Elective Total Joint Arthroplasty Research Articles

INCIDENTAL FINDINGS AND CLINICAL SIGNIFICANCE OF PREOPERATIVE CT IMAGING FOR THE PLANNING OF ROBOTIC ARTHROPLASTY

Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures used for the management of end-stage arthritis. With the recent introduction of robotic-assisted joint replacement, Computed tomography (CT) has become part of required pre-operative planning.The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on the planned joint arthroplasty.All consecutive patients undergoing an elective TJA (total joint arthroplasty; hip or knee) were retrospectively identified, over a 4-year period (December 2019 and November 2023). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation.A total of 987 patients (female: 514 patients (52.1%)) undergoing TJA were identified (THA: 444 patients (45.0%); TKA: 400 patients (40.5%); UKA: 143 patients (14.5%)). Incidental findings within imaged areas were identified in 227 patients (23.0%). Of these findings, 74 (7.5%) were significant, requiring further investigation or management, 40 (4.1%) of which represented potential malignancy and 4 (0.4%) resulting in a new cancer diagnosis. A single patient was found to have an aneurysm requiring urgent vascular intervention. Surgery was delayed for further investigation in 4 patients (0.4%). Significant findings were more frequent in THA patients (THA: 43 (9.7%) TKA/UKA: 31 (5.7%)Within our cohort, 74 (7.5%) patients had significant incidental findings that required further investigations or management, with 4 (0.4%) having a previously undiagnosed malignancy. We strongly advocate that all robotic arthroplasty planning CTs are reviewed and reported by a specialist, to avoid missing undiagnosed malignancies and other significant diagnoses.

Opiate prescription after hip and knee arthroplasty: a retrospective cohort study.

Excessive opiate analgesia in relation to orthopaedic surgery is associated with morbidity and mortality. Pre-operative use of opiates is associated with higher post-operative use. There is little information about opiate prescribing practices in relation to elective total joint arthroplasty (TJA) in New Zealand rural centres. The aims of this study were to describe opiate use before, immediately after and 1 year after TJA, and to compare prescribing practices with local guidelines. A retrospective cohort study of elective primary hip and knee arthroplasties was conducted between January 2018 and April 2019. Opiate use was evaluated from clinical records and from electronic prescribing records and described in morphine milligram equivalents (MME) with a particular focus on pre-operative and post-operative periods, and use after 1 year. In the study period, 199 patients underwent 203 joint arthroplasties. Of these, data from 157 patients were analysed. Patient data were not analysed because of unavailable files (N=20), non-elective procedures (N=11), bilateral arthroplasties (N=4), deaths (N=4) and incomplete information (N=3). Pre-operative opiates were used by 92 (59%) patients, of whom 70 (76%) were not using opiates after 1 year. There were 126 (80%) patients who were discharged with opiate prescriptions and the vast majority, 121 (96%), did not receive discharge prescriptions that conformed to local guidelines. Despite undergoing joint arthroplasty, about one quarter of patients who had been prescribed opiates before the operation were still receiving opiates after 1 year. There was poor compliance with local guidelines.

Racial Disparities in Treatment and Outcomes of Patients With Hepatitis C Undergoing Elective Total Joint Arthroplasty

BackgroundAfrican Americans have the highest prevalence of chronic Hepatitis C virus (HCV) infection. Racial disparities in outcome are observed after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study sought to identify if disparities in treatments and outcomes exist between Black and White patients who have HCV prior to elective THA and TKA. MethodsPatient demographics, comorbidities, HCV characteristics, perioperative variables, in-hospital outcomes, and postoperative complications at 1-year follow-up were collected and compared between the 2 races. Patients who have preoperative positive viral load (PVL) and undetectable viral load were identified. Chi-square and Fisher’s exact tests were used to compare categorical variables, while 2-tailed Student’s Kruskal-Wallis t-tests were used for continuous variables. A P value of less than .05 was statistically significant. ResultsThe liver function parameters, including aspartate aminotransferase and model for end-stage liver disease scores, were all higher preoperatively in Black patients undergoing THA (P = .01; P < .001) and TKA (P = .03; P = .003), respectively. Black patients were more likely to undergo THA (65.8% versus 35.6%; P = .002) and TKA (72.1% versus 37.3%; 0.009) without receiving prior treatment for HCV. Consequently, Black patients had higher rates of preoperative PVL compared to White patients in both THA (66% versus 38%, P = .006) and TKA (72% versus 37%, P < .001) groups. Black patients had a longer length of stay for both THA (3.7 versus 3.3; P = .008) and TKA (4.1 versus 3.0; P = .02). ConclusionsThe HCV treatment prior to THA and TKA with undetectable viral load has been shown to be a key factor in mitigating postoperative complications, including joint infection. We noted that Black patients were more likely to undergo joint arthroplasty who did not receive treatment and with a PVL. While PVL rates decreased over time for both races, a significant gap persists for Black patients.

Prevalence of Methicillin Resistant Staphylococcus aureus Colonisation in Patients undergoing Total Joint Arthroplasty: A Retrospective Observational Study

Introduction: Methicillin Resistant Staphylococcus aureus (MRSA) presents a significant, yet preventable, complication in Total Joint Arthroplasties (TJAs). Surgical Site Infections (SSIs) of prosthetic joints resulting from MRSA lead to substantial patient morbidity, mortality, and impose a significant burden on healthcare budgets. One method to mitigate these risks is to screen for MRSA colonisation prior to elective surgeries. The prevalence of MRSA colonisation in nasal mucosa ranges from 0.18-7.2% in different patient populations, with a nosocomial prevalence of 1.7%. Aim: To determine the prevalence of MRSA colonisation in all patients undergoing elective TJA, including Total Hip Replacement (THR) or Total Knee Replacement (TKR). Materials and Methods: A retrospective observational study was conducted on a total of 407 patients scheduled for elective TJAs. Data from 407 patients who underwent elective TJA between January 2020 and December 2022 (a period of three years) were selected for the study. Data compilation and analysis of the study subjects were performed retrospectively until March 2023 at the Sanjay Gandhi Institute of Trauma and Orthopaedics, a tertiary care Orthopaedic centre in Bengaluru, Karnataka, India. The study subjects were screened for MRSA colonisation through nasal swab culture and sensitivity. Patients with positive MRSA culture results were treated with decolonisation therapy, which involved the local application of 2% mupirocin and chlorhexidine body wash for five days. Descriptive data analytics were employed in the study, and tables were generated using Microsoft Word 2010 and Microsoft Excel 2010 (Microsoft Corp, Redmond, WA, USA). Results: The prevalence rates of MRSA nasal colonisation were n1=8 (8.42%), n2=2 (2%), and n3=16 (7.55%) for the years 2020 (n1), 2021 (n2), and 2022 (n3), respectively, at the centre. The period prevalence rate of MRSA colonisation in the nasal mucosa over three years was N=26 (6.4%). Conclusion: The present study revealed a high period prevalence of MRSA colonisation (6.4%) in patients undergoing TJAs. Therefore, all elective TJAs should undergo MRSA screening and decolonisation using 2% intranasal mupirocin and daily chlorhexidine body wash for five days as a successful treatment modality for all patients with MRSA-positive nasal colonisation. This approach helps prevent postoperative SSIs caused by MRSA.

Impact of preoperative frailty on choice of anesthesia modality and outcomes in elderly total joint replacement patients

This study investigated the correlation between the degree of frailty and postoperative adverse outcomes after total joint arthroplasty (TJA) in patients undergoing TJA who received general anesthesia (GA) or intraspinal anesthesia (IA). The cohort comprised 660 elderly patients who underwent TJA and were assessed using the Fatigue, Resistance, Ambulation, Illness and Loss of Weight (FRAIL) scale. A total of 660 patients aged 65 years or older who underwent elective total joint arthroplasty were included in the analysis. Of them, 182 (27.58%) were identified as frail. GA was performed in 252 patients and IA in 408 patients. The type of anesthesia did not significantly affect outcomes across the Healthy, Pre-frailty and Frailty groups (p &gt; 0.05). During the 1-year follow-up period, 78 deaths occurred: 3 in the Healthy group, 16 in the Pre-frailty group, and 59 in the Frailty group, revealing significant differences in mortality rates among these groups (p &lt; 0.05). Multivariate logistic regression analysis indicated that frailty significantly increased the risk of 1-year postoperative mortality following total joint arthroplasty in this elderly cohort (p &lt; 0.05). Specifically, the Frailty group exhibited a 2.674-fold higher risk of 1-year postoperative death compared to the Healthy group. Further analysis within the frail elderly population demonstrated that GA was a significant predictor of increased 1-year postoperative mortality risk (p &lt; 0.05), with frail patients undergoing GA experiencing a 2.958-fold higher risk of death within one year post-operation compared to those receiving IA. In conclusion, the results support prioritizing IA in frail elderly patients to minimize the adverse effects of GA on long-term mortality risk.

AZU1: a new promising marker for infection in orthopedic and trauma patients?

Early and reliable detection of infection is vital for successful treatment. Serum markers such as C-reactive protein (CRP) and procalcitonin (PCT) are known to increase with a time lag. Azurocidin 1 (AZU1) has emerged as a promising marker for septic patients, but its diagnostic value in orthopedic and trauma patients remains unexplored. Between July 2020 and August 2023, all patients necessitating inpatient treatment for periprosthetic joint infection (PJI), peri-implant infection (II), soft tissue infection, chronic osteomyelitis, septic arthrodesis, bone non-union with and without infection were enrolled. Patients undergoing elective total joint arthroplasty (TJA) served as the control group. Blood samples were collected and analyzed for CRP, white blood cell count (WBC), PCT, and AZU1. Based on the inclusion and exclusion criteria 222 patients were included in the study (trauma = 38, soft tissue infection = 75, TJA = 33, PJI/II = 39, others = 37). While sensitivity and specificity were comparably high for AZU1 (0.734/0.833), CRP and PCT had higher specificity (0.542/1 and 0.431/1, respectively), and WBC a slightly higher sensitivity (0.814/0.455) for septic conditions. Taken together, the area under the curve (AUC) showed the highest accuracy for AZU1 (0.790), followed by CRP (0.776), WBC (0.641), and PCT (0.656). The Youden-Index was 0.57 for AZU1, 0.54 for CRP, 0.27 for WBC, and 0.43 for PCT. Elevated AZU1 levels effectively distinguished patients with a healthy condition from those suffering from infection. However, there is evidence suggesting that trauma may influence the release of AZU1. Additional research is needed to validate the diagnostic value of this new biomarker and further explore its potential clinical applications.

Maintenance of Surgical Optimization in Total Joint Arthroplasty Patients

BackgroundThere are increased efforts to maximize medical optimization to improve the outcomes of total joint arthroplasty (TJA). However, there is a paucity of literature demonstrating that optimized parameters are maintained throughout the perioperative period. MethodsA retrospective review of 877 elective TJA patients from 2015 to 2019 was conducted. Patients who underwent medical optimization for body mass index (BMI), hemoglobin A1c (HbA1c), hemoglobin, albumin, and smoking status were reviewed at the initial visit, preoperatively, time of surgery, and one year postoperatively. For each of these variables at each time point, patients were stratified into 3 optimization groups. Analyses were performed to identify mean time to optimization, loss of optimization, and maintenance of optimization. ResultsPatients considered not optimized due to specific parameters at the initial visit were as follows: BMI (19%), HbA1c (13.5%), hemoglobin (16%), albumin (19%), and smoking status (9.5%). The mean time to optimization was 187.7 days [longest being BMI (220.1 days), and the shortest being HbA1c (60.9 days) (P = .0003)]. Patients who had intermediate optimization of BMI at the preoperative visit were at higher risk [odds ratio: 2.1 (0.97 to 4.6)] of worsening BMI by time of surgery (P < .0001). Between the preoperative and surgery time points, over 93.5% of patients maintained or improved optimization. ConclusionsSurgeon led medical optimization efforts alongside a TJA program provide maintenance of, or improvement in optimization in more than half of TJA patients up to one year postoperatively. Patients who had a BMI between 40 and 45 at the preoperative visit are at significant risk of increasing their BMI by the day of surgery.

Total Hip and Total Knee Arthroplasty Outpatient Case Volume During the 2020 COVID-19 Pandemic in New York and California

BackgroundInpatient total hip and total knee arthroplasty were substantially impacted by the SARS-CoV-2 (COVID-19) pandemic. We sought to characterize the transition of total joint arthroplasty (TJA) to the outpatient setting in 2 large state health systems during this pandemic. MethodsAdult patients who underwent primary elective TJA between January 1, 2016 and December 31, 2020 were retrospectively reviewed using the New York Statewide Planning and Research Cooperative System and California Department of Health Care Access and Information datasets. Yearly inpatient and outpatient case volumes and patient demographics, including age, sex, race, and payer coverage, were recorded. Continuous and categorical variables were compared using descriptive statistics. Significance was set at P < .05. ResultsIn New York during 2020, TJA volume decreased 16% because 22,742 fewer inpatient TJAs were performed. Much of this lost volume (46.6%) was offset by a 166% increase in outpatient TJA. In California during 2020, TJA volume decreased 20% because 34,114 fewer inpatient TJAs were performed. Much of this lost volume (37%) was offset by a 47% increase in outpatient TJA. ConclusionsThis present study demonstrates a marked increase in the proportion of TJA being performed on an outpatient basis in both California and New York. In both states, despite a decrease in overall TJA volume in 2020, outpatient TJA volume increased markedly. Level of EvidenceTherapeutic Level IV, Retrospective Cohort Study.

Medicare Advantage Is Associated with Lower Utilization of Total Joint Arthroplasty.

Medicare Advantage (MA) insurers use managed care techniques to review the utilization of medical services and control costs. It is unclear if MA enrollees have a lower utilization of elective surgical procedures such as inpatient hip and knee total joint arthroplasty (TJA), which have traditionally been covered by traditional Medicare (TM) without restrictions. We conducted a cross-sectional study using a 20% sample of 2018 TM claims and MA encounter records for 5,300,188 TM enrollees and 1,970,032 MA enrollees who were 65 to 85 years of age. We calculated unadjusted and adjusted differences (controlling for beneficiary and market characteristics) in the incidence of TJA for MA compared with TM, and by MA plan type. Finally, we calculated differences in the time to contact with an orthopaedic surgeon and time to the surgical procedure among enrollees with an osteoarthritis diagnosis. After controlling for observable characteristics, there was a 15.6% lower incidence of TJA in MA enrollees compared with TM enrollees (p < 0.001). Compared with TM enrollees, health maintenance organization (HMO) enrollees were 28.1% less likely to undergo TJA, controlling for observable characteristics (p < 0.001). From the initial diagnosis, the time to contact with an orthopaedic surgeon and the time to the surgical procedure were also lower among TM enrollees compared with MA enrollees. At 2 years after an osteoarthritis diagnosis, 10.4% of TM enrollees, 7.9% of preferred provider organization (PPO) enrollees, and 5.7% of HMO enrollees had undergone inpatient TJA. MA coverage was associated with a lower utilization of elective, inpatient hip and knee TJA. MA was also associated with a longer time to orthopaedic surgeon evaluation and surgical procedure. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Tranexamic Acid Is Safe in Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty.

Tranexamic acid (TXA) is increasingly utilized during total knee arthroplasty (TKA) and total hip arthroplasty (THA) to decrease blood loss; however, there are concerns with regard to potential thromboembolic complications, particularly in high-risk patients. This study sought to define a subset of patients at elevated risk for thromboembolic complications following total joint arthroplasty (TJA) and to compare postoperative outcomes between patients who received TXA and those who did not. Patients who underwent primary, elective TJA from 2015 to 2021 were identified in the Premier Healthcare Database. Patients with a history of venous thromboembolism, defined as a history of pulmonary embolism or deep vein thrombosis, were identified and formed the high-risk cohort. Patient demographic characteristics, hospital factors, patient comorbidities, antithrombotic medication use, perioperative blood transfusion, and 90-day complications were assessed and compared between patients who received TXA and those who did not. Univariate regression and multivariable regression were performed to account for potential confounders. The high-risk cohort comprised 70,759 patients who underwent TJA, of whom 46,074 (65.1%) received TXA and 24,685 (34.9%) did not. After controlling for confounding factors, patients in the TXA cohort had similar risks of pulmonary embolism (adjusted odds ratio [OR], 0.90 [95% confidence interval (CI), 0.79 to 1.02]; p = 0.097), stroke (adjusted OR, 0.97 [95% CI, 0.69 to 1.37]; p = 0.867), and myocardial infarction (adjusted OR, 0.93 [95% CI, 0.69 to 1.24]; p = 0.614) compared with patients who did not receive TXA. Patients who received TXA demonstrated decreased risks of transfusion (adjusted OR, 0.42 [95% CI, 0.38 to 0.46]; p < 0.001) and 90-day readmission (adjusted OR, 0.87 [95% CI, 0.80 to 0.94]; p < 0.001). TXA utilization was not associated with an increased risk of postoperative pulmonary embolism, stroke, or myocardial infarction in patients with a history of venous thromboembolism. Furthermore, patients who received TXA had a decreased risk of transfusion and readmission. This evidence suggests that TXA may be safely utilized among select high-risk patients. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Impact of Postoperative COVID-19 Infection Status on Outcomes in Elective Primary Total Joint Arthroplasty

BackgroundAlthough Coronavirus disease 2019 (COVID-19) infection causes major morbidity and mortality, it is unclear what the impact of postoperative COVID-19 infection is on 30-day outcomes after total joint arthroplasty (TJA). MethodsThere were 2,340 patients who underwent TJA in 2021, identified using the National Surgical Quality Improvement Program database, with 925 total hip arthroplasty (THA) patients (39.5%) and 1,415 total knee arthroplasty (TKA) patients (60.5%), overall. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for postoperative COVID-19–positive and COVID-19–negative patients who underwent TKA or THA. ResultsPostoperative COVID-19–positive THA patients were found to have a significantly increased risk of pneumonia (odds ratio [OR] 42.57), sepsis (OR 12.77), readmission (OR 12.06), non-home discharge (OR 3.78), and longer length of stay (hazard ratio 1.62). Postoperative COVID-19–positive TKA patients had an increased risk of 30-day mortality (OR 14.17), superficial infection (OR 3.17), pneumonia (OR 34.68), unplanned intubation (OR 18.31), ventilator use for more than 48 hours (OR 18.31), pulmonary embolism (OR 11.98), urinary tract infection (OR 5.16), myocardial infarction (OR 16.02), deep vein thrombosis (OR 4.69), non-home discharge (OR 1.79), reoperation (OR 3.17), readmission (OR 9.61), and longer length of stay (hazard ratio 1.49). ConclusionsPatients who contracted COVID-19 within 30 days after TJA were at increased risk of mortalities, medical complications, readmissions, reoperations, and non-home discharges. It is important for orthopedic surgeons to understand these adverse outcomes to better counsel patients and mitigate these risks, particularly in higher risk populations.

The Role of a Registered Dietitian Nutritionist in Improving Weight Loss Prior to Elective Total Joint Arthroplasty in Overweight or Obese Adults Among Participants in MODIFY, a Pre-surgical Optimization Program

The Role of a Registered Dietitian Nutritionist in Improving Weight Loss Prior to Elective Total Joint Arthroplasty in Overweight or Obese Adults Among Participants in MODIFY, a Pre-surgical Optimization Program

Staphylococcus aureus colonization and periprosthetic joint infection in patients undergoing elective total joint arthroplasty: a narrative review.

Peri-prosthetic joint infections (PJIs) following total joint arthroplasty (TJA) are associated with higher treatment costs, longer hospital admissions and increased morbidity and mortality. Colonization with Staphylococcus aureus is an independent and modifiable risk factor for PJIs and carriers of S. aureus are ten times more likely than non-carriers for post-operative infections. Screening and targeted decolonization, vs universal decolonization without screening, remains a controversial topic. We recommend a tailored approach, based on local epidemiological patterns, resource availability and logistical capacity. Universal decolonization is associated with lower rates of SSI and may reduce treatment costs.

A Novel Protocol for Nasal Decolonization Using Prolonged Application of an Alcohol-Based Nasal Antiseptic Reduces Surgical Site Infections in Total Joint Arthroplasty Patients: A Retrospective Cohort Study.

Background: Current nasal decolonization strategies utilize pre-operative agents without consideration for short-term re-colonization or de novo colonization. Many strategies utilize an antibiotic-based agent, raising concerns of limited gram-negative antimicrobial coverage and the emergence of resistant bacterial strains. This study evaluated the clinical utility of a non-antibiotic, alcohol-based nasal decolonization agent in decreasing surgical site infection (SSI) rates after total joint arthroplasty. Patients and Methods: We retrospectively compared an 18-month cohort of elective primary total joint arthroplasty patients treated peri-operatively with an alcohol-based sanitizer to historical controls. The alcohol-based agent was administered pre-operatively the day of surgery and for two weeks after surgery. Patients were followed for 90 days and assessed for signs or symptoms of SSI. Patient and caregiver compliance was recorded. There were 779 patients included in the experimental group and 647 included in the historical control group. Results: Patients receiving alcohol-based nasal decolonization had a lower rate of SSI compared with controls not receiving nasal decolonization (0.64% [5/779] vs. 1.55% [10/647]; p = 0.048; odds ratio, 2.43). Utilization of an alcohol-based nasal sanitizer in the pre-operative and prolonged post-operative setting decreased infection rates by 41.3% in our elective total joint arthroplasty setting. Conclusions: When used pre- and post-operatively, alcohol-based nasal decolonization of bacteria in patients undergoing total joint arthroplasty led to a substantial decrease in SSIs.

Relationship Between Pre- and Post-Operative C-Reactive Protein (CRP), Neutrophil-to-Lymphocyte Ratio (NLR), and Platelet-to-Lymphocyte Ratio (PLR) With Post-Operative Pain After Total Hip and Knee Arthroplasty: An Observational Study.

Anesthetic technique and postoperative pain management are crucial for total joint arthroplasty (TJA) patients. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP) are new, simple, and cost-effective predictors for prognosis. The predictive value of NLR as an inflammatory marker can predict post-operative pain caused by inflammatory pathways secondary to surgical trauma. CRP is also the most sensitive and specific biomarker of inflammation whereas PLR was also recently considered a possible marker for inflammation which may further contribute to pain and sequelae.Thus, anesthetists can make decisions about the amount, time, and type of analgesic to use based on preoperative values of these parameters to provide maximum postoperative pain control and facilitate early rehabilitation. Thus, the current study was conducted to determine the relationship between CRP, NLR, and PLR levels and the intensity of pain in patients following total hip arthroplasty (THA) and total knee arthroplasty (TKA). A total of 105 patients scheduled for THA and TKA fulfilling the study's inclusion criteria were enrolled.Inclusion criteria of the study were all the patients giving written consent, ASA Grade I-III, patients between 18 and 90 years who were scheduled for elective lower extremity TJA, and all the patients who remained admitted until stitches were removed. Patients were given intrathecal 15 mg hyperbaric bupivacaine via 25G atraumatic spinal needle in the L3-L4 interspace. The recorded data were demographic characteristics, preexisting comorbidities, number of blood transfusions, and operation time, postoperative analgesics given, duration of hospital stay, time of mobility, pain scoring as per visual analog scale (VAS) scoring system with an aim to establish a relationship between pre- and post-operative (Days 3 & 5) CRP, NLR, and PLR with post-operative pain after THA and TKA. The present study demonstrated a significant correlation (p < 0.002) between preoperative and postoperative NLR with pain after TJA whereas PLR and CRP did not show any significant relationship with post-operative pain after THA and TKA. A significantly higher NLR ratio was observed for patients on all the periods of observation (pre-op., Day 3, and Day 5). Pre-op. and Day 5 NLR of patients who required transfusion were significantly higher than those who did not require transfusion and patients with higher NLR values could be mobilized significantly later and had significantly higher duration of hospital stay. The correlation of CRP levels and PLR levels at different time intervals did not show a significant correlation with Day 3 and Day 5 pain scores. The present study demonstrated a significant correlation between preoperative and postoperative NLR with pain after TJA.

Utilization of Total Joint Arthroplasty by Rural-Urban Designation in Patients With Osteoarthritis in a Universal Coverage System

BackgroundUtilization of total joint arthroplasty (TJA) is affected by differences linked to sex, race, and socioeconomic status; there is little information about how geographic variation contributes to these differences. We sought to determine whether discrepancies in TJA utilization exist in patients diagnosed with osteoarthritis (OA) based upon urban-rural designation in a universal coverage system. MethodsWe conducted a cohort study using data from a US-integrated healthcare system (2015 to 2019). Patients aged ≥50 years who had a diagnosis of hip or knee OA were included. Total hip arthroplasty and total knee arthroplasty utilization (in respective OA cohorts) was evaluated by urban-rural designation (urban, mid, and rural). Incidence rate ratios (IRRs) for urban-rural regions were modeled using multivariable Poisson regressions. ResultsThe study cohort included 93,642 patients who have hip OA and 275,967 patients who had knee OA. In adjusted analysis, utilization of primary total hip arthroplasty was lower in patients living in urban areas (IRR = 0.87, 95% confidence interval = 0.81 to 0.94) compared to patients in rural regions. Similarly, total knee arthroplasty was used at a lower rate in urban areas (IRR = 0.88, 95% confidence interval = 0.82 to 0.95) compared with rural regions. We found no differences in the hip and knee groups within the mid-region. ConclusionsIn hip and knee OA patients enrolled in a universal coverage system, we found patients living in urban areas had lower TJA utilization compared to patients living in rural areas. Further research is needed to determine how patient location contributes to differences in elective TJA utilization. Level of EvidenceIII.

‘Maze’ not pathway: focus group exploration of patients’ and public experiences of the UK NHS elective total joint arthroplasty pathway

ObjectiveTo explore patient and public perceptions of planned improvements to the National Health Service (NHS) total joint arthroplasty (TJA) pathway.DesignThree qualitative focus groups undertaken March–May 2018, as part of a...

Sleep Disturbance Trends in the Short-Term Postoperative Period for Patients Undergoing Total Joint Arthroplasty.

Patients undergoing total joint arthroplasty (TJA) often experience preoperative/postoperative sleep disturbances. Although sleep quality generally improves > 6 months after surgery, patterns of sleep in the short-term postoperative period are poorly understood. This study sought to (1) characterize sleep disturbance patterns over the 3-month postoperative period and (2) investigate clinical and sociodemographic factors associated with 3-month changes in sleep. This retrospective analysis of prospectively collected data included 104 primary elective TJA patients. Patients were administered the PROMIS Sleep Disturbance questionnaire preoperatively and at 2 weeks, 6 weeks, and 3 months postoperatively. Median sleep scores were compared between time points using Wilcoxon signed-rank tests, stratified by preoperative sleep impairment. A multivariable logistic regression model identified factors associated with 3-month clinically improved sleep. The percentage of patients reporting sleep within normal limits increased over time: 54.8% preoperatively and 58.0%, 62.5%, and 71.8% at 2 weeks, 6 weeks, and 3 months post-TJA, respectively. Patients with normal preoperative sleep experienced a transient 4.7-point worsening of sleep at 2 weeks ( P = 0.003). For patients with moderate/severe preoperative sleep impairment, sleep significantly improved by 5.4 points at 2 weeks ( P = 0.002), with improvement sustained at 3 months. In multivariable analysis, patients undergoing total hip arthroplasty (versus knee; OR: 3.47, 95% CI: 1.06 to 11.32, P = 0.039) and those with worse preoperative sleep scores (OR: 1.13, 95% CI: 1.04 to 1.23, P = 0.003) were more likely to achieve clinically improved sleep from preoperatively to 3 months postoperatively. Patients experience differing patterns in postoperative sleep changes based on preoperative sleep disturbance. Hip arthroplasty patients are also more likely to experience clinically improved sleep by 3 months compared with knee arthroplasty patients. These results may be used to counsel patients on postoperative expectations and identify patients at greater risk of impaired postoperative sleep. Retrospective analysis of prospectively collected data.

Comparison of ultrasound-guided and palpation-inserted peripheral venous cannula in -patients before primary hip or knee arthroplasty: study protocol for a randomized controlled trial

BackgroundMore than 2 billion peripheral vascular cannulas are introduced globally each year. It is the most frequently performed invasive procedure in medicine worldwide. There is a group of patients with difficult intravenous access (DIVA). In experts’ hands, ultrasound-guided vascular access appears to be a significantly better method. Investigators hypothesize that UGVA is superior also in short-term patency of cannula and even for blood draw through cannula. Repeated cannula pricks in the operating room setting not only puts a lot of stress on the patient and medical staff, but they also waste OR time.MethodsThis investigator-initiated prospective randomized monocentric controlled trial is designed to randomly allocate 200 patients undergoing elective primary total joint arthroplasty of hip or knee to one of two groups as follows: Group C (control group) – peripheral venous cannula insertion by palpation or Group USG (intervention) – cannula insertion by ultrasound-guided vascular access. Our primary endpoint is to compare the number of attempts for ultrasound-guided insertion of the peripheral venous cannula with common palpation insertion of the peripheral venous cannula in overweight/obese patients (BMI ≥ 25). The secondary endpoint is a failure rate of the peripheral venous cannula to administer intravenous therapy up to 5 days postoperatively. Tertiary endpoints include a portion of long PVCs that are able to ensure blood draw up to 5 days postoperatively, time needed to insert PVC in each group, number of needle tip redirections in both groups, and reinsertion of PVC needed in both groups for any reason.DiscussionThis study is pragmatic and is looking for clinically relevant data. After completion, it will answer the question of whether it is clinically relevant to use ultrasound-guided vascular access in the context of not only short-term benefit of insertion, but also up to 5 days after insertion. Also, if this method can ensure blood draw through a peripheral vein cannula, it can save resources in the perioperative period — valuable especially considering the ongoing shortage of medical staff worldwide. If this hypothesis is confirmed, this finding could contribute to more widespread implementation of ultrasound-guided peripheral vascular access in the perioperative period.Trial registrationClinicalTrials.gov NCT05156008. Registered on 13.12.2021.

Routine Preoperative Dental Clearance for Total Joint Arthroplasty: Is There a Benefit?

Background Periprosthetic joint infections (PJIs) place significant psychological and financial burdens on patients and healthcare systems. One measure to reduce the risk of PJIs is preoperative dental screening, for which there is no current consensus recommendation. This study aims to determine whether there is a difference in the rate of PJI and microorganism profile in patients who did and did not obtain preoperative dental clearance. Methodology A retrospective review was conducted among patients undergoing primary total hip arthroplasty and total knee arthroplasty from 2017 to 2021. A cohort of 8,654 patients who underwent routine dental clearance was matched with a cohort of patients who did not. Surgeons who changed their dental clearance protocol were also identified, and the rates of PJIs were compared before and after. Results No statistically significant difference was seen in the rate of PJIs between patients who did and did not undergo routine preoperative dental clearance. No statistically significant difference was seen in the rate of PJIs before and after for surgeons who changed their dental clearance protocol. The microorganism profile between the groups was also found to be without differences. Conclusions Eliminating dental clearance from routine preoperative clearance does not appear to increase the rates of acute PJIs following elective total joint arthroplasty (TJA) or to change the organism profile of the infections that did occur. It may be reasonable to not require routine preoperative dental clearance or to practice selective dental clearance in patients undergoing elective TJA, especially given the increased financial cost and delay in care experienced by patients.