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Martin VT, Zhang Y, Wang Z, Liu QL, Yu B. A systematic review and meta-analysis comparing intrawound vancomycin powder and povidone iodine lavage in the prevention of periprosthetic joint infection of hip and knee arthroplasties. J Orthop Sci 2024; 29:165-176. [PMID: 36470703 DOI: 10.1016/j.jos.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Focus on reviewing a vigorous research effort to improve the safety profile of vancomycin powder (VP) and its optimal dose in reducing periprosthetic joint infection (PJI) is the need of the hour. This systematic review and meta-analysis attempt to explore the ongoing use of VP and VP + povidone iodine (PI) lavage to prevent PJI of hip/knee arthroplasties and highlights its challenges among the orthopedic community about the existence of the major organism and its frequency in total joint arthroplasty (TJA) patients. METHODS We searched PubMed/MEDLINE, EMBASE databases regarding the outcomes of vancomycin powder (VP) and VP + povidone iodine (PI) combination in preventing periprosthetic joint infection of hip and knee arthroplasties. RESULTS In 5 of 7 studies, the combination of vancomycin powder (VP) and povidone iodine (PI) lavage have shown a lower risk of periprosthetic joint infection (PJI) in acute and high-risk hip and knee arthroplasties patients, with less or without serious adverse events and readmissions; while four of seven studies using VP-only found increasing rates of PJI in primary total knee arthroplasty and partial hip replacement in elderly patients with comorbidities, and significantly causes aseptic wound complications compared to the control group. CONCLUSIONS Intra-articular vancomycin powder (VP) and povidone iodine (PI) lavage showed a significant reduction of periprosthetic joint infection in primary and revision total joint arthroplasty. Before its widespread use in clinical settings, prospective randomized studies and, most importantly, its long-term efficacy and safety are recommended.
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Affiliation(s)
- Vidmi Taolam Martin
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
| | - Yan Zhang
- Department of Orthopaedics, Leping People's Hospital, Jiangxi Province 333300, China
| | - Zhaozhen Wang
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital, Jinan University, Institute of Biological and Medical Engineering, Guangdong Academy of Sciences, Guangzhou 510632, PR China
| | - Qiao-Lan Liu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China
| | - Bo Yu
- Department of Orthopaedics and Traumatology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
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Lapow JM, Lobao A, Kreinces J, Feingold J, Carr A, Sullivan T, Wellman DS, Asprinio DE. Predictors of in-hospital surgical site infections in surgically managed acetabular fractures: A nationwide analysis. J Orthop 2023; 45:48-53. [PMID: 37841903 PMCID: PMC10570961 DOI: 10.1016/j.jor.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023] Open
Abstract
Background A surgical site infection (SSI) rate of 4%-8% has been reported in patients who undergo open reduction and internal fixation (ORIF) for acetabular fractures. Studies have identified risk factors for SSI, but none have performed a nationwide analysis of SSI in surgically managed acetabular fracture patients. Methods The National Inpatient Sample (NIS) database was queried for patients who underwent ORIF for acetabular fractures from 2016 to 2019. Analysis was performed on all patients who underwent ORIF for acetabular fractures, as well as those who only underwent ORIF for isolated acetabular fractures. Clinical characteristics, hospital course, discharge disposition, and hospitalization costs were compared between groups. Multivariate regression analysis was conducted to assess predictors of SSI. Results 41,725 patients undergoing acetabular fracture repair were identified, of which 490 (1.2%) developed SSI during hospitalization. Age (45.90 vs 49.90, p < 0.001) and Injury Severity Scale (5.99 vs 8.30, p < 0.001) were increased in patients who developed SSI. History of hypertension (HTN) (OR = 2.343, 95% CI 1.96-2.80, p < 0.001), longer hospital length of stay (30.27 days vs 10.00 days, p < 0.001) and total charges ($469,005 vs $193,032, p < 0.001) were associated with SSI. Lower rates of routine discharge were seen in SSI patients (OR = 0.333, 95% CI 0.260-0.426, p < 0.001). Higher rates of inpatient death were associated with SSI (OR = 2.210, 95% CI 1.172-4.17, p = 0.019). Multiple procedures in addition to acetabular fracture repair, iliac artery embolization, substance abuse, later time to internal fixation and HTN were predictive of SSI (p < 0.001). Conclusions Severity of injury, time to fixation, and factors associated with compromised cardiovascular integrity were predictors of SSI. Identifying patients at risk for SSI should lead to clinical maneuvers that may optimize outcome.
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Affiliation(s)
- Justin M. Lapow
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Antonio Lobao
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Jason Kreinces
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Jacob Feingold
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Alexis Carr
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - Tim Sullivan
- New York Medical College, School of Medicine, 40 Sunshine Cottage Rd, Valhalla, NY, 10595, USA
| | - David S. Wellman
- Department of Orthopaedic Surgery, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA
| | - David E. Asprinio
- Department of Orthopaedic Surgery, Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA
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Anderson PM, Rudert M, Holzapfel BM, Meyer JS, Weißenberger M, Bölch SP. Conversion total hip arthroplasty following proximal femur fracture: A retrospective analysis. Technol Health Care 2023; 31:507-516. [PMID: 36404561 DOI: 10.3233/thc-220136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The incidence of conversion total hip arthroplasty (cTHA) following reduction and fixation for proximal femur fractures will increase in parallel to the aging population worldwide. OBJECTIVE The goal of this study is to report the frequency of bacterial detection and the outcome of cTHA at the authors' institution and to analyze preoperative factors that correlate with higher rates of bacterial growth and septic revision. METHODS 48 patients who had been converted to THA after osteosynthesis of a proximal femur fracture either by a one- or two-stage procedure were included. Septic failure rate and the frequency of bacterial detection at the time of fixation device removal were calculated. The influence of different preoperative factors was examined by the odds ratio. A receiver operating characteristic curve of c-reactive protein (CRP) for detection of bacterial growth at the time of fixation device removal was calculated. RESULTS 18.8% patients showed positive bacterial cultures, with Staph. epidermidis being the most frequent pathogen (33.3%). Septic failure after cTHA occurred in 4.2%. Fixation with cephalomedullary nails and complications with the internal fixation showed higher odds for bacterial growth at time of cTHA. CRP for predicting bacterial growth had an area under the curve of 0.661. Implant survival was worse when temporary spacers were used. CONCLUSION Bacterial detection rate at the time of cTHA is high, whereas septic failure rates are low. Isolated evaluation of inflammatory blood markers without other diagnostic modalities for infection is not decisive and does not justify a two-stage approach with implantation of a temporary spacer.
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Affiliation(s)
- Philip Mark Anderson
- Department of Orthopedics, Orthopädische Klinik, König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Maximilian Rudert
- Department of Orthopedics, Orthopädische Klinik, König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Boris Michael Holzapfel
- Department of Orthopedic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany
| | | | - Manuel Weißenberger
- Department of Orthopedics, Orthopädische Klinik, König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Sebastian Philipp Bölch
- Department of Orthopedics, Orthopädische Klinik, König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
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Jacob B, Wassilew G, von Eisenhart-Rothe R, Brodt S, Matziolis G. Topical vancomycin powder does not affect patella cartilage degeneration in primary total knee arthroplasty and conversion rate for secondary patella resurfacing. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04721-w. [PMID: 36538161 PMCID: PMC10374468 DOI: 10.1007/s00402-022-04721-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Vancomycin powder (VP) is an antibiotic first introduced in pediatric spinal surgery to prevent surgical site infections (SSI). Recently its topical application was expanded to total hip and knee arthroplasty (THA, TKA) and anterior cruciate ligament reconstruction (ACLR). Toxicity to cartilage is the subject of current research. The aim of this study was to prove the hypothesis that topical application of VP in TKA does not result in a degeneration of patella cartilage. We propagate that the conversion rate for secondary patella resurfacing is not influenced by its use. MATERIALS AND METHODS Between 2014 and 2021, 4292 joints were included in this monocentric retrospective cohort study. All patients underwent TKA without primary patella resurfacing. After a change of the procedure in the hospital, one group (VPG) was administered VP intraoperatively. The other group (nVPG) received no VP during surgery (nVPG). The remaining perioperative procedure was constant over the investigation period. Conversion rates for secondary patella resurfacing for both groups were determined without making distinctions in the indication. A second cohort was composed of patients presenting for follow-up examination 12 months after TKA and included 210 joints. Retrospective radiographic evaluations were performed preoperatively, before discharge and at follow-up examination. Patella axial radiographs were analyzed for patella tracking (lateral patellar tilt, patellar displacement) and patella degeneration (Sperner classification, patellofemoral joint space). RESULTS There was no significant difference in the conversion rate for secondary patella resurfacing (4.24% VPG, 4.97% nVPG). Patella tracking and patella degeneration did not differ significantly between both groups. CONCLUSIONS The topical application of VP does not influence the conversion rate for secondary patella resurfacing. Moreover, it does not result in a degeneration of patella cartilage in TK. LEVEL OF EVIDENCE Retrospective case series, Level III.
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Affiliation(s)
- Benjamin Jacob
- Orthopaedic Department Waldkliniken Eisenberg, University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany.
| | - Georgi Wassilew
- Department of Orthopaedic Surgery, University Hospital Greifswald, Greifswald, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedics and Sports Orthopaedics, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Steffen Brodt
- Orthopaedic Department Waldkliniken Eisenberg, University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Georg Matziolis
- Orthopaedic Department Waldkliniken Eisenberg, University Hospital Jena, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
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Eriksson HK, Lazarinis S. Patient-related factors associated with superficial surgical site infection and progression to a periprosthetic joint infection after elective primary total joint arthroplasty: a single-centre, retrospective study in Sweden. BMJ Open 2022; 12:e060754. [PMID: 36123083 PMCID: PMC9486361 DOI: 10.1136/bmjopen-2022-060754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Superficial surgical site infection (SSSI) may increase the risk of serious complications such as periprosthetic joint infection (PJI). This study aims to identify patient-related risk factors associated with SSSI and investigate their correlation with the progression of PJI. DESIGN In this retrospective study, 1191 elective hip and knee prostheses were included. Patients were interviewed 3-5 months after surgery to answer questions about the postoperative period. Patient records were reviewed to determine whether there had been any documentation of wound-healing difficulties or whether antibiotics were prescribed to treat an infection related to arthroplasty surgery. SETTING Uppsala University Hospital, patients treated between November 2008 and December 2012. PARTICIPANTS The study population comprised 433 knees and 758 hips. OUTCOME MEASURES We studied patient-related risk factors (joint, age, sex, the American Society of Anesthesiologists (ASA) classification, body mass index (BMI), smoking, diabetes and rheumatic disease) to determine whether they were associated with (1) SSSI and (2) the progress from SSSI to PJI. RESULTS 84 (7%) patients of the total cohort developed SSSI. This infection progressed to a PJI in 24 (29%) of the patients. Factors with increased adjusted risk ratios (aRRs) for SSSIs were knee surgery (1.7; 95% CI: 1.1 to 2.7), age≥65 years (1.7; 95% CI: 1.1 to 2.8), BMI≥30 (1.9; 95% CI: 1.0 to 3.4) and ASA classification≥3 (1.7; 95% CI: 1.0 to 2.9). ASA classification≥3 was the only factor showing a significant progression from SSSI to PJI (aRR=3.3; 95% CI: 1.0 to 10.3). CONCLUSIONS The risk of progressing from an SSSI to a PJI is high. Older patients, patients with obesity, and those with a high ASA classification considered for elective total knee arthroplasty seem to have an increased risk of developing SSSI. Patients with a high ASA classification seem to have an increased risk of progressing from SSSI to PJI.
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Affiliation(s)
- Hannah K Eriksson
- Department of Surgical Sciences/Orthopaedics, Uppsala University, Uppsala, Sweden
| | - Stergios Lazarinis
- Department of Surgical Sciences/Orthopaedics, Uppsala University, Uppsala, Sweden
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Lee GW, Kwak WK, Lee KB. Comparison of 2-octyl cyanoacrylate skin adhesive and interrupted polypropylene sutures for wound closure in total ankle arthroplasty. J Orthop Surg Res 2021; 16:636. [PMID: 34689815 PMCID: PMC8543931 DOI: 10.1186/s13018-021-02791-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adhesive skin materials have increasingly been used in orthopedic surgery. We aimed to compare the efficacy and safety of skin adhesive (2-octyl cyanoacrylate and polymer mesh, Dermabond Prineo) and interrupted polypropylene sutures for wound closure in patients undergoing total ankle arthroplasty (TAA). METHODS We prospectively enrolled 107 consecutive patients (108 ankles) undergoing TAA and divided them into two groups: skin adhesive group (36 ankles) and suture group (72 ankles). The primary outcome assessment included wound complications and patient satisfaction for wound cosmesis. The secondary outcome assessment included duration of surgery, length of hospital stay, and the Ankle Osteoarthritis Scale (AOS) pain and disability score. RESULTS There was one case of allergic contact dermatitis, three cases of wound dehiscence, and one case of superficial surgical site infection in the skin adhesive group. Among them, one case each with allergic contact dermatitis and wound dehiscence finally progressed to deep surgical site infection. Three cases of wound dehiscence were also reported in the suture group; however, there was no case of surgical site infection. Patient satisfaction for wound cosmesis was significantly higher in the skin adhesive group than in the suture group (p = 0.001). There was no statistically significant difference between the groups in terms of secondary outcomes (p > 0.05). CONCLUSIONS Although the use of Dermabond Prineo showed better patient satisfaction for wound cosmesis, it showed significantly high wound complication rates and no other clinical benefits compared to interrupted polypropylene suture in TAA. Our results suggest that awareness of the possibility of wound complications is necessary when Dermabond Prineo is used in TAA.
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Affiliation(s)
- Gun-Woo Lee
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 42 Jebongro, Donggu, Gwangju, 61469, Republic of Korea
| | - Woo Kyoung Kwak
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 42 Jebongro, Donggu, Gwangju, 61469, Republic of Korea
| | - Keun-Bae Lee
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 42 Jebongro, Donggu, Gwangju, 61469, Republic of Korea.
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Park JW, Park HY, Park M, Yang M, Mun GH. Effects of antihypertensive drugs on surgical outcomes of breast reconstruction: a nationwide population-based claim study. Gland Surg 2021; 10:2130-2139. [PMID: 34422584 DOI: 10.21037/gs-21-220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/09/2021] [Indexed: 12/24/2022]
Abstract
Background Experimental studies have reported that angiotensin receptor blockers (ARBs) increase the risk of surgical complications. However, clinical data on their effect on surgical outcomes are limited. The aim of this study was to investigate the impact of perioperative use of ARBs on the outcomes of breast reconstruction using population-based claim data. Methods Data of patients who underwent direct-to-implant or abdomen-based autologous breast reconstruction after total mastectomy from April 2015 to December 2018 were obtained from the Health Insurance Review and Assessment Service database. The patients were categorized as ARB, non-ARB, control, and non-hypertension groups. The effects of ARBs on surgical complications, length of hospital stay, and complication-related medical costs were evaluated. Results Of the 9,036 patients who met the inclusion criteria, 5,192 underwent direct-to-implant reconstruction, and 3,844 underwent abdomen-based autologous reconstruction. The length of hospital stay was the longest and the surgical complication rate and complication-related medical cost were the highest in the ARB group after both reconstruction methods. Compared with non-treatment with antihypertensive drugs, ARB use was found to be an independent risk factor for surgical complications in direct-to-implant reconstruction [odds ratio (OR), 1.96; 95% confidence interval (CI), 1.09-3.50; P=0.0237] and complication-related medical cost (OR, 1.93; 95% CI, 1.10-3.40; P=0.0221) in abdomen-based autologous reconstruction. Conclusions Perioperative ARB use was associated with adverse postoperative breast reconstruction outcomes. These findings might have a significant impact on perioperative antihypertensive management; nevertheless, further studies are warranted to confirm the study findings.
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Affiliation(s)
- Jin-Woo Park
- Department of Plastic Surgery, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, Korea
| | - Hae Yeon Park
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Korea
| | - Minsu Park
- Department of Statistics, Keimyung University, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, Korea
| | - Mi Yang
- Seoul Mental Health Welfare Center, Dongsung 3-gil, Jongno-gu, Seoul, Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, Korea
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Aziz KT, Best MJ, Ren M, Nayar SK, Timothy Kreulen R, Gupta HO, Srikumaran U. The impact of chronic steroid use on early postoperative complications in shoulder surgery. PHYSICIAN SPORTSMED 2021; 49:223-228. [PMID: 32862751 DOI: 10.1080/00913847.2020.1811616] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Chronic steroid use has been associated with poor healing and worse long-term outcomes in patients undergoing orthopedic surgery, but the specific risk profile and short-term complications related to chronic steroids in patients undergoing outpatient shoulder surgery are inadequately defined. The purpose of this study is to characterize the effects of chronic steroids on 30-day post-operative complications following arthroscopic and open shoulder surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent arthroscopic and open rotator cuff repair, shoulder stabilization, and associated procedures from 2011 to 2018. Patients on chronic steroids were compared with patients not on chronic steroids. Demographic data and 30-day postoperative complications were analyzed. Multivariable logistic regression was used to isolate the effects of chronic steroid use on postoperative complications. RESULTS We identified 99,970 patients who underwent shoulder surgery during this period, of which 1.7% (1,662 patients) were on chronic steroids. Patients on chronic steroids were older (58.3 ± 0.30vs52.1 ± 0.05 years, p < 0.01), had higher average BMI (30.6 vs 30.1, p = 0.02), and were more likely to be female (54.9%vs38.0%, p < 0.01) and white (76.2%vs73.1%, p < 0.01). Patients on steroids had a higher American Society of Anesthesiologists class, and higher rates of diabetes, CHF, COPD, hypertension, bleeding disorders, and functionally dependency (all P < 0.01). Patients on chronic steroids were less likely to smoke (P < 0.01). Multivariable logistic regression revealed that chronic steroid use was an independent risk factor for major (OR 2.20[1.51-3.21], p < 0.001), minor (OR 2.32[1.13-3.2], p < 0.001), and infectious complications (OR 1.90[1.13-3.2], p = 0.01). CONCLUSIONS Preoperative chronic steroid use is independently associated with increased odds of major, minor, and infectious complications after open and arthroscopic rotator cuff repair, shoulder stabilization, and associated procedures. Patients on chronic steroids should be counseled about their increased risk for these complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk.
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Affiliation(s)
- Keith T Aziz
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mark Ren
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Suresh K Nayar
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - R Timothy Kreulen
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Hari Om Gupta
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Yaradılmış YU, Ateş A, Özer M, Özdemir E, Demirkale İ, Altay M. Do Low Hemoglobin Levels Affect the Healing Process of Periprosthetic Joint Infection? Cureus 2021; 13:e14393. [PMID: 33859919 PMCID: PMC8038909 DOI: 10.7759/cureus.14393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Revision knee arthroplasty (RKA) is associated with low hemoglobin (Hb) levels after surgery, which results mostly from perioperative blood loss. Periprosthetic joint infection (PJI) is one of the common reasons for RKA. This study aimed to determine whether low Hb levels affect the healing process of PJI. Methodology This retrospective study included 69 patients who underwent two-stage revision for PJI between 2013 and 2016. Patients were divided into two groups according to the latest Hb levels (Hb < 10 and Hb > 10 g/dL) during hospitalization for the first-stage revision surgery. Laboratory parameters of infection were measured during the cement spacer retention period: C-reactive protein (CRP), sedimentation rate (SEDIM), and white blood cell (WBC) count. Treatment was evaluated in two periods: cement spacer retention period (between the first surgery and second surgery) and the first normal CRP period (between the first surgery with the first normal CRP level during the cement spacer retention period). Infection parameters in the two time periods and reoperation with cement spacer were compared between the groups. Results The mean patient age was 67.3 ± 7.94 (50-87) years, and the female-to-male ratio was 4:1. No difference was found in the postoperative first control CRP, SEDIM, and WBC between the groups (p = 0.953, p = 0.3341, and p = 0.444, respectively). CRP-SEDIM control curves were observed in parallel, and no significant difference was found. The cement spacer retention period was 60.3 ± 24.8 (17-123) days, and the first normal CRP period was 87.3 ± 28.4 (14-161) days; no statistical difference was found between the groups (p = 0.727, p = 0.754). Conclusions In RKA, as low Hb level was not a negative factor of infection, blood transfusion should be avoided as it has many complications.
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Affiliation(s)
- Yüksel Uğur Yaradılmış
- Orthopaedics and Traumatology, Keçiören Health Practice and Research Center, Ankara, TUR
| | - Ahmet Ateş
- Orthopaedics and Traumatology, Keçiören Health Practice and Research Center, Ankara, TUR
| | - Mehmet Özer
- Orthopaedics and Traumatology, Keçiören Health Practice and Research Center, Ankara, TUR
| | - Erdi Özdemir
- Orthopaedics and Traumatology, Keçiören Health Practice and Research Center, Ankara, TUR
| | - İsmail Demirkale
- Orthopaedics and Traumatology, Keçiören Health Practice and Research Center, Ankara, TUR
| | - Murat Altay
- Orthopaedics and Traumatology, Keçiören Health Practice and Research Center, Ankara, TUR
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Abstract
INTRODUCTION Vancomycin powder (VP) is a well-established topical antibiotic used in spinal surgery to prevent surgical site infections. More recently its extension to hip and knee arthroplasty was introduced. The aim of this study was to examine toxic effects of VP on the viability of human chondrocytes. Our hypothesis was that VP damages human chondrocytes in vitro with increasing concentration and length of exposure. MATERIAL AND METHODS Primary human chondrocytes were isolated and cultured from donated human knee joints. VP was added to these cultures with increasing concentrations (0-50 mg/ml) and length of exposure (0-336 h). Toxicity and viability were analyzed using LDH und XTT Elisa assays. Cell structure and determination of vital versus dead cells were visualized using light microscopy and fluorescence microscopy. RESULTS Light microscopy and fluorescence microscopy visualized defect cell structures and cell death proportional to increasing dose and length of exposure to VP. The analysis of LDH activity data showed toxic effects on chondrocytes as early as 2,5 min after exposure to VP. XTT activity data revealed a significant toxic threshold of a VP concentration above 12.5 mg/ml. CONCLUSIONS These results show that exposure to high VP concentrations yields to a damage of human chondrocytes in vitro. Chondrotoxicity is an immediate effect that is proportional to VP concentration. Therefore, the intraarticular use of high concentrations of vancomycin powder in the presence of native cartilage tissue must be considered critically.
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Affiliation(s)
- Eric Röhner
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany.
| | - Timo Zippelius
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Sabrina Böhle
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Sebastion Rohe
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Georg Matziolis
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
| | - Benjamin Jacob
- Department of Orthopedics, Jena University Hospital, Campus Eisenberg, Klosterlausnitzer Straße 81, 07607, Eisenberg, Germany
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Hughes LD, Lum J, Mahfoud Z, Malik RA, Anand A, Charalambous CP. Comparison of Surgical Site Infection Risk Between Warfarin, LMWH, and Aspirin for Venous Thromboprophylaxis in TKA or THA: A Systematic Review and Meta-Analysis. JBJS Rev 2020; 8:e20.00021. [PMID: 33347014 DOI: 10.2106/jbjs.rvw.20.00021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Infection following arthroplasty can have devastating effects for the patient and necessitate further surgery. Venous thromboembolism (VTE) prophylaxis is required to minimize the risk of deep venous thrombosis and pulmonary embolism. Anticoagulation has been demonstrated to interfere with wound-healing and increase the risk of infection. We hypothesized that different anticoagulation regimes will have differing effects on rates of periprosthetic joint infection. The aim of this study was to compare the surgical site infection risk between the use of warfarin, low-molecular-weight heparin (LMWH), and aspirin for VTE prophylaxis following total knee or hip arthroplasty. METHODS A systematic literature search was conducted in November 2018 using the PubMed, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies that compared warfarin, LMWH, and/or aspirin with regard to surgical site infection rates following hip or knee arthroplasty. Meta-analyses were performed to compare the infection and VTE risks between groups. RESULTS Nine articles involving 184,037 patients met the inclusion criteria. Meta-analysis showed that warfarin prophylaxis was associated with a higher risk of deep infection (or infection requiring reoperation) (odds ratio [OR] = 1.929, 95% confidence interval [CI] = 1.197 to 3.109, p = 0.007) and surgical site infection overall (OR = 1.610, 95% CI = 1.028 to 2.522, p = 0.038) compared with aspirin in primary total joint arthroplasty, with similar findings also seen when primary and revision procedures were combined. There was no significant difference in infection risk between warfarin and LMWH and between LMWH and aspirin. There was a nonsignificant trend for VTE risk to be higher with warfarin compared with aspirin therapy for primary procedures (OR = 1.600, 95% CI = 0.875 to 2.926, p = 0.127), and this was significant when both primary and revision cases were included (OR = 2.674, 95% CI = 1.143 to 6.255, p = 0.023). CONCLUSIONS These findings caution against the use of warfarin for VTE prophylaxis for hip and knee arthroplasty. Further randomized head-to-head trials and mechanistic studies are warranted to determine how specific anticoagulants impact infection risk. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Luke D Hughes
- Health Education England-North West, Manchester, United Kingdom
| | - Joann Lum
- Blackpool Teaching Hospital NHS Trust, Blackpool, Lancashire, United Kingdom
| | - Ziyad Mahfoud
- Weill Cornell Medical College, Doha, Ad Dawhah, Qatar
| | | | - Anoop Anand
- Blackpool Teaching Hospital NHS Trust, Blackpool, Lancashire, United Kingdom
| | - Charalambos P Charalambous
- Blackpool Teaching Hospital NHS Trust, Blackpool, Lancashire, United Kingdom.,University of Central Lancashire, Preston, Lancashire, United Kingdom
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13
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Wang LS, Wang XY, Tu HT, Huang YF, Qi X, Gao YH. Octyl-2-cyanoacrylate tissue adhesive without subcuticular suture for wound closure after total hip arthroplasty: a prospective observational study on thirty-two cases with controls for 3 months follow-up. J Orthop Surg Res 2020; 15:467. [PMID: 33036638 PMCID: PMC7547444 DOI: 10.1186/s13018-020-01997-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/01/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Whether using tissue adhesive alone after subcutaneous suture can close the skin incision with safety as well as cosmetic appearance after total hip arthroplasty was not clear. METHODS A prospective study was conducted. The same surgical methods were consistent throughout the entire study. After implanting prosthesis, the joint capsule was reconstructed. Fascial and subcutaneous layer were respectively closed by continuous running barbed suture. Patients were randomized allocated to group A with octyl-2-cyanoacrylate tissue adhesive alone, to group B with tissue adhesive after continuous subcuticular suture, or to group C with skin staples. Time of closure, drainage, pain, wound complications, and cosmesis were compared. All data were analyzed statistically. RESULTS There was no significant difference in drainage, Visual Analog Scale score or early wound complications between the three groups. However, there was significant difference in time of closure (P = 0.013). In pairwise comparison, time of closure in groups A and B was significantly longer than those in group C (P = 0.001 and P = 0.023, respectively); time of closure in group A was significantly shorter than those in group B (P = 0.003). Patient and Observer Scar Assessment Scale total scores were not significantly different at 6 weeks and 3 months postoperatively (P = 0.078 and P = 0.284, respectively). CONCLUSION Tissue adhesive without subcuticular suture was similar with a combination of subcuticular suture and tissue adhesive as well skin staples in terms of safety and cosmetic appearance after total hip arthroplasty.
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Affiliation(s)
- Li-Shen Wang
- Department of Orthopedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Xin-Yu Wang
- Department of Orthopedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Hao-Tian Tu
- Department of Orthopedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Yi-Fan Huang
- Department of Orthopedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Xin Qi
- Department of Orthopedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China.
| | - Yu-Hang Gao
- Department of Orthopedic Surgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, China.
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14
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Matziolis G, Brodt S, Böhle S, Kirschberg J, Jacob B, Röhner E. Intraarticular vancomycin powder is effective in preventing infections following total hip and knee arthroplasty. Sci Rep 2020; 10:13053. [PMID: 32747743 DOI: 10.1038/s41598-020-69958-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 07/09/2020] [Indexed: 11/08/2022] Open
Abstract
Locally applied vancomycin is increasingly being used in primary hip and knee arthroplasty to reduce the risk of infection. Despite encouraging initial results, considerable debate remains on the basis of the data currently available. In particular, it has been unclear up to now whether local vancomycin is suitable to further reduce the risk of infection even if the rate of infection is already low (< 1%). In this monocentric retrospective cohort study, all primary total hip and knee arthroplasties performed between 2013 and 2018 were included. After a change in procedure at the hospital, 1 g vancomycin powder was applied intraarticularly before wound closure. The remaining perioperative procedure was constant over the investigation period. The follow-up was one year. The presence of an infection according to the currently valid MSIS criteria was defined as the endpoint. In patients with TKA two infections (0.3%) were observed under vancomycin prophylaxis in contrast to 44 infections (1.3%) in the control group (p = 0.033). In patients with THA two infections (0.5%) were observed under vancomycin prophylaxis and 48 infections (1.1%) in the control group without local vancomycin but this difference was statistically not significant. No wound complications requiring revision were observed as a result of the vancomycin. On the basis of the results of this study, intraarticular application of vancomycin powder in total hip and knee arthroplasty may be considered. Prospective randomized studies have to confirm this promising results prior a common recommendation.Level of Evidence III Retrospective cohort study.
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Gonzalez Della Valle A, Shanaghan KA, Nguyen J, Liu J, Memtsoudis S, Sharrock NE, Salvati EA. Multimodal prophylaxis in patients with a history of venous thromboembolism undergoing primary elective hip arthroplasty. Bone Joint J 2020; 102-B:71-77. [DOI: 10.1302/0301-620x.102b7.bjj-2019-1559.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE. Methods Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. Results Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. Conclusion Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71–77.
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Affiliation(s)
- Alejandro Gonzalez Della Valle
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Kate A. Shanaghan
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Joseph Nguyen
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Stavros Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Nigel E. Sharrock
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Eduardo A. Salvati
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
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16
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Thever Y, Teo BJX, Tan HCA. Predictive value of common serum glycaemic markers on periprosthetic joint infection following Total Joint Arthroplasty: A review of the literature. J Orthop 2020; 22:278-281. [PMID: 32581459 DOI: 10.1016/j.jor.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/01/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022] Open
Abstract
It is well established that diabetes mellitus and osteoarthritis commonly exist together and among various treatment modalities for osteoarthritis, Total Joint Arthroplasty (TJA) has been effective. Prosthetic Joint Infection (PJI) is a serious complication of TJA with high costs and morbidity associated with it. The aim of this study is to provide background information and relevance of diabetes on PJI, and to conduct a review on existing literature, to find out if common serum glycaemic markers in diabetes could be used as predictors for PJI after TJA. These markers include measuring pre-operative glucose levels with glycated haemoglobin (HbA1c) or capillary blood glucose, peri-operative or post-operative blood glucose levels. We have found that existing literature studying these markers as predictors of PJI after TJA has been largely contentious. Despite not being used widely in clinical practice, serum fructosamine has been shown to be more reliable and accurate than the above-mentioned markers. Future studies should be carried out to confirm and better understand this association.
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Affiliation(s)
- Yogen Thever
- National University of Singapore Yong Loo Lin School of Medicine, 10 Medical Dr, 117597, Singapore
| | - Bryon Jun Xiong Teo
- Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, 169608, Singapore
| | - Hwee Chye Andrew Tan
- Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, 169608, Singapore
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17
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Michalowitz A, Comrie R, Nicholas C, Wagner M, Kehoe J. Wound Complications after 2-Octyl Skin Closure Systems for Total Joint Arthroplasty. J Bone Jt Infect 2020; 5:101-105. [PMID: 32455101 PMCID: PMC7242402 DOI: 10.7150/jbji.42079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/23/2020] [Indexed: 01/05/2023] Open
Abstract
Introduction: Total joint arthroplasty is projected to expand rapidly by 2030. With large numbers of patients undergoing TJA, the choice of incisional closure has come into question. We compared the 2-Ocyl cyanoacrylate closure system of Dermabond ® Prineo ® with Exofin Fusion ® to compare rates of adverse wound outcomes after total joint arthroplasty. Secondary outcome measures were age, sex, and medical comorbidities between groups. Methods: We retrospectively reviewed adverse wound outcomes with skin closure in TJA in 281 patients (160 Dermabond Prineo and 121 Exofin Fusion). Clinical charts were analyzed out to the 6-week post-op visit. Results: The rate of overall adverse superficial wound outcomes was similar between the two groups with Dermabond Prineo (N=20) and Exofin Fusion (N=19). The rate of cellulitis was significantly higher for Dermabond Prineo when compared to Exofin Fusion (P=0.033). No other significant differences were found for rate of superficial or deep wound complications or for secondary outcomes. Conclusions: The two 2-octyl wound closure systems had similar adverse superficial wound complications. Except for Dermabond Prineo having a higher rate of post-operative cellulitis, there were no statistically significant differences for other superficial or deep adverse wound outcomes or secondary outcomes. A future randomized control trial or prospective cohort study is needed for a more robust analysis.
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18
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Sundaram K, Piuzzi NS, Patterson BM, Stearns KL, Krebs VE, Mont MA. Skin closure with 2-octyl cyanoacrylate and polyester mesh after primary total knee arthroplasty offers superior cosmetic outcomes and patient satisfaction compared to staples: a prospective trial. Eur J Orthop Surg Traumatol 2020; 30:447-53. [DOI: 10.1007/s00590-019-02591-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/02/2019] [Indexed: 02/06/2023]
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19
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Frenkel Rutenberg T, Vitenberg M, Yahav D, Spectre G, Velkes S. Surgical Site Infections in Elderly Fragility Hip Fractures Patients Undergoing Warfarin Treatment. J Orthop Trauma 2019; 33:518-24. [PMID: 31094939 DOI: 10.1097/BOT.0000000000001508] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Surgical site infection (SSI) is a devastating complication of proximal femoral fracture surgery, related with an increased morbidity and mortality. As warfarin treatment has been described as a risk factor for SSI, we aimed to compare patient and SSI characteristics in warfarin and nonanticoagulated patients. DESIGN Retrospective cohort study. SETTING Level-1 trauma center. PATIENTS Individuals 65 years of age and older with fragility hip fractures. INTERVENTION Patients were divided into 2 cohorts: warfarin treated (n = 85) or nonanticoagulated (n = 771). Demographics, in-hospital characteristics, laboratory data, prior hospitalizations, recent antibiotic use, and 1-year incidence of SSIs and their characteristics were gathered. MAIN OUTCOME MEASURES Postoperative SSIs. RESULTS Twelve patients (14.1%) from the warfarin group and 21 patients (2.7%) from the noncoagulated group had SSI (P < 0.001). Both groups were comparable in terms of demographics and Charlson comorbidity score. Warfarin-treated patients had reduced white blood and neutrophils counts (10.1 ± 3.2 vs. 11.6 ± 4.0 cells/mm and 8.1 ± 3.2 vs. 9.6 ± 3.9 cells/mm for both comparisons respectively; P < 0.001 for both). They were more likely to be admitted to a geriatric ward than to orthopedics ward and were delayed to theater (58.5 ± 44.5 vs. 30.6 ± 27.4 hours; P < 0.001). Following surgery, there was no difference in blood transfusions required, in-hospital complications, or time to infection. Rates of prior hospitalizations, antibiotic use, or type of bacteria did not differ. CONCLUSIONS Warfarin treatment in fragility hip fracture surgery is correlated with an increased risk for SSI, regardless of in-hospital complications, and hospitalizations before surgery or to the infection itself. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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20
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Gould D, Dowsey M, Spelman T, Jo I, Kabir W, Trieu J, Choong P. Patient-related risk factors for unplanned 30-day readmission following total knee arthroplasty: a protocol for a systematic review and meta-analysis. Syst Rev 2019; 8:215. [PMID: 31439039 PMCID: PMC6706890 DOI: 10.1186/s13643-019-1140-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/13/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Osteoarthritis is a debilitating condition as well as a growing global health problem, and total knee arthroplasty is an effective treatment for advanced stages of disease. Unplanned 30-day hospital readmission is an indicator of complications, which is a significant financial burden on healthcare systems. The objective is to perform a systematic review of patient-related factors associated with unplanned 30-day readmission following total knee arthroplasty. This information will inform future strategies to improve health outcomes after knee arthroplasty surgery. METHODS MEDLINE and EMBASE will be systematically searched using a comprehensive search strategy. Studies of higher quality than case series will be included, in order to optimise the quality of the findings of this review. We will include studies reporting on patient-related risk factors for unplanned 30-day readmission following primary or revision total knee arthroplasty for any indication. Case series will be excluded, as will studies reporting exclusively on intraoperative, clinician, hospital, and health system risk factors. The reference lists of selected papers will then be screened for any additional literature. Two reviewers will independently apply stringent eligibility criteria to titles, abstracts, and full texts of studies identified in the literature search. They will then extract data from the final list of selected papers according to an agreed-upon taxonomy and vocabulary of the data to be extracted. Assessment of risk of bias and quality of evidence will then take place. Finally, the effect size of each identified risk factor will be determined; meta-analysis will be performed where adequate data is available. DISCUSSION The findings of this review and subsequent meta-analysis will aid clinicians as they seek to understand the risk factors for 30-day readmission following total knee arthroplasty. Clinicians and patients will be able to use this information to align expectations of the postoperative course, which will enhance the recovery process, and aid in the development of strategies to mitigate identified risks. Another purpose of this review is to assist policy-makers in developing quality indicators for care and provide insights into the drivers of health costs. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019118154.
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Affiliation(s)
- Daniel Gould
- University of Melbourne Department of Surgery at St. Vincent’s Hospital Melbourne, Level 2 Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065 Australia
| | - Michelle Dowsey
- University of Melbourne Department of Surgery at St. Vincent’s Hospital Melbourne, Level 2 Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065 Australia
- Department of Othopaedics at St. Vincent’s Hospital Melbourne, Level 3 Daly Wing, 35 Victoria Parade, Fitzroy, 3065 Australia
| | - Tim Spelman
- University of Melbourne Department of Surgery at St. Vincent’s Hospital Melbourne, Level 2 Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065 Australia
| | - Imkyeong Jo
- University of Melbourne Department of Surgery at St. Vincent’s Hospital Melbourne, Level 2 Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065 Australia
| | - Wassif Kabir
- University of Melbourne Department of Surgery at St. Vincent’s Hospital Melbourne, Level 2 Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065 Australia
| | - Jason Trieu
- University of Melbourne Department of Surgery at St. Vincent’s Hospital Melbourne, Level 2 Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065 Australia
| | - Peter Choong
- University of Melbourne Department of Surgery at St. Vincent’s Hospital Melbourne, Level 2 Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065 Australia
- Department of Othopaedics at St. Vincent’s Hospital Melbourne, Level 3 Daly Wing, 35 Victoria Parade, Fitzroy, 3065 Australia
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Singh JA, Cleveland JD. Total knee arthroplasty outcomes in lupus: a study using the US National Inpatient Sample. Rheumatology (Oxford) 2019; 58:2130-2136. [DOI: 10.1093/rheumatology/kez176] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 04/08/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
To assess whether patients with lupus have more complications and/or health care utilization than patients without lupus after primary total knee arthroplasty (TKA).
Methods
We used diagnostic codes to identify lupus (710.0) in patients who underwent primary TKA (procedure code, 81.54) in the US National Inpatient Sample from 1998–2014. We performed separate logistic regression analyses to assess whether lupus was associated with each in-hospital post-primary TKA complication (implant infection, implant revision, transfusion, mortality) or health care utilization for the index hospitalization.
Results
Our study cohort consisted of 8 127 282 primary TKAs with a mean age of 66.4 years, 63% were female, 68% White, 97% with OA, and the Deyo-Charlson comorbidity score was zero in 51%; 30 912 TKAs were performed in people with lupus. In multivariable-adjusted analyses, lupus was independently associated with a significantly higher risk of transfusion, but no significant difference in implant infection, implant revision or mortality, with respective odds ratios [ORs] (95% confidence interval [CI]) of 1.34 (1.25, 1.42), 1.38 (0.73, 2.60), 1.35 (0.83, 2.19) and 0.83 (0.34, 2.03). Lupus was independently associated with a significantly higher risk of total hospital charges above the median, the length of hospital stay >3 days (median) and discharge to an inpatient facility, respective ORs (95% CI) were 1.42 (1.22, 1.66), 1.09 (1.04, 1.15) and 1.34 (1.27, 1.41).
Conclusion
Our finding of higher transfusion rate and health care utilization in lupus compared with non-lupus patients undergoing primary TKA informs surgeons, patients and policy makers regarding TKA outcomes in lupus, and can also guide appropriate resource allocation.
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Affiliation(s)
- Jasvinder A Singh
- Medicine Service, Birmingham VA Medical Center, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Medicine at the School of Medicine at the School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Epidemiology at the School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John D Cleveland
- Department of Medicine at the School of Medicine at the School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
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22
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Taneja A, El-Bakoury A, Khong H, Railton P, Sharma R, Johnston KD, Puloski S, Smith C, Powell J. Association between Allogeneic Blood Transfusion and Wound Infection after Total Hip or Knee Arthroplasty: A Retrospective Case-Control Study. J Bone Jt Infect 2019; 4:99-105. [PMID: 31192107 PMCID: PMC6536767 DOI: 10.7150/jbji.30636] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
Background: To assess using a retrospective case control study, whether patients undergoing primary, elective total hip or knee arthroplasty who receive blood transfusion have a higher rate of post-operative infection compared to those who do not. Materials and Methods: Data on elective primary total hip or knee arthroplasty patients, including patient characteristics, co-morbidities, type and duration of surgery, blood transfusion, deep and superficial infection was extracted from the Alberta Bone and Joint Health Institute (ABJHI). Logistic regression analysis was used to compare deep infection and superficial infection in blood-transfused and non-transfused cohorts. Results: Of the 27892 patients identified, 3098 (11.1%) received blood transfusion (TKA 9.7%; THA 13.1%). Overall, the rate of superficial infection (SI) was 0.5% and deep infection (DI) was 1.1%. The infection rates in the transfused cohort were SI 1.0% and DI 1.6%, and in the non-transfused cohort were SI 0.5% and DI 1.0%. The transfused cohort had an increased risk of superficial infection (adjusted odds ratio (OR) 1.9 [95% CI 1.2-2.9, p-value 0.005]) as well as deep infection (adjusted OR 1.6 [95% CI 1.1-2.2, p-value 0.008]). Conclusion: The odds of superficial and deep wound infection are significantly increased in primary, elective total hip and knee arthroplasty patients who receive blood transfusion compared to those who did not. This study can potentially help in reducing periprosthetic hip or knee infections.
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Affiliation(s)
- Ashish Taneja
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Ahmed El-Bakoury
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.,University of Alexandria, Egypt
| | - Hoa Khong
- Alberta Bone and Joint Health Institute, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Pam Railton
- Alberta Health Services, Calgary, Alberta, Canada
| | - Rajrishi Sharma
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada.,McCaig Institute for Bone and Joint Health
| | - Kelly Dean Johnston
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Shannon Puloski
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
| | - Christopher Smith
- Alberta Bone and Joint Health Institute, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - James Powell
- Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta, T2N 4N1, Canada
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Zhang X, Li T, Li Y, He M, Liu YQ, Wang MY, Xin SJ, Zhao Q. Protective effect of intraoperative re-dose of prophylactic antibiotics on surgical site infection in diabetic patients: a retrospective cohort study. Ann Transl Med 2019; 7:96. [PMID: 31019946 DOI: 10.21037/atm.2019.01.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Surgical site infection (SSI) has a high incidence in diabetic surgical patients. Preoperative antibiotic prophylaxis followed by an intraoperative re-dose was a common strategy in diabetic prolonged procedures. However, there were lacking studies on the relative benefits of this strategy on SSI. Our study aimed to clarify the effect of intraoperative re-dose of prophylactic antibiotics on SSI in diabetic patients. Methods A total of 1,840 diabetic patients with prolonged surgeries were included and Cefazolin was the only type of antibiotic prophylaxis. We assessed the relationship between intraoperative re-dose of cefazolin and 30-day incidence of SSI using a retrospective cohort study method. Results There were 361 diabetic cases with preoperative antibiotics only and 1,479 cases with pre- plus intraoperative antibiotics, in which 60 subjects suffered from SSI. Pre- plus intraoperative prophylaxis group had a lower rate of SSI in the overall and subgroup analyses when compared with preoperative only group. Operation location, combined with hypertension, poor blood glucose control, high WBC count and ASA score >2 were significantly associated with an increased risk of SSI for diabetic surgical patients (all P<0.05). Intraoperative re-dose of prophylactic antibiotics was statistically related to a lower incidence rate of SSI than preoperative prophylaxis alone (crude RR =0.47; 95% CI, 0.27-0.82; P<0.01), while the association remained significant even after adjusting the potential confounders (adjusted RR =0.51; 95% CI, 0.29-0.90; P=0.02). Conclusions For diabetic patients, intraoperative re-dose of prophylactic antibiotics may be an independent protective factor for the prevention of SSI. A specific perioperative antibiotics injection strategy should be encouraged for diabetic patients with prolonged surgeries to minimize the possibility of SSI.
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Affiliation(s)
- Xu Zhang
- Department of Social Medicine and Health Management, China Medical University, Shenyang 110122, China.,Department of Medical Administration, the First Hospital of China Medical University, Shenyang 110001, China
| | - Tan Li
- Department of Cardiovascular Ultrasound, the First Hospital of China Medical University, Shenyang 110001, China
| | - Yan Li
- NO. 1 English Department, School of Basic Sciences, China Medical University, Shenyang 110122, China
| | - Miao He
- Information Center, the First Hospital of China Medical University, Shenyang 110001, China
| | - Ya-Qi Liu
- Department of Medical Administration, the First Hospital of China Medical University, Shenyang 110001, China
| | - Meng-Ying Wang
- Department of Medical Administration, the First Hospital of China Medical University, Shenyang 110001, China
| | - Shi-Jie Xin
- Department of Vascular and Thyroid Surgery, the First Hospital of China Medical University, Shenyang 110001, China
| | - Qun Zhao
- Department of Social Medicine and Health Management, China Medical University, Shenyang 110122, China
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Machin M, Liu C, Coupland A, Davies AH, Thapar A. Systematic review of the use of cyanoacrylate glue in addition to standard wound closure in the prevention of surgical site infection. Int Wound J 2018; 16:387-393. [PMID: 30515975 DOI: 10.1111/iwj.13044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/01/2018] [Accepted: 11/11/2018] [Indexed: 11/30/2022] Open
Abstract
Surgical site infection (SSI) is associated with increased morbidity, length of stay, and cost. Cyanoacrylate glue is a low-cost, fluid-proof, antimicrobial barrier. The aim of this systematic review is to assess the use of cyanoacrylate glue after standard wound closure versus dressings in the reduction of SSI. Medline, Embase, Cochrane Library, and clinical trial registries were searched with no restrictions in accordance with PRISMA guidelines. Eligibility criteria were prospective studies comparing glue versus dressings after standardised wound closure. Two reviewers independently screened articles and utilised GRADE for quality assessment. Meta-analysis was not performed because of the heterogeneity of the data. Three articles were included in the review. Study quality was uniformly low. Incidence of SSI was low, between 0% and 4%. No significant differences were reported in the single randomised controlled trial. A single non-randomised parallel group trial reported a significant reduction in the incidence of SSI in the cyanoacrylate group. There was no consistent evidence demonstrating reduction in SSI as a result of the use of cyanoacrylate glue. Future studies should assess the use of cyanoacrylate in procedures with a higher rate of SSI, for example, lower limb bypass.
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Affiliation(s)
| | - Chen Liu
- School of Medicine, Imperial College London, London, UK
| | - Alex Coupland
- Academic Department of Vascular Surgery, Imperial College, London, UK
| | - Alun Huw Davies
- Academic Department of Vascular Surgery, Imperial College, London, UK
| | - Ankur Thapar
- Academic Department of Vascular Surgery, Imperial College, London, UK
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Miyahara HDS, Serzedello FR, Ejnisman L, Lima ALLM, Vicente JRN, Helito CP. INCISIONAL NEGATIVE-PRESSURE WOUND THERAPY IN REVISION TOTAL HIP ARTHROPLASTY DUE TO INFECTION. Acta Ortop Bras 2018; 26:300-304. [PMID: 30464709 PMCID: PMC6220663 DOI: 10.1590/1413-785220182605196038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To present our institution's experience with negative-pressure wound therapy (NPWT) as an adjuvant in wound healing of patients who have undergone revision total hip arthroplasty (THA) due to septic loosening in the presence of active fistula. METHODS We prospectively assessed patients presenting with THA infection, associated with the presence of fistula, treated with a PICO® device for NPWT, in combination with the standard treatment for prosthesis infection in our institution. Resolution of the infectious process and healing of the surgical wound without complications were considered an initial favorable outcome. RESULTS We assessed 10 patients who used PICO® in our department. No complications were identified in association with the use of the NPWT device. The mean follow-up of the patients after use of the device was 12.7 months. Only one patient progressed with fistula reactivation and recurrence of infection. CONCLUSION NPWT can be used in wound complications and infection following THA procedures safely and with promising results. Randomized prospective studies should be conducted to confirm its effectiveness. Level of Evidence IV, Case Series.
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