Patients Undergoing Revision Total Knee Research Articles

Characterizing the Magnitude and Risk Factors of Functional and Anatomic Limb Lengthening in Patients Undergoing Revision Total Knee Arthroplasty

BackgroundIn revision total knee arthroplasty (TKA), there is little information on the magnitude of potential limb lengthening, risk factors for lengthening, or its impact on patient-reported outcome measures. We aimed to quantify limb length alteration during revision TKA and assess risk factors for lengthening. MethodsWe identified 150 patients over a 3-year period who underwent revision TKA and had preoperative and postoperative EOS hip-to-ankle standing radiographs. The average patient age was 64 years, 51% were women; 68% had a pre-operative varus deformity and 21% had a pre-operative valgus deformity. Outcomes assessed included change in functional and anatomic limb length, risk factors for lengthening, and clinical outcome scores, including the Knee Osteoarthritis Outcome Score Joint Replacement (KOOS JR), and the Veterans RAND 12-item (VR12) Physical and Mental Scores. ResultsThere were 124 patients (83%) who had functional limb lengthening, and 108 patients (72%) had anatomic limb lengthening. Patients had an average functional limb lengthening of 7 mm (range, -22 to 35) and an average anatomic limb lengthening of 5 mm (range, -16 to 31). Patients undergoing revision for instability experienced significantly greater anatomic lengthening (7.6 versus 4.6, P = 0.047). Patients who had ≥ 10° of deformity were more likely to be functionally lengthened (91 versus 79%) and had significantly greater average functional lengthening (12 versus 6 mm; P = 0.003). There was no significant change in clinical outcome scores at 6 weeks and 1 year for patients lengthened ≥ 5 or 10 mm compared to those not lengthened as substantially. ConclusionsThere is major potential for functional and anatomic limb lengthening following revision TKA, with greater preoperative deformity and revision for instability being risk factors for lengthening.

Complex periprosthetic wound coverage in patients undergoing revision total knee arthroplasty: a single plastic surgeon study.

Options for soft tissue coverage in revision total knee arthroplasty (rTKA) range from primary wound closure to complex muscle flap reconstructions. The purpose of this study was to investigate the institutional experience of wound coverage options for complex soft tissue defects in rTKA. 77 patients undergoing rTKA with complex wound closure by a single plastic surgeon were retrospectively reviewed. The average follow-up was 30.1 months. In 18 (23.4%) patients, an intraoperative decision for primary closure was made. Fifty-nine patients (76.6%) received either a local fasciocutaneous (N = 18), a medial gastrocnemius (N = 37), a free latissimus dorsi (N = 3) or a lateral gastrocnemius flap (N = 1). Revision-free survival and complication rates were assessed and risk factors were analyzed with Cox-regression analysis. Medial gastrocnemius flaps had significant lower cumulative revision-free survival rates than local fasciocutaneous flaps (P = 0.021) and primary closures (P < 0.001) (42.5% vs. 71.5% vs. 100%,respectively). Comparing the most common complex closure procedures medial gastrocnemius flaps had the highest rate of prolonged wound healing (29.7%) and infection/reinfection (40.5%). Infection-associated flap procedures had significant lower cumulative revision-free survival rates (30.5%) than non-infection associated flap procedures (62.8%,P = 0.047). A history of more than two prior surgeries (HR = 6.11,P < 0.001) and an age ≥ 65 years (HR = 0.30,P = 0.018) significantly increased the risk of revision. The results of this study indicate that primary closure -if possible- should be preferred to early proactive muscle flap coverage. Even in the hands of an experienced plastic surgeon muscle flaps have high revision and complication rates. The study highlights the need to clarify flap indications and to investigate alternative approaches.

Commercial Synovial Antigen Testing is Inferior to Traditional Culture for the Diagnosis of Periprosthetic Joint Infection in Patients Undergoing Revision Total Knee Arthroplasty

BackgroundDespite its limitations, a culture remains the “gold standard” for pathogen identification in patients who have periprosthetic joint infection (PJI). Recently, a synovial fluid antigen test has been introduced by a commercial entity. The purpose of this multicenter study was to determine the accuracy of the antigen test in the diagnosis of PJI. MethodsThis retrospective study identified 613 patients undergoing revision total knee arthroplasty who had undergone preoperative synovial fluid analysis. A PJI was defined using the 2018 International Consensus Meeting (ICM) criteria. Patients who had an extended period (> 180 days) from aspiration to revision procedure (n = 62), those presenting within 90 days of their index arthroplasty procedure (n = 17), and patients who had an inconclusive ICM score (n = 8) were excluded. Using receiver operator characteristic curve analyses, we examined the utility of the microbial identification (MID) antigen test and any positive culture (either preoperative or intraoperative) in the diagnosis of PJI. ResultsA total of 526 patients were included. Of these, 125 (23.8%) were ICM positive and 401 (76.2%) were ICM negative. Culture demonstrated an area under the curve (AUC) of 0.864, sensitivity of 75.2%, and specificity of 97.5%. On the other hand, the MID test exhibited an AUC of 0.802, sensitivity of 61.6%, and specificity of 98.8%. The AUC of culture was significantly higher than that of the MID test (P = .037). The MID test was positive in 41.9% of culture-negative PJI cases. We also observed a high rate of discordance (29.7%) when both culture and the MID test were positive in the ICM-positive group. ConclusionsSynovial fluid antigen testing does not provide additional clinical benefit when compared to traditional cultures for the diagnosis of PJI. The antigen test had low sensitivity in the diagnosis of PJI and a relatively high rate of discordance with culture. Level of EvidenceLevel III.

Mid term outcomes of a novel metaphyseal porous titanium cone in revision total knee arthroplasty

IntroductionBone loss is present in all revision total knee arthroplasties. Metaphyseal cones allow surgeons to negotiate loss of femoral and tibial bone stock while obtaining stable bony fixation. This study examines the mid-term functional and radiographic outcomes in patients undergoing revision total knee arthroplasty (rTKA) utilizing a novel metaphyseal cone system. MethodsThis multicenter retrospective study examined all patients who received a porous, titanium tibial or femoral cone at four academic urban tertiary care institutions and presented for a minimum two-year follow-up. Patient demographics, indications for revision surgery, knee range-of-motion (ROM), re-revision rates, radiographic measurements, bone defect per AORI classification, and implant osseointegration were evaluated according to the Knee Society total knee arthroplasty (TKA) radiographic evaluation system. ResultsOne-hundred and four patients received 128 cone implants (84 tibial, 44 femoral cones; 24 patients with simultaneous ipsilateral tibial and femoral cones; 104 rTKA) with mean follow-up of 32.75 ± 6.54 months. The pre-operative main revision indications were aseptic loosening 36 (34.61 %), periprosthetic infection (PJI) 23 (22.11 %) and instability 18 (17.3 %). Thirteen rTKA underwent re-revision surgery: 3 for acute PJI, 4 for chronic PJI, 5 for instability, and 1 for mechanical failure of a hinged system. At most recent radiographic follow-up available, all unrevised cones had evidence of osteointegration and no visible implant migration.All-cause re-operation free survivorship was 87.5 % (91/104), and all-cause cone implant survivorship was 96.09 % (123/128 cones) at 2-year follow-up. ConclusionThis study demonstrates excellent mid-term outcomes of a novel porous, titanium metaphyseal cone in patients with large bone defects undergoing complex revision TKA. Level of evidenceIV, case series.

Tibial bone defect prediction based on preoperative artefact-reduced CT imaging is superior to standard radiograph assessment

PurposeThe purpose of this study was to evaluate the accuracy of preoperative CT-based Anderson Orthopaedic Research Institute (AORI)-grading and to correlate Computed tomography (CT)-based volumetric defect measurements with intraoperative AORI findings.Methods99 patients undergoing revision total knee arthroplasty (rTKA) with preoperative CT-images were identified in an institutional revision registry. CT-image segmentation with 3D-Slicer Software was used to create 3D tibial bone defects which were then graded according to the AORI-classification. The AORI classification categorizes tibial defects into three types: Type I has healthy cortical and cancellous bone near the joint line, Type II involves metaphyseal bone loss affecting one or both condyles, and Type III indicates deficient metaphyseal bone with distal defects and potential damage to the patellar tendon and collateral ligament attachments. These 3D-CT gradings were compared to preoperative X-ray and intraoperative AORI grading. The Friedman test was used to investigate differences between AORI values of each measurement method. Volumetric 3D-bone defect measurements were used to investigate the relationship between AORI classification and volumetric defect size in the three anatomic zones of the tibia.ResultsSubstantial agreements between preoperative 3D-CT AORI and intraoperative AORI (kappa = 0.663; P < 0.01) and fair agreements between preoperative X-ray AORI and intraoperative AORI grading (kappa = 0.304; P < 0.01) were found. Moderate correlations between volume of remaining bone and intraoperative AORI grading were found in epiphysis (rS = – 0.529; P < 0.001), metaphysis (rS = – 0.557; P < 0.001) and diaphysis (rS = – 0.421; P < 0.001). Small volumetric differences between AORI I vs. AORI II defects and relatively large differences between AORI II and AORI III defects in each zone were detected.ConclusionTibial bone defect prediction based on preoperative 3D-CT segmentation showed a substantial agreement with intraoperative findings and is superior to standard radiograph assessment. The relatively small difference in defect volume between AORI I, IIa and IIb suggests that updated CT-based classifications might hold benefits for the planning of rTKA.Level of evidenceRetrospective Cohort Study; III

Peripheral Nerve Catheter Reduces Postoperative Opioid Consumption and Pain in Revision Total Knee Arthroplasty.

Patients undergoing revision total knee arthroplasty (rTKA) have historically received high doses of opioids during the perioperative period. As awareness of opioid use has heightened, opioid administration has continuously decreased. This study aimed to evaluate if peripheral nerve catheter (PNC) use in rTKA reduces opiate consumption while maintaining similar pain control and postoperative function levels. A retrospective review of 354 patients who underwent rTKA between July 2019 and January 2022 was conducted. Fifty total patients who received an adductor canal PNC were propensity-matched 1:1 to a control group of 50 patients that did not receive a PNC. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalents per 24-hour interval. Postoperative pain and functional status were assessed using the verbal rating scale for pain and the Activity Measure for Post-Acute Care scores, respectively. Compared to the control group, the PNC group demonstrated significantly lower overall inpatient opiate consumption (98.68 ± 117.03 vs 176.69 ± 203.47 morphine milligram equivalents; 44.15% decrease, P= .021) and lower verbal rating scale pain scores at 60 to 72 hours postoperatively (4.85 ± 1.24 vs 5.83 ± 1.35; 16.81% decrease, P= .038). There was no significant difference in Activity Measure for Post-Acute Care scores postoperatively (raw score: 19.41 ± 3.61 vs 19.46 ± 3.18; 0.26% decrease, P= .952). Finally, the PNC cohort was significantly less likely to be readmitted within 90 days after surgery (0.0% vs 12.0%; P= .012). In rTKA patients, PNC can significantly reduce inpatient opioid consumption while maintaining a comparable functional recovery and superior pain control. Retrospective Cohort Study.

Clinical Outcomes of Offset Stem Couplers with or without Cone Augmentation in Revision Total Knee Arthroplasty.

Intramedullary stems are often required in patients undergoing revision total knee arthroplasty (rTKA) to achieve stable fixation. Significant bone loss may require the addition of a metal cone to maximize fixation and osteointegration. The purpose of this study was to investigate clinical outcomes in rTKA using different fixation techniques. We conducted a single-institution retrospective review of all patients who received a tibial and femoral stem during rTKA between August 2011 and July 2021. Patients were separated into three cohorts based on fixation construct: press-fit stem with an offset coupler (OS), fully cemented straight (CS) stem, and press-fit straight (PFS) stem. A subanalysis of patients who received tibial cone augmentation was also conducted. A total of 358 patients who underwent rTKA were included in this study, of which 102 (28.5%) had a minimum 2-year follow-up and 25 (7.0%) had a minimum 5-year follow-up. In the primary analysis, 194 patients were included in the OS cohort, 72 in the CS cohort, and 92 in the PFS cohort. When stem type alone was considered, there was no significant difference in rerevision rate (p = 0.431) between cohorts. Subanalysis of patients who received augmentation with a tibial cone demonstrated that OS implants led to significantly higher rates of rerevision compared with the other two stem types (OS: 18.2% vs. CS: 2.1% vs. PFS: 11.1%; p = 0.037). The findings of the present analysis demonstrate that CS and cones in rTKA may provide more reliable long-term outcomes compared with press-fit stems with OS. LEVEL III EVIDENCE: Retrospective Cohort Study.

Экстренное гистологическое исследование в диагностике перипротезной инфекции при ревизионном эндопротезировании коленного сустава

Introduction Diagnostic algorithms are used for detection of periprosthetic joint infection (PJI) including sampling for histological evaluation (HE). The purpose was to assess the diagnostic significance of emergency HE of fresh-frozen intraoperative biomaterial as part of preoperative PJI screening of patients undergoing revision total knee arthroplasty (RTKA). Material and methods The prospective study included 83 patients who were admitted to two trauma and orthopaedic centers for RTKA. The European Bone and Joint Infection Society 2021 (EBJIS21) algorithm was used to detect PJI of the knee joint. The diagnostic value of screening PJI with/without regard to the results of an emergency HE was compared with the results of a microbiological study (MBI) of all types of biomaterials obtained from each patient. Subanalysis was additionally performed in patients with aseptic instability and antimicrobial spacer. Results Pathomorphological examination of freshly frozen and paraffin-embedded tissues showed the difference of 7.2 %, which did not significantly affect the interpretation of the results (p &gt; 0.05). Diagnostically significant pathogens were identified in 83.3 % of cases with PJI confirmed by emergency HE (p &lt; 0.001). A positive emergency HE result increased the chances of isolating diagnostically significant organisms by 34 times (95 % confidence interval (CI): 4.721 – 244.859) as compared with negative HE cases. The proportion of detected cases with emergency HE included in the screening increased from 2.4 to 8.4 %. The inclusion of emergency HE in the screening improved the diagnostic value both in the general cohort of patients and in the subanalysis of comparison groups due to a two-fold increase in sensitivity. Conclusion Relevance of the emergency HE results and the PJI criteria should be considered as a significant prognostic factor for an infectious process, however, this technique should be used only in a complex algorithm for PJI detection. Poor outcomes in 18.2 % of cases of probable PJI necessitated a change in the approach to managing this cohort of patients.

Immune cell populations differ in patients undergoing revision total knee arthroplasty for arthrofibrosis

Arthrofibrosis following total knee arthroplasty (TKA) is a debilitating condition typically diagnosed based on clinical findings. To gain insight into the histopathologic immune cell microenvironment of arthrofibrosis, we assessed the extent of tissue fibrosis and quantified immune cell populations in specific tissue regions of the posterior capsule. We investigated specimens from three prospectively-collected, matched cohorts, grouped as patients receiving a primary TKA for osteoarthritis, revision TKA for arthrofibrosis, and revision TKA for non-arthrofibrotic, non-infectious reasons. Specimens were evaluated using hematoxylin and eosin staining, picrosirius red staining, immunofluorescence, and immunohistochemistry with Aperio®-based digital image analysis. Increased collagen deposition and increased number of α-SMA/ACTA2 expressing myofibroblasts were present in the arthrofibrosis group compared to the two non-arthrofibrotic groups. CD163 + macrophages were the most abundant immune cell type in any capsular sample with specific enrichment in the synovial tissue. CD163 + macrophages were significantly decreased in the fibrotic tissue region of arthrofibrosis patients compared to the patients with primary TKA, and significantly increased in adipose tissue region of arthrofibrotic specimens compared to non-arthrofibrotic specimens. Synovial CD117 + mast cells were significantly decreased in arthrofibrotic adipose tissue. Together, these findings inform diagnostic and targeted therapeutic strategies by providing insight into the underlying pathogenetic mechanisms of arthrofibrosis.

Red cell distribution width, eosinophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio can predict the development of infection and the number of antibiotics used in elderly patients undergoing revision total knee arthroplasty

Introduction: We aimed to evaluate the relationship between complete blood parameters reported to be associated with inflammation and development of complications, length of hospital stays and the number of antibiotics used in elderly patients undergoing revision total knee arthroplasty (rTKA).&#x0D; Material and Method: Our retrospective study was conducted in a single center and included 72 older patients who underwent rTKA operations. We recorded patients’ firs day preoperative, first day postoperative and 45th day postoperative whole blood parameters.&#x0D; Results: It was found that the development of postoperative infection and the number of antibiotics used were higher in patients with low preoperative Hb values and high platelet-to-lymphocyte ratio (PLR) rates. In patients with high RDW value and high eosinophil-lymphocyte ratio (ELR) one day after surgery, both the development of infection (P=0.002, P=0.002) and the number of antibiotics used during follow-up were found to be significantly higher ​(P

Risk of Venous Thromboemboli, Readmissions, and Costs in Opioid Use Disorder Patients Following Revision Total Knee Arthroplasty.

Opioid use disorder (OUD) patients have an increased risk of venous thromboembolism (VTE), readmissions, and higher costs following primary elective primary total joint arthroplasty, but these risks have not yet been clarified for other arthroplasty surgeries. Thus, the purpose of this study was to investigate whether OUD patients undergoing revision total knee arthroplasty (RTKA) have higher rates of: VTEs, readmissions, and costs of care. Patients who had a 90-day history of OUD prior to undergoing RTKA were identified and randomly matched to a comparison cohort in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, obesity, and tobacco use with a total of 16,851 patients collectively in both groups. The 90-day frequency and odds (OR) of developing VTE, deep vein thrombosis (DVTs), and PEs along with 90-day readmission rates and 90-day costs of care were analyzed. A p-value less than 0.01 was considered statistically significant. OUD patients undergoing RTKA were found to have a higher incidence and odds of VTE (2.91 vs. 1.88; OR: 1.58, p<0.0001) 90 days following RTKA. Compared to the matched cohort, patients who have OUD had a higher incidence and increased risk of lower extremity DVT (2.61 vs. 1.73; OR: 1.52, p=0.0008) and PE (0.97 vs. 55%; OR: 1.74, p=0.007). Furthermore, the likelihood (25.7 vs. 21.4%; OR: 1.26, p<0.0001) of being readmitted within 90 days was higher in OUD patients. Additionally, OUD was associated with significantly higher total global 90-day episode-of-care costs ($19,289.31 ± $17,378.71 vs. $17,292.87 vs. $11,690.61; p<0.0001). Patients who have OUD undergoing RTKA have higher rates of thromboembolic complications, readmission rates, and total global 90-day episode-of-care costs. Orthopaedic surgeons should educate OUD patients about these risks and titrate patient opioid consumption through multi-specialty interventions prior to surgery to improve outcomes and reduce costs.

Epidemiology of Obese Patients Undergoing Revision Total Knee Arthroplasty: Understanding Demographics, Comorbidities, and Propensity Weighted Analysis of Inpatient Outcomes.

Introduction:Obesity is a public health epidemic that is projected to grow in coming years. Observational data on the epidemiologic profile and immediate postoperative outcomes of obesity and morbid obesity after revision total knee arthroplasty (rTKA) are limited.Methods:Discharge data from the National Inpatient Sample was used to identify patients who underwent rTKA from 2006 to 2015. Patients were stratified into morbidly obese, obese, and not obese control cohorts. An analysis was performed to compare etiology of revision, demographic and medical comorbidity profiles, and immediate in-hospital economic and complication outcomes after rTKA.Results:An estimated 605,603 rTKAs were included in this analysis. Morbidly obese and obese patients were at significantly higher risk for any complication than not obese patients. Patients with obesity were associated with an increased risk of postoperative anemia but a lower risk of peripheral vascular disease and gastrointestinal, and hematoma/seroma complications compared with not obese patients. Patients with morbid obesity were associated with an increased risk of any, hematoma/seroma, wound dehiscence, postoperative infection, pulmonary embolism, and postoperative anemia complications and a lower risk of gastrointestinal complications when compared with not obese patients. Morbidly obese patients had a significantly longer length of stay than both obese and not obese patients, while no significant difference in length of stay was observed between obese and not obese patients.Discussion:Morbidly obese patients are at higher odds for worse postoperative medical and economic outcomes compared with those with obesity after rTKA. As the number of patients with obesity and morbid obesity continues to rise, these risk factors should be considered in preoperative discussions and perioperative protocol optimization.

Machine learning models accurately predict recurrent infection following revision total knee arthroplasty for periprosthetic joint infection.

This study aimed to develop and validate machine-learning models for the prediction of recurrent infection in patients following revision total knee arthroplasty for periprosthetic joint infection. A total of 618 consecutive patients underwent revision total knee arthroplasty for periprosthetic joint infection. The patient cohort included 165 patients with confirmed recurrent periprosthetic joint infection (PJI). Potential risk factors including patient demographics and surgical characteristics served as input to three machine-learning models which were developed to predict recurrent periprosthetic joint. The machine-learning models were assessed by discrimination, calibration and decision curve analysis. The factors most significantly associated with recurrent PJI in patients following revision total knee arthroplasty for PJI included irrigation and debridement with/without modular component exchange (p < 0.001), > 4 prior open surgeries (p < 0.001), metastatic disease (p < 0.001), drug abuse (p < 0.001), HIV/AIDS (p < 0.01), presence of Enterococcus species (p < 0.01) and obesity (p < 0.01). The machine-learning models all achieved excellent performance across discrimination (AUC range 0.81-0.84). This study developed three machine-learning models for the prediction of recurrent infections in patients following revision total knee arthroplasty for periprosthetic joint infection. The strongest predictors were previous irrigation and debridement with or without modular component exchange and prior open surgeries. The study findings show excellent model performance, highlighting the potential of these computational tools in quantifying increased risks of recurrent PJI to optimize patient outcomes. IV.

The application of close incisional negative pressure wound therapy in revision arthroplasty among asian patients: a comparative study

IntroductionPeri-prosthetic joint infection (PJI) was one of the main causes of revision of arthroplasty. In order to reduce wound complications and surgical site infections, close incisional negative pressure wound therapy (ciNPWT) has been introduced into arthroplasty. This study was designed to review the clinical benefits of the application of ciNPWT in revision arthroplasty.MethodsThis was a single-centre retrospective comparative study approved by the Institutional Review Board. Patients, who underwent revision total knee arthroplasty or revision total hip arthroplasty at the author’s institution from January 2016 to October 2019, were included in this study. The ciNPWT cohort included all eligible patients, who underwent operations from January 2018 to October 2019, with the use of ciNPWT(n = 36). The control cohort included all eligible patients, who underwent operations from January 2016 to December 2017 with the use of conventional dressing(n = 48). The incidences of wound complications were compared to both cohorts.ResultsThere was a statistically significant difference in the rate of superficial surgical site infection (SSI) between control cohort and ciNPWT cohort (12.5% in control vs 0% in ciNPWT, p = 0.035). However, there was no statistically significance of the overall wound complication rate for both cohorts. (14.6% in control vs 8.3% in ciNPWT, p = 0.504).ConclusionsThe application of ciNPWT could result in a lower rate of superficial surgical site infection when compared with conventional dressing among the patients undergoing revision total knee and total hip arthroplasties.Trial registrationUW19-706

Preoperative Mental Health Influences Patient-Reported Outcome Measures and Satisfaction After Revision Total Knee Arthroplasty

BackgroundA higher prevalence of mental health conditions has been reported in patients undergoing revision total knee arthroplasty (rTKA). This study investigated the effect of preoperative mental health on patient-reported outcome measures (PROMs) and satisfaction after rTKA. MethodsA total of 245 patients who underwent rTKA in 2004-2018 were identified from our institutional joint registry. The most common indications were aseptic loosening (n = 111), infection (n = 70), and instability (n = 35). 36-item Short-Form health survey (SF-36) mental component summary (MCS) was used to stratify the cohort into: Low-MCS (SF-36 MCS <50; n = 112) and control (SF-36 MCS ≥50; n = 133) groups. Knee Society score, Oxford knee score, SF-36 physical score, and a satisfaction questionnaire were used to compare the low-MCS and control at 6 months and 2 years. ResultsAll PROMs were poorer in the low-MCS group at 6 months and 2 years. However, both groups demonstrated a comparable improvement in each PROM and a similar proportion attained the minimal clinically important difference. Fewer patients in the low-MCS group were satisfied at 2 years (72.2% vs 84.5%, P = .045). Lower preoperative SF-36 MCS was independently associated with increased odds of dissatisfaction (OR 1.037, 95% CI 1.004-1.070, P = .027). Although the change in SF-36 MCS was greater in the low-MCS group, the final value remained lower at 2 years. ConclusionWhile patients with poor mental health had inferior PROMs preoperatively and postoperatively, a similar percentage experienced a clinically meaningful improvement at 2 years. Perioperative optimization of psychological factors should still be emphasized as these patients were at a higher risk of dissatisfaction after rTKA.

Rheumatoid Arthritis Versus Osteoarthritis in Patients Receiving Revision Total Knee Arthroplasty in the United States: Increased Perioperative Risks? A National Database-Based Propensity Score-Matching Study.

The impacts of rheumatoid arthritis (RA) on perioperative risks among patients undergoing revision total knee arthroplasty (rTKA) have not been investigated yet. Thus, we hypothesized that patients with RA sustained increased perioperative risks and higher resource consumption burdens as compared to patients with osteoarthritis (OA) during the perioperative period. The National Inpatient Sample (NIS) database was used to compare the demographic characteristics, major in-hospital complications, resource consumptions, and in-hospitalization mortality between patients with RA and OA after rTKA. A 1:1 propensity score-matching, χ2 test, independence-sample T-test, and logistic regression analysis were done in statistical analyses to answer our hypotheses. 4.3% (6363/132,405) of rTKA patients were diagnosed with RA. They tended to be women and received revision for infection but with similar ages as compared to patients with OA. Except for acute postoperative anemia (odds ratio [OR] = 1.196), blood transfusion (OR = 1.179), prolonged hospitalization (OR = 1.049), and higher total cost (OR = 1.145), patients with RA sustained decreased odds of acute renal failure (OR = 0.804) and urinary complications (OR = 0.467). Besides, the other observed in-hospital complications showed no differences between patients with RA and OA. Despite consuming greater in-hospital resources, patients with RA did not suffer increased odds of most in-hospital complications and in-hospital mortality for a revision TKA during the perioperative period. Compared with patients with OA, patients with RA sustained equivalent perioperative risks in the United States between 2002 and 2014.

Low-Dose Aspirin is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Knee Arthroplasty: A Retrospective Cohort Study.

Venous thromboembolism (VTE) events are rare, but serious complications of total joint replacement affect patients and health care systems due to the morbidity, mortality, and associated cost of its complications. There is currently no established universal standard of care for prophylaxis against VTE in patients undergoing revision total knee arthroplasty (rTKA). The aim of this study was to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or sufficient in preventing VTE in patients undergoing rTKAs versus 325-mg ASA BID. In 2017, our institution adopted a new protocol for VTE prophylaxis for arthroplasty patients. Patients initially received 325-mg ASA BID for 1 month and then changed to a lower dose of 81-mg BID. A retrospective review from 2011 to 2019 was conducted identifying 1,438 consecutive rTKA patients and 90-day postoperative outcomes including VTE, gastrointestinal, and wound bleeding complications, acute periprosthetic joint infection, and mortality. In the 74 months prior to protocol implementation, 1,003 rTKAs were performed and nine VTE cases were diagnosed (0.90%). After 26 months of the protocol change, 435 rTKAs were performed with one VTE case identified (0.23%). There was no significant difference in rates or odds in postoperative pulmonary embolism (PE; p = 0.27), DVT (p = 0.35), and total VTE rates (p = 0.16) among patients using either protocol. There were also no differences in bleeding complications (p = 0.15) or infection rate (p = 0.36). No mortalities were observed. In the conclusion, 81-mg ASA BID is noninferior to 325-mg ASA BID in maintaining low rates of VTE and may be safe for use in patients undergoing rTKA.

Association of Anesthesia Type with Postoperative Outcome and Complications in Patients Undergoing Revision Total Knee Arthroplasty

Revision total knee arthroplasty (TKA) is an increasingly common procedure and is effective in treating knee osteoarthritis, but it has higher complication rates than primary TKA. Anesthetic choice poses perioperative risk that has been extensively studied in primary TKA, showing favorable results for regional anesthesia compared with general anesthesia. The impact of anesthetic choice in revision TKAs is not well studied. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision TKAs between 2014 and 2017 were divided into three anesthesia cohorts: (1) general anesthesia, (2) regional anesthesia, and (3) combined general-regional anesthesia. Univariate and multivariate analyses were used to analyze patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post hoc analysis. In total, 8,820 patients were identified. Of whom, 3,192 patients underwent general anesthesia, 3,474 patients underwent regional anesthesia, and 2,154 patients underwent combined anesthesia. After multivariate analyses, regional anesthesia was associated with decreased odds for any complication (p = 0.008), perioperative blood transfusion (p < 0.001), and extended length of stay (p < 0.001) compared with general anesthesia. In addition, regional anesthesia was associated with decreased odds for perioperative blood transfusion (p < 0.001) and extended length of stay (p = 0.006) compared with combined anesthesia. However, following multivariate analysis, regional anesthesia was not associated with decreased odds of wound, pulmonary, renal, urinary tract, thromboembolic, and cardiac complications, and was not associated with return to operating room, extended length of stay, minor and major complications, and mortality. Retrospective analysis of a large surgical database suggests that patients receiving general anesthesia have increased likelihood for developing adverse postoperative outcomes relative to patients receiving regional anesthesia. Prospective and controlled trials should be conducted to verify these findings.

Wound Complications in Revision Total Knee Arthroplasty: An Analysis of ACS-NSQIP

Introduction: Wound complications in patients undergoing revision total knee arthroplasty (RTKA) can be attributed to intraoperative, postoperative and patient- specific factors. Purpose was to evaluate rates wound complications and associated comorbid risk factors in patients undergoing RTKAs. Methods and Materials: ACS-NSQIP (2010-2014) used to identify patients who underwent RTKAs based on the CPT codes 27486, 27487. Pregnant women, children, emergency admissions were excluded. Demographic factors, comorbidities were evaluated among patients with wound complications, defined as a surgical site infection or wound disruption. Â Descriptive and Chi-Square analysis were performed to determine if patient demographics or comorbidities was associated with increased rates of postoperative wound-related complications. Results: Total of 8,317 patients underwent RTKA. Majority of patients were females (59.0%) treated as elective cases (92.2%) in the inpatient setting (99.0%) and discharged home (68.7%). Comorbidities included obesity (61.4%), diabetes (20.6%), hypertension (66.4%), steroid use (4.9%), presence of wound (2.5%), and sepsis (3.2%). Wound complications occurred in 3.2% of patients. Using Chi Square analysis, obese patients 5.4 times more likely to develop a complication (p=0.21), smokers 7.2 times more likely to develop a complication (p<0.05), Steroid use 9.6 times more likely to develop wound complication (p<0.05), septic patients 58.7 times more likely to develop a wound complications (p<0.001) and patients with wounds were 112.3 times more likely to develop wound complication(p<0.001). Conclusion: Obesity, smoking, steroid use, sepsis and presence of wound were associated with developing a wound related complication. Investigation into perfusion of the surrounding tissue is warranted.

Estimated Glomerular Filtration Rate as a Risk Stratification Tool for Early Complications in Revision Total Hip and Knee Arthroplasty

BackgroundEstablishing an association between postoperative outcomes and the spectrum of renal function would allow for more informed decisions to manage surgical risks and improved patient-specific care. Estimated glomerular filtration rate (eGFR) can be calculated from standard prescreening measurements to gauge renal function. This work investigates the effect of eGFR, as a continuous and categorical variable, on mortality and major and minor complications in patients undergoing revision total knee and hip arthroplasty. Methods25,056 patients having undergone revision total hip and knee arthroplasty from 2013 to 2016 were identified using the National Quality Improvement Program database. The investigated outcomes included 30-day mortality, major complications, and minor complications. Multivariate regression models were created to evaluate the effect of eGFR on the outcomes of interest. Multivariate spline regressions were generated to assess for nonlinear relationships between eGFR as a continuous variable and the outcomes. ResultsOur study revealed that as eGFR decreased <60 mL/min/1.73 m2, mortality (P = .0001), any major complication (P < .001), and any minor complication (P < .001) increased. Patients with eGFR 15-30 mL/min/1.73 m2 had increased risk for mortality (P = .033). There was an increased risk for any major complication at an eGFR 30-60 and <15 mL/min/1.73 m2, (P < .05). There was an increased risk of minor complications for those with hyperfiltration and <60 mL/min/1.73 m2. ConclusionPatients with lower preoperative eGFR generally display an increased risk for complications after revision total hip and knee arthroplasty. Proper consideration should be given to this patient population before surgical intervention to allow for preventative measures to be taken to improve patient outcomes.