviewed and meta-analyzed the literature to take into account all relevant evidence, particularly studies published since 2010.

METHODS

The PubMed, Ovid Embase, Web of Science, and EBSCOHost databases were searched and studies were selected and analyzed according to MOOSE recommendations. Methodological quality of included studies was assessed using the Newcastle-Ottawa Scale. Data were qualitatively synthesized or meta-analyzed using a random-effects model.

RESULTS

A total of 40 studies involving 3,037,683 cases were included. Qualitative analysis suggested that smoking is associated with worse patient-reported outcomes within one year after surgery, and meta-analysis showed that smoking significantly increased risk of the following outcomes: total complications (OR 1.41, 95% CI 1.01-1.98), wound complications (OR 1.77, 95% CI 1.50-2.10), prosthetic joint infection (OR 1.84, 95% CI 1.52-2.24), aseptic loosening (OR 1.62, 95% CI 1.12-2.34), revision (OR 2.12, 95% CI 1.46-3.08), cardiac arrest (OR 4.90, 95% CI 2.26-10.60), cerebrovascular accident (OR 2.22, 95% CI 1.01-4.85), pneumonia (OR 2.35, 95% CI 1.17-4.74), acute renal insufficiency (OR 2.01, 95% CI 1.48-2.73), sepsis (OR 4.35, 95% CI 1.35-14.00), inpatient mortality (OR 12.37, 95% CI 4.46-34.28), and persistent opioid consumption (OR 1.64, 95% CI 1.39-1.92).

CONCLUSION

Smoking patients undergoing THA and TKA are at increased risk of numerous complications, inpatient mortality, persistent opioid consumption, and worse 1-year patient-reported outcomes. Pre-surgical protocols for these outcomes should give special consideration to smoking patients.

Thirty-Day Morbidity and Mortality in Patients With COPD Following Open Reduction and Internal Fixation for Rotational Ankle Fractures

Prior orthopedic literature has found patients with chronic obstructive pulmonary disease (COPD) to be at an increased risk for postoperative morbidity and mortality. Thus, the purpose of this study is to identify whether there are any differences in risk for 30-day morbidity or mortality following ORIF for ankle fractures between adult patients with COPD and without COPD. Patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database from 2006 to 2018. Patients were divided into 2 cohorts: non-COPD and COPD patients. In this analysis, demographics data, medical comorbidities, and thirty-day postoperative outcomes were analyzed between the 2 cohorts. Bivariate and multivariate analyses were performed. Of 10,346 total patients who underwent operative treatment for ankle fracture, 9986 patients (96.5%) did not have a history of COPD whereas 360 (3.5%) had COPD. Following adjustment to control for demographic and comorbidity data, relative to patients without COPD, those with COPD had an increased risk of pneumonia (odds ratio [OR] 4.601; p = .001), unplanned intubation (OR 3.085; p = .043), and hospital readmission (OR 1.828; p = .020). Patients with COPD did not have a statistically significant difference with regards to mortality (OR 2.729; p = .080). Adult patients with COPD are at an increased risk for pneumonia, unplanned intubation, and hospital readmission within 30 days following ORIF of ankle fractures compared to patients without COPD. Despite these risks, this is a relatively safe procedure for these patients and the presence of COPD alone should not serve as a barrier to surgery.

Perioperative administration of methylprednisolone was associated with postoperative pulmonary complications in elderly patients undergoing hip fracture surgery

BACKGROUND

Postoperative pulmonary complications (PPCs) seriously affect the postoperative prognosis of elderly patients underwent hip fracture surgery. Although methylprednisolone is increasingly used, the association between perioperative methylprednisolone and PPCs is still controversial. The study aims to determine whether perioperative administration of methylprednisolone is associated with PPCs in elderly patients during hip fracture surgery.

PATIENTS AND METHODS

In this retrospective cohort study, records of 584 patients (≥ 65 years) who underwent hip fracture surgery between January 2013 and October 2020 were extracted. Univariate and multivariate regression analysis were performed to identify the risk factors for PPCs. To further explore the association between administration of methylprednisolone and PPCs, 53 patients received methylprednisolone and 53 patients without methylprednisolone were matched for the confounding factors using propensity score matching (PSM) analysis. The odds ratios (OR) and 95% confidence intervals (CI) for the above variables were analyzed.

RESULTS

The incidence of PPCs during postoperative hospitalization was 6.83% (38/556) among the elderly patients following hip fracture surgery. Patients with PPCs had higher postoperative mortality rate, longer hospital stay, more hospitalization cost, and higher incidence of cardiac arrest (all P < 0.05). Multivariate logistic regression analysis showed that age, hypertension, hypoglycemia, hypoproteinemia and perioperative methylprednisolone were independent risk factors for PPCs. Moreover, administration of methylprednisolone was significantly correlated with PPCs both before PSM adjustment (OR = 3.25; 95% CI, 1.67 to 6.33; P = 0.001) and after PSM adjustment (OR = 6.68; 95% CI, 1.40 to 31.82; P = 0.017).

CONCLUSION

Perioperative administration of methylprednisolone is a risk factor for PPCs in elderly patients undergoing hip fracture surgery.

Rifampicin resistance and risk factors associated with significantly lower recovery rates after two stage revision in patients with prosthetic joint infection

PURPOSE

Rifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favorable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing two-stage revision.

METHODS

We reviewed medical records and microbiology reports of 73 patients (41 males and 32 females) undergoing two-stage revision due to PJI between 2017 and 2019. Patient-specific data, co-morbidities and the antibiotic resistance of microbiological isolates were registered. 48 patients had hip, 22 had knee, 2 had shoulder and 1 had elbow joint infection. Obtained data were statistically analyzed with a logistic regression model.

RESULTS

Rifampicin-sensitive organism was isolated in 53 cases (72.6%). Recovery rate was 92.5% in the sensitive and 60.0% in the resistant group. We observed that rifampicin resistance significantly reduced the probability of recovery. Furthermore, in the rifampicin-sensitive group, the probability of recovery decreased with advancing age with a significant drop above the age of 60 years. The effect of age is negligible in the rifampicin-resistant group. We also found that type 2 diabetes mellitus has a negative effect on recovery. Coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (50% of the isolates) and Gram-negative rods in the resistant group (40%).

CONCLUSIONS

Rifampicin resistance was associated with lower recovery rates among patients undergoing two-stage revision due to PJI. Higher age and type 2 diabetes mellitus had negative impact on clinical outcome.

Defining Failure in Primary Total Joint Arthroplasty: The Minimal Clinically Important Difference for Worsening Score

BACKGROUND

We define the value of the Minimal Clinically Important Difference for Worsening (MCID-W) for Patient-Reported Outcomes Measurement Information System Physical Function short form 10-a (PROMIS-PF-10a) score for primary total joint arthroplasty (TJA) of the hip and knee and describe the risk factors for patients scoring worse than the MCID-W.

METHODS

This retrospective study was performed using 3414 primary TJA patients. PROMIS-PF-10a scores were collected at the preoperatively and postoperatively, and patients were classified based on reaching Minimal Clinically Importance Difference for Improvement (MCID-I), MCID-W, or "no significant change" after TJA (scores betweex`n MCID-W and MCID-I). MCID-W and MCID-I values were determined by a distribution method. The association between numerous variables and scoring worse than the MCID-W of PROMIS-PF-10a was then evaluated through multiple logistic regression. A threshold for preoperative PROMIS-PF-10a score predicting decline past MCID-W was determined using the Youden index and receiver operating characteristic curve.

RESULTS

The MCID-W for TJA was -1.89. Notably, increasing length of stay (odds ratio [OR] 1.073, 95% confidence interval [CI] 1.029-1.119, P < .001) and increasing preoperative PROMIS-PF-10a scores (OR 1.117, 95% CI 1.091-1.144, P < .001) were associated with increased likelihood of decline past the MCID-W of the PROMIS-PF-10a for TJA compared with patients who achieved the MCID-I. A community hospital with a dedicated joint replacement center was associated with a decreased risk for decline past the MCID-W (OR 0.601, 95% CI 0.402-0.899; P = .013).

CONCLUSION

We described the MCID-W value (-1.89) for the PROMIS-PF-10a questionnaire for knee and hip TJA and associated patient- and hospital-level risk factors for failure after TJA. Healthcare funding initiatives should be directed toward modifiable factors associated with clinically significant worse outcomes after TJA.

Low incidence of clinically relevant bleeding complications after fast-track arthroplasty: a register study of 8,511 arthroplasties

BACKGROUND AND PURPOSE

Fast-track total joint replacement (TJR) has become increasingly common. Routine thromboprophylaxis for pulmonary embolism and deep venous thrombosis prevention lasts from 2 to 5 weeks. This retrospective registry study focused on clinically relevant bleeding complications 90 days after fast-track primary TJR.

PATIENTS AND METHODS

All primary fast-track total hip (THA) and knee arthroplasties (TKA) performed between 2015 and 2016 were extracted from the Finnish Arthroplasty Register and Finnish Hospital Discharge Register. Type of arthroplasty and indication for the operation were combined with diagnoses of clinically relevant bleeding complications within 90 days of surgery. The incidence of these bleedings was the primary outcome measure.

RESULTS

Of the total of 8,511 patients (mean age 67 years (SD 10); 60% female), 45% underwent unilateral THA, 52% unilateral TKA, and 3% bilateral TKA. The incidence of clinically relevant bleeding complications within 90 days was 1% (95% CI 0.8-1.3). No difference was observed in bleeding incidence between the groups. The 87 bleedings comprised 57 operative site bleedings, 17 gastrointestinal bleedings, 6 intracranial non-traumatic bleedings, 5 bleedings from the nose or another undetermined site, and 2 intraocular bleedings. 1 death due to intracranial bleeding was recorded, and hence clinically relevant bleeding-specific 90-day mortality was 0.01%.

INTERPRETATION

The incidence of clinically relevant bleeding complications was low. However, they cause patient discomfort, increase the use of healthcare services, and can be life-threatening and even fatal.

Sepsis and Total Joint Arthroplasty

The number of annual total joint arthroplasties (TJA) is increasing. Periprosthetic joint infections (PJI) occur when there is infection involving the prosthesis and surrounding tissue, which has the potential to develop into sepsis if left untreated. Sepsis in patients who have undergone TJA is life threatening and requires urgent treatment. If sepsis is due to PJI, the focus should be on early intravenous antibiotics with aspiration as soon as possible to diagnose the infection. Patients who develop sepsis after surgery for PJI are particularly at high risk for mortality and need to be treated in the intensive care unit.

Sex Differences in Serum C-Reactive Protein Course after Total Hip Arthroplasty

Background

Gender-specific medicine has become an important part in investigating the course of various diseases. C-reactive protein (CRP) is used as an inflammatory marker for detecting inflammations and even infections after total hip arthroplasty (THA). The general course of CRP after THA is well known, but there is controversy about its association with sex. Therefore, we aimed to investigate if there is an influence of sex on the CRP after THA in the first 10 days after operation in a complication-free course in male and female patients and to re-evaluate the specific postoperative CRP course with its maximum on the second to third postoperative days.

Methods

We retrospectively reviewed patients who had been treated with THA due to primary osteoarthritis through the same approach using an equal model of a cementless stem and a cup and complication-free between 2013 and 2016. Patients with active inflammation, rheumatoid arthritis, secondary arthrosis, active cancer disease, and documented postoperative complications were not included. The CRP values before THA and up to 10 days after THA were recorded and tested for sex discrepancy. Factor analyses were performed, and CRP values were adjusted for confounders (age, operation time, diabetes mellitus, and body mass index [BMI]).

Results

A total of 1,255 patients (728 women and 527 men) were finally analyzed. Men were younger and had a longer operation time and a higher BMI compared to women. The prevalence of overweight was higher in men, while obesity (BMI > 40 kg/m²), diabetes mellitus, renal failure, and American Society of Anaesthesiologists status showed no significant difference between men and women. Men had significantly higher CRP values than women between the 2nd and the 7th postoperative days, with the largest difference on the 4th postoperative day (men, 130.48 mg/L; women, 87.26 mg/L; p = 0.018).

Conclusions

Based on the results of more precise sex-specific evaluation of the postoperative CRP course after THA, the present study showed for the first time that there was a gender discrepancy in the CRP course after complication-free THA in the first 7 postoperative days. Furthermore, this study confirmed the postoperative CRP course with its maximum on the third postoperative day.

Review of calcium-sulphate-based ceramics and synthetic bone substitutes used for antibiotic delivery in PJI and osteomyelitis treatment

Infection in orthopaedic and trauma surgery remains a destructive complication with particularly challenging diagnosis and treatment due to bacterial antibiotic resistance and biofilm formation.

Along with surgical debridement and systemic antibiotics, an important type of adjuvant therapy is local antibiotic delivery, with the purpose of eliminating bacterial colonization and biofilm development.

Calcium sulphate, as a synthetic absorbable biomaterial used for local antibiotic delivery, has experienced an increasing popularity during the last decade, with multiple promoted advantages such as predictable antibiotic elution kinetics, complete and quick biodegradation, good biocompatibility, and limited associated complications.

A series of commercially available antibiotic-delivery systems based on calcium sulphate are under investigation and in clinical use, with different presentations, compositions, and application techniques.

The current article presents the main available calcium-sulphate-based products and the existing data about the clinical and preclinical research results, stemming from their implementation as local antibiotic carriers for surgical site and implant-associated infections treatment and prevention.

Cite this article: EFORT Open Rev 2021;6:297-304. DOI: 10.1302/2058-5241.6.200083

Insulin Dependence Increases the Risk of Complications and Death in Total Joint Arthroplasty: A Systematic Review and Meta-(Regression) Analysis

Objectives

To investigate the proportion of insulin‐dependent diabetes mellitus (IDDM) patients among diabetic patients undergoing total joint arthroplasty (TJA) and whether insulin dependence is associated with postoperative complications.

Methods

A systematic literature search was performed in EMBASE, PubMed, Ovid, Medline, the Cochrane Library, Web of Science, the China Science and Technology Journal Database, and China National Knowledge Infrastructure from the inception dates to 10 September 2019. Observational studies reporting adverse events with IDDM following TJA were included. Primary outcomes were cardiovascular complications, pulmonary complications, kidney complications, wound complications, infection, and other complications within 30 days of surgery. Secondary outcomes were the proportion of IDDM patients among diabetic patients undergoing TJA and its time trend.

Results

A total of 19 studies involving 85,689 participants were included. Among patients undergoing TJA, 26% of diabetic patients had IDDM. Compared with non‐insulin‐dependent diabetes (NIDDM), the incidences of cardiac arrest (risk ratio [RR], 2.346; 95% confidence interval [CI], 1.553 to 3.546), renal failure (relative risk [RR], 2.758; 95% CI, 1.830 to 4.156), deep incisional surgical site infection (RR, 1.968; 95% CI, 1.107 to 3.533), wound dehiscence (RR, 2.209; 95% CI, 1.830 to 4.156), and death (RR, 2.292; 95% CI, 1.568 to 3.349) were all significantly increased in IDDM. A significant time trend was witnessed for the prevalence of IDDM (P = 0.014). There was no statistical significance for organ/space surgical site infection, thrombotic events (deep venous thrombosis/ pulmonary embolism), and revision rates.

Conclusion

Insulin‐dependent diabetes is an independent high‐risk factor for increased adverse outcomes relative to NIDDM, suggesting that hierarchical and optimal blood glucose management may contribute to reducing the adverse complications after surgery for these patients. In addition, because the risk of sepsis, deep wound infection, organ/space surgical site infection, urinary tract infection, renal insufficiency, and renal failure significantly increase after TJA in IDDM patients, more active postoperative antimicrobial prophylaxis may be needed on the premise of protecting renal function.

How I do it - Second stage revision total knee arthroplasty

BACKGROUND

Infection is a potentially devastating complication following primary total knee arthroplasty, and the traditional gold-standard treatment for chronic prosthetic joint infection has been in the form of a two-stage revision total knee arthroplasty. This involves a first stage - removal of all implants and infected material, with implantation of a temporary spacer - followed by a second stage which includes reimplantation with a definitive prosthesis.

INDICATIONS

Although the outcomes of single-stage and two-stage revision arthroplasty surgeries are similar, there are certain indications such as atypical or more virulent organisms, patient factors and soft tissue factors that would favour a two-stage approach.

SURGICAL TECHNIQUE

The second stage revision procedure consists of explantation of the spacer with a debridement and synovectomy. Further samples are sent for microbiological analysis. Once the surgical field is clean and lavaged, the definitive prosthesis is implanted.

CONCLUSIONS

A second stage revision total knee arthroplasty is a reliable procedure for the treatment of chronic prosthetic joint infection. There is a significant re-revision rate, predominantly due to recurrent deep infection.

Is there an optimal age for total knee arthroplasty?: A systematic review

PURPOSE

The purpose of this systematic review was to elucidate the optimal age for patients undergoing total knee arthroplasty (TKA), to optimize the balance between the benefits and risks by analyzing patient-reported outcome measurements (PROM), revision rate, and mortality according to age.

MATERIALS AND METHODS

A rigorous and systematic approach was used and each of the selected studies was evaluated for methodological quality. Data were extracted according to the following: study design, patients enrolled, patient age at the time of surgery, follow-up period, PROM, revision rate, and mortality.

RESULTS

Thirty-nine articles were included in the final analysis. The results were inconsistent in the PROM analysis, but there was consensus that PROM were good in patients in their 70s . In the revision rate analysis, there was consensus that the revision rate tends to increase in TKA in younger patients, but no significant difference was observed in patients > 70 years of age. In the mortality analysis, there was consensus that the mortality was not significantly different in patients < 80 years of age, but tended to increase with age.

CONCLUSION

This systematic review shows that the PROM were good when TKA was performed in patients between 70 and 80 years of age; the best PROM could be achieved around 70 years of age, and no significant difference in the revision or mortality rates was observed between 70 and 80 years of age; however, mortality tended to increase with age. Therefore, the early 70s could be recommended as an optimal age to undergo TKA.

Veterans Undergoing Total Hip and Knee Arthroplasty: 30-day Outcomes as Compared to the General Population

INTRODUCTION

The Veterans Affairs (VA) health system is vital to providing joint replacement care to our retired service members but has come under recent scrutiny. The purpose of this study was to compare the short-term outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA) between the VA cohort and the general cohort.

METHODS

We retrospectively reviewed 10.460 patients with primary THA and TKA from the Veterans Affairs Corporate Data Warehouse. As a control group, we queried the American College of Surgeons-National Surgical Quality Improvement Program database and identified 58,820 patients with primary THA and TKA over the same time period. We compared length of stay, mortality rates, 30-day complication rates, and 30-day readmissions. We performed a multivariate logistic regression analysis to identify the independent effect of the VA system on adverse outcomes.

RESULTS

Veterans are more likely to be men (93% versus 41%, P < 0.001) and have increased rates of medical comorbidities (all P < 0.001). The rate of short-term complications (all P < 0.001) were all higher in the VA cohort. When controlling for demographics and medical comorbidities, VA patients were more likely to have a readmission (P < 0.001), prolonged length of stay > 4 days (P < 0.001), and experience a complication within 30 days (P < 0.001).

DISCUSSION

Despite controlling for higher rates of medical comorbidities, VA patients undergoing primary THA and TKA had poorer short-term outcomes than the civilian cohort. Additional research is needed to ensure our veteran cohort is appropriately optimized and address the discrepancy with the outcomes of the civilian.

Operative Fixation of Hip Fractures in Nonagenarians: Is It Safe?

BACKGROUND

With the shift in hip fracture epidemiology toward older individuals as well as the shift in demographics toward nonagenarians, it is important to understand the outcomes of treatment for these patients.

METHODS

Geriatric patients (≥65 years old) who underwent surgery for hip fracture were identified in the 2005-2017 National Surgical Quality Improvement Program database and stratified into 2 age groups: <90 and ≥90 years old (nonagenarians). Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for complications and 30-day readmissions. Risk factors for serious adverse events (SAEs) and 30-day mortality in nonagenarians were characterized.

RESULTS

This study included 51,327 <90 year olds and 15,798 nonagenarians. Overall rate of SAEs in nonagenarians was 19.89% while in <90 year olds was 14.80%. Multivariate analysis revealed higher risk for blood transfusion (relative risk [RR] = 1.21), death (RR = 1.74), pneumonia (RR = 1.24), and cardiac complications (RR = 1.33) in nonagenarians (all P < .001). Risk factors for SAEs in nonagenarians include American Society of Anesthesiologists ≥3, dependent functional status, admitted from nursing home/chronic/intermediate care, preoperative hypoalbuminemia, and male gender (all P < .05), but not time to surgery (P > .05). In fact, increased time to surgery in nonagenarians was associated with lower risk of 30-day mortality (RR = 0.90, P = .048).

CONCLUSION

Overall complication risk after hip fracture fixation in nonagenarians remains relatively low but higher than their younger counterparts. Interestingly, since time to surgery was not associated with adverse outcomes in nonagenarians, the commonly accepted 48-hour operative window may not be critical to this population. Additional time for preoperative medical optimization in this vulnerable population appears prudent.

Prevalence of idiopathically elevated ESR and CRP in patients undergoing primary total knee arthroplasty as a function of body mass index

BACKGROUND

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are commonly used inflammatory markers utilized to aid in the diagnosis of periprosthetic infection (PJI). Patients with obesity, however, are known to have elevated baseline levels of these inflammatory markers. Therefore, this retrospective study aimed to determine the relationship between elevated ESR and CRP and body mass index (BMI) in patients undergoing total knee arthroplasty (TKA). In doing so, physicians can better determine whether BMI should be taken into account when evaluating the prognostic value of elevated preoperative ESR and CRP levels for risk of PJI in primary TKA patients.

METHODS

This is a retrospective case series of 181 patients who had undergone primary TKA at a single institution. Patients undergoing primary unilateral TKA were eligible unless they had undergone previous TKA, contralateral knee symptoms, or elevated white blood cell (WBC) count. A linear regression model was utilized to demonstrate the relationship between proportions of patients with elevated biomarker values and categories of BMI. Analysis of variance and independent two-sample t-tests were utilized to assess differences in mean ESR, CRP, and WBC levels between the "healthy patients" and "patients with comorbidities" subgroups within each BMI category.

RESULTS

Eligible patients (n = 181) were stratified by BMI category. Elevated ESR was associated significantly with BMI (ESR: r2 = 0.89, P < 0.001) unlike elevated CRP (r2 = 0.82, P = 0.133) and WBC count (r2 = .01; P = .626). No statistically significant differences in ESR values and WBC count between the "healthy patients" versus "patients with comorbidities" were demonstrated within any BMI category. In patients of normal weight (BMI 20-25 kg/m2), "healthy patients" had a statistically significantly higher mean CRP level than "patients with comorbidities" (1.73 mg/L vs. 0.70 mg/L, P < 0.001). There were no other statistically significant differences in mean CRP levels by health status.

CONCLUSION

Caution is advised when utilizing ESR and CRP to diagnose periprosthetic joint infection without considering BMI given that increasing preoperative levels of ESR and CRP are correlated with higher BMI.

Sepsis and septic shock after craniotomy: Predicting a significant patient safety and quality outcome measure

OBJECTIVES

Sepsis and septic shock are important quality and patient safety metrics. This study examines incidence of Sepsis and/or septic shock (S/SS) after craniotomy for tumor resection, one of the most common neurosurgical operations.

METHODS

Multicenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify patients undergoing craniotomy for tumor (CPT 61510, 61521, 61520, 61518, 61526, 61545, 61546, 61512, 61519, 61575) from 2012-2015. Univariate and multivariate logistic regression models were used to identify risk factors for S/SS.

RESULTS

There were 18,642 patients that underwent craniotomy for tumor resection. The rate of sepsis was 1.35% with a mortality rate of 11.16% and the rate of septic shock was 0.65% with a 33.06% mortality rate versus an overall mortality rate of 2.46% in the craniotomy for tumor cohort. The 30-day readmission rate was 50.54% with S/SS vs 10.26% in those without S/SS. Multiple factors were identified as statistically significant (p <0.05) for S/SS including ascites (OR = 33.0), ventilator dependence (OR = 4.5), SIRS (OR = 2.8), functional status (OR = 2.3), bleeding disorders (OR = 1.7), severe COPD (OR = 1.6), steroid use (OR = 1.6), operative time >310 minutes (OR = 1.5), hypertension requiring medication (OR = 1.5), ASA class ≥ 3 (OR = 1.4), male sex (OR = 1.4), BMI >35 (OR = 1.4) and infratentorial location.

CONCLUSIONS

The data indicate that sepsis and septic shock, although uncommon after craniotomy for tumor resection, carry a significant risk of 30-day unplanned reoperation (35.60%) and mortality (18.21%). The most significant risk factors are ventilator dependence, ascites, SIRS and poor functional status. By identifying the risk factors for S/SS, neurosurgeons can potentially improve outcomes. Further investigation should focus on the creation of a predictive score for S/SS with integration into the electronic health record for targeted protocol initiation in this unique neurosurgical patient population.

Hypogonadism Is Associated With Increased Risks of Postoperative Complications Following Total Hip Arthroplasty

BACKGROUND

Despite being a relatively common problem among aging men, hypogonadism has not been previously studied as a potential risk factor for postoperative complications following total hip arthroplasty (THA).

METHODS

In total, 3903 male patients with a diagnosis of hypogonadism who underwent primary THA from 2006 to 2012 were identified using a national insurance database and compared to 20:1 matched male controls using a logistic regression analysis.

RESULTS

Hypogonadism was associated with an increased risk of major medical complications (odds ratio [OR] 1.24, P = .022), urinary tract infection (OR 1.43, P < .001), wound complications (OR 1.33, P = .011), deep vein thrombosis (OR 1.64, P < .001), emergency room visit (OR 1.24, P < .001), readmission (OR 1.14, P = .015), periprosthetic joint infection (OR 1.37 and 1.43, P < .05), dislocation (OR 1.51 and 1.48, P < .001), and revision (OR 1.54 and 1.56, P < .001) following THA. A preoperative diagnosis of hypogonadism was associated with increased total reimbursement and charges by $390 (P < .001) and $4514 (P < .001), respectively.

CONCLUSION

The diagnosis of hypogonadism is associated with an elevated risk of postoperative complications and increased cost of care following primary THA. Data from this study should influence the discussion between the patient and the provider prior to undergoing joint replacement and serve as the basis for further research.

Does Polycythemia Vera Increase Risk of Postoperative Complications Following Primary Total Joint Arthroplasty? A Retrospective Matched Control Cohort Study of 6932 Polycythemia Vera Patients

BACKGROUND

There is sparsity of data on outcomes following joint arthroplasty among polycythemia vera (PV) patients. The aim of this study is to evaluate postoperative outcomes following primary total knee (TKA) and hip (THA) arthroplasty among PV patients.

METHODS

A retrospective Medicare database review identified 6932 PV patients who underwent a primary total joint arthroplasty (4643 TKAs and 2289 THAs) from 2006 to 2013. A comparison of hospital length of stay, mortality, and the diagnosis of surgical site infections (SSIs), stroke, myocardial infarction, acute pulmonary embolism (PE), deep vein thrombosis (DVT), and other postoperative complications was made between PV patients undergoing TKA and THA and their respective matched control groups.

RESULTS

PV was significantly associated with increased rates of acute PE (2.3% vs 1.6%; odds ratio [OR] 1.44, 95% confidence interval [CI] 1.17-1.75), DVT (4.2% vs 3.6%; OR 1.40, 95% CI 1.20-1.61, P < .001), postoperative hematoma (0.6% vs 0.4%; OR 1.57, 95% CI 1.03-2.28), and SSI (4.5% vs 3.6%; OR 1.25, 95% CI 1.08-1.44, P = .002) following TKA. Among PV patients who underwent a primary THA, PV was significantly associated with increased rate of acute PE (1.9% vs 1.4%; OR 1.40, 95% CI 1.01-1.88, P = .035), DVT (3.5% vs 2.6%; OR 1.32, 95% CI 1.04-1.66, P = .035), postoperative hematoma (1.1% vs 0.6%; OR 1.86, 95% CI 1.22-2.80), and 1-year mortality (2.2% vs 1.6%; OR 1.43, 95% CI 1.06-1.89, P = .016).

CONCLUSION

PV was significantly associated with increased risk for DVT, PE, postoperative hematoma, SSI (TKA only), and 1-year mortality (THA only) following primary total joint arthroplasty.

Relationship between body mass index and the risk of periprosthetic joint infection after primary total hip arthroplasty and total knee arthroplasty

Background

Periprosthetic joint infection (PJI) is a disastrous complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The relationship between body mass index (BMI) and the incidence of PJI remains controversial. To better understand the impact of increasing BMI on PJI, we conducted this study to investigate the dose-response relationship between BMI and the risk of PJI after primary THA or TKA.

Methods

A systematic search was conducted in PubMed, Embase, and Cochrane Library databases from inception to August 17, 2019. After study selection and data extraction, a dose-response meta-analysis was performed to investigate the relationship between BMI and PJI. Adjusted relative risks (RRs) with 95% confidence intervals (CIs) were pooled using fixed-effects or random-effects models.

Results

Eleven studies comprising 505,303 arthroplasties were included. The dose-response analysis showed a significant non-linear relationship between BMI and the risk of PJI (P_{non-linearity} <0.001). Patients following THA (RR, 1.489; 95% CI, 1.343–1.651; P<0.001) were more likely to suffer from PJI than patients following TKA. Furthermore, American Society of Anesthesiologists (ASA) score ≥3 (RR, 2.287; 95% CI, 1.650–3.170; P<0.001), lung disease (RR, 1.484; 95% CI, 1.208–1.823; P<0.001) and diabetes (RR, 1.695; 95% CI, 1.071–2.685; P=0.024) were identified as risk factors for PJI, but male (RR, 1.649; 95% CI, 0.987–2.755; P=0.056) and hypertension (RR, 0.980; 95% CI, 0.502–1.916; P=0.954) were not recognized as risk factors for PJI.

Conclusions

The J-shaped non-linear relationship demonstrated that increased BMI was associated with an increased risk for PJI after primary THA or TKA. Patients following THA were more likely to suffer from PJI than patients following TKA. Also, patients with ASA score ≥3, lung disease and diabetes have a higher risk of PJI. Gender and hypertension did not influence the incidence of PJI.

Retrospective Comparative Study of the Influence on Quality of Primary Total Hip Arthroplasty by the EndoCert-Certification System in a Communal Hospital

The EndoCert^®-Initiative system sets specific requirements for the structural, process and result quality in certified Arthroplasty Centers in Germany. However, it remains unclear to what extent the certification process can increase the quality in total hip and knee arthroplasty. Aim of the comparative retrospective study is to analyse the change in quality of total hip arthroplasty in a communal hospital before and after the certification process. All primary total hip arthroplasties (n = 366) between 2013 and 2016 were included in the study retrospectively and grouped by treatment period. Treatment was performed in group 1 without clinical pathways, in group 2 pathway-controlled without a valid certificate and in group 3 pathway-controlled after final completion of the certification process. Outcome quality was analysed using quality indicators defined by the EndoCert-Initiative and further predefined indicators. Results show quality improvement under certified pathway-controlled treatment, e.g. time of surgery, cup and stem positioning, blood transfusion rate, periprosthetic fractures. However, improvements were not significantly in all cases and limitations must be recognized. Positive effects of the certification process legitimate capital investment and efforts. Further quality indicators may be implemented in the certification process to improve quality of treatment in arthroplasty.

Integrated clinical pathways with watertight, multi-layer closure to improve patient outcomes in total hip and knee joint arthroplasty

The number of primary total hip and knee replacement surgeries is increasing primarily due to an aging population. There is also a concomitant increase in the number of complications which could be attributed to high variation in arthroplasty techniques, peri-operative methods and the absence of integrated clinical pathways (ICP) to mitigate risks such as surgical site infections (SSIs). The implementation of ICPs incorporating watertight, multi-layer closure could increase the preventative effectiveness against joint prosthetic adverse events. The objective of this review is to describe the ICPs implemented by one US facility to help address ten adverse events synergistically.

One-Stage Arthroplasty or Revision for Seronegative Infections in Hip and Knee

Objective

To assess the safety and effectiveness of one‐stage total joint arthroplasty (TJA) or revision for seronegative infections after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Methods

This retrospective study included a total of 495 patients who had undergone one‐stage total joint (hip or knee) arthroplasty or revision with a diagnosis of osteoarthritis secondary to sepsis, osteoarthritis or osteonecrosis of the femoral head (ONFH) secondary to internal fixation surgery of the hip joint, and one‐stage revision for prosthesis loosening after THA or TKA from January 2012 to December 2016. Bacterial cultures were taken from all patients (from joint fluid or articular cavity fluid and four to six different parts of soft tissues) during the operation. If the cultures were positive, patients received antibiotic treatment. Microbiology results from surgical samples, clinical evaluations, SF‐12 score (physical component summary [PCS] and mental component summary [MCS]), Harris hip score (HHS) or Hospital for Special Surgery (HSS) score, and patients' satisfaction was recorded at every follow‐up session.

Results

A total of 24 patients had a positive result for bacterial culture (4.85%). The bacterial culture results showed that there were 19 cases (79.16%) of gram‐positive cocci (Staphylococcus aureus), 4 cases (16.67%) of gram‐negative bacilli, and 1 case (4.17%) of fungi. For at least 24 months (mean 35 months) follow‐up, no reinfection was discovered. The mean HHS or HSS score improved significantly from 36.29 points preoperatively to 84.21 points postoperatively (P < 0.001). The mean PCS score improved from 10.15 preoperatively to 20.34 postoperatively, and the mean MCS from 13.22 preoperatively to 21.76 postoperatively, with significant differences. Most of the patients were satisfied.

Conclusion

One‐stage arthroplasty or revision with exhaustive debridement, adequate dosage, and duration of sensitive antibiotics is safe and effective for patients who have seronegative infection of hip or knee joints.

The effect of smoking on outcomes following primary total hip and knee arthroplasty: a population-based cohort study of 117,024 patients

Background and purpose - Smoking is a modifiable risk factor that may adversely affect postoperative outcomes. Healthcare providers are increasingly denying smokers access to total hip and knee arthroplasty (THA and TKA) until they stop smoking. Evidence supporting this is unclear. We assessed the effect of smoking on outcomes following arthroplasty.Patients and methods - We identified THAs and TKAs from the Clinical Practice Research Datalink, which were linked with datasets from Hospital Episode Statistics and the Office for National Statistics to identify outcomes. The effect of smoking on postoperative outcomes (complications, medications, revision, mortality, patient-reported outcome measures [PROMs]) was assessed using adjusted regression models.Results - We studied 60,812 THAs and 56,212 TKAs (11% smokers, 33% ex-smokers, 57% non-smokers). Following THA, smokers had an increased risk of lower respiratory tract infection (LRTI) and myocardial infarction compared with non-smokers and ex-smokers. Following TKA, smokers had an increased risk of LRTI compared with non-smokers. Compared with non-smokers (THA relative risk ratio [RRR] = 0.65; 95% CI = 0.61-0.69; TKA RRR = 0.82; CI = 0.78-0.86) and ex-smokers (THR RRR = 0.90; CI = 0.84-0.95), smokers had increased opioid usage 1-year postoperatively. Similar patterns were observed for weak opioids, paracetamol, and gabapentinoids. 1-year mortality rates were higher in smokers compared with non-smokers (THA hazard ratio [HR] = 0.37, CI = 0.29-0.49; TKA HR = 0.52, CI = 0.34-0.81) and ex-smokers (THA HR = 0.53, CI = 0.40-0.70). Long-term revision rates were not increased in smokers. Smokers had improvement in PROMs compared with preoperatively, with no clinically important difference in postoperative PROMs between smokers, non-smokers, and ex-smokers.Interpretation - Smoking is associated with more medical complications, higher analgesia usage, and increased mortality following arthroplasty. Most adverse outcomes were reduced in ex-smokers, therefore smoking cessation should be encouraged before arthroplasty.

Evaluation of Absorbent Versus Conventional Wound Dressing

BACKGROUND

Lower-limb endoprosthetic operations and spinal operations are among the more common types of orthopedic procedures. Postoperative woundhealing disturbances and infections can lead to longer periods of hospital stay and recovery as well as to higher morbidity and mortality.

METHODS

209 patients who had been judged to have an indication for a primary knee or hip endoprosthesis or for a primary spinal operation were included in this randomized trial (ClinicalTrials.gov: NCT01988818) over the period June 2014- February 2015. After randomization, patients in the intervention group were given a trial dressing (Mepilex-Border Post-Op) and those in the control group were given a conventional adhesive dressing (Cosmopor). The primary endpoint was blister formation.

RESULTS

In the overall study population, only a single case of blister formation was seen. The affected patient belonged to the intervention group but was mistakenly given a control dressing and developed blisters on the 6th day after surgery. Dressings were changed less frequently in the intervention group, and this difference was statistically significant (p<0.001). The patients, nurses, and physicians all expressed greater satisfaction with the trial dressings than with the control dressings (p<0.001).

CONCLUSION

The intervention group did not differ from the control group with respect to the primary endpoint, postoperative blister formation. The patients, nurses, and physicians all judged the dressing used in the intervention group more favorably than the conventional dressing.

Outcome of single-stage versus two-stage exchange for revision knee arthroplasty for chronic periprosthetic infection

The gold standard for treating chronic periprosthetic joint infection is still considered to be double-stage exchange revision. The purpose of this review is to analyse the difference in terms of eradication rates and functional outcome after single- and double-stage prosthetic exchange for chronic periprosthetic joint infection around the knee.

We reviewed full text articles written in English from 1992 to 2018 reporting the success rates and functional outcomes of either single-stage exchange or double-stage exchange for knee arthroplasty revision performed for chronic infection. In the case of double-stage exchange, particular attention was paid to the type of spacer: articulating or static.

In all, 32 articles were analysed: 14 articles for single-stage including 687 patients and 18 articles for double-stage including 1086 patients. The average eradication rate was 87.1% for the one-stage procedure and 84.8% for the two-stage procedure. The functional outcomes were similar in both groups: the average Knee Society Knee Score was 80.0 in the single-stage exchange group and 77.8 in the double-stage exchange. The average range of motion was 91.4° in the single-stage exchange group and 97.8° in the double-stage exchange group.

Single-stage exchange appears to be a viable alternative to two -stage exchange in cases of chronic periprosthetic joint infection around the knee, provided there are no contra-indications, producing similar results in terms of eradication rates and functional outcomes, and offering the advantage of a unique surgical procedure, lower morbidity and reduced costs.

Cite this article: EFORT Open Rev 2019;4:495-502. DOI: 10.1302/2058-5241.4.190003

Gender Differences for Hip and Knee Arthroplasty: Complications and Healthcare Utilization

INTRODUCTION

The influence of patient gender on complications and healthcare utilization remains unexplored. The purpose of the present study was to determine if patient gender significantly affected outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Retrospective cohort study of THA and TKA patients was performed using the Nationwide Inpatient Sample from 2002 to 2011. Only patients who underwent elective procedures and those with complete perioperative data were included. Multivariate logistic regression was used to compare the rates of adverse events between male and female cohorts while controlling for baseline characteristics.

RESULTS

A total of 6,123,637 patients were included in the study (31.2% THA and 68.8% TKA). The cohort was 61.1% female. While males had a lower rate of any adverse event (odds ratio [OR] = 0.8, P < .001), urinary tract infection (OR = 0.4, P < .001), deep vein thrombosis/pulmonary embolism (OR = 0.9, P < .001), and blood transfusion (OR = 0.5, P < .001), male gender was associated with statistically significant increases in the rates of death (OR = 1.6, P < .001), acute kidney injury (OR = 1.6, P < .001), cardiac arrest (OR = 1.7, P < .001), myocardial infarction (OR = 1.6, P < .001), pneumonia (OR = 1.1, P < .001), sepsis (OR = 1.6, P < .001), surgical site infection (OR = 1.4, P < .001), and wound dehiscence (OR = 1.4, P < .001).

CONCLUSION

Males had increased rates of many individual adverse events. Females had higher rates of urinary tract infection, which translated to an overall higher rate of adverse events in females because of the rarity of the other individual adverse events.

Primary Total Hip Arthroplasty in Patients Less Than 50 Years of Age at a Mean of 16 Years: Highly Crosslinked Polyethylene Significantly Reduces the Risk of Revision

BACKGROUND

The purpose of this study is to evaluate clinical and radiographic outcomes of patients less than 50 years of age undergoing primary total hip arthroplasty (THA) at a minimum of 10 years.

METHODS

Three hundred nine consecutive THAs performed on 273 patients were reviewed. At a minimum of 10 years, 13 were deceased and 23 were lost to follow-up leaving 273 THAs in 237 patients who were followed for a mean of 16 years (range 10-19.9). The cohort consisted of 116 females (49%) and 121 males (51%), with a mean age of 42.3 years at the time of surgery (range 19-49). The majority of preoperative diagnoses included osteoarthritis in 149 (63%) and avascular necrosis in 55 (23%). Two hundred sixteen had highly crosslinked polyethylene (HXLPE) and 57 had non-HXLPE acetabular liners. The femoral stems were cementless in 98% (266/273) and the acetabular components were cementless in all cases. Femoral head composition was cobalt-chromium in all cases and the majority of sizes in the non-HXLPE cohort were 28 mm (52/57; 91%), while the HXLPE group primarily consisted of 28 mm (141/216; 65%) and 32 mm (74/216; 34%) heads. Analysis involved Kaplan-Meier survivorship with a log-rank test for equivalence, Fisher's exact test for pairwise comparisons, and a paired t-test for Harris Hip Score, with alpha = 0.05 being statistically significant.

RESULTS

There were 6 revisions for wear in the non-HXLPE group (10.5%) compared to none in the HXLPE group (P < .001). Similarly, survivorship with revision for any reason as the endpoint at 16 years was significantly higher at 93.0% in the XLPE group (95% confidence interval 88.7-95.7) compared to 85.7% (95% confidence interval 73.5-92.6) in the non-HXLPE group (P = .023). Additional revisions in the HXLPE group included 6 for instability (2.8%), 5 secondary to infection (2.4%), and 3 stem failures (1.4%). Non-wear-related revisions in the non-HXLPE group included 5 due to instability (8.8%) and 3 due to stem failures (5.3%). The mean Harris Hip Scores for the entire cohort improved from a mean of 46.2 points preoperatively to 89.8 points at most recent follow-up (P < .001).

CONCLUSION

The use of HXLPE has led to a significant reduction in the risk of failure in patients <50 years old, with over 93% survivorship at 16 years. Instability and infection, however, remain substantial causes of failure.

LEVEL OF EVIDENCE

Therapeutic Level III.

Haematogenous prosthetic knee infections: Prospective cohort study of 58 patients

BACKGROUND

Prosthetic joint infection (PJI) is a rare (incidence, 0.15% to 0.9%) but serious complication of knee arthroplasty. Haematogenous PJI of the knee (KhPJI) which accounts for 10% of cases, has been less studied than PJI due to other mechanisms. The primary objective of this study in patients with KhPJI of the knee was to determine the 2-year infection eradication failure rate after either exchange arthroplasty or arthrotomy/synovectomy/irrigation (ASI), combined with prolonged peri-operative antibiotic therapy, at a referral centre for complex osteo-articular infections.

HYPOTHESIS

ASI within 2 weeks after symptom onset and one-stage exchange arthroplasty produce similar 2-year success rates in patients with KhPJI of the knee.

MATERIAL AND METHODS

A prospective observational cohort study was performed in patients managed for PJI of the knee between 2003 and 2015. The primary outcome measure was the occurrence of a septic event or of KhPJI -related death during a minimum follow-up of 2 years.

RESULTS

Of 265 patients with PJI after total knee arthroplasty, 58 (22.1%) had KhPJI with onset more than 3 months after the last arthroplasty procedure and were included in the study. Among them, one-third had immune deficiencies. The most common causative organisms were streptococci (n=25, 43%) and Staphylococcusaureus (n=20, 34%). The primary focus of infection was identified in only 64% of patients and was most often cutaneous (n=19, 33%) or dental (n=11, 19%). A septic event or KhPJI-related death occurred in 5/34 (15%) patients after one-stage exchange arthroplasty and 6/19 (32%) patients after ASI within 15 days after symptom onset (p=0.03). Patient characteristics, type of prosthesis, and causative organism were not significantly associated with failure to eradicate the infection.

CONCLUSION

ASI carried a high failure rate despite being performed within 15 days after symptom onset. One-stage exchange arthroplasty seems to be the best surgical option, particularly as the exact time of symptom onset may be difficult to determine. Identifying and eradicating the primary focus of infection is crucial.

LEVEL OF EVIDENCE

II, low-powered prospective cohort study.

High annual surgeon volume reduces the risk of adverse events following primary total hip arthroplasty: a registry-based study of 12,100 cases in Western Sweden

Background and purpose - Most earlier publications investigating whether annual surgeon volume is associated with lower levels of adverse events (AE), reoperations, and mortality are based on patient cohorts from North America. There is also a lack of adjustment for important confounders in these studies. Therefore, we investigated whether higher annual surgeon volume is associated with a lower risk of adverse events and mortality within 90 days following primary total hip arthroplasty (THA). Patients and methods - We collected information on primary total hip arthroplasties (THA) performed between 2007 and 2016 from 10 hospitals in Western Sweden. These data were linked with the Swedish Hip Arthroplasty Register and a regional patient register. We used logistic regression (simple and multiple) adjusted for age, sex, comorbidities, BMI, fiation technique, diagnosis, surgical approach, time in practice as orthopedic specialist and annual volume. Annual surgeon volume was calculated as the number of primary THAs the operating surgeon had performed 365 days prior to the index THA. Results - 12,100 primary THAs, performed due to both primary and secondary osteoarthritis by 268 different surgeons, were identified. The median annual surgeon volume was 23 primary THAs (range 0-82) 365 days prior to the THA of interest and the mean risk of AE within 90 days was 7%. If the annual volume increased by 10 primary THAs in the simple logistic regression the risk of AE decreased by 10% and in the adjusted multiple regression the corresponding number was 8%. The mortality rate in the study was low (0.2%) and we could not find any association between 90-day mortality and annual surgeon volume. Interpretation - High annual surgical activity is associated with a reduced risk of adverse events within 90 days. Based on these findings healthcare providers should consider planning for increased surgeon volume.