Joint Arthroplasty Procedures Research Articles

Improving Operating Room Efficiency, Part 1: General Managerial and Preoperative Strategies.

Health-care expenditure in the United States was $1.2 trillion in 2012 and is projected to increase to $2.5 trillion per year by 20231,2. With the current trends of unsustainable growth and increasing cost, health-care facilities are faced with a crucial need to optimize productivity and decrease expenditure while continuing to provide patient-centered care3. The operating room is often considered the financial epicenter for many hospitals, accounting for about 35% to 40% of costs and 60% to 70% of revenue. With the cost of operating room time ranging between $22/min and $133/min (average, $62/min), substantial cost-saving measures are essential4-6. Surgical cost reduction is especially relevant in orthopaedic surgery as total joint arthroplasty procedures in the older population are among the highest of all health-care expenses7. …

Orthopaedic Healthcare Worldwide: The Role of Standardization in Improving Outcomes.

Orthopaedic Healthcare Worldwide: The Role of Standardization in Improving Outcomes.

Recognizing and managing infections in total joint arthroplasty.

Periprosthetic joint infections are a devastating complication of joint arthroplasty procedures, affecting 1% to 4% of patients. With the increasing demand for joint replacement, the clinical and financial burden of periprosthetic joint infections is challenging. This article reviews the diagnosis and treatment of periprosthetic joint infections.

The Synovial Lining and Synovial Fluid Properties after Joint Arthroplasty

The lubrication of the cartilaginous structures in human joints is provided by a fluid from a specialized layer of cells at the surface of a delicate tissue called the synovial lining. Little is known about the characteristics of the fluids produced after a joint arthroplasty procedure. A literature review was carried out to identify papers that characterized the synovial lining and the synovial fluids formed after total hip or knee arthroplasty. Five papers about synovial lining histology and six papers about the lubricating properties of the fluids were identified. The cells making up the re-formed synovial lining, as well as the lining of interface membranes, were similar to the typical Type A and B synoviocytes of normal joints. The synovial fluids around joint replacement devices were typically lower in viscosity than pre-arthroplasty fluids but the protein concentration and phospholipid concentrations tended to be comparable, suggesting that the lining tissue function was preserved after arthroplasty. The widespread, long-term success of joint arthroplasty suggests that the lubricant formed from implanted joint synovium is adequate for good clinical performance in the majority of joints. The role the fluid plays in component wear or failure is a topic for future study.

Does a Preoperative Educational Class Increase Patient Compliance

Past studies have shown successful outcomes regarding the use of various interventional education methods in improving patient compliance. At our institution, different educational resources are offered and encouraged, including a 2-hour–long educational class, to prepare patients who are undergoing total joint arthroplasty procedures. Given the significant impact that patient compliance with preoperative instruction can have on overall outcomes of these procedures, this study was intended to assess the effects that the educational classes can have on patient compliance with this institution’s 6-point preoperative total joint arthroplasty protocol. The study analyzed 2 groups, those who did and did not attend the preoperative classes, and compliance rates were compared between the 2. It was hypothesized that patients who did attend the classes would be more compliant to the protocol compared to those who did not. Although results from the study showed that there were no significant differences in adherence between the 2 groups, future quality assessment studies can build off this in order to move toward achieving optimal patient compliance with preoperative instructions.

Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis

Objective To determine whether the perioperative use of hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasties are associated with an increased risk for perioperative complications.Design Retrospective cohort study...

Measuring Rapid Recovery Program Outcomes: Are All Patients Candidates for Rapid Recovery

Total joint arthroplasty procedures have been demonstrated to be effective in the treatment of end stage hip and knee arthritis. The purpose of this paper is to outline various processes utilized to assess the outcomes of rapid recovery programs and to outline areas where future research and metrics will be beneficial in demonstrating the effectiveness of these programs. We have highlighted the use of large databases [NIS (National Inpatient Sample) and NSQIP (National Surgical Quality Improvement Program)] to help identify patients who are candidates for the rapid recovery approach. Continued thorough investigation should not only justify rapid recovery, but also move traditional joint arthroplasty programs to more efficient cost effective care once appropriate metrics are identified that support the need for resources for rapid recovery programs.

Unipedal Balance Is Affected by Lower Extremity Joint Arthroplasty Procedure 1 Year Following Surgery

Lower Extremity Joint Arthroplasty (LEJA) surgery is an effective way to alleviate painful osteoarthritis. Unfortunately, these surgeries do not normalize the loading asymmetry during the single leg stance phase of gait. Therefore, we examined single leg balance in 234 TJA patients (75 hips, 65 knees, 94 ankles) approximately 12 months following surgery. Patients passed if they maintained single leg balance for 10s with their eyes open. Patients one year following total hip arthroplasty (THA-63%) and total knee arthroplasty (TKA-69%) had similar pass rates compared to a total ankle arthroplasty (TAA-9%). Patients following THA and TKA exhibit better unilateral balance in comparison with TAA patients. It may be beneficial to include a rigorous proprioception and balance training program in TAA patients to optimize functional outcomes.

Biofilms in periprosthetic orthopedic infections.

As the number of total joint arthroplasty and internal fixation procedures continues to rise, the threat of infection following surgery has significant clinical implications. These infections may have highly morbid consequences to patients, who often endure additional surgeries and lengthy exposures to systemic antibiotics, neither of which are guaranteed to resolve the infection. Of particular concern is the threat of bacterial biofilm development, since biofilm-mediated infections are difficult to diagnose and effective treatments are lacking. Developing therapeutic strategies have targeted mechanisms of biofilm formation and the means by which these bacteria communicate with each other to take on specialized roles such as persister cells within the biofilm. In addition, prevention of infection through novel coatings for prostheses and the local delivery of high concentrations of antibiotics by absorbable carriers has shown promise in laboratory and animal studies. Biofilm development, especially in an arthoplasty environment, and future diagnostic and treatment options are discussed.

Preoperative Skin Disinfection Methodologies for Reducing Prosthetic Joint Infections

Surgical site infections following lower extremity total joint arthroplasty procedures remain a substantial economic burden to the patient, the treating institution, and the health care system. The complexity of these surgical procedures creates the potential for various patient- or surgery-related risk factors for infection. Although there is much literature regarding the use of many preventative methods, a consensus regarding the true efficacy and application of such practices is generally not available. In this review, we reviewed the preoperative skin disinfection methodologies that have been used for reducing periprosthetic infections following lower extremity total joint arthroplasty. Currently, cumulative evidence suggests that preoperative chlorhexidine baths or chlorhexidine-impregnated wipes may reduce the colonization of pathogenic organisms on the skin. In addition, multiple showers or topical applications of chlorhexidine may lead to more substantial reduction in colony counts. Advanced preoperative whole-body cleaning with chlorhexidine-containing cloths rather than site-specific application may confer additional advantages. Further randomized controlled trials with carefully planned protocols and endpoints are needed to determine if this conclusively leads to reduction in the rate of surgical site infections.

Hip resurfacing arthroplasty and perioperative blood testing.

It is standard practice in many institutions to routinely perform preoperative and postoperative haemoglobin level testing in association with hip joint arthroplasty procedures. It is our observation, however, that blood transfusion after uncomplicated primary hip arthroplasty in healthy patients is uncommon and that the decision to proceed with blood transfusion is typically made on clinical grounds. We therefore question the necessity and clinical value of routine perioperative blood testing about the time of hip resurfacing arthroplasty. We present analysis of perioperative blood tests and transfusion rates in 107 patients undertaking unilateral hybrid hip resurfacing arthroplasty by the senior author at a single institution over a three-year period. We conclude that routine perioperative testing of haemoglobin levels for hip resurfacing arthroplasty procedures does not assist in clinical management. We recommend that postoperative blood testing only be considered should the patient demonstrate clinical signs of symptomatic anaemia or if particular clinical circumstances necessitate.

The impact of resident involvement on post-operative morbidity and mortality following orthopaedic procedures: a study of 43,343 cases

Few studies have addressed the role of residents' participation in morbidity and mortality after orthopaedic surgery. The present study utilized the 2005-2010 National Surgical Quality Improvement Program (NSQIP) dataset to assess the risk of 30-day post-operative complications and mortality associated with resident participation in orthopaedic procedures. The NSQIP dataset was queried using codes for 12 common orthopaedic procedures. Patients identified as having received one of the procedures had their records abstracted to obtain demographic data, medical history, operative time, and resident involvement in their surgical care. Thirty-day post-operative outcomes, including complications and mortality, were assessed for all patients. A step-wise multivariate logistic regression model was constructed to evaluate the impact of resident participation on mortality- and complication-risk while controlling for other factors in the model. Primary analyses were performed comparing cases where the attending surgeon operated alone to all other case designations, while a subsequent sensitivity analysis limited inclusion to cases where resident participation was reported by post-graduate year. In the NSQIP dataset, 43,343 patients had received one of the 12 orthopaedic procedures queried. Thirty-five percent of cases were performed with resident participation. The mortality rate, overall, was 2.5 and 10 % sustained one or more complications. Multivariate analysis demonstrated a significant association between resident participation and the risk of one or more complications [OR 1.3 (95 % CI 1.1, 1.4); p < 0.001] as well as major systemic complications [OR 1.6 (95 % CI 1.3, 2.0); p < 0.001] for primary joint arthroplasty procedures only. These findings persisted even after sensitivity testing. A mild to moderate risk for complications was noted following resident involvement in joint arthroplasty procedures. No significant risk of post-operative morbidity or mortality was appreciated for the other orthopaedic procedures studied. II (Prognostic).

English

Abstract Introduction Periprosthetic joint infection has remained the most annihilating adversity and intriguing challenge confronting orthopaedic surgeons following joint arthroplasty procedures globally. The criticality of a surgeon’s decision in identifying an underlying infection prior to revision arthroplasties and in managing such situations appropriately can never be understated. The current article reviews the role of novel synovial fluid biomarkers, including Polymerase Chain Reaction, C-Reactive Protein, leukocyte enzymes and other multiple molecular markers in identifying early PJIs. Conclusion The current literature is extremely scarce on these newer modalities, and their role in standard clinical practice is still greatly dubious and debatable. The research in this subject has a long way ahead and is reckoned in future, to elucidate our perspective and outlook on such scenarios.

Revision Total Joint Arthroplasty: The Epidemiology of 63,140 Cases in New York State

Recent evidence suggests a substantial rise in the number of revision total joint arthroplasty (TJA) procedures performed. The New York State SPARCS inpatient database was utilized to identify revision total shoulder, knee, and hip arthroplasty procedures between 1993 and 2010. Yearly incidence and related epidemiology were analyzed. A total of 1,806 revision TSA, 26,080 revision TKA, and 35,254 revision THA cases were identified. The population-based incidence of these procedures increased 288%, 246%, and 44% respectively (P<0.001). Revision burden for hip arthroplasty decreased from 16.1% in 2001 to 11.5% in 2010 (P<0.001). The rates of revision TSAs and TKAs increased at a substantially faster rate than that of revision THAs. Revision burden for hip arthroplasty steadily has decreased since 2001.

Trust, but Verify

Trust, but Verify

Shoulder and Elbow Arthroplasty in Younger Patients

Joint arthroplasty is common in elderly patients with arthritis. The success of joint arthroplasty in the elderly population has increased the indications for joint arthroplasty in younger patients. The success and increased indications are due to advances in technology and joint arthroplasty design and materials, as well as to bone-conserving approaches that are more applicable to younger patients. Although most joint arthroplasty procedures are for the hip and knee, the upper extremity (shoulder and elbow) is the fastest-growing segment of joint arthroplasty procedures. This article presents innovative approaches to shoulder and elbow arthroplasty that are designed to treat younger patients with arthritis of the shoulder and elbow.

Cartilage Regeneration and the Role of Vibrational Spectroscopy in Future Joint Arthroplasty

The most advanced options nowadays available in joint arthroplasty rely on the application to diseased joints of human-made bearing surfaces consisting of microstructurally engineered polyethylene and ceramics as substitutes for the damaged joint cartilage and, partly, for bone. However, it is progressively becoming clear that, whatever superior the biomaterial designed for this purpose, owing to the quite severe structural requirements for human joints, including high contact stresses and aggressive environment at the load-bearing surface, it will have a necessarily limited service lifetime. Giving a quite critical but fundamentally true statement, one could say that, so far, no single product has yet been capable to meet all such severe requirements. Moreover, it is not clear if such a perfect biomaterial will ever exist. This is the main reason for pursuing repair (rather than replacement) of damaged cartilage. In this paper, we inquire about the present status and expected progress in healing osteoarthritis (OA) of chronically damaged joints, and surmise that such innovative procedures could sometime, in the near future, replace the current joint arthroplasty procedures, thus avoiding the unavoidably intrusive surgery associated with nowadays total joint replacements. After reviewing the state of art in the new field of joint cartilage healing, we shall stress the potential importance of vibrational spectroscopy both in diagnostics and in accelerating discoveries through the future developments of therapeutic approaches to cartilage diseases.

Paradoxical Cerebral Embolism After Total Knee Arthroplasty

Deep vein thrombosis is a frequent complication following total joint arthroplasty and other major orthopedic procedures. Pulmonary embolism occurs with or without a diagnosis of deep vein thrombosis, although infrequently (1.5%-10%). In patients with congenital cardiac defects, such as a patent foramen ovale, paradoxical cerebral embolism may also occur. This article describes a case of a 52-year-old woman who sustained a paradoxical cerebral embolism following total knee arthroplasty. In the workup of a patient with a known murmur and stroke symptoms, paradoxical cerebral embolism should be included in the differential. The initial evaluation should incorporate transesophageal echocardiography because of its accuracy in the demonstration of the cardiac physiology. An abnormal intracardiac or intrapulmonary shunt is essential for paradoxical cerebral embolism, allowing the entrance of the thrombus into cerebral circulation from the venous system. No clear consensus has been reached on the management of patients at risk for paradoxical cerebral embolism prior to orthopedic procedures. However, when an embolic stroke is diagnosed acutely, ideal management includes thrombolytic therapy, but further research is needed to confirm that this is the correct management. Due to the risk of recurrence, postoperative thromboprophylaxis is recommended with or without closure of the foramen ovale. Most importantly, and as demonstrated by the current patient, who partially recovered but did not require walking assistance after 2-year follow-up, treating physicians should be prepared to counsel patients through a lengthened physical rehabilitative process.

Prevention methodologies against infection after total joint arthroplasty

Surgical site infections after lower extremity total joint arthroplasty procedures remain a substantial economic burden to the patient, the treating institution, and the healthcare system. The complexity of these surgical procedures creates the potential for various patient-related or surgery-related risk factors for infection. Although there is much literature regarding the use of many preventative methods, a consensus regarding the true efficacy and application of such practices generally is not available. In this review, we evaluated selected preventative measures including: the Centers for Disease Control and Prevention recommendations, skin preparation techniques, surgical draping techniques, operative dress, operating room ventilation, hair removal techniques, as well as operating room traffic control. Our literature review consisted of searching PubMed, EMBASE, Ovid, and other relevant orthopaedic journal databases. Preference was given to randomized-controlled trials, data from national registries, and meta-analyses within the past 5 years written in the English language. After reviewing the available literature, we present the authors’ current preferred infection prevention methodology and protocol.

Clostridium septicum growth from a total knee arthroplasty associated with intestinal malignancy: a case report

BackgroundPrevious reports of infection with Clostridium septicum have identified an unexpected association with concurrent malignancy. The reported rate of associated malignancy has been found to be as high as 81 percent. The purpose of this case report was to present a case of a total knee arthroplasty infected with C. septicum and the subsequent finding of an occult colonic malignancy.Case presentationA 74 year-old man underwent uneventful bilateral total knee arthroplasties. Two weeks post-operatively, he presented with acute swelling, redness and pain of the left knee. Aspiration of the knee was sent for cell count and culture. The cell count demonstrated 39,000 white blood cells per cubic millimeter with 71% of white blood cells identified as neutrophils. Synovial fluid cultures identified the presence of C. septicum, Enterobacter and coagulase negative Staphylococcus. After urgent irrigation and debridement and polyethylene exchange of the affected knee, the patient was placed on intravenous Penicillin G for a period of six weeks. Two weeks into his course of antibiotics, the patient developed hematochezia and was found to have an obstructive colonic malignancy. The patient underwent hemi-colectomy and has since made a complete recovery of both his malignancy and total knee arthroplasty infection.ConclusionRecognition of the association between C. septicum and malignancy is especially important considering the large predicted increase in total joint arthroplasty procedures over the coming decades. In addition to the standard treatment for infection after total joint arthroplasty, identification of Clostridium septicum should initiate a search for associated occult malignancy.