Elective Total Hip Research Articles

Does Prednisone Dose Affect Rates of Periprosthetic Joint Infection Following Primary Total Hip and Total Knee Arthroplasty?

BackgroundPrednisone use is associated with higher rates of periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). However, the relationship between prednisone dosage and infection risk is ill-defined. Therefore, this study aimed to assess the relationship between prednisone dosage and rates of PJI following TJA. MethodsA national database was queried for all elective total hip (THA) and total knee arthroplasty (TKA) patients between 2015 and 2020. Patients who received oral prednisone following TJA were matched in a 1:2 ratio based on age and sex to patients who did not. Univariate and multivariate regression analyses were performed to assess the 90-day risk of infectious complications based on prednisone dosage as follows: 0 to 5, 6 to 10, 11 to 20, 21 to 30, and >30 milligrams. Overall, 1,322,043 patients underwent elective TJA (35.9% THA, 64.1% TKA). Of these, 14,585 (1.1%) received prednisone and were matched to 29,170 patients who did not. ResultsAfter controlling for confounders, TKA patients taking prednisone were at increased risk for sepsis (adjusted odds ratio [aOR] 2.76, P < .001), PJI (aOR 2.67, P < .001), and surgical site infection (aOR: 2.56, P = .035). THA patients taking prednisone were at increased risk for sepsis (aOR: 3.21, P < .001) and PJI (aOR: 1.73, P = .001). No dose-dependent relationship between prednisone and infectious complications was identified when TJA was assessed in aggregate. ConclusionPatients receiving prednisone following TJA were at increased risk of PJI and sepsis. A dose-dependent relationship between prednisone and infectious complications was not identified. Arthroplasty surgeons should be aware of these risks and counsel TJA patients who receive prednisone therapy.

Unintended Consequences? Medicare Commercial Partnerships Complicate Arthroplasty Care and Registry-Based Research: Commentary on an article by Jennifer C. Wang, BS, et al.: "The Rise of Medicare Advantage. Effects on Total Joint Arthroplasty Patient Care and Research".

Commentary The health-care environment has undergone major changes over the past 20 years, including the expansion of partnerships between commercial insurance carriers and the U.S. Department of Health and Human Services (HHS) through its subagency, the Centers for Medicare & Medicaid Services (CMS). Most orthopaedic surgeons performing arthroplasty procedures have probably observed the growing proportion of their patients with Medicare Advantage (commercially managed Medicare) plans. Few among us were likely aware of the full implication of this transition on clinical practice, patient outcomes, and the effectiveness of registry-based arthroplasty research. Wang and colleagues provide a thoughtful analysis of patient demographic characteristics, medical comorbidities, and 90-day postoperative adverse outcomes that were identified for 697,317 patients who underwent elective total hip or total knee arthroplasty in hospitals participating in the Premier Healthcare Database. The authors identified a 335% relative increase in patient participation in Medicare Advantage plans from 2004 to 2020, with increased enrollment of non-White patients, a propensity for increased Medicare Advantage enrollment in urban environments, and increased arthroplasty care engagement in teaching hospitals. While differences in medical comorbidities were not substantially different between patients enrolled in the 2 plan types, Medicare Advantage patients experienced an increased risk for stroke and acute kidney injury following surgery. The authors extrapolate their findings beyond the core data obtained to present their perspectives on the impact of CMS insurance privatization on the future of high-quality joint arthroplasty care. Increased administrative burdens, including pre-authorization coordination for appropriate and clinically indicated surgical treatment, have been encountered by most practicing surgeons and their support teams. The transition of quality reporting through qualified registries—including the American Joint Replacement Registry—has been built around traditional Medicare enrollment reporting mechanisms. At least 1 potentially unintended consequence of the transition toward Medicare Advantage plans is the shielding of patient-based procedural outcomes from these mechanisms—which may serve to undermine innovation and validation. There are some notable limitations of the study, which the authors have outlined. It is very challenging to use administrative databases to fully identify and investigate all factors that may influence adverse postoperative outcomes. While the database used by the authors identifies postoperative surgical and medical complications, it does not address the long-term performance of the implants and techniques. Moreover, the composite medical complexity of patients may not be fully represented in the analyzed data. The factors and conditions underlying patient decisions to select traditional Medicare or Medicare Advantage plans cannot be assessed, and the potential impact of selection bias on the study findings cannot be determined. The study highlights the unanticipated consequences that may arise when fiscally driven policy intersects with specialized medical care. Future studies will be valuable to determine whether the observations in this study are sustained as the growth of Medicare Advantage plans continues—especially with the trends suggesting that under-represented minority patients will potentially be the most adversely affected. With potential implications for arthroplasty care delivery and the future ability to utilize qualified registries to assess arthroplasty outcomes, it is crucial for advocacy efforts to guide policymakers toward ensuring the successful provision of arthroplasty care—including transparency of outcomes among patients who have elected to participate in Medicare Advantage programs.

MT42 Oxidized Zirconium Use in Primary Joint Arthroplasty: A 90-Day Episode of Care Analysis in a Large US Metropolitan Statistical Area (MSA) for Elective Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA)

Centers for Medicare and Medicaid Services has made hospitals accountable for better clinical and economical outcomes of total joint arthroplasty by introducing the Comprehensive Care for Joint Replacement Model. The objective of this study was to evaluate 90-day outcomes and costs of using Oxidized Zirconium (OxZr)1 knee and hip implants compared to non-OxZr from the New York-Newark-Jersey MSA.

Outcomes of Femoral Neck Fracture Surgery Compared Elective Total Hip Arthroplasty: Evaluation of 340 Patients

Outcomes of Femoral Neck Fracture Surgery Compared Elective Total Hip Arthroplasty: Evaluation of 340 Patients

The effect of suprainguinal fascia iliaca blocks on morphine use after total hip arthroplasty: a retrospective cohort study

Background: Good pain control after total hip arthroplasty improves patient outcomes. Fascia iliaca blocks are used as part of multimodal pain management. Objectives: We compared patient-controlled intravenous (PCIA) morphine use between patients with pre- operatively placed suprainguinal fascia iliaca compartment block (SFICB), using 40 ml ropivacaine 0.375%, and a control group (NB). Design and setting: Retrospective, single-centre cohort study. Methods: A database of the Imeldaziekenhuis in Bonheiden, Belgium was analysed. This database contained data of total hip arthroplasties performed between April 29 2019 and May 7 2021. Inclusion criteria were age &gt;18 years and undergoing an elective total hip arthroplasty. The exclusion criterium was incomplete data registration. 277 patients were included in the study, 203 patients in the SFICB group and 74 in the NB group. A retrospective comparison between these two groups was performed. Main outcome measures: The primary endpoint was PCIA morphine use at 24 hours. Secondary endpoints were PCIA morphine use between 24 and 48 hours, Numeric Rating Scale pain scores, peroperative sufentanil use, postoperative piritramide consumption and nausea. Results: The median dose of PCIA morphine at 24 hours was 5 [2 to 9] mg in the SFICB group compared to 9.5 [5 to 15.75] mg in the NB group (P=0.000034). Lower pain scores at 48 hours (P=0.0003) and peroperative sufentanil consumption (P=0.015) were reported in the SFICB group. The median NRS pain score (P=0.02) and intravenous piritramide consumption (P=0.014) on the recovery ward were significantly higher in the SFICB group than in the NB group. No difference was reported for PCIA morphine use between 24 and 48 hours, pain score at 24 hours and nausea. Conclusions: Preoperative suprainguinal fascia iliaca block leads to less PCIA morphine consumption the first 24 hours, lower NRS pain scores at 48 hours and lower peroperative opioid need for total hip arthroplasty.

Financial implications of the renewed reimbursement system of total hip arthroplasty in Belgium

In Belgium, from June 1st 2018 on, a renewed reim- bursement for hip arthroplasty implants was launched and from January 1st 2019 on, a lump sum covering doctors' fees for "low variable patients", was introduced. We investigated the impact of both reimbursement systems on the funding of a University Hospital in Belgium. All patients from the UZ Brussel with a severity of illness score of one or two whom had an elective total hip replacement implanted between January 1st and May 31st 2018, were included retrospectively. We compared their invoicing data to those of patients operated in the same period but one year later. Moreover, we simulated the invoicing data of both groups as if they had been operated in the other period. Overall, we compared invoicing data of 41 patients before and 30 after the introduction of both renewed reimbursement systems. After the introduction of both new laws, we noted a loss of funding per patient and per intervention between 46.8€ and 753.5€ for a single room and, between 105.5€ and 1877.7€ for a double room. We noted the highest loss in the subcategory "physicians' fees". The renewed reimbursement system is not "budget neutral". In time, the new system can lead to an optimization of care, but it can also lead to a progressive decrease of funding if future fees and implant reimbursements would be aligned towards the national mean. More- over, we fear the new financing system could affect the quality of care and/or result in the selection of profitable patients.

Association Between Initial Prescription Size and Likelihood of Opioid Refill After Total Knee and Hip Arthroplasty

BackgroundThe present study was designed to test the hypothesis that there was no association between initial opioid prescription size and the likelihood of refill after elective primary total knee (TKA) and hip arthroplasty (THA). MethodsWe retrospectively analyzed large national datasets of commercial and Medicare insurance claims to identify a weighted cohort of 120,889 primary total joint arthroplasties (76,900 TKA and 43,989 THA) comprised of opioid-naive patients aged 18 to 75 years who had surgery between January 2015 and November 2019. The primary outcome was refill of any prescription opioid medication within 30 days after discharge, and the primary predictor variable was the total amount of opioid filled in the initial discharge prescription measured in oral morphine equivalents (OMEs). Logistic regressions were used to estimate the likelihood of refill, given a particular prescription size while adjusting for multiple patient factors, including age, sex, comorbidities, and year of surgery. ResultsThe 30-day refill rate was 59.6% following TKA and 26.1% for THA. Adjusted odds of refill decreased by 2% for every 75 OME (10 tablets of 5 mg oxycodone) increase to the initial prescription size among the THA cohort (adjusted odds ratio [OR] = 0.98; 95% CI 0.97-0.99), and decreased by 3% for the TKA cohort (aOR = 0.97; 95% CI 0.97-0.98). ConclusionThese nationally representative data demonstrated that larger initial opioid prescription size was associated with small but clinically insignificant decreases in 30-day refill after total joint arthroplasty. This finding should allay concerns about efforts to decrease postsurgical opioid prescribing.

The Effect of Systemic Tranexamic Acid on Blood Loss and Blood Transfusion Requirement in Elective Total Hip Arthroplasty.

Although total hip arthroplasty (THA) is one of the most successful surgical procedures of the last century, high rates of bleeding and allogeneic blood transfusion may be required. Tranexamic acid (TXA) is an antifibrinolytic agent that has been increasingly used in THA in recent years to reduce blood loss and the need for transfusion. In this study, the effect of two doses of TXA, which was administered intravenously (iv) before and after surgery in unilateral THA patients, on total blood loss and blood transfusion need was compared retrospectively. A total of 327 patients who underwent elective THA at our department between January 2011 and January 2020 were identified. Demographic data, blood parameters before and after surgery and complications seen during a 90-day follow-up period were recorded from patient files. Total blood loss amounts were calculated according to Nadler&apos;s formula. The amount of transfused blood was recorded. 127 patients treated with IV TXA and 119 patients not given TXA were assigned to separate groups and compared. Total mean blood loss, decrease in hemoglobin levels and amount of blood transfusion were lower in the TXA group compared to the control group (p=0.001; p=0.001; p=0.001, respectively). The length of stay hospital was shorter in the TXA group than the control group (p=0.001). We think that it is an effective and reliable method in THA since giving IV TXA twice, as 15 mg / kg preoperatively and 10 mg / kg after the operation significantly reduces blood loss and the need for blood transfusion without causing an increase in thromboembolic complications.

Liberal use of local anaesthetic and the risk of toxicity in elective arthroplasties at a tertiary teaching hospital

Background Local anaesthetic systemic toxicity (LAST) is a life-threatening potential complication that may follow the administration of local anaesthetic (LA) drugs, and is cumulative across the drug class. Local anaesthetics are commonly administered via different routes for elective orthopaedic procedures – both by anaesthetists and surgeons. We hypothesized that total doses of LA may be routinely encroaching upon toxicity. Methods All total hip or knee arthroplasties (THAs and TKAs) performed within a 3 month period at the John Hunter Hospital (tertiary referral centre and teaching hospital) were audited to assess total administration of LA. Demographics, surgical characteristics, use of general anaesthesia or sedation, and use of local anaesthetic via any route of administration was recorded. For each patient, a weight-based theoretical maximum safe dose was calculated and compared against the dose they received. Data is presented as mean ± SD, percentages. Statistical significance was determined at p &lt; 0.05. Results 130 THAs and TKAs were identified within the audit period. 52 patients exceeded their drug-class theoretical maximum safe dose. 49 patients exceeded their weight-based maximum dose for a single LA agent, in all cases ropivacaine. Non-obese individuals receive significantly higher mean dose than obese individuals (119.4% [98.6–140.3] vs 78.82% [65.95–91.69], p = 0.001). No LAST events were identified. Conclusions Patients who received elective total hip or knee arthroplasties were exposed to concerningly high total doses of local anaesthetic, suggesting that greater awareness of the additive toxicity of drugs within this class is required.

Number of Stairs at Home Does Not Influence Discharge Disposition following Elective Total Hip Arthroplasty

Background Pragmatic challenges of the patient’s home environment, specifically the number of stairs (NOS) required to enter or navigate a patient’s home may influence discharge destination (DD) and length of stay (LOS) following primary Total Hip Arthroplasty (THA). Questions/purposes This study investigates whether the NOS at home predicts discharge to a post-acute-care-facility (PACF) following THA. Methods 548 consecutive THA patients at a single urban arthroplasty center between 2011-2014 were reviewed. Patient factors including age, sex, BMI, length of stay, operative time, Anesthesia Score Assessment (ASA), the Risk-Assessment-and-Prediction-Tool (RAPT) and NOS stairs were analyzed. Logistic regression was performed to identify predictors for disposition to PACF. Groups were cohorted by number of stairs, and incidence of PACF discharge was determined. Results 238 (43.4%) patients were discharged to PACF. The NOS at home had no impact on discharge to PACF (OR 1.02, 95% CI .993-1.04, p=0.209). Older age (OR 1.09, 95% 1.07-1.10, p&lt;0.0001), LOS (OR 1.23, 95% 1.08-1.39, p=0.001), higher ASA (OR 1.74, 95% 1.19-2.53, p=0.004), and lower RAPT score (OR 0.0.865, 95% 0.781-0.958, p=0.005) were significant predictors for disposition to PACF (p&lt;0.005). Female sex was protective in discharge to PACF (OR 0.391, 95% 0.260-0.587, p&lt;0.0001). The incidence of PACF discharge was similar between groups of unavoidable stairs at home. Conclusion The NOS at home did not influence discharge destination following THA. This retrospective study helps discharge planning and in setting expectations for patients undergoing THA by supporting a home discharge in the setting of unavoidable stairs.

Systemic Effects of Trauma and Trauma-Derived Exosomes on Bone Marrow Function

INTRODUCTION: Severe trauma disrupts bone marrow (BM) function and is associated with persistent anemia and immunosuppression. Exosomes are extracellular vesicles that have been implicated in disease, cellular functions, and immunomodulation. The effects of trauma plasma-derived exosomes on BM hematopoiesis have not been studied; we hypothesized that trauma plasma-derived exosomes would suppress BM function. METHODS: Plasma was collected from a prospective, cohort study of trauma patients (n = 15) with hip and/or femur fractures and an Injury Severity Score greater than 15; elective total hip arthroplasty patients (n = 11) served as operative controls. Exosomes were isolated from plasma with the Invitrogen Total Exosome Isolation Kit. Healthy BM was cultured with either 2% plasma, 50 µg, 100 µg, or 200 µg of exosomal protein and BM progenitor growth (CFU-GEMM, BFU-E, and CFU-GM) assessed. Differences were compared using the Mann-Whitney t-test, with significance defined as p < 0.05 vs total hip arthroplasty. RESULTS: Trauma patients were significantly younger than total hip arthroplasty patients (mean 44 vs 61 years), with no difference in sex between groups. In vitro exposure to 2% trauma plasma significantly decreased growth of all BM progenitors (Table). In vitro exposure to 50 µg did not affect BM progenitor growth; 100 µg and 200 µg of trauma exosomal protein significantly decreased growth of BFU-E (22% and 14%) and CFU-GM (12% and 13%). Table. - Cohort CFU-GEMM (/50k Plated Cells) BFU-E (/50k Plated Cells) CFU-GM (/50k Plated Cells) 2% THA plasma 18 ± 3 39 ± 2 46 ± 5 50 µg THA exosomal protein 18 ± 3 23 ± 2 51 ± 2 100 µg THA exosomal protein 19 ± 1 22 ± 3 51 ± 5 200 µg THA exosomal protein 22 ± 2 22 ± 3 47 ± 6 2% trauma plasma 15 ± 3* 29 ± 6* 40 ± 7* 50 µg trauma exosomal Protein 17 ± 3 19 ± 4 47 ± 5 100 µg trauma exosomal protein 20 ± 3 17 ± 2* 45 ± 6* 200 µg trauma exosomal protein 22 ± 2 19 ± 1* 41 ± 4* *p < 0.05.THA, total hip arthroplasty. CONCLUSION: Both plasma and plasma-derived exosomes from trauma patients adversely affect BM function. Systemic effects of plasma-derived exosomes may contribute to altered hematopoiesis after severe trauma; further analysis of exosomal content may improve our understanding of altered BM function.

Predicting Postoperative Troponin in Patients Undergoing Elective Hip or Knee Arthroplasty: A Comparison of Five Cardiac Risk Prediction Tools.

Background Elderly patients undergoing hip or knee arthroplasty are at a risk for myocardial injury after noncardiac surgery (MINS). We evaluated the ability of five common cardiac risk scores, alone or combined with baseline high-sensitivity cardiac troponin I (hs-cTnI), in predicting MINS and postoperative day 2 (POD2) hs-cTnI levels in patients undergoing elective total hip or knee arthroplasty. Methods This study is ancillary to the Genetics-InFormatics Trial (GIFT) of Warfarin Therapy to Prevent Deep Venous Thrombosis, which enrolled patients 65 years and older undergoing elective total hip or knee arthroplasty. The five cardiac risk scores evaluated were the atherosclerotic cardiovascular disease calculator (ASCVD), the Framingham risk score (FRS), the American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) calculator, the revised cardiac risk index (RCRI), and the reconstructed RCRI (R-RCRI). Results None of the scores predicted MINS in women. Among men, the ASCVD (C-statistic of 0.66; p=0.04), ACS-NSQIP (C-statistic of 0.69; p=0.01), and RCRI (C-statistic of 0.64; p=0.04) predicted MINS. Among all patients, spearman correlations (rs) of the risk scores with the POD2 hs-cTnI levels were 0.24, 0.20, 0.11, 0.11, and 0.08 for the ASCVD, Framingham, ACS-NSQIP, RCRI, and R-RCRI scores, respectively, with p values of <0.001, <0.001, <0.001, 0.006, and 0.025. Baseline hs-cTnI predicted MINS (C-statistics: 0.63 in women and 0.72 in men) and postoperative hs-cTnI (rs = 0.51, p=0.001). Conclusion In elderly patients undergoing elective hip or knee arthroplasty, several of the scores modestly predicted MINS in men and correlated with POD2 hs-cTnI.

Potential value of preoperative fasting blood glucose levels in the identification of postoperative delirium in non-diabetic older patients undergoing total hip replacement: The perioperative neurocognitive disorder and biomarker lifestyle study.

BackgroundPostoperative delirium (POD) is a common complication after total hip replacement. This study aims to explore the relationship between preoperative fasting blood glucose (FBG) levels and POD in non-diabetic older patients undergoing total hip replacement.Materials and methodsThis study included a total of 625 patients undergoing elective total hip replacement under combined spinal and epidural anesthesia from the PNDABLE study. The relationship between POD and preoperative FBG was analyzed by using the logistic regression model. The associations of FBG with individual cerebrospinal fluid (CSF) biomarkers were detected by using the multivariable linear regression model controlling for age, gender, and education level. The mediation effects were explored by mediation analyses with 5,000 bootstrap iterations, while sensitivity analysis was used to test the reliability and stability of the results. The receiver operating characteristic (ROC) curve and the nomogram model were applied to evaluate the efficacy of FBG and POD-related CSF biomarkers in predicting POD. POD assessment was performed two times daily by a trained anesthesiologist at 9:00–10:00 am and 2:00–3:00 pm on postoperative days 1–7 or before the patients were discharged from the hospital. POD was defined by the Confusion Assessment Method (CAM), and POD severity was measured using the Memorial Delirium Assessment Scale (MDAS). Enzyme-linked immunosorbent assay (ELISA) was used to measure CSF Aβ40, Aβ42, T-tau, and P-tau levels.ResultsPOD was detected in 10.2% (60/588) of the patients. Logistic regression analysis showed that after adjusting for age and education level, the increased levels of FBG (OR 1.427, 95% CI 1.117–1.824, P = 0.004), CSF P-tau (OR 1.039, 95% CI 1.019–1.060, P < 0.001), and CSF T-tau (OR 1.013, 95% CI 1.009–1.018, P < 0.001) were risk factors for POD, and the increased level of CSF Aβ42 (OR 0.996, 95% CI 0.994–0.998, P = 0.001) was a protective factor for POD. Multivariable linear regression models showed that when adjusting for age, gender, and education level, in the POD group, higher preoperative FBG levels were negatively correlated with the CSF Aβ42 level (β = −0.290, P = 0.028) and positively correlated with CSF P-tau (β = 0.384, P = 0.004) and T-tau (β = 0.447, P < 0.001). In the non-POD group, a higher preoperative FBG was not related to CSF biomarkers. Mediated effect analysis showed that CSF T-tau (proportion = 17.1%) had an apparent mediation effect on the relationship between FBG and POD. Sensitivity analysis revealed that the results from the logistic regression and multivariable linear regression models were consistent with previous results.ConclusionIncreased preoperative FBG was a risk factor for POD in older patients without T2DM, and T-tau might mediate the relationship between FBG and POD.

Lumbar Erector Spinae Plane Block for Total Hip Arthroplasty Comparing 24-Hour Opioid Requirements: A Randomized Controlled Study.

Design Prospective, randomized, controlled trial. Patients. Sixty-three adult patients with an American Society of Anesthesiologists Status I–III who are undergoing elective primary total hip arthroplasty. Interventions. Patients were randomized to the control group (no block) or the ESPB group (preoperative ultrasound-guided lumbar ESPB). Intraoperatively, all patients received spinal anesthesia with moderate sedation. Postoperatively, patients received a standardized multimodal analgesia protocol. Measurements. The primary outcome was cumulative opioid consumption at 24 hours postoperatively. Secondary outcomes included cumulative opioid consumption at 8 hours and through 48 hours postoperatively and pain scores at 24 and 48 hours post surgery. Main Results. Thirty-one patients were randomized to the control group (spinal alone) and 32 patients to the ESPB group. The median opioid requirement in the first 8 hours after surgery was higher in the control group (28 mg of oral morphine equivalents (OME) versus 5 mg of OME in the ESPB group) (p = 0.013). There was no statistically significant difference in opioid consumption between the groups at 24 hours (p = 0.153) or 48 hours (p = 0.357) postoperatively. There was no statistically significant difference in pain scores between the two groups through 24 hours (p = 0.143) or 48 hours (p = 0.617) after surgery. Conclusion Lumbar ESPB reduces opioid utilization during the first 8 hours postoperatively after total hip arthroplasty but not thereafter. Evaluating the use of either adding a local anesthetic adjunct to the ESPB or using longer-acting local anesthetic warrants further investigation.

Prostate Cancer History and Total Hip Arthroplasty: A Matched Cohort Analysis Investigating Venous Thromboembolism and Anticoagulation

BackgroundProstate cancer (PCa) is a common cancer among men in the United States. While malignancy is a known cause of venous thromboembolism (VTE), little is known about the effect of PCa history on postoperative complications after elective total hip arthroplasty (THA). This study aimed to evaluate the risk of hematologic complications in patients with a history of PCa taking common postoperative anticoagulants. MethodsTHA patients were identified through the PearlDiver Mariner database. Patients with a history of PCa were placed in one of the following cohorts based on postoperative anticoagulant prescription: aspirin, warfarin, low-molecular-weight heparin, direct Xa inhibitor, or any anticoagulant. PCa cohorts were matched 1:3 to patients without a history of PCa with the same anticoagulant prescription based on age, gender, and Charlson Comorbidity Index. Postoperative complications were evaluated using multivariable logistic regression. ResultsA total of 74,744 patients that underwent THA were included. PCa patients taking any anticoagulant were found to have increased risk of postoperative deep vein thrombosis (DVT) (odds ratio: 1.25, lower 99% confidence interval: 1.09, upper 99% confidence interval: 1.43, P value <.001). PCa patients taking warfarin, low-molecular-weight heparin, and direct Xa inhibitors additionally showed increased risk of postoperative DVT. Patients taking aspirin did not have an increased risk of postoperative DVT. ConclusionsOur results suggest postoperative aspirin prophylaxis may not increase VTE complication risk when compared to other anticoagulants. Surgeons should be aware that PCa history may be an independent risk factor for VTE, and these patients may benefit from medical optimization.

Predictors and complications of blood transfusion in rheumatoid arthritis patients undergoing total joint arthroplasty.

Our research investigated predictors of postoperative blood transfusion rate following total joint arthroplasty (TJA) in patients with rheumatoid arthritis (RA) and evaluated the incidence of complications in the transfusion group and non-transfusion group. The authors retrospectively analyzed risk factors among 320 RA patients who underwent elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) from January 2010 to December 2018. Demographic characteristics, laboratory results, medication history, and surgical protocol were gathered from electronic medical records. Univariable and multivariable logistic regression analyses were conducted to measure the impact of relevant variables on the need for transfusions. In addition, we compared the incidence of complications associated with transfusion. The cohort comprised 320 RA patients, aged 57.4 ± 12.0years, of whom 137 required postoperative blood transfusions and 183 did not. BMI, type of surgery, duration of surgery, disease activity score 28 (DAS28-CRP), tranexamic acid (TXA) administration, and preoperative hemoglobin (Hb) were all risk factors for transfusion after adjusting for the planned procedure. Previously published predictors, such as BMI, low preoperative hemoglobin, duration of surgery, procedure type (THA), were also identified in our analysis. Moreover, TXA administration and the DAS28-CRP showed the potential to influence risk. The incidence of postoperative complications was increased in patients who received blood transfusions compared to non-transfusion group. Our findings could help to identify RA patient population requiring blood transfusions, to ensure the necessary steps are adopted to limit blood loss and improve blood management strategies. Key Points • The risk factors for blood transfusion in rheumatoid arthritis patients undergoing total joint arthroplasty were BMI, the type of surgery, duration of surgery, TXA administration, DAS28-CRP, and preoperative hemoglobin. • The incidence of postoperative complications was increased in patients who received blood transfusions compared to non-transfusion group.

Outpatient Total Joint Arthroplasty: Are We Closing the Racial Disparities Gap?

As ne arly half of all total joint arthroplasty (TJA) procedures are projected to be performed in the outpatient setting by 2026, the impact of this trend on health disparities remains to be explored. This study investigated the racial/ethnic differences in the proportion of TJA performed as outpatient as well as the impact of outpatient surgery on 30-day complication and readmission rates. The ACS National Surgical Quality Improvement Program was retrospectively reviewed for all patients who underwent primary, elective total hip and knee arthroplasty (THA, TKA) between 2011 and 2018. The proportion of TJA performed as an outpatient, 30-day complications, and 30-day readmission among African American, Hispanic, Asian, Native American/Alaskan, and Hawaiian/Pacific Islander patients were each compared to White patients (control group). Analyses were performed for each racial/ethnic group separately. A general linear model (GLM) was used to calculate the odds ratios for receiving TJA in an outpatient vs. inpatient setting while adjusting for age, gender, body mass index (BMI), functional status, and comorbidities. In total, 170,722 THAs and 285,920 TKAs were analyzed. Compared to White patients, non-White patients had higher likelihood of THA or TKA performed as an outpatient (OR 1.31 and 1.24 respectively for African American patients, OR 1.65 and 1.76 respectively for Hispanic patients, and OR 1.66 and 1.59 respectively for Asian patients, p < 0.001). Outpatient surgery did not lead to increased complications in any of the study groups compared to inpatient surgery (p > 0.05). However, readmission rates were significantly higher for outpatient TKA in all the study groups compared to inpatient TKA (OR range 2.47-10.15, p < 0.001). Complication and readmission rates were similar between inpatient and outpatient THA for all the study groups. While this study demonstrated higher proportion of TJA performed as an outpatient among most non-White racial/ethnic groups, this observation should be tempered with the increased readmission rates observed in outpatient TKA, which could further the disparities gap in health outcomes.

Reduction in Offset Is Associated With Worse Functional Outcomes Following Total Hip Arthroplasty

BackgroundConflicting reports exist about the effect of offset variation on functional outcomes following total hip arthroplasty. Reproducing native hip offset is thought to optimize function by restoring biomechanics and appropriately tensioning the hip abductor muscles. The aim of this study is to assess the effect of failing to restore global hip offset in comparison to the native contralateral hip. MethodsA retrospective analysis of a prospective patient cohort was performed on patients undergoing an elective primary total hip arthroplasty. A total of 414 patients who had a minimum of 12 months of follow-up were included. Postoperative plain radiographs were analyzed for offset and compared to the contralateral native hip. Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Veterans RAND 12 (VR-12) scores were assessed preoperatively and at 12 months postoperatively. ResultsRegression analyses indicated that a reduction in offset of >20 mm resulted in worse WOMAC pain (P = .005) and motion (P = .015) scores compared to those with maintained offset. WOMAC function (P = .063), global (P = .025), and VR-12 scores were not affected (physical P = .656; mental P = .815). Reduction in offset up to 20 mm and increased offset were not significantly associated with patient-reported outcome measures (P-values ranged from .102 to .995). ConclusionThis study demonstrated an association between reduction in offset by >20 mm and worse WOMAC pain and motion scores following total hip arthroplasty. Surgeons should avoid decreases in offset >20 mm in order to optimize functional outcomes.

Temporal Trends in Deep Surgical Site Infections After Six Orthopaedic Procedures Over a 12-year Period Within a US-based Healthcare System.

Centers of excellence and bundled payment models have driven perioperative optimization and surgical site infection (SSI) prevention with decolonization protocols and antibiotic prophylaxis strategies. We sought to evaluate time trends in the incidence of deep SSI and its causative organisms after six orthopaedic procedures in a US-based integrated healthcare system. We conducted a population-level time-trend study using data from Kaiser Permanente's orthopaedic registries. All patients who underwent primary anterior cruciate ligament reconstruction (ACLR), total knee arthroplasty (TKA), elective total hip arthroplasty (THA), hip fracture repair, shoulder arthroplasty, and spine surgery were identified (2009 to 2020). The annual incidence of 90-day deep SSI was identified according to the National Healthcare Safety Network/Centers for Disease Control and Prevention guidelines with manual chart validation for identified infections. Poisson regression was used to evaluate annual trends in SSI incidence with surgical year as the exposure of interest. Annual trends in overall incidence and organism-specific incidence were considered. The final study sample was composed of 465,797 primary orthopaedic procedures. Over the 12-year study period, a decreasing trend in deep SSI was observed for ACLR and hip fracture repair. Although there was variation in incidence rates for specific operative years for TKA, elective THA, shoulder arthroplasty, and spine surgery, no consistent decreasing trends over time were found. Decreasing rates of Staphylococcus aureus infections over time after hip fracture repair, shoulder arthroplasty, and spine surgery and decreasing trends in antibiotic resistance after elective THA and spine surgery were also observed. Increasing trends of polymicrobial infections were observed after TKA and Cutibacterium acnes after elective THA. The overall incidence of deep SSI after six orthopaedic procedures was rare. Decreasing SSI rates were observed for ACLR and hip fracture repair within our US-based healthcare system. Polymicrobial infections after TKA and Cutibacterium acnes after elective THA warrant closer surveillance. IV.

Temporal trends in comorbidity in adult elective hip and knee arthroplasty patients in England : a national population-based cohort study from the National Joint Registry.

Our main aim was to describe the trend in the comorbidities of patients undergoing elective total hip arthroplasties (THAs) and knee arthroplasties (KAs) between 1 January 2005 and 31 December 2018 in England. We combined data from the National Joint Registry (NJR) on primary elective hip and knee arthroplasties performed between 2005 and 2018 with pre-existing conditions recorded at the time of their primary operation from Hospital Episodes Statistics. We described the temporal trend in the number of comorbidities identified using the Charlson Comorbidity Index, and how this varied by age, sex, American Society of Anesthesiologists (ASA) grade, index of multiple deprivation, and type of KA. We included 696,504 and 833,745 elective primary THAs and KAs respectively, performed for any indication. Between 2005 and 2018, the proportion of elective THA and KA patients with one or more comorbidity at the time of their operation increased substantially (THA: 20% to 38%, KA: 22% to 41%). This was driven by increases in four conditions: chronic obstructive pulmonary disease (COPD) (2018: ~17%), diabetes without complications (2018: THA 10%, KA 14%), myocardial infarction (2018: 4%), and renal disease (2018: ~8%). Notably, renal disease prevalence increased from < 1% in 2005 to ~8% in 2018. Between 2005 and 2018 there were significant changes in the number of comorbidities recorded in patients having elective primary THAs and KAs. Renal disease is now one of the most prevalent comorbidities in this patient population. Future research should explore whether this comorbidity trend has increased the burden on other medical specialities to optimize these patients before surgery and to provide additional postoperative care.Cite this article: Bone Joint J2022;104-B(9):1052-1059.