Arthroplasty Surgery Research Articles

Assessment of the safety and efficacy of intravenous versus topical tranexamic acid in patients undergoing primary total hip and knee arthroplasty surgeries with respect to decreasing peri-operative blood loss and blood transfusion rates: a prospective and comparative study

Background: Synthetic antifibrinolytic agent like tranexamic acid has been increasingly used in Arthroplasty surgeries to decrease the peri-operative blood loss. The current study was undertaken to compare the efficacy between the intravenous and Topical route of TXA in deceasing the blood loss and transfusion rate in patients undergoing primary total hip and knee arthroplasty (THR and TKR) surgeries. Methods: A total of 120 patients were enrolled in the study with 60 each undergoing THR and TKR surgeries with 30 each given TXA in IV and Topical routes. Outcomes were assessed in terms of mean 24 hours drain output, mean blood loss, mean drop in hemoglobin blood transfusion rate. Results: The mean drain output was more in the IV group in both THR and TKR patients (p>0.05). The mean blood loss was more in the Topical group in both THR and TKR patients (p>0.05). The mean drop in hemoglobin was more in the Topical group, with the difference being significant in the THR patients (p<0.05) and being insignificant in TKR patients (p>0.05). In IV group 9 patients (15%) and in Topical group 25 patients (41.67%) needed blood transfusions, the difference being statistically significant. Conclusions: Both IV and Topical routes of TXA are equally effective in decreasing the peri-operative blood loss and transfusion rates in patients undergoing primary arthroplasty surgeries, with IV route having slightly upper hand as compared to the Topical route.

The safety of preoperative carbohydrate drinks in extremely elderly patients assessed by gastric ultrasonography: a randomized controlled trial

BackgroundModern perioperative guidelines encourage drinking oral carbohydrates 2 h before management. Nevertheless, research on the safety of preoperative carbohydrate drinks, particularly in extremely elderly patients is lacking. We aimed to evaluate the safety of carbohydrate drinks 2 h before surgery in extremely elderly patients (≥ 80 years) using gastric ultrasonography.MethodsWe conducted a randomized prospective comparative study of 70 patients aged over 80 years who were scheduled for total knee arthroplasty, hip fracture or humerus fracture surgery. These patients were randomly assigned to the carbohydrate group (n = 35), which fasted from midnight, except for drinking 355 mL of a carbohydrate-containing fluid 2 h before surgery, or the fasting group (n = 35), which fasted from midnight and drank no fluid before surgery. The primary outcome of the study was the cross-sectional area (CSA) of the gastric antrum in the right lateral decubitus position (RLDP) before surgery. The secondary outcomes included CSA in the supine position, intraoperative blood glucose levels and their variability coefficients, Perlas grade, and the visual analog scale of subjective feelings.ResultsThe CSA in the RLDP and supine positions revealed no differences between the carbohydrate and fasting groups at 0 h preoperatively (P > 0.05). In the qualitative assessment, preoperative 0-h Perlas grading did not differ significantly between the groups (P > 0.05). From 2 h before surgery to transfer out of the post-anesthesia care unit, the average blood glucose level of patients in the carbohydrate group was significantly higher than that in the fasting group (P < 0.001) but remained within the normal range. Moreover, the blood glucose variability coefficient was significantly lower in the carbohydrate group than in the fasting group (P = 0.009). Oral intake of 355 mL carbohydrates before surgery significantly relieved patients’ feelings (P < 0.001).ConclusionPreoperative consumption of carbohydrate drinks 2 h before surgery is safe in “healthy” extremely elderly patients. In addition, preoperative drinking has potential value in maintaining ideal blood glucose levels and stable blood glucose fluctuations perioperatively and improving subjective perceptions of preoperative preparation. This finding warrants further investigation in clinical practice.Trial registrationChinese Clinical Trial Registry (Registration Number ChiCTR1900024812), first registered on 29/07/2019.

A potential link between inflammatory profiles, clinical pain, pain catastrophizing and long-term outcomes after total knee arthroplasty surgery.

Chronic postoperative pain after total knee replacement (TKR) is a major clinical problem. It is still unclear if specific inflammatory mediators are associated with long-term postoperative pain complications. The current exploratory study aimed to (1) evaluate a multiplex of inflammatory mediators 5 years after TKR surgery in patients with different degrees of postoperative pain intensities and (2) study any association of the markers with clinical pain intensity, cognitive and functional outcomes. Plasma samples were collected 5 years after TKR surgery from 76 knee patients (43 females; 33 males) and analysed for 44 inflammatory markers. Pain (using visual analogue scale, VAS), the pain catastrophizing scale (PCS) and the Oxford knee score (OKS) were evaluated. Patients were categorized as high or low groups based on VAS, PCS and OKS scores. Associations between inflammatory markers, VAS, PCS and OKS were analysed and the marker expressions were compared between groups. Pearson's correlations found 12 biomarkers associated with VAS (p < 0.05), 4 biomarkers with PCS and 3 biomarkers with OKS (p < 0.05). Four markers were altered in patients suffering from high compared to low chronic postoperative pain, three markers were altered in high compared to low catastrophizers and three markers were altered in patients with poor functional scores (p < 0.05). The present exploratory study suggests that low-grade inflammation might be present in a subset of patients with high pain, high catastrophizing and low function 5 years after TKR. These exploratory results provide insights into some of the long-term postoperative complications after TKR surgery. This exploratory study evaluated a subset of inflammatory markers and the association to clinical pain intensity, knee function and pain catastrophizing in patients 5 years after total knee replacement surgery. Our results provide insights into the understanding of the underlying mechanisms that may drive the long experience of pain after TKR surgery.

Metals accumulation affects bone and muscle in osteoporotic patients: A pilot study

Osteoporosis is the most common bone disease, characterized by decreased bone mineral density (BMD) and often associated to decreased muscle mass and function. Metal exposure plays a role in the pathophysiology of osteoporosis and affects also muscle quality. The aim of this study was to assess the association between metal levels in bone and muscle samples and the degeneration of these tissues. A total of 58 subjects (30 male and 28 female) was enrolled and classified in osteoporotic (OP, n = 8), osteopenic (Ope, n = 30) and healthy (CTR, n = 20) subjects, according to BMD measures. Femoral head bone samples and vastus lateralis muscle samples were collected during hip arthroplasty surgeries. Inductively Coupled Plasma Mass Spectrometry (ICP-MS) analysis showed increased levels of Al, Cd and Pb in OP and Ope bone tissue compared to CTR subjects (p = 0.04, p = 0.005 and p = 0.01, respectively). Whereas, increased levels of Co, Cd and Pb were measured in OP and Ope muscle tissues, compared to CTRs (p < 0.001, p = 0.02 and p = 0.01, respectively). In addition, Al, Cd and Pb levels in bone and Cd and Co levels in muscle were negatively correlated with BMD. A negative association among Co, Cd, Cr and Hg levels and muscle fibers diameter was also observed in muscle tissues. This study assessed that metal exposure can affects bone and muscle tissue quality and may contribute to the onset and progression of musculoskeletal diseases such as osteoporosis. Therefore, it is important to implement metal exposure assessment and their impact on disease development, in order to manage and prevent metal accumulation effects on bone and muscle quality.

Antibiotics Prophylaxis Practice in Arthroplasty Surgeries.

Background Infection in orthopedic surgery is one of the most dreaded complications. It is associated with prolonged morbidity, disability, and increased mortality. One of the cornerstones of the prevention of infections is antibioticprophylaxis. This study assessed the practice of antibiotic prophylaxis in arthroplasty surgeries in our local hospital. Methods One hundred and seventy-one elective joint replacement patients were retrospectively analyzed for documentation of antibiotic plan in postoperative instruction, choice of antibiotic, dose, anddosage. Compliance with the dosage (duration and frequency) of antibiotic prophylaxis was compared among patients who underwent different operations, among patients whose operation notes had antibiotics plans, and among those patients whose operation notes lacked this information. Results Ninety-six females and 75 males with a mean age of 71.4±9.8 years who underwent hip replacement, knee replacement, or shoulder replacement were included in this study. Preoperative and postoperative antibiotics were received by 100% and 94.7% of patients, respectively. In 19.3%, there was no instruction about postoperative antibiotics while 4% missed at least one postoperative dose. The dosage of postoperative prophylactic antibiotics was variable as 26.3% of the patients experienced delayed administration of doses. Not having intravenous access, failure to prescribe antibiotics, and prescribing antibiotics in the "once only" rather than "regular medication" section of the medication chart were the reasons for improper timing of antibiotic doses. Observing surgical safety checklist was effective in ensuring preoperative antibiotic administration, whereasfailing to document antibiotic plan in operation note was associated with poor compliance with postoperative dosage. Interprofessional participation is crucial to compliance with antibioticprophylaxis practice. Conclusion This study identified key areas for improvement in our antibiotics prophylaxis practice. It resulted in implementing strategies to improve staff's awareness about the importance of timely administration of prophylactic antibiotics and proper documentation by all team members.

Hip prosthesis and colon surgery, a decade of surveillance on surgical site infections in Italy, a prospective cohort study: rates, trends, and disease burden in DALYs

BackgroundSurveillance programs are a key element of interventions aiming to reduce rates of surgical site infections (SSIs). The aim of this study was to evaluate rates and trends of SSIs following hip arthroplasty and colon surgery procedures in Piedmont, a region in North-western Italy, from 2010 to 2019. Further, we aimed to assess the burden of SSIs in terms of Disability-Adjusted Life-Years (DALYs).MethodsA prospective cohort study was conducted among 42 hospitals participating in the surveillance system. Procedure-specific SSI rates were calculated and the 2010 - 2019 trend was evaluated using Spearman's Rho test. Patients were stratified according to age, sex and infection risk index according to life expectancy in order to calculate DALYs, using a modified version of the ECDC’s BCoDE toolkit: disease models for both procedure types were adapted to incorporate long-term disability associated with SSIs.ResultsOverall, 20,356 hip arthroplasty and 11,011 colon surgery procedures were monitored over 10 years and were included in our analyses. Hip arthroplasty and colon surgery cumulative SSIs rates were 1.5% and 8% respectively. Using the Spearman’s Rho test, we evaluated a significant downward trend from 2010 to 2019 for colon surgery interventions (Rs − 0.7, p < 0.05), while there was no difference for hip arthroplasty. (Rs − 0.04, p > 0.05).Regarding disease burden, a total of 955.3 (95%CI 837.7–1102.98) and 208.65 (95%CI 180.87–240.90) DALYs were calculated for SSIs following hip arthroplasty, whilst 76.58 (95%CI 67.15–90.71) and 38.62 (95% CI 33.09–45.36) DALYs for SSIs in colon surgery, in 2010 and 2019, respectively.ConclusionsThe significant decrease both in terms of incidence and DALYs found in this study for colon surgery and the stability for hip arthroplasty support the role of surveillance networks in improving quality of care. Despite the smaller SSI rate, the burden associated with SSIs following hip arthroplasty was higher, which is important to consider in light of the aging population in Italy.

Factors Influencing Patient Satisfaction with Total Joint Replacement Surgery.

Replacement arthroplasty surgery is a surgical procedure that is needed to restore the activity of a joint. Patient satisfaction regarding arthroplasty surgery is influenced by post-operative complication rate, ability to afford care, and quality of interaction. In this study, we assessed patients' postoperative complications, mobility, and pain management as proxies for their overall satisfaction with total joint replacement (TJR). An anonymous web-based survey was conducted for patients who had undergone any total joint replacement surgery in the US. Respondents were adults living in the United States. 180 individuals met the inclusion criteria and responded to the survey. Age, education, gender, and race were fitted against the patient satisfaction level with the surgeon. While education [P=0.4720], gender [P=0.5097 ], and race [P=0.8183] were not significant, age in years [P=0.02340] was predictive of overall satisfaction levels [R2=0.0213]. When controlling for BMI, infection [P=0.0164], nerve damage [P=0.0250], delayed healing [P=0.0024], hematoma [P=0.0497], were more likely to occur in participants who have had a knee replacement, as compared to shoulder and hip replacement surgery. When controlling for mobility before surgery vs.mobility after surgery [P=0.0114], patients who selected the highest level of mobility before surgery were likely to select the highest level of mobility after surgery. Medicaid, Medicare, private insurance, employer-based insurance, and no insurance were fitted against the patient's self-reported difficulty in paying for their treatment/care. Although employer-based insurance [P=0.0790] was not significant in predicting difficulty in paying for the surgery, patients with Medicaid [P=0.0280], Medicare [P=0.0200], or private insurance [P=0.0343] did. In this cohort, older patients were associated with having improved satisfaction with the surgeon who performed their joint replacement. Complications were higher in patients who underwent a knee arthroplasty compared to a shoulder or hip arthroplasty.

Periprosthetic femoral fractures.

The incidence of periprosthetic femoral fractures is rising in the UK, because of an ageing population and an increasing number of hip arthroplasty operations being performed. They can occur intra- or postoperatively, and usually follow low energy trauma. They present with pain, swelling over the thigh, and an inability to weight bear. Periprosthetic femoral fractures are usually classified as per the unified classification system. Their management usually is dependent on their classification, with type A (fracture at level of greater or lesser trochanter) managed non-operatively with protected weight bearing, type B (fracture adjacent to implant) managed with either open reduction internal fixation or revision surgery, and type C (fracture distal to implant) managed with open reduction internal fixation. Owing to their complexity, these patients must be adequately optimised before surgery and appropriately rehabilitated.

Modified frailty index (mFI): is it a predictor for early postoperative complications in arthroplasty surgery?

It has been demonstrated that the modified frailty index (mFI) is a powerful and effective tool in the prediction of perioperative risk in many surgical fields. In many previous studies, mFI has been found to be successful in prediction of perioperative adverse effects. The aim of this study was to determine whether the mFI can be a predictor for early postoperative complications in arthroplasty surgery. 145 patients aged 45-85 undergoing primary or revision total knee and hip arthroplasty were included in this prospective study. mFI was calculated in all patients, and patients included in the current study were grouped as "Frail" (n=42) and "Nonfrail" (n=103) patients according to modified frailty index values. Postoperative complications (myocardial infarction, cardiac arrest, pulmonary embolism, septic shock, postoperative dialysis requirement, cerebrovascular event, reintubation, prolonged mechanical ventilation, surgical wound complications), duration of hospitalization, requirement for intensive care unit (ICU) admission and rehospitalization and 30-day mortality were recorded and the correlation between mFI and these parameters were evaluated. The mean age was 67.58±9.35 years, and 72.4% of the patients were female. The percentage of frail patients in the current study was 28.9%. The percentage of ASA-1, ASA-2, and ASA-3 patients was 17.2%, 57.2%, and 25.5%, respectively. The rate of ICU admission, MI, septic shock, postoperative dialysis requirement, prolonged MV requirement, hospital readmission, and 30-day mortality were 45.2%, 14.3%, 16.7%, 16.7%, 14.3%, 11.9%, and 16.7%, respectively in the frail group and were 7.8%, 1%, 1.9%, 2.9, 1.9% and 3.9%, respectively in the nonfrail group. Advanced age, male gender, high ASA score and prolonged duration of surgery were found to be predictive factors for postoperative complications. Advanced age, high ASA score and prolonged duration of surgery were found to be predictive factors for ICU admission. Advanced age, male gender and high ASA score were found to be strong predictors of 30-day mortality. mFI was found to be a strong predictor for postoperative complications and mortality. It is an easy, reliable, and simple method to evaluate frailty during the preoperative period. NCT05424575.

Robotic trials in arthroplasty surgery.

Total hip and knee arthroplasty (THA, TKA) are largely successful procedures; however, both have variable outcomes, resulting in some patients being dissatisfied with the outcome. Surgeons are turning to technologies such as robotic-assisted surgery in an attempt to improve outcomes. Robust studies are needed to find out if these innovations are really benefitting patients. The Robotic Arthroplasty Clinical and Cost Effectiveness Randomised Controlled Trials (RACER) trials are multicentre, patient-blinded randomized controlled trials. The patients have primary osteoarthritis of the hip or knee. The operation is Mako-assisted THA or TKA and the control groups have operations using conventional instruments. The primary clinical outcome is the Forgotten Joint Score at 12 months, and there is a built-in analysis of cost-effectiveness. Secondary outcomes include early pain, the alignment of the components, and medium- to long-term outcomes. This annotation outlines the need to assess these technologies and discusses the design and challenges when conducting such trials, including surgical workflows, isolating the effect of the operation, blinding, and assessing the learning curve. Finally, the future of robotic surgery is discussed, including the need to contemporaneously introduce and evaluate such technologies.

Good Short-Term Survivorship of Constrained Condylar Revision Knee Implants With Medial Pivot Kinematics: A Level IV Retrospective Study

BackgroundThe need for revision total knee arthroplasty surgery is increasing worldwide, and, in many cases, a constrained implant is required to provide joint stability. The purpose of this study was to examine the early loosening and functional outcome of a novel constrained condylar (CCK) revision total knee system designed to have medial pivot (MP) kinematics. MethodsA retrospective cohort study was performed, collecting clinical data from all patients who underwent revision total knee arthroplasty using a novel MP CCK system with a minimum four-year clinical follow-up. Patient demographics, survivorship, complications, and Forgotten Joint Score were analyzed based upon chart review. ResultsThere were 49 patients available for follow-up, who had a 100% survivorship free of aseptic loosening. All-cause revision survivorship was 92%. There were 4 patients who subsequently underwent rerevision. The causes for rerevision included periprosthetic joint infection in 2 patients, coronal plane instability in one patient, and a traumatic knee dislocation in one patient. There were 45 patients who completed the Forgotten Joint Score, who had an average of 49.8 (± 32.8, range 6.25 to 100). ConclusionsAt 4 years, mid-term follow-up, this novel CCK revision total knee system designed to have MP kinematics had good patient-reported outcomes with no revision for aseptic loosening. Future studies should evaluate the mid- and long-term survivorship of this innovative implant.

How Active Are Our Patients in the First 6 Weeks Following Total Knee Arthroplasty?

BackgroundPatient activity after total knee arthroplasty (TKA) surgery has been estimated through patient-reported outcome measures. The use of data from an implanted sensor that transmits daily gait activity provides a more objective, complete recovery trajectory. MethodsIn this retrospective analysis of 794 patients who received a TKA with sensors in the tibial extension between October 4, 2021, and January 13, 2023, the average age of the patients was 64 years, and the cohort was 54.9% women. During the 6-week postoperative period, 90.3% of patients transmitted data. Patient activity in terms of qualified step count, cadence, walking speed, stride length, functional tibial range of motion (ROM), and functional knee ROM were compared at 1 week, 3 weeks, and 6 weeks postoperatively. ResultsAll gait parameters increased in the first 6 weeks postsurgery: qualified step count increased 733%, cadence increased 22%, walking speed increased 50%, stride length increased 17%, tibial ROM increased 19%, and functional knee ROM increased 14%. There were statistically significant differences at both postoperative periods (P = .029, P < .001, and P < .001 at 3 and 6 weeks, respectively) in step counts for different body mass index (BMI) categories, with qualified step counts decreasing with increasing BMI. Patients under 65 years tended to have a higher qualified step count than those 65 and older at all time points, but these differences were not statistically significant. Men had significantly higher step counts than women (P < .001 at 1, 3, and 6 weeks). ConclusionsInitial results with an implanted sensor that collects data during activities of daily living confirm that 90% of patients transmit objective gait metrics daily after TKA surgery. Those results differ by sex and BMI. Level of EvidenceIII Retrospective Cohort Study.

Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis

BackgroundThis study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery. MethodsA retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student’s T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables. ResultsOur study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty. ConclusionsThere was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non–total joint surgeons, although their patient population was more complex. Level of evidenceIII.

Early Biofilm Formation on the Drain Tip after Total Knee Arthroplasty Is Not Associated with Prosthetic Joint Infection: A Pilot Prospective Case Series Study of a Single Center

Background: Periprosthetic joint infection (PJI) is a devastating complication of arthroplasties that could occur during the surgery. The purpose of this study was to analyze the biofilm formation through microbiological culture tests and scanning electron microscopy (SEM) on the tip of surgical drainage removed 24 h after arthroplasty surgery. Methods: A total of 50 consecutive patients were included in the present prospective observational study. Drains were removed under total aseptic conditions twenty-four hours after surgery. The drain tip was cut in three equal parts of approximately 2–3 cm in length and sent for culture, culture after sonication, and SEM analysis. The degree of biofilm formation was determined using a SEM semi-quantitative scale. Results: From the microbiological analysis, the cultures of four samples were positive. The semi-quantitative SEM analysis showed that no patient had grade 4 of biofilm formation. A total of 8 patients (16%) had grade 3, and 14 patients (28%) had grade 2. Grade 1, scattered cocci with immature biofilm, was contemplated in 16 patients (32%). Finally, 12 patients (24%) had grade 0 with a total absence of bacteria. During the follow-up (up to 36 months), no patient showed short- or long-term infectious complications. Conclusions: Most of the patients who underwent primary total knee arthroplasty (TKA) showed biofilm formation on the tip of surgical drain 24 h after surgery even though none showed a mature biofilm formation (grade 4). Furthermore, 8% of patients were characterized by a positivity of culture analysis. However, none of the patients included in the study showed signs of PJI up to 3 years of follow-up.

Previous cartilage surgery is associated with inferior patient-reported outcomes after knee arthroplasty.

The hypothesis of the present study assumed that a history of focal cartilage lesions would not affect Knee Injury and Osteoarthritis Outcome scores (KOOSs) following knee arthroplasty compared to a matched national cohort of knee arthroplasty patients. Fifty-eight knee arthroplasty patients with previous surgery for focal cartilage lesions (cartilage cohort) were compared to a matched cohort of 116 knee arthroplasty patients from the Norwegian Arthroplasty Register (control group). Age, sex, primary or revision arthroplasty, type of arthroplasty (total, unicondylar or patellofemoral), year of arthroplasty surgery and arthroplasty brand were used as matching criteria. Demographic data and KOOS were obtained through questionnaires. Regression models were employed to adjust for confounding factors. Mean follow-up post knee arthroplasty surgery was 7.6 years (range 1.2-20.3) in the cartilage cohort and 8.1 (range 1.0-20.9) in the control group. The responding patients were at the time of surgery 54.3 versus 59.0 years in the cartilage and control group, respectively. At follow-up the control group demonstrated higher adjusted Knee Injury and Osteoarthritis Outcome subscores than the previous focal cartilage patients with a mean adjusted difference (95% confidence interval in parentheses): Symptoms 8.4 (0.3, 16.4), Pain 11.8 (2.2, 21.4), Activities of daily living (ADL) 9.3 (-1.2, 18.6), Sport and recreation 8.9 (-1.6, 19.4) and Quality of Life (QoL) 10.6 (0.2, 21.1). The control group also demonstrated higher odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores with odds ratio: Symptoms 2.7 (1.2, 6.4), Pain 3.0 (1.3, 7.0), ADL 2.1 (0.9, 4.6) and QoL 2.4 (1.0, 5.5). Previous cartilage surgery was associated with inferior patient-reported outcomes after knee arthroplasty. These patients also exhibited significantly lower odds of reaching the patient-acceptable symptom state threshold for the Knee Injury and Osteoarthritis Outcome subscores. Level III.

Readmission to a non-index hospital following total joint replacement.

It is unclear whether mortality outcomes differ for patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery who are readmitted to the index hospital where their surgery was performed, or to another hospital. We analyzed linked hospital and death records for residents of New South Wales, Australia, aged ≥ 18 years who had an emergency readmission within 90 days following THA or TKA surgery between 2003 and 2022. Multivariable modelling was used to identify factors associated with non-index readmission and to evaluate associations of readmission destination (non-index vs index) with 90-day and one-year mortality. Of 394,248 joint arthroplasty patients (THA = 149,456; TKA = 244,792), 9.5% (n = 37,431) were readmitted within 90 days, and 53.7% of these were admitted to a non-index hospital. Non-index readmission was more prevalent among patients who underwent surgery in private hospitals (60%). Patients who were readmitted for non-orthopaedic conditions (62.8%), were more likely to return to a non-index hospital compared to those readmitted for orthopaedic complications (39.5%). Factors associated with non-index readmission included older age, higher socioeconomic status, private health insurance, and residence in a rural or remote area. Non-index readmission was significantly associated with 90-day (adjusted odds ratio (aOR) 1.69; 95% confidence interval (CI) 1.39 to 2.05) and one-year mortality (aOR 1.31; 95% CI 1.16 to 1.47). Associations between non-index readmission and mortality were similar for patients readmitted with orthopaedic and non-orthopaedic complications (90-day mortality aOR 1.61; 95% CI 0.98 to 2.64, and aOR 1.67; 95% CI 1.35 to 2.06, respectively). Non-index readmission was associated with increased mortality, irrespective of whether the readmission was for orthopaedic complications or other conditions.

Machine learning can predict anterior elevation after reverse total shoulder arthroplasty: A new tool for daily outpatient clinic?

The aim of the present study was to individuate and compare specific machine learning algorithms that could predict postoperative anterior elevation score after reverse shoulder arthroplasty surgery at different time points. Data from 105 patients who underwent reverse shoulder arthroplasty at the same institute have been collected with the purpose of generating algorithms which could predict the target. Twenty-eight features were extracted and applied to two different machine learning techniques: Linear regression and support vector regression (SVR). These two techniques were also compared in order to define to most faithfully predictive. Using the extracted features, the SVR algorithm resulted in a mean absolute error (MAE) of 11.6° and a classification accuracy (PCC) of 0.88 on the test-set. Linear regression, instead, resulted in a MAE of 13.0° and a PCC of 0.85 on the test-set. Our machine learning study demonstrates that machine learning could provide high predictive algorithms for anterior elevation after reverse shoulder arthroplasty. The differential analysis between the utilized techniques showed higher accuracy in prediction for the support vector regression. Level of Evidence III: Retrospective cohort comparison; Computer Modeling.

Revision Arthroplasty Among Medicare Patients in the United States – Arthroplasty Surgeons are Doing More for Less

BackgroundPreviously documented trends of major joint arthroplasty demonstrate increasing volume and decreasing reimbursement for primary total knee and total hip arthroplasty procedures. As such, the purpose of this study was to evaluate trends in revision knee and hip arthroplasty volume and true Medicare reimbursements to physicians. MethodsThe publicly accessible Centers for Medicare and Medicaid files were evaluated. Data were retrieved from the Part B National Summary Data File and queried for revision knee and hip arthroplasty billed to Medicare from 2000 to 2021. The total charge submitted to Medicare, Medicare reimbursement, number of revision arthroplasty surgeries performed, and average reimbursement per surgery were collected for each year. All monetary data were adjusted for inflation to 2021 dollars. ResultsThere were 492,360 revision total knee arthroplasty surgeries and 424,163 revision hip arthroplasty procedures billed to Medicare from 2000 to 2021. Medicare was billed a total of $919,603,674.86 for revision knee and $862,979,761.57 for revision hip arthroplasty during that time. Medicare reimbursed physicians an average of $1,499.89 per knee revision and $1,603.32 per hip revision surgery. The total volume of revision knee arthroplasty increased by 9,380 (62%) and revision hip decreased by 1,743 (9%) from the year 2000 to 2021. However, there was a decrease of average reimbursement per procedure of more than 37% ($1,987.14 to 1,254) and 39% ($2,149.87 to 1,311.17), respectively. ConclusionsDespite a notable increase in the volume of revision total knee and stagnant revision hip arthroplasty, total billings to and reimbursements from Medicare for these procedures have not changed markedly per year. Importantly, this means that physicians are conducting more of these high-impact procedures yearly, while being reimbursed per procedure at a declining rate. This may indicate a need to re-assess billing and reimbursement rates for revision arthroplasty, in the context of the ever-increasing inflation rate.

DO WE NEED LAMINAR FLOW IN TRAUMA?

Laminar flow theatres were first introduced in the United Kingdom in the 1960s and 1970s and have become standard in orthopaedic surgery involving implants. A study from 1982 showed a 50% reduction in infections with joint arthroplasties when compared to conventional theatres and laminar flow became standard in the following decades. Recent evidence including a meta-analysis from 2017 questions the effectiveness of these theatre systems. Most of the evidence for Laminar flow use is based on arthroplasty surgery. We aimed to determine the effect of using non-laminar flow theatres on our trauma patients.A total of 1809 patients who had trauma surgery were identified from 2019 to 2021. 917 patients were operated on in a laminar theatre and 892 in a non-laminar theatre across two operating sites. We identified the surgical site infections as reported through our surveillance program within the first 90 days of infection. Patient co-morbidities were noted through patient records and procedure length was also noted.Of the 1809 trauma patients identified between the years of 2019 and 2021, 917 patients had operations in a laminar flow theatre and 892 in a non-laminar theatre. Of the 892 operated in non-laminar flow theatres, 543 were operated in the University Hospital of Wales (UHW) and 349 at the University Hospital of Llandough (UHL). An analysis of soft tissue infections and hospital acquired infections post-operatively demonstrated 15/543 and 71/543 respectively for non-laminar UHW infections and 4/349 and 21/349 for non-laminar UHL infections. A look at laminar flow patients showed 25/917 with soft tissue infections and 86/917 hospital acquired infections. There was no difference between laminar and non-laminar flow theatre infection rates showing rates of 12.1% and 12.2% respectively.In our trauma patients we noticed no significant advantage of using laminar flow theatres when compared to non-laminar flow theatres. This is in keeping with some recently published literature. Laminar flow theatres have been shown to decrease airborne pathogen counts under controlled conditions, but we conclude in the day to day environment of trauma theatres these conditions are either not met or that the theoretical advantage of laminar flow does not translate to a direct advantage of reduction of infections which may be achieved by standard prophylactic antibiotics.

Incidence of vascular injury associated with knee arthroplasty: series of cases.

The incidence of vascular injury associated with knee arthroplasty is scarce, but, when they occur, the consequences are serious. Describe the incidence of vascular lesions in our center and evaluate time to diagnosis, resolution and follow-up. Retrospective cohort during the 2010-2019 period of primary arthroplasties and knee revision. The incidence of vascular lesions and their demographic characteristics were analyzed. Type of lesion, diagnostic method and treatment were recorded. It was evaluated in distant follow-up of pain and functionality. 7.940 primary total knee arthroplasty and revision surgeries were recorded, and a report of 7 emergency cases for vascular lesions was also recorded, with an incidence of 0.088%. 3 vascular lesions were caused by direct laceration of the popliteal artery, 1 case of thrombosis of the popliteal artery and 3 cases of pseudoaneurysmal lesion of the superior genicular artery. Three vascular lesions that occurred in primary arthroplasty were immediately repaired by a vascular surgeon. Pseudoaneurysm lesions and thrombosis were resolved by angiographic procedure. Vascular complications around the knee are rare. Time to diagnosis and treatment is essential. Digital angiography is a diagnostic and therapeutic tool. There are various repair techniques, whether it's embolization, cauterization, stenting or endoprosthesis; therefore, digital angiography is a safe method with a low complication rate. The incidence of vascular lesions in knee arthroplasty in our center is very low. The cases were diagnosed and resolved early, without registering subsequent complications with good functional results in distant follow-up.