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Budin M, Luo TD, Gehrke T, Citak M. How reliable is the soft tissue radiological knee index in predicting superficial surgical site infection following total knee arthroplasty? Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05346-x. [PMID: 38693290 DOI: 10.1007/s00402-024-05346-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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/15/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION The purpose of this study was to evaluate the association between the Soft Tissue Radiological Knee (SToRK) Index and the risk of developing a superficial surgical site infection (SSSI) following primary total knee arthroplasty (TKA). METHODS The SToRK Index was measured using calibrated long leg radiographs (LLR) in 174 patients undergoing TKA. RESULTS A moderate correlation was found between the SToRK Index and body mass index (BMI) (rs=0.574; p < 0.001). The SToRK Index was a better predictor of SSSI in females than males. In females, a SToRK Index cutoff of 2.01 had a sensitivity and specificity of 41.3% and 74.6% for developing SSSI, respectively, with a positive likelihood ratio of 1.63. CONCLUSION The SToRK Index can be used as an additional tool in assessing the risk for SSSI after TKA. It might be more predictive in females due to the different fat distribution compared to males.
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Affiliation(s)
- Maximilian Budin
- Department of Orthopaedic Surgery, HELIOS ENDO-Clinic Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - T David Luo
- Department of Orthopaedic Surgery, HELIOS ENDO-Clinic Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, HELIOS ENDO-Clinic Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, HELIOS ENDO-Clinic Hamburg, Holstenstraße 2, 22767, Hamburg, Germany.
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Carender CN, Fruth KM, Lewallen DG, Berry DJ, Abdel MP, Bedard NA. Obesity and Primary Total Hip Arthroplasty: The Absolute versus Relative Risk of Periprosthetic Joint Infection at 15 Years. J Arthroplasty 2024:S0883-5403(24)00249-3. [PMID: 38521248 DOI: 10.1016/j.arth.2024.03.033] [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: 12/15/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND To make an informed decision about total hip arthroplasty (THA), surgeons and patients need to understand the absolute and relative risks of periprosthetic joint infection (PJI). We sought to evaluate the long-term risk of PJI following primary THA stratified by body mass index (BMI) and PJI-related risk factors. METHODS We identified 21,550 primary THAs performed from 2000 to 2021 at a single institution. Patients were stratified as having 0, 1, or ≥ 2 PJI risk factors (diabetes, chronic kidney disease, nonprimary osteoarthritis, immunosuppression, or active smoking) and into BMI categories. The 15-year cumulative risk of PJI was evaluated by BMI and PJI risk factors. RESULTS For the entire cohort, the 15-year absolute risk of PJI was 2%. For patients who did not have PJI risk factors, the absolute risk of PJI at 15 years was 1% in normal weight, 2% in class III obesity, and 4% in class IV obesity. Patients who had class III and IV obesity had a 3-times and 9-times higher relative risk of PJI, respectively (P = .03, P < .001). Among patients who had ≥ 2 PJI risk factors, the absolute risk of PJI at 15 years was 2% in normal weight, 4% in class III obesity, and 18% in class IV obesity. CONCLUSIONS Healthy patients who had class III and IV obesity had a 3-times and 9-times increased risk of PJI at 15 years relative to normal weight patients. However, the absolute risk of PJI at 15 years was 2 and 4%, respectively. Given emerging data questioning whether BMI modification decreases PJI risk, surgeons and patients must consider both a 3-times to 9-times increased relative risk of PJI and a 2 to 4% absolute risk of PJI at 15 years for healthy patients who had a BMI ≥ 40. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Kristin M Fruth
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Qureshi I, Lin CC, Anil U, Butler JJ, Walls RJ. Do Patients With Insulin-Dependent and Non-Insulin-Dependent Diabetes Have Different Risks for Complications After Total Ankle Arthroplasty? Foot Ankle Int 2024:10711007241235897. [PMID: 38501710 DOI: 10.1177/10711007241235897] [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] [Indexed: 03/20/2024]
Abstract
BACKGROUND Patients with diabetes undergoing total ankle arthroplasty tend to be at greater risk for complications than those without diabetes. However, the effect of diabetes severity and how it impacts the risk for perioperative complications is less clear. The purpose of this study was to compare (1) complications, (2) length of hospital stay, and (3) readmissions within 30 days for total ankle arthroplasty (TAA) patients without diabetes, patients with non-insulin-dependent diabetes, and patients with insulin-dependent diabetes. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a total of 1803 patients undergoing TAA between 2007 and 2019 were collected. The relationship between diabetes status (no diabetes [n = 1,589], insulin-dependent [n = 169], and non-insulin-dependent [n = 45]) and outcomes were compared. Multivariate linear regression models were used to adjust for confounding variables such as age, sex, race, body mass index, smoking, steroid use, hypertension, chronic obstructive pulmonary disease, anesthesia type, dyspnea, and outpatient status. Statistical significance was set at P <.05. RESULTS Insulin-dependent diabetes was an independent risk factor for increased odds of infection within 30 days (odds ratio 6.47, 95% CI 0.79-33.66; P = .043). Hospital length of stay was also increased in patients with non-insulin-dependent diabetes (β = 0.21, 95% CI 0.02-0.40; P = .031) and insulin-dependent diabetes (β = 0.40, 95% CI 0.04-0.76; P = .028). However, neither diabetic state demonstrated a statistically significant increase in readmissions or wound complications within 30 days. CONCLUSION Patients with insulin-dependent diabetes included in this cohort were at increased risk of having an infection within 30 days after TAA. Additionally, patients with diabetes status had an increased hospital length of stay. These results can inform patients on their potential outcomes after total ankle arthroplasty based on their diabetes status. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ibraheem Qureshi
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | | | - Utkarsh Anil
- NYU Langone Orthopedic Hospital, New York, NY, USA
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Schmerler J, Bergstein VE, ElNemer W, Harris AB, Khanuja HS, Srikumaran U, Hegde V. The weight of complications: high and low BMI have disparate modes of failure in total hip arthroplasty. Arthroplasty 2024; 6:9. [PMID: 38433261 PMCID: PMC10910669 DOI: 10.1186/s42836-024-00233-7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/03/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Body mass index (BMI) has been shown to influence risk for revision total hip arthroplasty (rTHA), but few studies have specifically examined which causes of rTHA are most likely in different BMI classes. We hypothesized that patients in different BMI classes would undergo rTHA for disparate reasons. METHODS Ninety-eight thousand six hundred seventy patients undergoing rTHA over 2006-2020 were identified in the National Inpatient Sample. Patients were classified as underweight, normal-weight, overweight/obese, or morbidly obese. Multivariable logistic regression was used to analyze the impact of BMI on rTHA for periprosthetic joint infection (PJI), dislocation, periprosthetic fracture (PPF), aseptic loosening, or mechanical complications. Analyses were adjusted for age, sex, race/ethnicity, socioeconomic status, insurance, geographic region, and comorbidities. RESULTS Compared to normal-weight patients, underweight patients were 131% more likely to have a revision due to dislocation and 63% more likely due to PPF. Overweight/obese patients were 19% less likely to have a revision due to dislocation and 10% more likely due to PJI. Cause for revision in morbidly obese patients was 4s1% less likely to be due to dislocation, 8% less likely due to mechanical complications, and 90% more likely due to PJI. CONCLUSIONS Overweight/obese and morbidly obese patients were more likely to undergo rTHA for PJI and less likely for mechanical reasons compared to normal weight patients. Underweight patients were more likely to undergo rTHA for dislocation or PPF. Understanding the differences in cause for rTHA among the BMI classes can aid in patient-specific optimization and management to reduce postoperative complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jessica Schmerler
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA.
| | - Victoria E Bergstein
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - William ElNemer
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Andrew B Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Harpal S Khanuja
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA
| | - Vishal Hegde
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD, 21287, USA
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Eymard F, Aron-Wisnewsky J. Osteoarthritis in patients with obesity: The bariatric surgery impacts on its evolution. Joint Bone Spine 2024; 91:105639. [PMID: 37734439 DOI: 10.1016/j.jbspin.2023.105639] [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] [Received: 07/13/2023] [Revised: 08/28/2023] [Accepted: 09/03/2023] [Indexed: 09/23/2023]
Abstract
Obesity is one of the main modifiable risk factors for osteoarthritis (OA). Moreover, obesity is associated with greater pain intensity and functional limitation, but also with a significantly lower responder rate to intra-articular treatments. Consequently, an arthroplasty is indicated earlier and more frequently in patients with obesity. However, pain and functional symptoms improve slightly less after arthroplasty in patients with obesity, who display higher incidence of early and late complications following prosthetic surgery. Bariatric surgery (BS) has increased worldwide and is efficient to induce major and sustainable weight-loss. Importantly, BS significantly reduces pain and functional limitation in patients with symptomatic knee OA. Biomarkers analysis also revealed a decrease in catabolic factors and an increase in anabolic one after BS suggesting a structural protective effect in knee OA. Nevertheless, the impact of BS prior to arthroplasty remains unclear. BS seems to decrease short- and mid-term complications such as infections or thrombosis. However, BS does not appear to modify long-term complications rate, and may even increase it, especially revisions and infections. Although few studies have compared the symptomatic and functional outcomes of joint replacement with or without BS, these are not significantly improved by prior BS. Despite these heterogeneous results, medico-economic studies found that BS prior to arthroplasty was cost-effective. To conclude, BS could significantly reduce the symptoms of OA and potentially slow its progression, but appears more disappointing in preventing long-term complications of arthroplasties and improving their functional results.
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Affiliation(s)
- Florent Eymard
- Department of Rheumatology, Henri-Mondor University Hospital, Assistance publique-Hôpitaux de Paris, AP-HP, 1, rue Gustave-Eiffel, 94000 Créteil, France.
| | - Judith Aron-Wisnewsky
- Department of Nutrition, Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, AP-HP, 75013 Paris, France; Sorbonne université, Inserm, Nutrition and Obesity: Systemic Approaches, NutriOmics, 75013 Paris, France
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Wier J, Liu KC, Richardson MK, Gettleman BS, Kistler NM, Heckmann ND, Lieberman JR. Higher Blood Glucose Levels on the Day of Surgery Are Associated with an Increased Risk of Periprosthetic Joint Infection After Total Hip Arthroplasty. J Bone Joint Surg Am 2024; 106:276-287. [PMID: 38127864 DOI: 10.2106/jbjs.23.00546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Hyperglycemia has been identified as a risk factor for periprosthetic joint infection (PJI) after total hip arthroplasty (THA). However, there is no consensus with regard to the preoperative blood glucose level (BGL) on the day of the surgical procedure associated with increased risk. We sought to identify preoperative BGL thresholds associated with an increased risk of PJI. METHODS The Premier Healthcare Database was retrospectively queried for adult patients who underwent primary, elective THA and had a measurement of the preoperative BGL recorded on the day of the surgical procedure (preoperative BGL) from January 1, 2016, to December 31, 2021. The association between preoperative BGL and 90-day PJI risk was modeled using multivariable logistic regression with restricted cubic splines. Patients with and without diabetes with a preoperative BGL associated with 1.5 times greater odds of PJI (high preoperative BGL) were then compared with patients with a normal preoperative BGL. RESULTS In this study, 90,830 patients who underwent THA and had a recorded preoperative BGL were identified. The preoperative BGL associated with 1.5 times greater odds of PJI was found to be 277 mg/dL in patients with diabetes and 193 mg/dL in patients without diabetes. Compared with the normal preoperative BGL cohort, those with high preoperative BGL had increased odds of PJI (adjusted odds ratio [OR], 2.60 [95% confidence interval (CI), 1.45 to 4.67] for patients with diabetes and 1.66 [95% CI, 1.10 to 2.51] for patients without diabetes) and 90-day readmissions (adjusted OR, 1.92 [95% CI, 1.45 to 2.53] for patients with diabetes and 1.66 [95% CI, 1.37 to 2.00] for patients without diabetes). CONCLUSIONS Increased preoperative BGL was found to be associated with an increased risk of PJI following primary THA. Surgeons should be aware of patients with diabetes and a preoperative BGL of >277 mg/dL and patients without diabetes but with a preoperative BGL of >193 mg/dL. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Julian Wier
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | | | - Natalie M Kistler
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
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Piuzzi NS, Klika AK, Lu Q, Higuera-Rueda CA, Stappenbeck T, Visperas A. Periprosthetic joint infection and immunity: Current understanding of host-microbe interplay. J Orthop Res 2024; 42:7-20. [PMID: 37874328 DOI: 10.1002/jor.25723] [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: 05/31/2023] [Revised: 09/19/2023] [Accepted: 10/17/2023] [Indexed: 10/25/2023]
Abstract
Periprosthetic joint infection (PJI) is a major complication of total joint arthroplasty. Even with current treatments, failure rates are unacceptably high with a 5-year mortality rate of 26%. Majority of the literature in the field has focused on development of better biomarkers for diagnostics and treatment strategies including innovate antibiotic delivery systems, antibiofilm agents, and bacteriophages. Nevertheless, the role of the immune system, our first line of defense during PJI, is not well understood. Evidence of infection in PJI patients is found within circulation, synovial fluid, and tissue and include numerous cytokines, metabolites, antimicrobial peptides, and soluble receptors that are part of the PJI diagnosis workup. Macrophages, neutrophils, and myeloid-derived suppressor cells (MDSCs) are initially recruited into the joint by chemokines and cytokines produced by immune cells and bacteria and are activated by pathogen-associated molecular patterns. While these cells are efficient killers of planktonic bacteria by phagocytosis, opsonization, degranulation, and recruitment of adaptive immune cells, biofilm-associated bacteria are troublesome. Biofilm is not only a physical barrier for the immune system but also elicits effector functions. Additionally, bacteria have developed mechanisms to evade the immune system by inactivating effector molecules, promoting killing or anti-inflammatory effector cell phenotypes, and intracellular persistence and dissemination. Understanding these shortcomings and the mechanisms by which bacteria can subvert the immune system may open new approaches to better prepare our own immune system to combat PJI. Furthermore, preoperative immune system assessment and screening for dysregulation may aid in developing preventative interventions to decrease PJI incidence.
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Affiliation(s)
- Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Adult Reconstruction Research (CCARR), Cleveland Clinic, Cleveland, Ohio, USA
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Adult Reconstruction Research (CCARR), Cleveland Clinic, Cleveland, Ohio, USA
| | - Qiuhe Lu
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Anabelle Visperas
- Department of Orthopaedic Surgery, Cleveland Clinic Adult Reconstruction Research (CCARR), Cleveland Clinic, Cleveland, Ohio, USA
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Genito CJ, Darwitz BP, Greenwald MA, Wolfgang MC, Thurlow LR. Hyperglycemia potentiates increased Staphylococcus aureus virulence and resistance to growth inhibition by Pseudomonas aeruginosa. Microbiol Spectr 2023; 11:e0229923. [PMID: 37933971 PMCID: PMC10715105 DOI: 10.1128/spectrum.02299-23] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/29/2023] [Indexed: 11/08/2023] Open
Abstract
IMPORTANCE Individuals with diabetes are prone to more frequent and severe infections, with many of these infections being polymicrobial. Polymicrobial infections are frequently observed in skin infections and in individuals with cystic fibrosis, as well as in indwelling device infections. Two bacteria frequently co-isolated from infections are Staphylococcus aureus and Pseudomonas aeruginosa. Several studies have examined the interactions between these microorganisms. The majority of these studies use in vitro model systems that cannot accurately replicate the microenvironment of diabetic infections. We employed a novel murine indwelling device model to examine interactions between S. aureus and P. aeruginosa. Our data show that competition between these bacteria results in reduced growth in a normal infection. In a diabetic infection, we observe increased growth of both microbes and more severe infection as both bacteria invade surrounding tissues. Our results demonstrate that diabetes changes the interaction between bacteria resulting in poor infection outcomes.
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Affiliation(s)
- Christopher J. Genito
- Division of Oral and Craniofacial Health Sciences, University of North Carolina at Chapel Hill Adams School of Dentistry, Chapel Hill, North Carolina, USA
| | - Benjamin P. Darwitz
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Matthew A. Greenwald
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- Marsico Lung Institute, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Matthew C. Wolfgang
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
- Marsico Lung Institute, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Lance R. Thurlow
- Division of Oral and Craniofacial Health Sciences, University of North Carolina at Chapel Hill Adams School of Dentistry, Chapel Hill, North Carolina, USA
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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Cieremans D, Muthusamy N, Singh V, Rozell JC, Aggarwal V, Schwarzkopf R. Does antibiotic bone cement reduce infection rates in primary total knee arthroplasty? Eur J Orthop Surg Traumatol 2023; 33:3379-3385. [PMID: 37133753 DOI: 10.1007/s00590-023-03557-3] [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] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 04/23/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Infection after total knee arthroplasty (TKA) impacts the patient, surgeon, and healthcare system significantly. Surgeons routinely use antibiotic-loaded bone cement (ALBC) in attempts to mitigate infection; however, little evidence supports the efficacy of ALBC in reducing infection rates compared to non-antibiotic-loaded bone cement (non-ALBC) in primary TKA. Our study compares infection rates of patients undergoing TKA with ALBC to those with non-ALBC to assess its efficacy in primary TKA. METHODS A retrospective review of all primary, elective, cemented TKA patients over the age of 18 between 2011 and 2020 was conducted at an orthopedic specialty hospital. Patients were stratified into two cohorts based on cement type: ALBC (loaded with gentamicin or tobramycin) or non-ALBC. Baseline characteristics and infection rates determined by MSIS criteria were collected. Multilinear and multivariate logistic regressions were performed to limit significant differences in demographics. Independent samples t test and chi-squared test were used to compare means and proportions, respectively, between the two cohorts. RESULTS In total, 9366 patients were included in this study, 7980 (85.2%) of whom received non-ALBC and 1386 (14.8%) of whom received ALBC. There were significant differences in five of the six demographic variables analyzed; patients with higher Body Mass Index (33.40 ± 6.27 vs. 32.09 ± 6.21; kg/m2) and Charlson Comorbidity Index values (4.51 ± 2.15 vs. 4.04 ± 1.92) were more likely to receive ALBC. The infection rate in the non-ALBC was 0.8% (63/7,980), while the rate in the ALBC was 0.5% (7/1,386). After adjusting for confounders, the difference in rates was not significant between the two groups (OR [95% CI]: 1.53 [0.69-3.38], p = 0.298). Furthermore, a sub-analysis comparing the infection rates within various demographic categories also showed no significant differences between the two groups. CONCLUSION Compared to non-ALBC, the overall infection rate in primary TKA was slightly lower when using ALBC; however, the difference was not statistically significant. When stratifying by comorbidity, use of ALBC still showed no statistical significance in reducing the risk of periprosthetic joint infection. Therefore, the advantage of antibiotics in bone cement to prevent infection in primary TKA is not yet elucidated. Further prospective, multicenter studies regarding the clinical benefits of antibiotic use in bone cement for primary TKA are warranted.
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Affiliation(s)
- David Cieremans
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Nishanth Muthusamy
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Vivek Singh
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Vinay Aggarwal
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York University, Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA.
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Bosler AC, Deckard ER, Buller LT, Meneghini RM. Obesity is Associated With Greater Improvement in Patient-Reported Outcomes Following Primary Total Knee Arthroplasty. J Arthroplasty 2023; 38:2484-2491. [PMID: 37595768 DOI: 10.1016/j.arth.2023.08.031] [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: 05/17/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Body mass index (BMI) cutoffs have been established for total knee arthroplasty (TKA) patients due to increased risk of medical complications in obese patients. However, evidence-based medical optimization may mitigate risk in these patients. This study examined the influence of BMI on patient-reported outcome measures (PROMs) following primary TKA with specialized perioperative optimization. METHODS Between 2016 and 2020, 1,329 consecutive primary TKAs using standardized perioperative optimization were retrospectively reviewed. Patients were categorized into ordinal groups based on BMI in 5 kg/m2 increments (range, 17 to 61). Primary outcomes related to activity level, pain, function, and satisfaction were evaluated. BMI groups ≥35 had significantly lower age, more women, and higher prevalence of comorbidities (P ≤ .004). Mean follow-up was 1.7 years (range, 1 to 5 years). RESULTS Each successive BMI group from 35 to ≥50 demonstrated continually greater improvement in pain with level walking and stair climbing (P ≤ .001), Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (P = .001), and greater satisfaction (P = .007). No patients who had a BMI ≥35 were revised for aseptic loosening, and rates of periprosthetic joint infection were not different between BMI groups (P = 1.000). CONCLUSION Despite being more debilitated preoperatively, patients who had a BMI ≥35 experienced greater improvements in PROMs compared to patients who had lower BMI. Given the significant improvements in PROMs and quality of life in obese patients, with appropriate perioperative optimization, these patients should not be prohibited from having a TKA when appropriately indicated. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ashton C Bosler
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Evan R Deckard
- Indiana Joint Replacement Institute, Indianapolis, Indiana
| | - Leonard T Buller
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Indiana Joint Replacement Institute, Indianapolis, Indiana
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Magruder ML, Yao VJH, Rodriguez AN, Ng MK, Sasson V, Erez O. Does Semaglutide Use Decrease Complications and Costs Following Total Knee Arthroplasty? J Arthroplasty 2023; 38:2311-2315.e1. [PMID: 37279843 DOI: 10.1016/j.arth.2023.05.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 03/01/2023] [Revised: 05/20/2023] [Accepted: 05/24/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Diabetes mellitus (DM) and obesity are associated with total knee arthroplasty (TKA) complications. Semaglutide, a medication for DM and weight loss, can potentially affect TKA outcomes. This study investigated whether semaglutide use during TKA demonstrates fewer: (1) medical complications; (2) implant-related complications; (3) readmissions; and (4) costs. METHODS A retrospective query was performed using a National database to 2021. Patients undergoing TKA for osteoarthritis with DM and semaglutide use were successfully propensity score-matched to controls semaglutide = 7,051; control = 34,524. Outcomes included 90-day postoperative medical complications, 2-year implant-related complications, 90-day readmissions, in-hospital lengths of stay, and costs. Multivariate logistical regressions calculated odds ratios (ORs), 95% confidence intervals, and P values (P < .003 as significance threshold after Bonferroni correction). RESULTS Semaglutide cohorts had higher incidence and odds of myocardial infarction (1.0 versus 0.7%; OR 1.49; P = .003), acute kidney injury (4.9 versus 3.9%; OR 1.28; P < .001), pneumonia (2.8 versus 1.7%; OR 1.67; P < .001), and hypoglycemic events (1.9 versus 1.2%; OR 1.55; P < .001), but lower odds of sepsis (0 versus 0.4%; OR 0.23; P < .001). Semaglutide cohorts also had lower odds of prosthetic joint infections (2.1 versus 3.0%; OR 0.70; P < .001) and readmission (7.0 versus 9.4%; OR 0.71; P < .001), and trended toward lower odds of revisions (4.0 versus 4.5%; OR 0.86; P = .02) and 90-day costs ($15,291.66 versus $16,798.46; P = .012). CONCLUSION Semaglutide use during TKA decreased risk for sepsis, prosthetic joint infections, and readmissions, but also increased risk for myocardial infarction, acute kidney injury, pneumonia, and hypoglycemic events.
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Affiliation(s)
- Matthew L Magruder
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Vincent J H Yao
- Sophie Davis Biomedical Education Program at the CUNY School of Medicine, New York, New York
| | - Ariel N Rodriguez
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Victor Sasson
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Orry Erez
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
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Atrey A, Yates AJ, O'Connor MI, Thomson Z, Waddell JP, Broderick J, Zylberg A, Wall C, Emmerson B, Campbell D, Khoshbin A. The International Initiative to Measure Perceived Risk in Arthroplasty: The Results From a Multinational Survey. J Arthroplasty 2023; 38:2247-2253. [PMID: 37595767 DOI: 10.1016/j.arth.2023.08.003] [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: 12/27/2022] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND There is an inherent moral imperative to avoid complications from arthroplasty. Doing so at ideal cost is also associated with surgeon reputation, and, increasingly in health care delivery systems that measure and competitively score outcomes, reimbursement to the surgeons and their hospitals. As a result, patients who are perceived to be in higher risk comorbidity groups, such as the obese and diabetics, as well as those challenged by socioeconomic factors may face barriers to access elective arthroplasty. METHODS In this initiative, surveys were sent to surgeons in 8 different countries, each adapted for their own unique payment, remuneration, and punitive models. The questions in the surveys pertained to surgeons' perception of risk regarding medical and socioeconomic factors in patients indicated for total hip or knee arthroplasty. This paper primarily reports on the results from Canada, Ireland, and the United Kingdom. RESULTS The health care systems varied between a universal/state funded health care system (Canada) to those that were almost exclusively private (India). Some health care systems have "bundled" payment with retention of fees for postoperative complications requiring readmission/reoperation and including some with public publication of outcome data (United States and the United Kingdom), whereas others had none (Canada). There were some major discrepancies across different countries regarding the perceived risk of diabetic patients, who have variable Hemoglobin A1c cut-offs, if any used. However, overall the perception of risk for age, body mass index, age, sex, socioeconomic, and social situations remained surprisingly consistent throughout the health care systems. Any limitations set were primarily driven by surgeon decision making and not external demands. CONCLUSION Surgeons will understandably try and optimize the health status of patients who have reversible risks as shown by best available evidence. The evidence is of variable quality, and, especially for irreversible social risk factors, limited due to concerns over cost and quality outcomes that can be influenced by experience-driven perceptions of risk. The results show that perceptions of risk do have such influence on access across many health care delivery environments. The authors recommend better risk-adjustment models for medical and socioeconomic risk factors with possible stratification/exclusions regarding reimbursement adjustments and reporting to help reverse disparities of access to arthroplasty.
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Affiliation(s)
- Amit Atrey
- Division of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - Adolph J Yates
- Division of Orthopedics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Zoe Thomson
- Division of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - James P Waddell
- Division of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
| | - James Broderick
- St. Vincent's University Hospital, Dublin, Ireland; Cappagh National Orthopaedic Hospital, Dublin, Ireland; UCD School of Medicine, Dublin, Ireland
| | | | - Christopher Wall
- Department of Orthopaedics, Darling Downs Hospital, Toowoomba, Queensland, Australia
| | - Ben Emmerson
- Orthopaedics, North East England Training Program, Newcastle-Upon-Tyne, UK
| | - David Campbell
- Wakefield Orthopaedic Clinic, Adelaide, South Australia, Australia
| | - Amir Khoshbin
- Division of Orthopaedics, University of Toronto, Toronto, Ontario, Canada
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Tidd JL, Pasqualini I, McConaghy K, Higuera CA, Deren ME, Visperas A, Klika AK, Piuzzi NS. The Use of Oral Antibiotics After Total Joint Arthroplasty: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202310000-00004. [PMID: 37812675 DOI: 10.2106/jbjs.rvw.23.00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
» There is conflicting and insufficient evidence that extended oral antibiotic (EOA) therapy prevents infection in high-risk patients undergoing primary total joint arthroplasty (TJA), limiting recommendation for or against the practice.» In the case of aseptic revision TJA, the evidence is also conflicting and limited by underlying confounders, preventing recommendation for use of EOA.» There is fair evidence that use of EOA after debridement antibiotic therapy and implant retention of the prosthesis prolongs infection-free survival, but randomized controlled trials are needed. On the other hand, there is strong evidence that patients undergoing 2-stage revision should receive a period of suppressive oral antibiotics after the second stage.» The optimal duration of EOA in primary TJA, aseptic revision, and debridement antibiotic therapy and implant retention of the prosthesis is unknown. However, there is strong evidence that 3 months of EOA suppression may be appropriate after reimplantation as part of 2-stage exchange arthroplasty.» Complications secondary to EOA are reported to be between 0% and 13.7%, yet are inconsistently reported and poorly defined. The risks associated with antibiotic use, including development of antimicrobial resistance, must be weighed against a possible decrease in infection rate.
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Affiliation(s)
- Joshua L Tidd
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | | | - Kara McConaghy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Carlos A Higuera
- Levitetz Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Matthew E Deren
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anabelle Visperas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
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Chang WP, Peng YX. Differences Between Patients With Diabetes Mellitus and Obese Patients in Occurrence of Peri-Prosthetic Joint Infection: A Systemic Review and Meta-Analysis. Surg Infect (Larchmt) 2023; 24:671-683. [PMID: 37722014 DOI: 10.1089/sur.2023.139] [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] [Indexed: 09/20/2023] Open
Abstract
Background: To understand the differences between patients with diabetes mellitus and obese patients with respect to the occurrence of peri-prosthetic joint infection (PJI) after lower-extremity joint arthroplasty as well as to identify differences in PJI occurrence at different time periods. Patients and Methods: The Cochrane Library, CINAHL, MEDLINE, and PubMed were searched for literature published between January 2000 and July 2022. Our targets were studies involving patients with PJI who had already been diagnosed as having diabetes mellitus or being obese before receiving lower-extremity joint arthroplasty. Analysis was performed using Comprehensive Meta-Analysis Software (CMA) Version 3 (Biostat, Inc., Englewood, NJ, USA). Results: A total of 53,522 patients with diabetes mellitus and 360,018 obese patients were included. The forest plot for patients with and without diabetes mellitus indicated that patients with diabetes mellitus were more likely to contract PJIs than were patients without diabetes mellitus (odds ratio, 1.84; 95% confidence interval [CI], 1.56-2.16) and that no differences existed among early, delayed, and late PJI occurrence in patients with diabetes mellitus. The forest plot for obese and non-obese patients indicated that obese patients were more likely to contract PJIs than were non-obese patients (odds ratio, 1.86; 95% CI, 1.53-2.14) and that among obese patients, early PJI occurrence was higher than was late PJI occurrence. In addition, the mixed model indicated that obese patients were more likely to develop early PJIs than were patients with diabetes mellitus. Conclusions: Patients with diabetes mellitus and obese patients were more likely to develop PJIs than were patients without diabetes mellitus and non-obese patients, and that obese patients were more likely to develop early PJIs than late PJIs. Also, obese patients were more likely to develop early PJIs than patients with diabetes mellitus.
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Affiliation(s)
- Wen-Pei Chang
- Department of Nursing, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Yu-Xuan Peng
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
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Aljuhani WS, Alanazi AM, Saeed AI, Alhadlaq KH, Alhoshan YS, Aljaafri ZA. Patient-related risk factors of prosthetic joint infections following total hip and knee arthroplasty at King Abdulaziz Medical City, a 10-year retrospective study. J Orthop Surg Res 2023; 18:717. [PMID: 37736732 PMCID: PMC10514936 DOI: 10.1186/s13018-023-04210-9] [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: 09/04/2023] [Accepted: 09/15/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Total joint arthroplasty (TJA) can be associated with the development of periprosthetic joint infection (PJI). It is necessary to determine the modifiable and non-modifiable risk factors of PJI to provide optimum healthcare to TJA candidates. METHODS This single-center retrospective review investigated 1198 patients who underwent TJA from 2012 to 2022. The data analysis comprised two stages. The first stage was a descriptive analysis, while the second stage was a bivariate analysis. The sociodemographic data, medical history, operative details, and presence of PJI postoperatively were evaluated. RESULTS The study sample consisted of 1198 patients who underwent TJA. The mean patient age was 63 years. Among the patients, only 1.3% had PJI. No comorbidity was significantly related to PJI. General anesthesia was used in almost 21% of the patients and was significantly associated with a higher risk of infection (p = 0.049). An increased operative time was also significantly related to PJI (p = 0.012). Conversely, tranexamic acid (TXA) administration was a protective factor against PJI (p = 0.017). CONCLUSION Although PJI is not a common complication of TJA, multiple risk factors such as general anesthesia and prolonged operative time play a significant role in its development. In contrast, TXA administration is thought to reduce the risk of PJI effectively.
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Affiliation(s)
- Wazzan S Aljuhani
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah M Alanazi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah I Saeed
- Department of Orthopedic Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Khalid H Alhadlaq
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yazeed S Alhoshan
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ziad A Aljaafri
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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Koch KA, Spranz DM, Westhauser F, Bruckner T, Lehner B, Alvand A, Merle C, Walker T. Impact of Comorbidities and Previous Surgery on Mid-Term Results of Revision Total Knee Arthroplasty for Periprosthetic Joint Infection. J Clin Med 2023; 12:5542. [PMID: 37685609 PMCID: PMC10488668 DOI: 10.3390/jcm12175542] [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: 06/11/2023] [Revised: 08/13/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
(1) Background: In the treatment of periprosthetic joint infection (PJI), the individual host status and previous surgical procedures appear to have a relevant influence on success rates and clinical outcome of knee revision surgery. Current data about the predictive value are limited in this subgroup of patients. (2) Methods: Retrospectively, 107 patients (109 knees) undergoing two-stage exchange knee arthroplasty for PJI using a rotating-hinge design with at least two years follow-up. The cumulative incidence (CI) for different endpoints was estimated with death as competing risk. Univariate and multivariate analyses for potential predictive factors were performed. Patient-related outcome measures (PROMs) for clinical outcome were evaluated. (3) Results: At 8 years, the CI of any revision was 29.6%, and of any reoperation was 38.9%. Significant predictors for risk of re-revision were the Charlson Comorbidity Index (CCI) and the number of previous surgical procedures prior to explanation of the infected implant. The functional and clinical outcome demonstrated acceptable results in the present cohort with a high comorbidity level. (4) Conclusions: A compromised host status and multiple previous surgical procedures were identified as negative predictors for re-revision knee surgery in the treatment of PJI. Reinfection remained the major reason for re-revision. Overall mortality was high.
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Affiliation(s)
- Kevin-Arno Koch
- Department of Orthopaedic Surgery, University Hospital of Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany; (K.-A.K.); (D.M.S.); (F.W.); (B.L.)
| | - David M. Spranz
- Department of Orthopaedic Surgery, University Hospital of Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany; (K.-A.K.); (D.M.S.); (F.W.); (B.L.)
| | - Fabian Westhauser
- Department of Orthopaedic Surgery, University Hospital of Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany; (K.-A.K.); (D.M.S.); (F.W.); (B.L.)
| | - Tom Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 305, 69120 Heidelberg, Germany;
| | - Burkhard Lehner
- Department of Orthopaedic Surgery, University Hospital of Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany; (K.-A.K.); (D.M.S.); (F.W.); (B.L.)
| | - Abtin Alvand
- Adult Hip and Knee Service, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Windmill Road, Headington, Oxford OX3 7LD, UK;
| | - Christian Merle
- Orthopaedic Centre Paulinenhilfe, Diakonie-Klinikum Stuttgart, Rosenbergstraße 38, 70176 Stuttgart, Germany;
| | - Tilman Walker
- Department of Orthopaedic Surgery, University Hospital of Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany; (K.-A.K.); (D.M.S.); (F.W.); (B.L.)
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Abhari S, Rhea EB, Arrington DD, Smith LS, Yakkanti MR, Malkani AL. Is There a Difference in PROMs Between Morbidly Obese Patients and Nonobese Patients Following Primary Total Knee Arthroplasty? Arthroplast Today 2023; 22:101169. [PMID: 37521737 PMCID: PMC10374861 DOI: 10.1016/j.artd.2023.101169] [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: 02/10/2023] [Revised: 05/02/2023] [Accepted: 05/24/2023] [Indexed: 08/01/2023] Open
Abstract
Background Patient satisfaction and patient-reported outcome measures (PROMs) are important for patients, surgeons, and payers in the current healthcare climate. Morbidly obese patients (body mass index [BMI] >40) have demonstrated higher incidence of complications after total knee arthroplasty (TKA) and can have difficulty obtaining access for their surgical care. The purpose of this study was to evaluate PROMs and patient satisfaction in morbidly obese patients undergoing primary TKA. Methods A total of 75 patients with BMI >40 kg/m2 undergoing robotic-assisted TKA were retrospectively identified and matched 2:1 to a consecutive cohort of patients with BMI <35. The average BMI of the study cohort was 42.4 kg/m2 (39.5-51.3) compared to 28.6 kg/m2 (18.5-34.9) in the control group. Clinical outcomes, PROMs, and patient satisfaction were evaluated at a minimum 2-year follow-up. Results The patients of the BMI >40 cohort were less likely to be discharged home (P = .0076), had less active flexion at 2 years (P = .0046), and had worse knee scores at 2 years (0.0497). Despite this, the percentage of patients who were satisfied or very satisfied after surgery was similar between the groups (87.5% vs 91.2%, P = .1943). Conclusions Morbidly obese patients are less likely to be discharged directly to home and may have functional differences after primary TKA. However, morbidly obese patients have similar PROMs and are as satisfied as nonobese patients at 2 years. Morbidly obese patients with end-stage knee osteoarthritis should also be able to enjoy the benefits of primary TKA following medical and surgical optimization.
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Affiliation(s)
- Sarag Abhari
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY, USA
| | - Evan B. Rhea
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY, USA
| | | | | | | | - Arthur L. Malkani
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY, USA
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Dale H, Fenstad AM, Hallan G, Overgaard S, Pedersen AB, Hailer NP, Kärrholm J, Rolfson O, Eskelinen A, Mäkelä KT, Furnes O. Increasing risk of revision due to infection after primary total hip arthroplasty: results from the Nordic Arthroplasty Register Association. Acta Orthop 2023; 94:307-315. [PMID: 37378447 DOI: 10.2340/17453674.2023.13648] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 09/22/2022] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND AND PURPOSE The incidence of periprosthetic joint infection after total hip arthroplasty (THA) may be increasing. We performed time-trend analyses of risk, rates, and timing of revision due to infection after primary THAs in the Nordic countries from the period 2004-2018. PATIENTS AND METHODS 569,463 primary THAs reported to the Nordic Arthroplasty Register Association from 2004 to 2018 were studied. Absolute risk estimates were calculated by Kaplan-Meier and cumulative incidence function methods, whereas adjusted hazard ratios (aHR) were assessed by Cox regression with the first revision due to infection after primary THA as primary endpoint. In addition, we explored changes in the time span from primary THA to revision due to infection. RESULTS 5,653 (1.0%) primary THAs were revised due to infection during a median follow-up time of 5.4 (IQR 2.5-8.9) years after surgery. Compared with the period 2004-2008, the aHRs for revision were 1.4 (95% confidence interval [CI] 1.3-1.5) for 2009-2013, and 1.9 (CI 1.7-2.0) for 2014-2018. The absolute 5-year rates of revision due to infection were 0.7% (CI 0.7-0.7), 1.0% (CI 0.9-1.0), and 1.2% (CI 1.2-1.3) for the 3 time periods respectively. We found changes in the time span from primary THA to revision due to infection. Compared with 2004-2008, the aHR for revision within 30 days after THA was 2.5 (CI 2.1-2.9) for 2009-2013, and 3.4 (CI 3.0-3.9) for 2013-2018. The aHR for revision within 31-90 days after THA was 1.5 (CI 1.3-1.9) for 2009-2013, and 2.5 (CI 2.1-3.0) for 2013-2018, compared with 2004-2008. CONCLUSION The risk of revision due to infection after primary THA almost doubled, both in absolute cumulative incidence and in relative risk, throughout the period 2004-2018. This increase was mainly due to an increased risk of revision within 90 days of THA. This may reflect a "true" increase (i.e., frailer patients or more use of uncemented implants) and/or an "apparent" increase (i.e., improved diagnostics, changed revision strategy, or completeness of reporting) in incidence of periprosthetic joint infection. It is not possible to disclose such changes in the present study, and this warrants further research.
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Affiliation(s)
- Håvard Dale
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway.
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway
| | - Søren Overgaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg, Denmark; The Danish Hip Arthroplasty Register, Aarhus, Denmark
| | - Alma B Pedersen
- The Danish Hip Arthroplasty Register, Aarhus, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Nils P Hailer
- Section of Orthopaedics, Department of Surgical Sciences, Uppsala University Hospital, Sweden; The Swedish Arthroplasty Register, Gothenburg, Sweden
| | - Johan Kärrholm
- The Swedish Arthroplasty Register, Gothenburg, Sweden; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Ola Rolfson
- The Swedish Arthroplasty Register, Gothenburg, Sweden; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, and Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland; The Finnish Arthroplasty Register, Helsinki, Finland
| | - Keijo T Mäkelä
- The Finnish Arthroplasty Register, Helsinki, Finland; Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku, Finland
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Norway
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Jaqueto PA, Sabbag IC, Silva LPDA, Nunes LFB, Mattos CADE, Leandro-Merhi VA. INVERSE RELATIONSHIP BETWEEN PLASMA PROTEINS AND SATISFACTORY SURGICAL WOUNDS OUTCOME. Acta Ortop Bras 2023; 31:e263313. [PMID: 37323150 PMCID: PMC10263440 DOI: 10.1590/1413-785220233102e263313] [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] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/05/2022] [Indexed: 06/17/2023]
Abstract
Objective This study investigated the factors associated with satisfactory early postoperative wound conditions. Method A prospective study was conducted with patients (n=179) submitted to osteosynthesis in general, in a hospital orthopedics service. In the preoperative period, patients underwent laboratory exams and the surgical indications were based on the type of fracture and the patient's clinical conditions. In the postoperative period, patients were evaluated based on the presence of complications and considering their surgical wounds. Chi-square, Fisher, Mann-Whitney, and Kruskal-Wallis tests were used in the analysis. To identify the factors associated with wound condition, univariate and multiple logistic regression analysis was used. Results In the univariate analysis, each transferring unit reduction increased the chance of satisfactory outcome by 1.1% (p=0.0306; OR= 0.989 (1.011); 95%CI= 0.978;0.999; 1.001;1.023). The presence of SAH increased 2.7 fold the chance of satisfactory outcome (p=0.0424; OR= 2,667; 95%CI= 1,034;6,877). Hip fracture increased 2.6 fold the chance of satisfactory outcome (p=0.0272; OR=2.593; IC95%=1.113; 6.039). And the absence of a compound fracture increased 5.5 fold the chance of satisfactory wound outcome (p=0.0004; OR=5,493; 95%CI=2,132;14,149). In the multiple analysis, patients with non compound fractures were 9.7 times more likely to experience a satisfactory outcome when compared to patients with compound fractures (p=0.0014; OR=9,687; 95%CI= 2,399; 39,125). Conclusion There was an inverse relationship between plasma proteins levels and satisfactory surgical wounds outcome. Only exposure remained associated with wound conditions. Level Of Evidence: II, Prospective Study.
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Affiliation(s)
- Pedro Augusto Jaqueto
- . Pontifícia Universidade Católica de Campinas (PUC-Campinas), Postgraduated Program in Health Sciences, Campinas, SP, Brazil
| | | | | | | | | | - Vânia Aparecida Leandro-Merhi
- . Pontifícia Universidade Católica de Campinas (PUC-Campinas), Postgraduated Program in Health Sciences, Campinas, SP, Brazil
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Diaz Dilernia F, Blanchard T, Vasarhelyi E, Lanting B, Howard J. Minimum 2 Year Outcomes of All-Polyethylene Tibial Components in Patients who have Body Mass Index of 35 or Greater. J Arthroplasty 2023; 38:S157-S163. [PMID: 37019318 DOI: 10.1016/j.arth.2023.03.078] [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: 11/14/2022] [Revised: 03/26/2023] [Accepted: 03/26/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Several studies have reported negative results after total knee arthroplasty (TKA) in obese patients. This study aims to analyze the minimum 2 year outcomes in patients who have a body mass index (BMI) ˃35 undergoing cemented TKA using an all-polyethylene tibial component (APTC) at a minimum of two years of follow-up. METHODS We retrospectively studied 163 obese patients (192 TKAs) who underwent a primary cemented TKA using an APTC comparing the outcomes of 96 TKA patients who had a BMI ˃35 to 39.9 (group A) with 96 patients who a TKA and a BMI ≥ 40 (group B). Median follow-up of groups A and B was 3.8 years and 3.5 years respectively (P=0.02). Multiple regression analyses were performed to evaluate independent risk factors associated with complications. Kaplan-Meier survival curves were estimated, defining failure as the need for any further femoral or tibial revision surgery with implant removal, irrespective of the reason. RESULTS There was no significant difference at the latest follow-up patient reported outcomes between both groups. Survivorship, as defined by revision for any reason, was 99% for group A and 99% for group B (P=1.00). There was one aseptic tibial failure in group A, and one septic failure in group B. Multiple regression analyses showed no significant associations between age (Odds Ratio [OR]= 1.00; P=0.98; 95% Confidence Interval (CI)= 0.93 to 1.08), sex (OR=1.38; P=0.70; 95% CI=0.26 to 7.25), BMI (OR=1.00; P=0.95; 95% CI=0.87 to 1.16), and complication rate. CONCLUSIONS At a median 3.7-year follow-up, the use of an APTC provided excellent outcomes and survivorship in patients who had Class 2 and Class 3 obesity.
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Affiliation(s)
- Fernando Diaz Dilernia
- Division of Orthopedic Surgery, London Health Sciences Centre, Western University, University Hospital, 339 Windermere Road, London, Ontario, Canada, N6A 5A5
| | - Trevor Blanchard
- Division of Orthopedic Surgery, London Health Sciences Centre, Western University, University Hospital, 339 Windermere Road, London, Ontario, Canada, N6A 5A5
| | - Edward Vasarhelyi
- Division of Orthopedic Surgery, London Health Sciences Centre, Western University, University Hospital, 339 Windermere Road, London, Ontario, Canada, N6A 5A5
| | - Brent Lanting
- Division of Orthopedic Surgery, London Health Sciences Centre, Western University, University Hospital, 339 Windermere Road, London, Ontario, Canada, N6A 5A5
| | - James Howard
- Division of Orthopedic Surgery, London Health Sciences Centre, Western University, University Hospital, 339 Windermere Road, London, Ontario, Canada, N6A 5A5.
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Baker HP, Seidel H, Vatti L, Weaver D, Wallace SS, Scott BL. Concurrent Hardware Removal is Associated With Increased Odds of Infection Following Conversion Total Knee Arthroplasty. J Arthroplasty 2023; 38:680-684.e1. [PMID: 36307051 DOI: 10.1016/j.arth.2022.10.029] [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: 08/16/2022] [Revised: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The optimal timing of removal of periarticular implants prior to conversion total knee arthroplasty (TKA) remains to be determined. The purpose of this study was to compare infection rates in conversion TKA when hardware removal was performed in either a staged or concurrent manner. METHODS We performed a retrospective study using a national insurance claims database of patients who underwent removal of hardware on the same day or within 1 year before their TKA. A total of 16,099 patients met the criteria. After matching, both final cohorts consisted of 4,502 patients. The 90-day and 1-year rates of prosthetic joint infection were calculated. RESULTS The rates of infection were 1.64% and 3.00% in the staged group and 2.62% and 3.95% in the concurrent group at 90 days and 1 year postoperatively, respectively (P = .001, P = .01). Logistic regression analyses demonstrated that patients who had hardware removal greater than 3 months prior to TKA had significantly lower odds of infection at 1-year postop (Odds Ratio 0.61 95% Confidence Interval 0.45-0.84; P = .003). CONCLUSION Removal of hardware performed concurrently or within 3 months of a TKA is associated with increased odds of prosthetic joint infection at 1 year postoperatively. Surgeons should consider removing periarticular hardware prior to TKA when possible.
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Affiliation(s)
- Hayden P Baker
- The University of Chicago, Department of Orthopaedic Surgery, Chicago, Illinois
| | - Henry Seidel
- The University of Chicago, Department of Orthopaedic Surgery, Chicago, Illinois
| | - Lohith Vatti
- The University of Chicago, Department of Orthopaedic Surgery, Chicago, Illinois
| | - Douglas Weaver
- The University of Chicago, Department of Orthopaedic Surgery, Chicago, Illinois
| | - Sara S Wallace
- The University of Chicago, Department of Orthopaedic Surgery, Chicago, Illinois
| | - Bryan L Scott
- Massachusetts General Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts
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22
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Heimroth J, Neufeld EV, Sodhi N, Walden T, Willinger ML, Boraiah S. Relationship Between Preoperative Nutritional Status and Predicting Short-Term Complications Following Revision Total Hip Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00208-5. [PMID: 36878436 DOI: 10.1016/j.arth.2023.02.077] [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: 09/21/2022] [Revised: 02/22/2023] [Accepted: 02/26/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND The association between malnutrition and complications following primary total joint arthroplasty is well-delineated, however, nutritional status has yet to be explored specifically in revision total hip arthroplasty (THA). Therefore, our objective was to examine if a patient's nutritional status based on body mass index, diabetic status, and serum albumin predicted complications following a revision THA. METHODS A retrospective national database review identified 12,249 patients who underwent revision THA from 2006 to 2019. Patients were stratified based on body mass index (<18.5=underweight, 18.5 to 29.9=healthy/overweight, >30=obese), diagnosis of diabetes (no diabetes, insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM)), and preoperative serum albumin (<3.5=malnourished, >3.5=non-malnourished). Multivariate analyses was performed using Chi-squared tests and multiple logistic regressions. RESULTS In all groups including underweight (1.8%), healthy/overweight (53.7%), and obese (44.5%), those without diabetes were less likely to be malnourished (p<0.001), while those with IDDM had a higher rate of malnutrition (p<0.001). Underweight patients were significantly more malnourished compared to healthy/overweight or obese patients (p<0.05). Malnourished patients had an increased risk of wound dehiscence/surgical site infections (p<0.001), urinary tract infection (p<0.001), requiring a blood transfusion (p<0.001), sepsis (p<0.001), and septic shock (p<0.001). Malnourished patients also have worse postoperative pulmonary and renal function. CONCLUSIONS Patients who are underweight or have IDDM are more likely to be malnourished. The risk of complications within 30 days of surgery following revision THA significantly increases with malnutrition. This study shows the utility of screening underweight and IDDM patients for malnutrition prior to revision THA to minimize complications.
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Affiliation(s)
- Jamie Heimroth
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, New Hyde Park, NY.
| | - Eric V Neufeld
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, New Hyde Park, NY
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, New Hyde Park, NY
| | - Timothy Walden
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, New Hyde Park, NY
| | - Max L Willinger
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, New Hyde Park, NY
| | - Sreevathsa Boraiah
- Department of Orthopaedic Surgery, Northwell Health Long Island Jewish Medical Center/North Shore University Hospital, New Hyde Park, NY
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Luger M, de Vries M, Feldler S, Hipmair G, Gotterbarm T, Klasan A. A propensity score-matched analysis on the impact of patient and surgical factors on early periprosthetic joint infection in minimally invasive anterolateral and transgluteal total hip arthroplasty. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04756-z. [PMID: 36629904 PMCID: PMC10374686 DOI: 10.1007/s00402-022-04756-z] [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: 03/17/2022] [Accepted: 12/29/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Increased risk of periprosthetic joint infection (PJI) in minimally invasive (MIS) total hip arthroplasty (THA) is still debated. This study aimed to identify differences in surgical and patient-related risk factors for PJI between an MIS anterolateral approach and transgluteal-modified Hardinge approach. METHODS A retrospective cohort of 5315 THAs performed between 2006 and 2019 at a single institution was screened. Short stem THAs performed via an MIS anterolateral approach in the supine position and standard straight stem THAs performed via a transgluteal modified Hardinge approach were included. Propensity score matching was performed to control for selection bias. After matching, 1405 (34.3%) short stem THAs implanted via MIS anterolateral approach and 2687 (65.7%) straight stem THAs implanted via a transgluteal modified Hardinge approach were included. The risk of PJI due to patient-specific and surgical factors was retrospectively analyzed using chi-square test and multivariate regression analysis. RESULTS PJI occurred in 1.1% in both MIS anterolateral and transgluteal approach (p = 0.823). Multivariate regression showed an increased infection risk for patients with a BMI between 35 and 39.99 kg/m2 (OR 6.696; CI 1.799-24.923; p = 0.005), which could not be demonstrated for transgluteal approach (OR 0.900; CI 0.900-4.144; p = 0.93). A BMI ≥ 40 kg/m2 (OR 14.150; CI 2.416-82.879; p = 0.003) was detected as a risk factor for PJI only in anterolateral approach. Increased operation time ≥ 121 min showed a significantly increased risk for PJI in the general cohort (OR 6.989; CI1.286-37.972; p = 0.024). CONCLUSION Minimally invasive anterolateral and transgluteal THA show a comparable rate of early PJI within the first year of index surgery. A BMI of ≥ 35 kg/m2 was detected as a clear risk factor for infection in the anterolateral approach. Prolonged operation time ≥ 121 min increases the risk of PJI regardless of approach.
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Affiliation(s)
- Matthias Luger
- Department for Orthopedics and Traumatology, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020, Linz, Austria. .,Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria.
| | - Marcel de Vries
- Department for Orthopedics and Traumatology, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020, Linz, Austria.,Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Sandra Feldler
- Department for Orthopedics and Traumatology, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020, Linz, Austria.,Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Günter Hipmair
- Department for Orthopedics and Traumatology, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020, Linz, Austria.,Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Tobias Gotterbarm
- Department for Orthopedics and Traumatology, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020, Linz, Austria.,Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Antonio Klasan
- Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
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Volkmar AJ, Schultz JD, Rickert MM, Polkowski GG, Engstrom SM, Martin JR. Dexamethasone Is Associated With a Statistically Significant Increase in Postoperative Blood Glucose Levels Following Primary Total Knee Arthroplasty. Arthroplast Today 2023; 19:101076. [PMID: 36624747 DOI: 10.1016/j.artd.2022.101076] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/05/2022] [Accepted: 11/29/2022] [Indexed: 01/05/2023] Open
Abstract
Background Dexamethasone has the potential to cause a transient increase in blood glucose levels. Recent evidence has suggested the potential for a linearly increased risk of periprosthetic joint infection beginning at blood glucose levels of ≥115 mg/dL and an optimal cutoff of 137 mg/dL. We designed the following study to determine (1) what percentage of our patients had postoperative day 1 (POD1) glucose levels above 137 mg/dL and (2) if the administration of dexamethasone further increased this risk. Methods All primary total knee arthroplasties performed from 1998 to 2021 at our institution were identified and retrospectively reviewed. Patient demographics, dexamethasone administration, and perioperative glucose levels were recorded. Outcomes included POD1 glucose levels, infection rate, and all-cause reoperations and revisions. Results The average POD1 glucose level for the entire cohort (n = 5353) was 138.7 mg/dL. The percentage of patients with a glucose level of 137 mg/dL or higher was significantly greater in patients that received dexamethasone (55.2% vs 37.7%; P < .0001). Significantly higher glucose levels were seen with dexamethasone administration in both diabetic (187.7 vs 173.4 mg/dL; P < .0001) and nondiabetic patients (137.7 vs 128.0 mg/dL; P < .0001). Dexamethasone use was associated with a nonstatistically significant increase in infection rates (1.7% vs 1.0%; P = .177). Conclusions Administration of dexamethasone is associated with a statistically significant increase in POD1 glucose levels, regardless of diabetic status. Dexamethasone use should continue to be closely monitored given the potential risks of elevated postoperative glucose levels and the potential for periprosthetic infection.
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25
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Hagerty MP, Walker-Santiago R, Tegethoff JD, Stronach BM, Keeney JA. Tobacco Use Is Associated with More Severe Adverse Outcomes Than Morbid Obesity after Aseptic Revision TKA. J Knee Surg 2023; 36:201-207. [PMID: 34225364 DOI: 10.1055/s-0041-1731459] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/07/2023]
Abstract
The association of morbid obesity with increased revision total knee arthroplasty (rTKA) complications is potentially confounded by concurrent risk factors. This study was performed to evaluate whether morbid obesity was more strongly associated with adverse aseptic rTKA outcomes than diabetes or tobacco use history-when present as a solitary major risk factor. Demographic characteristics, surgical indications, and adverse outcomes (reoperation, revision, infection, and amputation) were compared between 270 index aseptic rTKA performed for patients with morbid obesity (n = 73), diabetes (n = 72), or tobacco use (n = 125) and 239 "healthy" controls without these risk factors at a mean 75.7 (range: 24-111) months. There was no difference in 2-year reoperation rate (17.8 vs. 17.6%, p = 1.0) or component revision rate (8.2 vs. 8.4%) between morbidly obese and healthy patients. However, higher reoperation rates were noted in patients with diabetes (p = 0.02) and tobacco use history (p < 0.01), including higher infection (p < 0.05) and above knee amputation (p < 0.01) rates in patients with tobacco use history. Multivariate analysis retained an independent association between smoking history and amputation risk (odds ratio: 7.4, 95% confidence interval: 1.7-55.2, p < 0.01). Morbid obesity was not associated with an increased risk of reoperation or component revision compared with healthy patients undergoing aseptic revision. Tobacco use was associated with increased reoperation and above knee amputation. Additional study will be beneficial to determine whether risk reduction efforts are effective in mitigating postoperative complication risks.
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Affiliation(s)
| | - Rafael Walker-Santiago
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri School of Medicine, Columbia, Missouri
| | | | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - James A Keeney
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri School of Medicine, Columbia, Missouri
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Walocha D, Bogdan P, Gordon AM, Magruder ML, Conway CA, Razi AE, Choueka J. Risk factors for the development of a peri-prosthetic joint infection up to 2 Years following primary reverse shoulder arthroplasty. J Orthop 2023; 35:69-73. [PMID: 36411844 PMCID: PMC9674881 DOI: 10.1016/j.jor.2022.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 06/06/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022] Open
Abstract
Background Reverse shoulder arthroplasty (RSA) has become commonly used to treat glenohumeral osteoarthritis (GHOA), of which complications such as peri-prosthetic joint infections (PJIs) may develop. The objective of this study was to compare patient demographics of those who did and did not develop PJIs within 2 years after primary RSA for GHOA and identify risk factors for this sequela. Methods A nationwide database was queried from 2005 to 2014 for Medicare patients treated with primary RSA (International Classification of Disease (ICD-9) procedural code 81.88) for GHOA. Patients who developed PJIs within 2-years of primary RSA defined the study group, whereas those who were devoid of infections represented the comparison group. Our study consisted of 51,824 patients, of which 879 (1.69%) developed a PJI. Patient demographics comprising the Elixhauser comorbidity index (ECI) were compared using Chi-Square analyses. Multivariable logistic regression models were used to compute the odds-ratios (OR) of patient-specific factors associated with acquiring a PJI within 2 years after RSA. P values less than 0.002 were significant. Results Patients developing a PJI had higher mean ECI (8 vs. 6; p < 0.0001). The greatest risk factors for developing PJIs within 2-years following RSA were male sex (OR: 2.10, 95%CI: 1.81-2.43, p < 0.0001), pathologic weight loss (OR: 1.78, 95%CI: 1.45-2.17, p < 0.0001), iron deficiency anemia (OR: 1.75, 95%CI: 1.49-2.06, p < 0.0001), morbid obesity (OR: 1.52, 95%CI: 1.21-1.88, p = 0.0001), rheumatoid arthritis (OR: 1.32, 95%CI: 1.13-1.54, p = 0.0003), arrhythmias (OR: 1.26, 95%CI 1.09-1.46, p = 0.001), and depressive disorders (OR: 1.23, 95%CI 1.06-1.43, p = 0.001). Conclusions The greatest risk factors for PJIs within 2 years of primary RSA included male sex; additional modifiable risk factors included iron deficiency anemia, pathologic weight loss, and obesity. Preoperative screening can help to identify modifiable risk factors and alter management for high-risk patients to potentially minimize PJIs.
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Affiliation(s)
- Daniel Walocha
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
- State University of New York (SUNY) Downstate, College of Medicine, Brooklyn, NY, USA
| | - Paulina Bogdan
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
- State University of New York (SUNY) Downstate, College of Medicine, Brooklyn, NY, USA
| | - Adam M. Gordon
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Matthew L. Magruder
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Charles A. Conway
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Afshin E. Razi
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Jack Choueka
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
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Muacevic A, Adler JR, Albqami SN, Barri A, Albatly M, Arafah O. Use of Antibiotic Lavage in Total Knee Replacement to Prevent Postoperative Infection. Cureus 2022; 14:e32727. [PMID: 36686072 PMCID: PMC9850443 DOI: 10.7759/cureus.32727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To determine the effectiveness of using antibiotic lavage in preventing postoperative infections in total knee replacement (TKR) patients. Methods Data on all patients who underwent TKR, either primary or secondary, during the period from May 2015 to April 2019 were collected. Many factors (both patient-related and surgery-related) that can increase the risk of surgical site infection (SSI) were taken into consideration to eliminate confounding factors. Results A total of 685 patients were identified; out of those, 232 patients received intraoperative antibiotic lavage and 453 did not. We noted that out of all 13 patients who developed SSI, only one patient (7.7%) had received antibiotic lavage, while the other 12 (92.3%) patients did not receive antibiotic lavage. However, the difference was not statistically significant (p=0.078). Conclusion Using intraoperative vancomycin lavage was associated with a decrease in the incidence of SSI post-TKR, but the difference was not statistically significant. However, more studies are needed in this area.
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Huang J, Lin S, Bai X, Li W, Zhang R, Miao C, Zhang X, Huang Z, Chen M, Weng S. Decorated Polyetheretherketone Implants with Antibacterial and Antioxidative Effects through Layer-by-Layer Nanoarchitectonics Facilitate Diabetic Bone Integration with Infection. ACS Appl Mater Interfaces 2022; 14:52579-52598. [PMID: 36380598 DOI: 10.1021/acsami.2c11574] [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] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Patients suffering diabetic bone defects still need some new and effective strategies to achieve enhanced prognostic effects. Although medical implants are the common treatment of bone defects, the excessive oxidative stress and high risk of bacterial infection in diabetes mellitus lead to a higher risk of implant failure. To improve the healing ability of diabetic bone defects, herein, polyetheretherketone (PEEK) was modified through a developed layer-by-layer (LBL) construction strategy to obtain multifunctional PEEK (SP@(TA-GS/PF)*3) by the assembly of tannic acid (TA), gentamicin sulfate (GS) and Pluronic F127 (PF127) on the basis of prepared porous PEEK through sulfonation (SPEEK). The prepared SP@(TA-GS/PF)*3 exhibited sustained antimicrobial activity and enhanced the differentiation of osteoblast (MC3T3-E1) for needed osteogenesis. Moreover, SP@(TA-GS/PF)*3 scavenged excessive oxidative stress to promote the growth of H2O2 damaged HUVEC with enhanced secretion of VEGF for neovascularization. In addition, the remarkable in vivo outcomes of angiogenesis and osseointegration were revealed by the subcutaneous implant model and bone tissue implant model in diabetic rats, respectively. The in vitro and in vivo results demonstrated that modified PEEK with multifunction can be an attractive tool for enhancing bone integration under diabetic conditions, underpinning the clinical application potential of modified implants for diabetic osseointegration.
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Affiliation(s)
- Jiyue Huang
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Shishui Lin
- Department of Orthopedic Surgery, Shengli Clinical Medical College of Fujian Medical University, Jinshan Hospital of Fujian Provincial Hospital, Fuzhou, 350001, China
| | - Xinxin Bai
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Weixiang Li
- Department of Pharmaceutical Analysis, School of Pharmacy, Fujian Medical University, Fuzhou, 350122, China
| | - Rui Zhang
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Chenfang Miao
- Department of Pharmaceutical Analysis, School of Pharmacy, Fujian Medical University, Fuzhou, 350122, China
| | - Xintian Zhang
- Department of Pharmaceutical Analysis, School of Pharmacy, Fujian Medical University, Fuzhou, 350122, China
| | - Zhengjun Huang
- Department of Pharmaceutical Analysis, School of Pharmacy, Fujian Medical University, Fuzhou, 350122, China
| | - Min Chen
- Department of Orthopedic Surgery, Fujian Medical University Union Hospital, Fuzhou, 350001, China
| | - Shaohuang Weng
- Department of Pharmaceutical Analysis, School of Pharmacy, Fujian Medical University, Fuzhou, 350122, China
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Lin YC, Lin YH, Chou JH, Lo YT, Chang CH, Lee SH, Lin SH. Higher reinfection rate after two-stage revision arthroplasty in patients with refractory diabetes mellitus: a retrospective analysis with a minimum ten-year follow up. BMC Musculoskelet Disord 2022; 23:990. [PMID: 36397029 PMCID: PMC9670390 DOI: 10.1186/s12891-022-05964-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background Treatment protocols for two-stage revision arthroplasty with diabetes mellitus (DM) have not yet been established. The control of glycated hemoglobin (HbA1c) in two-stage revision arthroplasty is still debated. This study aimed to clarify the importance of preoperative HbA1c levels before each stage of revision arthroplasty and to analyze the risk factors for reinfection. Methods Five hundred eighty-eight patients suffered from first-time PJI and was treated in our institute from January 1994 to December 2010 were reviewed. The mean follow-up time was 13.8 (range, 10.2–24.8) years. Patients underwent two-stage revision arthroplasty with DM at presentation were included. The endpoint of the study was reinfection of the revision arthroplasty. Demographic, survivorship, and surgical variables were also analyzed. Results Eighty-eight patients were identified and grouped by HbA1c level before the first stage surgery: Groups 1 and 2 had HbA1c levels < 7% and ≥ 7%, respectively. Reinfection was identified in 4.55% (2/44) and 18.18% (8/44) of the patients in Groups 1 and 2, respectively. Survivorship analysis revealed correction of the HbA1c before the final stage of revision arthroplasty as an independent factor (p < 0.001). The identified risks for reinfection were HbA1c levels ≥ 7% before final-stage surgery, ≥ 3 stages of revision arthroplasty, and extended-spectrum beta-lactamase (ESBL)-Escherichia coli PJI. Conclusion The HbA1c level before the final stage of revision arthroplasty could affect staged revision arthroplasty outcomes. Therefore, the necessity of postponing the elective final-stage revision arthroplasty procedure for HbA1c control should be further investigated in the future.
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Wiznia DH, Jimenez R, Harrington M. Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Diabetes Mellitus Disparities. J Am Acad Orthop Surg 2022; 30:1017-22. [PMID: 34534181 DOI: 10.5435/JAAOS-D-21-00425] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/23/2021] [Indexed: 02/01/2023] Open
Abstract
This is one of a series of articles that focuses on maximizing access to total joint arthroplasty by providing preoperative optimization pathways to all patients to promote the best results and minimize postoperative complications. Because of inequities in health care, an optimization process that is not equipped to support the underserved can potentially worsen disparities in the utilization of arthroplasty. A staggering 10.5% of the American population lives with diabetes mellitus. Diabetes prevalence is 17% higher in rural communities compared with urban communities. Rates of diabetes are higher in African American, Hispanic, and American Indian populations. Barriers to health care are higher in rural areas and for vulnerable communities, positioning the management of diabetes at the intersection of risk. Poor glycemic control is a predictor of periprosthetic joint infection. Optimization tools include assessing for food security, knowledge of a social safety net and community resources, patient diabetic literacy, and relationships with primary care providers to ensure continuous check-ins as well as partnering with specialty endocrine diabetic clinics. Several strategic recommendations, such as healthcare navigators and promotores (Latinx population), are made to enable and empower, such as continuous glucose monitoring, the preoperative patient to reach a safe preoperative optimization goal for their TJA surgery.
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Yu J, Wang M, Shen H. Intermuscular Fat, But Not Subcutaneous Fat, Correlated With Major Complications After Primary Total Hip Arthroplasty. Acad Radiol 2022. [DOI: 10.1016/j.acra.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 11/22/2022]
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Wu HH, Samuel LT, Silvestre J, Acuña AJ, Nelson CL, Israelite CL, Kamath AF. The accuracy of patient-reported weight prior to total joint arthroplasty and arthroscopy of the lower extremity. Arch Orthop Trauma Surg 2022; 142:2381-2388. [PMID: 34331581 DOI: 10.1007/s00402-021-04095-5] [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: 04/30/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The accuracy of preoperative patient-reported weight was never evaluated in patients undergoing lower extremity procedures. The purpose of this study was to: (1) compare the disparity between patient-reported and measured weights in patients undergoing lower extremity total joint arthroplasty (LE-TJA) and arthroscopy; and (2) investigate the association between patient-specific factors (patient age, BMI, zip code, and psychiatric comorbidities) and the accuracy of patient-reported weight. METHODS Preoperative self-reported weights were retrospectively compared to measured weights in 400 LE-TJA and 85 control arthroscopy patients. The difference between reported and measured weights was calculated. Additionally, the percent of accurate reporting within 0.5, 1, and 5 kg ranges of the measured weight was calculated. Outcomes were compared between surgical modalities as well as between patient-specific factors. RESULTS There was low disparity (p = 0.838) between patient-reported and measured weights among LE-TJA (mean difference 0.18 ± 3.63 kg; p = 0.446) and that of arthroscopy (0.27 ± 4.08 kg; p = 0.129) patients. Additionally, LE-TJA patients were equally likely to report weights accurately within 0.5 kg of the measured weight (74% vs. 71.76%; p = 0.908). LE-TJA and arthroscopy patients had similar reporting accuracy within 1 and 5 kg of the measured weights (p > 0.05). CONCLUSION Preoperative patient-reported weights demonstrated acceptable accuracy in both LE-TJA and lower extremity arthroscopic orthopaedic patient populations making it a potentially reliable parameter of preoperative assessment.
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Affiliation(s)
- Hao-Hua Wu
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Linsen T Samuel
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Jason Silvestre
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Alexander J Acuña
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA
| | - Charles L Nelson
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Craig L Israelite
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Center for Hip Preservation, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Mail code A41, Cleveland, OH, 44195, USA.
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Mederake M, Hofmann UK, Benda S, Schuster P, Fink B. Diagnostic Value of CRP and Serum WBC Count during Septic Two-Stage Revision of Total Hip Arthroplasties. Antibiotics (Basel) 2022; 11:1098. [PMID: 36009968 PMCID: PMC9404910 DOI: 10.3390/antibiotics11081098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/07/2022] [Accepted: 08/10/2022] [Indexed: 11/30/2022] Open
Abstract
The diagnostic value of C-reactive protein (CRP) and the serum white blood cell (WBC) count is still barely defined for decision making during septic two-stage revision surgery of hip arthroplasty. We, therefore, compared these values between stages as well as between the groups without and with reinfection in 117 patients. A total of 106 patients were reinfection-free (91%). The median follow-up was 51 months. With a ΔCRP of −10 mg/L and a ΔWBC count of −1000/µL, a significant decrease between stages (p = 0.001) could be observed. When comparing the CRP and WBC count values between groups, however, no significant difference was found at stage one, stage two and even the difference between these two time points (reinfection-free ΔCRP of −11 mg/L and ΔWBC count of −1000/µL vs. reinfection ΔCRP of −5 mg/L (p = 0.131) and ΔWBC count of −1100/µL) (p = 0.424). The diagnostic value was poor for the calculated parameters (area under the curve (AUC) 0.5–0.6). The courses of the mean CRP values of both groups were similar. We conclude that the CRP and WBC count are not helpful to guide the decision making in individual cases.
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Hussein IH, Zalikha AK, Crespi Z, Tuluca A, Arapovic AE, El-othmani MM. The Impact of Morbid Obesity on In-hospital Outcomes after Revision Total Hip Arthroplasty: An Analysis of the National Inpatient Sample. J Am Acad Orthop Surg Glob Res Rev 2022; 6. [PMID: 35944109 PMCID: PMC9359813 DOI: 10.5435/jaaosglobal-d-22-00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/18/2022] [Indexed: 11/18/2022]
Abstract
Introduction: There remain limited data on the effect of obesity on in-hospital outcomes after revision total hip arthroplasty (rTHA). Methods: Discharge data from the National Inpatient Sample were used to identify patients undergoing rTHA from 2006 to 2015. Propensity score analysis was done to analyze the effects of obesity and morbid obesity on in-hospital economic and complication outcomes after rTHA. Results: The estimated 460,297 rTHAs were done during the study period. Obese patients were more likely to suffer from any complication than not obese patients (41.44% versus 39.41%, P = 0.0085), and morbidly obese patients were more likely to suffer from any complication than obese patients (47.22% versus 41.44%, P < 0.0001). Obesity was associated with increased risk of postoperative anemia compared with not obese patients, while morbid obesity was associated with increased risk of postoperative anemia, hematoma/seroma, wound dehiscence, and postoperative infection (P < 0.05). Morbidly obese patients also had a significantly greater average length of stay (6.40 days) than obese (5.23 days) and not obese (5.37 days) patients (P < 0.0001). Discussion: Although both obesity and morbid obesity are associated with higher risk of in-hospital postoperative complications after rTHA, morbid obesity is a larger risk factor and is associated with a longer length of stay.
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MacMahon A, Rao SS, Chaudhry YP, Hasan SA, Epstein JA, Hegde V, Valaik DJ, Oni JK, Sterling RS, Khanuja HS. Preoperative Patient Optimization in Total Joint Arthroplasty-The Paradigm Shift from Preoperative Clearance: A Narrative Review. HSS J 2022; 18:418-427. [PMID: 35846267 PMCID: PMC9247589 DOI: 10.1177/15563316211030923] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 02/07/2023]
Abstract
Background: Total joint arthroplasty (TJA) is one of the most common procedures performed in the United States. Outcomes of this elective procedure may be improved via preoperative optimization of modifiable risk factors. Purposes: We sought to summarize the literature on the clinical implications of preoperative risk factors in TJA and to develop recommendations regarding preoperative optimization of these risk factors. Methods: We searched PubMed in August 2019 with an update in September 2020 for English-language, peer-reviewed publications assessing the influence on outcomes in total hip and knee replacement of 7 preoperative risk factors-obesity, malnutrition, hypoalbuminemia, diabetes, anemia, smoking, and opioid use-and recommendations to mitigate them. Results: Sixty-nine studies were identified, including 3 randomized controlled trials, 8 prospective cohort studies, 42 retrospective studies, 6 systematic reviews, 3 narrative reviews, and 7 consensus guidelines. These studies described worse outcomes associated with these 7 risk factors, including increased rates of in-hospital complications, transfusions, periprosthetic joint infections, revisions, and deaths. Recommendations for strategies to screen and address these risk factors are provided. Conclusions: Risk factors can be optimized, with evidence suggesting the following thresholds prior to surgery: a body mass index <40 kg/m2, serum albumin ≥3.5 g/dL, hemoglobin A1C ≤7.5%, hemoglobin >12.0 g/dL in women and >13.0 g/dL in men, and smoking cessation and ≥50% decrease in opioid use by 4 weeks prior to surgery. Surgery should be delayed until these risk factors are adequately optimized.
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Affiliation(s)
- Aoife MacMahon
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandesh S. Rao
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yash P. Chaudhry
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Syed A. Hasan
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremy A. Epstein
- Department of Medicine, Johns Hopkins
University School of Medicine, Baltimore, MD, USA
| | - Vishal Hegde
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel J. Valaik
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julius K. Oni
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S. Sterling
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harpal S. Khanuja
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA,Department of Orthopaedic Surgery,
Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,Harpal S. Khanuja, MD, Department of
Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave.,
Baltimore, MD 21224-2780, USA.
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Ashkenazi I, Morgan S, Graif N, Shaked O, Shohat N, Khoury A, Snir N, Warschawski Y. Increased postoperative glycemic variability is associated with increased mortality in diabetic patients undergoing hip arthroplasty for hip fracture. Arch Orthop Trauma Surg 2022; 143:2773-2779. [PMID: 35900587 DOI: 10.1007/s00402-022-04558-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/04/2022] [Accepted: 07/17/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Increased glycemic variability (GV) during hospitalization has been associated with increased rates of surgical site and periprosthetic joint infections (PJI) following elective total joint arthroplasty. Uncertainty exists surrounding GV as a predictor for complications in urgent arthroplasty cases following hip fractures. In this study, we evaluated the association between GV and postoperative complications in diabetic patients undergoing total hip arthroplasty (THA) and hemiarthroplasty (HA) for hip fractures. METHODS We analyzed data on 2421 consecutive patients who underwent THA or HA at our institution from 2011 to 2020. Patients with a known diagnosis of diabetes mellitus who had a minimum of three postoperative glucose values taken within the first week after surgery were included. GV was assessed using a coefficient of variation. Outcomes included short- and long-term mortality, reoperations, prosthetic joint infection (PJI) requiring revision and readmissions for any cause. RESULTS The final cohort consisted of 482 patients (294 females, 188 males). Higher GV was associated with an increased 90-day mortality (p = 0.017). GV was not associated with 30-day mortality (p = 0.45), readmissions of any cause at 30 or 90 days (p = 0.99, p = 0.91, respectively), reoperation of any cause (p = 0.91) or PJI requiring revision surgery (p = 0.42). CONCLUSIONS Higher GV in the postoperative period is associated with increased rates of mortality in diabetic patients following THA and HA for hip fractures. Efforts should be made to monitor and control glucose variability in the postoperative period.
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Affiliation(s)
- Itay Ashkenazi
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Samuel Morgan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Graif
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Or Shaked
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Noam Shohat
- Department of Orthopedics, Shamir Medical Center, Beer-Yaakov, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Amal Khoury
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Nimrod Snir
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Yaniv Warschawski
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel.
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Lygrisse KA, Teo G, Singh V, Muthusamy N, Schwarzkopf R, William L. Comparison of silver-embedded occlusive dressings and negative pressure wound therapy following total joint arthroplasty in high BMI patients: a randomized controlled trial. Arch Orthop Trauma Surg 2022; 143:2989-2995. [PMID: 35779102 DOI: 10.1007/s00402-022-04530-1] [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: 04/19/2022] [Accepted: 06/16/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION High body mass index (BMI) and wound drainage following total joint arthroplasty (TJA) can lead to wound healing complications and periprosthetic joint infection. Silver-embedded occlusive dressings and negative pressure wound therapy (NPWT) have been shown to reduce these complications. The purpose of this prospective trial was to compare the effect of silver-embedded dressings and NPWT on wound complications in patients with BMI ≥ 35 m/kg2 undergoing TJA. METHODS We conducted a randomized control trial of patients who had a BMI > 35 m/kg2 and were undergoing primary TJA between October 2017 and February 2020. Patients who underwent revision surgery, or those with an active infection, previous scar, history of wound healing complications, post-traumatic degenerative joint disease with hardware, or inflammatory arthritis were excluded. Patients were randomized to receive either a silver-embedded occlusive dressing (control) or NPWT. Frequency distributions, means, and standard deviations were used to describe patient demographics, postoperative complications, 90-day readmissions, and reoperations. T-test and chi-squared tests were used to test for significant differences between continuous and categorical variables, respectively. RESULTS Two hundred-thirty patients with 3-month follow-up were included. One-hundred-fifteen patients received the control and 115 patients received NPWT. There were six patients (5.2%) in the control group with wound complications (drainage: n = 5, non-healing wound: n = 1) and two patients (1.7%) in the NPWT with complications (drainage: n = 2). There were no 90-day readmissions in the control group versus two (1.8%) 90-day readmissions in the NPWT group. Finally, three patients (2.6%) in the control group underwent reoperations (irrigation and debridement [I&D], I&D with modular implant exchange, and implant revision), while none in the NPWT group had undergone reoperation. The two groups showed insignificant differences in wound complications (p = 0.28), 90-day readmissions (p = 0.50), and reoperations (p = 0.25). CONCLUSION Patients with BMI ≥ 35 m/kg2 undergoing TJA have no statistical difference in early wound complications, readmissions, or reoperations when treated with either silver-embedded dressings or NPWT.
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Affiliation(s)
- Katherine A Lygrisse
- Department of Orthopedic Surgery, Huntington Hospital, Zucker School of Medicine Hofstra/Northwell, 270 Park Ave, Huntington, NY, 11743, USA
| | - Greg Teo
- Department of Orthopedic Surgery, Hospital for Special Surgeries, 541 East 71st St, 7th Fl, New York, NY, 10021, USA
| | - Vivek Singh
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA
| | - Nishanth Muthusamy
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA.
- Department of Orthopedic Surgery, Division of Adult Reconstructive Surgery, NYU Langone Health, 301, East 17th Street, New York, NY, 10003, USA.
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA
| | - Long William
- Department of Orthopedic Surgery, Hospital for Special Surgeries, 541 East 71st St, 7th Fl, New York, NY, 10021, USA
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Carender CN, Glass NA, DeMik DE, Elkins JM, Brown TS, Bedard NA. Projected Prevalence of Obesity in Primary Total Knee Arthroplasty: How Big Will the Problem Get? J Arthroplasty 2022; 37:1289-95. [PMID: 35271971 DOI: 10.1016/j.arth.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/14/2022] [Accepted: 03/02/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Obesity is a well-established risk factor for complications following primary total knee arthroplasty (TKA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary TKA patients in the United States through 2029. METHODS Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27447 was used to identify primary TKA patients in NSQIP. Individuals were categorized according to body mass index (kg/m2) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029. RESULTS A total of 8,372,221 individuals were included (7,986,414 BRFSS, 385,807 NSQIP TKA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary TKA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary TKA from 60% to 64%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 69% of primary TKA will be obese/morbidly obese. CONCLUSION By 2029, we estimate ≥69% of primary TKA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow. LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
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Richard RD, Gaski GE, Farooq H, Wagner DJ, McKinley TO, Natoli RM. Risk factors for complications within 30 days of operatively fixed periprosthetic femur fractures. J Clin Orthop Trauma 2022; 31:101925. [PMID: 35799883 PMCID: PMC9253917 DOI: 10.1016/j.jcot.2022.101925] [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: 02/11/2022] [Revised: 04/25/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND With a rising number of periprosthetic femur fractures (PPFFs) each year, the primary objective of our study was to quantify risk factors that predict complications following operative treatment of PPFFs. METHODS A retrospective cohort study of 231 patients with a periprosthetic femur fracture was conducted at an Academic, Level 1 Trauma Center. The main outcome measurement of interest was complications, as defined by the ACS-NSQIP, within 30 days of surgery. RESULTS 56 patients had 96 complications. Bivariate analyses revealed ASA score, preoperative ambulatory status, length of stay, discharge disposition, time from admission to surgery, length of surgery, perioperative change in hemoglobin, Charlson comorbidity index, cerebral vascular accident/transient ischemic attack, chronic obstructive pulmonary disease, diabetes mellitus, and receipt of a blood transfusion were associated with development of a complication (p < 0.1). Multivariate logistic regression showed length of stay (OR 1.11, 95% CI 1.03-1.19; p = 0.006), receipt of a blood transfusion (OR 2.48, 95% CI 1.14-5.42; p = 0.02), and diabetes mellitus (OR 2.17, 95% CI 1.03-4.56; p = 0.04) remained independently predictive of complication. CONCLUSIONS Length of stay, receipt of a blood transfusion, and diabetes were associated with increased perioperative risk for developing a complication following operative treatment of periprosthetic femur fractures. Methods to decrease length of stay or transfusion rates may mitigate complication risk in these patients. LEVEL OF EVIDENCE Prognostic, Level III.
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Affiliation(s)
- Raveesh D. Richard
- Centura Orthopaedics & Spine, 9949 South Oswego Stree, Suite 200 Parker, CO, 80134, USA
| | - Greg E. Gaski
- Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Hassan Farooq
- Indiana University School of Medicine, Department of Orthopaedic Surgery, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA
| | - Daniel J. Wagner
- Indiana University School of Medicine, Department of Orthopaedic Surgery, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA
| | - Todd O. McKinley
- Indiana University School of Medicine, Department of Orthopaedic Surgery, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA
| | - Roman M. Natoli
- Indiana University School of Medicine, Department of Orthopaedic Surgery, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA,Corresponding author. Department of Orthopaedic Surgery Indiana University School of Medicine, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA.
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40
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Zhuang T, Shapiro LM, Amanatullah DF, Maloney WJ, Kamal RN. Costs and benefits of routine hemoglobin A1c screening prior to total joint arthroplasty: a cost-benefit analysis. Current Orthopaedic Practice 2022; Publish Ahead of Print. [DOI: 10.1097/bco.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Carender CN, Glass NA, DeMik DE, Elkins JM, Brown TS, Bedard NA. Projected Prevalence of Obesity in Primary Total Hip Arthroplasty: How Big Will the Problem Get? J Arthroplasty 2022; 37:874-879. [PMID: 35124192 DOI: 10.1016/j.arth.2022.01.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 12/01/2021] [Accepted: 01/26/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Obesity is associated with higher rates of adverse outcomes following primary total hip arthroplasty (THA). The purpose of this study is to utilize 3 national databases to develop projections of obesity within the general population and primary THA patients in the United States through 2029. METHODS Data from the National Surgical Quality Improvement Program (NSQIP), the Behavior Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey were queried for years 1999-2019. Current Procedural Terminology code 27130 was used to identify primary THA patients in NSQIP. Individuals were categorized according to body mass index (kg/m2) by year: normal weight (≤24.9); overweight (25.0-29.9); obese (30.0-39.9); and morbidly obese (≥40). Multinomial logistic regression was used to project categorical body mass index data for years 2020-2029. RESULTS A total of 8,222,013 individuals were included (7,986,414 BRFSS, 235,599 NSQIP THA). From 2011 to 2019, the prevalence of normal weight and overweight individuals declined in the general population (BRFSS) and in primary THA. Prevalence of obese/morbidly obese individuals increased in the general population from 31% to 36% and in primary THA from 42% to 49%. Projection models estimate that by 2029, 46% of the general population will be obese/morbidly obese and 55% of primary THA will be obese/morbidly obese. CONCLUSION By 2029, we estimate ≥55% of primary THA to be obese/morbidly obese. Increased resources dedicated to care pathways and research focused on improving outcomes in obese arthroplasty patients will be necessary as this population continues to grow. LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
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Affiliation(s)
- Christopher N Carender
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - David E DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Jacob M Elkins
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Timothy S Brown
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX
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Bui TI, Gill AL, Mooney RA, Gill SR. Modulation of Gut Microbiota Metabolism in Obesity-Related Type 2 Diabetes Reduces Osteomyelitis Severity. Microbiol Spectr 2022; 10:e0017022. [PMID: 35315698 PMCID: PMC9045376 DOI: 10.1128/spectrum.00170-22] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/03/2022] [Indexed: 12/01/2022] Open
Abstract
Staphylococcus aureus is an opportunistic pathogen causing osteomyelitis through hematogenous seeding or contamination of implants and open wounds following orthopedic surgeries. The severity of S. aureus-mediated osteomyelitis is enhanced in obesity-related type 2 diabetes (obesity/T2D) due to chronic inflammation impairing both adaptive and innate immunity. Obesity-induced inflammation is linked to gut dysbiosis, with modification of the gut microbiota by high-fiber diets leading to a reduction in the symptoms and complications of obesity/T2D. However, our understanding of the mechanisms by which modifications of the gut microbiota alter host infection responses is limited. To address this gap, we monitored tibial S. aureus infections in obese/T2D mice treated with the inulin-like fructan fiber oligofructose. Treatment with oligofructose significantly decreased S. aureus colonization and lowered proinflammatory signaling postinfection in obese/T2D mice, as observed by decreased circulating inflammatory cytokines (tumor necrosis factor-α [TNF-α]) and chemokines (interferon-γ-induced protein 10 kDa [IP-10], keratinocyte-derived chemokine [KC], monokine induced by interferon-γ [MIG], monocyte chemoattractant protein-1 [MCP-1], and regulated upon activation, normal T cell expressed and presumably secreted [RANTES]), indicating partial reduction in inflammation. Oligofructose markedly shifted diversity in the gut microbiota of obese/T2D mice, with notable increases in the anti-inflammatory bacterium Bifidobacterium pseudolongum. Analysis of the cecum and plasma metabolome suggested that polyamine production was increased, specifically spermine and spermidine. Oral administration of these polyamines to obese/T2D mice resulted in reduced infection severity similar to oligofructose supplementation, suggesting that polyamines can mediate the beneficial effects of fiber on osteomyelitis severity. These results demonstrate the contribution of gut microbiota metabolites to the control of bacterial infections distal to the gut and polyamines as an adjunct therapeutic for osteomyelitis in obesity/T2D. IMPORTANCE Individuals with obesity-related type 2 diabetes (obesity/T2D) are at a five times increased risk for invasive Staphylococcus aureus osteomyelitis (bone infection) following orthopedic surgeries. With increasing antibiotic resistance and limited discoveries of novel antibiotics, it is imperative that we explore other avenues for therapeutics. In this study, we demonstrated that the dietary fiber oligofructose markedly reduced osteomyelitis severity and hyperinflammation following acute prosthetic joint infections in obese/T2D mice. Reduced infection severity was associated with changes in gut microbiota composition and metabolism, as indicated by increased production of natural polyamines in the gut and circulating plasma. This work identifies a novel role for the gut microbiome in mediating control of bacterial infections and polyamines as beneficial metabolites involved in improving the obesity/T2D host response to osteomyelitis. Understanding the impact of polyamines on host immunity and mechanisms behind decreasing susceptibility to severe implant-associated osteomyelitis is crucial to improving treatment strategies for this patient population.
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Affiliation(s)
- Tina I. Bui
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Ann Lindley Gill
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Robert A. Mooney
- Department of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Center for Musculoskeletal Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Steven R. Gill
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Center for Musculoskeletal Research, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Lewis G. Antibiotic-free antimicrobial poly (methyl methacrylate) bone cements: A state-of-the-art review. World J Orthop 2022; 13:339-353. [PMID: 35582158 PMCID: PMC9048499 DOI: 10.5312/wjo.v13.i4.339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 04/07/2021] [Revised: 11/30/2021] [Accepted: 03/07/2022] [Indexed: 02/06/2023] Open
Abstract
Prosthetic joint infection (PJI) is the most serious complication following total joint arthroplasty, this being because it is associated with, among other things, high morbidity and low quality of life, is difficult to prevent, and is very challenging to treat/manage. The many shortcomings of antibiotic-loaded poly (methyl methacrylate) (PMMA) bone cement (ALBC) as an agent for preventing and treating/ managing PJI are well-known. One is that microorganisms responsible for most PJI cases, such as methicillin-resistant S. aureus, have developed or are developing resistance to gentamicin sulfate, which is the antibiotic in the vast majority of approved ALBC brands. This has led to many research efforts to develop cements that do not contain gentamicin (or, for that matter, any antibiotic) but demonstrate excellent antimicrobial efficacy. There is a sizeable body of literature on these so-called “antibiotic-free antimicrobial” PMMA bone cements (AFAMBCs). The present work is a comprehensive and critical review of this body. In addition to summaries of key trends in results of characterization studies of AFAMBCs, the attractive features and shortcomings of the literature are highlighted. Shortcomings provide motivation for future work, with some ideas being formulation of a new generation of AFAMBCs by, example, adding a nanostructured material and/or an extract from a natural product to the powder and/or liquid of the basis cement, respectively.
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Affiliation(s)
- Gladius Lewis
- Department of Mechanical Engineering, University of Memphis, Memphis, TN 38152, United States
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Bülow E, Hahn U, Andersen IT, Rolfson O, Pedersen AB, Hailer NP. Prediction of Early Periprosthetic Joint Infection After Total Hip Arthroplasty. Clin Epidemiol 2022; 14:239-253. [PMID: 35281208 PMCID: PMC8904265 DOI: 10.2147/clep.s347968] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/18/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose To develop a parsimonious risk prediction model for periprosthetic joint infection (PJI) within 90 days after total hip arthroplasty (THA). Patients and Methods We used logistic LASSO regression with bootstrap ranking to develop a risk prediction model for PJI within 90 days based on a Swedish cohort of 88,830 patients with elective THA 2008–2015. The model was externally validated on a Danish cohort with 18,854 patients. Results Incidence of PJI was 2.45% in Sweden and 2.17% in Denmark. A model with the underlying diagnosis for THA, body mass index (BMI), American Society for Anesthesiologists (ASA) class, sex, age, and the presence of five defined comorbidities had an area under the curve (AUC) of 0.68 (95% CI: 0.66 to 0.69) in Sweden and 0.66 (95% CI: 0.64 to 0.69) in Denmark. This was superior to traditional models based on ASA class, Charlson, Elixhauser, or the Rx Risk V comorbidity indices. Internal calibration was good for predicted probabilities up to 10%. Conclusion A new PJI prediction model based on easily accessible data available before THA was developed and externally validated. The model had superior discriminatory ability compared to ASA class alone or more complex comorbidity indices and had good calibration. We provide a web-based calculator (https://erikbulow.shinyapps.io/thamortpred/) to facilitate shared decision making by patients and surgeons. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/T0qfHTvBEs4
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Affiliation(s)
- Erik Bülow
- The Swedish Arthroplasty Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Correspondence: Erik Bülow, The Swedish Arthroplasty Register, Centre of Registers Västra Götaland, Gothenburg, SE-413 45, Sweden, Tel +46 70 08 234 28, Email
| | - Ute Hahn
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Mathematics, Aarhus University, Aarhus, Denmark
| | - Ina Trolle Andersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Ola Rolfson
- The Swedish Arthroplasty Register, Centre of Registers Västra Götaland, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nils P Hailer
- Department of Surgical Sciences/Orthopaedics, Uppsala University Hospital, Uppsala, Sweden
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Shah NV, Huddleston HP, Wolff DT, Newman JM, Pivec R, Naziri Q, Shah VR, Maheshwari AV. Does Surgical Approach for Total Hip Arthroplasty Impact Infection Risk in the Obese Patient? A Systematic Review. Orthopedics 2022; 45:e67-e72. [PMID: 34978509 DOI: 10.3928/01477447-20211227-03] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This systematic review evaluated the combined effects of obesity and surgical approach on periprosthetic joint infection (PJI) rates after total hip arthroplasty (THA). Wound complication and PJI rates were elevated among patients with body mass index (BMI) of 30 kg/m2 or greater and 35 kg/m2 or greater, respectively, with the direct anterior approach (DAA). A BMI of 30 kg/m2 or greater also increased the risk of PJI with the posterior approach. Patients with BMI of 30 kg/m2 or greater undergoing anterolateral approach THA did not have increased risk of PJI. Patients with elevated BMI (≥30 kg/m2) are at risk for PJI, regardless of approach. Patients undergoing DAA THA who have BMI of 35 kg/m2 or greater may have an increased risk of PJI compared with those undergoing THA with other approaches. [Orthopedics. 2022;45(2):e67-e72.].
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Lach MS, Rosochowicz MA, Richter M, Jagiełło I, Suchorska WM, Trzeciak T. The Induced Pluripotent Stem Cells in Articular Cartilage Regeneration and Disease Modelling: Are We Ready for Their Clinical Use? Cells 2022; 11:529. [PMID: 35159338 PMCID: PMC8834349 DOI: 10.3390/cells11030529] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 02/01/2023] Open
Abstract
The development of induced pluripotent stem cells has brought unlimited possibilities to the field of regenerative medicine. This could be ideal for treating osteoarthritis and other skeletal diseases, because the current procedures tend to be short-term solutions. The usage of induced pluripotent stem cells in the cell-based regeneration of cartilage damages could replace or improve on the current techniques. The patient’s specific non-invasive collection of tissue for reprogramming purposes could also create a platform for drug screening and disease modelling for an overview of distinct skeletal abnormalities. In this review, we seek to summarise the latest achievements in the chondrogenic differentiation of pluripotent stem cells for regenerative purposes and disease modelling.
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Ong J, Tang A, Rozell JC, Babb JS, Schwarzkopf R, Lin D. Factors predicting hip joint aspiration yield or “dry taps” in patients with total hip arthroplasty. J Orthop Surg Res 2022; 17:42. [PMID: 35065660 PMCID: PMC8783512 DOI: 10.1186/s13018-022-02942-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/24/2021] [Indexed: 11/29/2022] Open
Abstract
Background Image-guided joint aspirations used to assist the diagnosis of periprosthetic joint infection (PJI) may commonly result in a dry tap–or insufficient fluid for culture and cell count analysis. Dry tap aspirations are painful and invasive for patients and often utilize a subsequent saline lavage to obtain a microbiology sample. Currently, there is a paucity of the literature addressing predictors that could suggest whether a dry tap will occur. The purpose of this study was to examine the effects of various factors on “dry tap” occurrence in patients with suspected PJI following total hip arthroplasty (THA). Methods A retrospective review was performed among THA patients suspected for PJI who received image-guided joint aspiration procedures at our institution from May 2016 to February 2020. The procedural factors included the imaging modality used for aspiration, anatomic approach, needle gauge size used, and the presence of a trainee. The patient-specific factors included number of prior ipsilateral hip surgeries, femoral head size, ESR/CRP values, and BMI. Results In total, 336 patients met our inclusion criteria. One hundred and twenty hip aspirations resulted in a dry tap (35.7%) where the patients underwent a saline lavage. Among the procedural and patient-specific factors, none of the factors were found to be statistically different between the two cohorts nor conferred any greater odds of a dry tap occurring. Conclusion No associations with dry tap occurrence were found among the procedural and patient-specific factors studied. Further research is needed to identify additional factors that may be more predictive of dry taps.
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Abstract
The preoperative period prior to elective total joint arthroplasty (TJA) is a critical time for lifestyle interventions since a scheduled surgery may help motivate patients to lose weight. Weight loss may reduce complications associated with obesity following TJA and enable patients with severe obesity (body mass index [BMI] > 40 kg/m2) to become eligible for TJA, as many institutions use a 40 kg/m2 cut-off for offering surgery. A comprehensive review was conducted to (1) provide background on complications associated with obesity following TJA, (2) synthesize prior research on the success rate of patients losing weight after being denied TJA for severe obesity, (3) discuss bariatric surgery before TJA, and (4) propose mobile health telemedicine weight loss interventions as potential weight loss methods for patients preoperatively. It is well established that obesity increases complications associated with TJA. In total knee arthroplasty (TKA), obesity increases operative time, length of stay, and hospitalization costs as well as the risk of deep infection, revision, and component malpositioning. Obesity may have an even larger impact on complications associated with total hip arthroplasty (THA), including wound complications and deep infection. Obesity also increases the risk of hip dislocation, aseptic loosening, and venous thromboembolism after THA. Synthesis of the only two studies (n = 417), to our knowledge, that followed patients denied TJA for severe obesity demonstrated that only 7% successfully reduced their BMI below 40 kg/m2 via lifestyle modifications and ultimately underwent TJA. Unfortunately, bariatric surgery may only increase certain post-TKA complications including death, pneumonia, and implant failure, and there is limited research on preoperative weight loss via lifestyle modification. A review of short-term mobile health weight loss interventions that combined personalized counseling with self-monitoring via a smartphone app found about 5 kg of weight loss over 3-6 months. Patients with severe obesity have more weight to lose and may have additional motivation to do so before TJA, so weight loss results may differ by patient population. Research is needed to determine whether preoperative mobile health interventions can help patients become eligible for TJA and produce clinically significant weight loss sufficient to improve postoperative outcomes.
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Affiliation(s)
- Michael W Seward
- Mayo Clinic, Department of Orthopedic Surgery, 200 1st St SW, Rochester, MN 55905 USA
| | - Antonia F Chen
- Brigham and Women's Hospital, Department of Orthopaedic Surgery, 75 Francis Street, Boston, MA 02115 USA
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Linke S, Thürmer A, Bienger K, Kleber C, Bellova P, Lützner J, Stiehler M. Microbiological pathogen analysis in native versus periprosthetic joint infections: a retrospective study. J Orthop Surg Res 2022; 17:9. [PMID: 34991635 DOI: 10.1186/s13018-021-02850-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The presence or absence of an implant has a major impact on the type of joint infection therapy. Thus, the aim of this study was the examination of potential differences in the spectrum of pathogens in patients with periprosthetic joint infections (PJI) as compared to patients with native joint infections (NJI). METHODS In this retrospective study, we evaluated culture-positive synovial fluid samples of 192 consecutive patients obtained from January 2018 to January 2020 in a tertiary care university hospital. For metrically distributed parameters, Mann-Whitney U was used for comparison between groups. In case of nominal data, crosstabs and Chi-squared tests were implemented. RESULTS Overall, 132 patients suffered from periprosthetic joint infections and 60 patients had infections of native joints. The most commonly isolated bacteria were coagulase-negative Staphylococci (CNS, 28%), followed by Staphylococcus aureus (S. aureus, 26.7%), and other bacteria, such as Streptococci (26.3%). We observed a significant dependence between the types of bacteria and the presence of a joint replacement (p < 0.05). Accordingly, detections of CNS occurred 2.5-fold more frequently in prosthetic as compared to native joint infections (33.9% vs. 13.4% p < 0.05). In contrast, S. aureus was observed 3.2-fold more often in NJIs as compared to PJIs (52.2% vs. 16.4%, p < 0.05). CONCLUSION The pathogen spectra of periprosthetic and native joint infections differ considerably. However, CNS and S. aureus are the predominant microorganisms in both, PJIs and NJIs, which may guide antimicrobial therapy until microbiologic specification of the causative pathogen.
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Liu C, Brinkmann E, Chou SH, Tejada Arias K, Cooper L, Javedan H, Iorio R, Chen AF. Team Approach: Preoperative Management of Metabolic Conditions in Total Joint Replacement. JBJS Rev 2021; 9:01874474-202112000-00003. [PMID: 34910700 DOI: 10.2106/jbjs.rvw.21.00112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Total joint arthroplasties (TJAs) of the knee and hip have been considered 2 of the most successful surgical procedures performed to date. » Frailty is defined as increased vulnerability to adverse outcomes with physiologic stress. » Preoperative optimization of frailty and metabolic bone conditions, including osteoporosis, vitamin D deficiency, and diabetes, through a multidisciplinary approach can help improve outcomes and minimize costs after TJA.
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Affiliation(s)
- Christina Liu
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Elyse Brinkmann
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sharon H Chou
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Karla Tejada Arias
- Harvard Medical School, Boston, Massachusetts
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Cooper
- Harvard Medical School, Boston, Massachusetts
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Houman Javedan
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Richard Iorio
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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