Primary Joint Arthroplasty Research Articles

Twenty-Year Experience With Primary Distal Radioulnar Joint Arthroplasty From a Single Institution

The use of implant arthroplasty in the distal radioulnar joint is increasing. Two main types of implants are commonly used, ulnar head prosthesis (UHP) and hemi or semi-constrained total distal radioulnar joint arthroplasty. The literature consists mainly of small patient series. The purpose of this study was to examine our long-term outcomes of distal radioulnar joint arthroplasty. Patient data were collected in a patient registry from 2000 to 2019. The follow-up included radiographic examination, physical examination, Mayo Wrist Scores, pain level, range of motion, and grip strength. Reoperations were recorded. The implants were a semi-constrained prosthesis and a metallic UHP. The mean age at surgery was 50 years. Patient demographics were similar, but the semi-constrained group had a higher preoperative percentage of instability (85 vs 52 percent). The median follow-up time was 30 months for the semi-constrained implants group and 102 months for the UHP group. A total of 53 primary semi-constrained total joint arthroplasties and 102 UHPs were included. The grip strength and Mayo Wrist Score improved for both the implant groups. Pain reduced in 76% of the patients. Supination improved for the semi-constrained total joint arthroplasty group. Lifting capacity was better in the semi-constrained total joint arthroplasty patients. The unadjusted reoperation rate was 23% for the semi-constrained implants group and 34% for the UHP group. Twenty-two implants were bilateral; these had comparable results to unilateral implants. Kaplan-Meier survival curves demonstrated 94% survival rate for the semi-constrained implants group and 87% survival for the UHP group after 5 years. The risk factors associated with reoperation for the combined implant group included younger age at surgery, previous wrist surgery, ulnar shortening, and wrist fusion. Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent. The semi-constrained implants group had better lifting capacity. The bilateral implants had comparable outcomes to the unilateral implants. Therapeutic IV.

When and How Should I Use Antibiotic Cement in Primary and Revision Joint Arthroplasty?

Periprosthetic joint infections (PJIs) remain one of the most challenging and devastating complications associated with total joint arthroplasty. Therefore, prevention and the ability to effectively treat PJIs are critical. One such tool for both the prevention and treatment of PJIs is the use of antibiotic-loaded bone cement (ALBC). ALBC provides an effective local delivery method of antibiotics. Low dose (<2 g per 40-g batch) is commonly used for prophylaxis, while high dose (>3.6 g per 40-g batch) is used for the treatment of PJIs. This review focuses on the efficacy, safety, and cost-effectiveness of ALBC for both the prevention as well as the treatment of PJIs.

Preoperative Opioid Use Results in Greater Postoperative Opioid Consumption After Thumb Basal Joint Arthroplasty

PurposeThumb basal joint arthroplasty surgery is a common hand surgery after which patients often require opioids. To better understand safe opioid consumption patterns, this study sought to identify risk factors for filling a second prescription and/or prolonged opioid use (prescription over 6 months after the surgery). Preoperative opioid use was hypothesized to show an association with greater postoperative opioid use.MethodsA retrospective review of consecutive patients who underwent primary thumb basal joint arthroplasty was conducted, yielding 110 patients for analysis. Demographic and clinical data were collected. Opioid prescription data were extracted from 6 months before the surgery to 9 months after the surgery using a state prescription drug monitoring program. Bivariate and multivariate analyses were performed for filling a second opioid prescription or filling an opioid prescription over 6 months after the surgery.ResultsAll the patients filled their initial postoperative prescription. Of the 110 patients, 26.4% filled an opioid prescription before the surgery, 42% filled a second postoperative prescription, and 14.5% were still consuming opioids over 6 months after the surgery. Patients using preoperative opioids had 7-fold higher odds of filling a second opioid prescription and 37-fold higher odds of prolonged use. No other demographic or clinical factors, including the type of procedure or number of initial opioids prescribed, were associated with increased use of postoperative opioids. Of all the opioid prescriptions filled after the initial postoperative prescription, only 9.3% were prescribed by a surgeon’s office.ConclusionsPatients who undergo thumb basal joint arthroplasty with preoperative opioid use have much greater odds of filling a second opioid prescription and prolonged use after the surgery. Low initial surgeon-provided opioid dosages did not correlate to filling a second prescription, indicating that lower initial doses are feasible. Finally, nearly all opioid-naïve patients who filled a second opioid prescription received them from providers other than a surgeon, indicating the need for greater communication with nonsurgical providers simultaneously caring for patients in the perioperative period.Type of study/level of evidenceTherapeutic III.

A 15-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Carpometacarpal Joint Arthroplasty.

The purpose of this study was to help understand national practice patterns in carpometacarpal (CMC) arthroplasty and how they have evolved with evidence-based recommendations over the past 15 years. The American Board of Plastic Surgery (ABPS) started collecting practice data on primary CMC joint arthroplasty in 2006 as a portion of its continuous certification (CC) process. Data on primary CMC arthroplasty from May 2006 through December 2013 were reviewed and compared to those from January 2014 to March 2020. National practice trends observed in these data were evaluated. Comprehensive evidence-based medicine reviews published in 2008, 2011, 2013, and 2017 were reviewed alongside the CC data. In all, 570 primary CMC joint arthroplasty cases were included from May 2006 to March 2020. The average age at the time of repair was 62 years and the patient population was predominantly female (79%). Most cases were done under general anesthesia (69%), and there was an increase in the use of regional anesthesia with nerve block when our 2 cohorts were compared (27% vs 37%; P = .020). A trapezium excision with flexor carpi radialis tendon ligament reconstruction was the most popular technique (72%) and an increase in the use of simple trapeziectomy was observed (6% vs 14%; P = .001). One-third of patients did not receive any form of deep vein thrombosis prophylaxis. The ABPS CC data provide a databank that allows for direct observation of national practice trends and sheds light on potential avenues for improvement in patient care.

One day versus three days’ antibiotic prophylaxis in joint arthroplasty. A prospective randomized controlled trial

Objectives: The objectives of the study was to compare the effectiveness of 1 day versus 3 days post-operative antibiotic prophylaxis in decreasing surgical site infection (SSI) rate after arthroplasty surgery. Methods: A prospective, randomized controlled trial was conducted over 1 year, in Cairo University Hospitals. The study included adult patients, who were scheduled for arthroplasty. Sixty patients were divided into two groups, 30 patients in each. The first group of patients received cefazolin for 1 day postoperatively (1-day group) and the other group for 3 days postoperatively (3-days group). Patients were randomized using the sealed opaque envelope method. Results: There were 32 females and 28 males. The mean patient age was 52 years (range 20–85 years). Wound infection developed in four cases (one case from the 1-day group and three cases from the 3-days group). All infections occurred within the early post-operative period, and completely resolved after proper management. Correlating the SSI to the type of surgery, operative time, the associated medical co-morbidities, and the duration of antimicrobial prophylaxis was not statistically significant. Conclusion: This study suggests that there is no significant difference in the prevalence of SSI between 1 day and 3 days of antimicrobial prophylaxis after primary joint arthroplasty within the average post-operative follow-up period of 3 months.

Equivalent VTE rates after total joint arthroplasty using thromboprophylaxis with aspirin versus potent anticoagulants: retrospective analysis of 4562 cases across a diverse healthcare system

BackgroundGuidelines support aspirin thromboprophylaxis for primary total hip and knee arthroplasty (THA and TKA) but supporting evidence has come from high volume centers and the practice remains controversial.MethodsWe studied 4562 Medicare patients who underwent elective primary THA (1736, 38.1%) or TKA (2826, 61.9%) at 9 diverse hospitals. Thirty-day claims data were combined with data from the health system’s electronic medical records to compare rates of venous thromboembolism (VTE) between patients who received prophylaxis with: (1) aspirin alone (47.3%), (2) a single, potent anticoagulant (29%), (3) antiplatelet agents other than aspirin or multiple anticoagulants (21.5%), or (4) low-dose subcutaneous unfractionated heparin or no anticoagulation (2.2%). Sub-analyses separately evaluating THA, TKA and cases from lower volume hospitals (n = 975) were performed.ResultsThe 30-day VTE incidence was 0.6% (29/4562). VTE rates were equal in patients receiving aspirin and those receiving a single potent anticoagulant (0.5% in both groups). Patients with VTE were significantly older than patients without VTE (mean 76.5 vs. 73.1 years, P = 0.04). VTE rate did not associate with sex or hospital case volume. On bivariate analysis considering age, aspirin did not associate with greater VTE risk compared to a single potent anticoagulant (OR = 2.1, CI = 0.7–6.3) with the numbers available. Odds of VTE were increased with use of subcutaneous heparin or no anticoagulant (OR = 6.4, CI = 1.2–35.6) and with multiple anticoagulants (OR = 3.6, CI = 1.1–11.2). THA and TKA demonstrated similar rates of VTE (0.5% vs. 0.7%, respectively, P = 0.43). Of 975 cases done at lower volume hospitals, 387 received aspirin, none of whom developed VTE.ConclusionsThis study provides further support for aspirin as an effective form of pharmacological VTE prophylaxis after total joint arthroplasty in the setting of a multi-modal regimen using 30-day outcomes. VTE occurred in 0.7% of primary joint arthroplasties. Aspirin prophylaxis did not associate with greater VTE risk compared to potent anticoagulants in the total population or at lower volume hospitals.

The impact of an enhanced recovery programme on length of stay and post-discharge resource usage following hip and knee arthroplasty : a service evaluation and cost analysis.

AimsThe aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis.MethodsBetween May and December 2019, 100 patients requiring hip or knee arthroplasty were enrolled with the intention that each would have a preadmission discharge plan, a preoperative education class with nominated helper, a day of surgery admission and mobilization, a day one discharge, and access to a 24/7 dedicated helpline. Each was matched with a patient under the pre-existing pathway from the previous year.ResultsMean LOS for ERAS patients was 1.59 days (95% confidence interval (CI) 1.14 to 2.04), significantly less than that of the matched cohort (3.01 days; 95% CI 2.56 to 3.46). There were no significant differences in readmission rates for ERAS patients at both 30 and 90 days (six vs four readmissions at 30 days, and nine vs four at 90 days). Despite matching, there were significantly more American Society of Anesthesiologists (ASA) grade 3 patients in the ERAS cohort. There was a mean cost saving of £757.26 (95% CI £-1,200.96 to £-313.56) per patient. This is despite small increases in postoperative resource usage in the ERAS patients.ConclusionERAS represents a safe and effective means of reducing LOS in primary joint arthroplasty patients. Implementation of ERAS principles has potential financial savings and could increase patient throughput without compromising care. In elective care, a preadmission discharge plan is key.Cite this article: Bone Jt Open 2021;2(11):966–973.

Editor's Spotlight/Take 5: How Large a Study Is Needed to Detect TKA Revision Rate Reductions Attributable to Robotic or Navigated Technologies? A Simulation-based Power Analysis.

Editor's Spotlight/Take 5: How Large a Study Is Needed to Detect TKA Revision Rate Reductions Attributable to Robotic or Navigated Technologies? A Simulation-based Power Analysis.

Is Shared Decision-making Associated with Better Patient-reported Outcomes? A Longitudinal Study of Patients Undergoing Total Joint Arthroplasty.

Although shared decision-making (SDM) has knowledge and satisfaction benefits for patients and is promising, we lack data demonstrating that SDM is associated with better patient-reported functional outcomes. Such data would support the integration and prioritization of SDM into all aspects of orthopaedic care. (1) Is a measure of SDM before total joint arthroplasty associated with better patient-reported outcome measures (PROMs) 1 year postoperatively? (2) What is the relationship between the measure of SDM and two measures of patient experience (patient rating of the provider and patient likelihood of recommending the provider) at 1 year postoperatively? In this observational longitudinal survey-based study, patients receiving an initial THA or TKA from a large, multispecialty medical group in the Midwestern United States were surveyed after they were scheduled for surgery and again at 12 months after their procedure. The three-item collaboRATE measure of SDM was added to existing patient surveys of PROMs. However, the surgeons and their department had no organized approach to SDM during this time. The surveys also included the Oxford knee or hip score and two validated measures of patient experience (patient rating of the provider and whether a patient would recommend the provider). Of the 2779 eligible primary joint arthroplasties that occurred from April 23, 2018 to May 1, 2019, 48% (1334 procedures; 859 TKAs and 485 THAs) of the patients responded to both the preoperative and 12-month postoperative surveys. Most of the patients who were included in the analytic sample were white (93%; 1255 of 1344), with only 3% (37) using Medicaid benefits at the time of surgery. Differences between responders and nonresponders were present and explored in an analysis. Patient responses were analyzed in regression models to estimate the association between preoperative collaboRATE scores and the Oxford knee or hip scores, and patient experience measures 12 months postoperatively. There was a moderate, positive association between preoperative collaboRATE scores and the Oxford scores at 12 months, after adjustment for potential confounders such as patient age and preoperative functional score (β = 0.58; 95% CI 0.14-1.02; p = 0.01). Similarly, patients with preoperative collaboRATE scores had marginally higher patient experience scores at 12 months postoperatively (β = 0.14; 95% CI 0.05-0.24; p = 0.003) and were more likely to recommend their surgeon (OR 1.43; 95% CI 1.11-1.84; p = 0.005). The patient experience measures were also modestly correlated with collaboRATE scores in cross-sectional associations, both preoperatively and at 12 months postoperatively (0.29 ≤ r ≤ 0.54; p < 0.01). The association between preoperative collaboRATE scores and Oxford hip or knee scores suggests that SDM could be one tool to encourage better outcomes. Although previous studies have shown that SDM can improve patient experience, the lack of a strong correlation in our study suggests that PROMs and experience measures are separate domains, at least partly. Improving preoperative SDM between the surgeon and patient might help improve surgical outcomes for patients undergoing TKA and THA. Level II, therapeutic study.

Cost analysis on virtual clinic follow-up after primary joint arthroplasty

BackgroundAs previously reported, a virtual clinic (VC) effectively manages the increasing need to review and monitor patients after primary joint replacement. Such procedure is increasing steadily in number, with more than 200,000 procedures performed annually in the UK. Considering that face-to-face review following routine uncomplicated primary joint arthroplasty is costly and time consuming, guidelines suggest reviewing patients at regular intervals through radiographs and patient-reported outcome measures (PROMs). MethodsWe reviewed our VC experience in a large teaching hospital. A single surgeon established the VC, and all primary hip and knee replacements over an 18-month period (January 2016 to July 2017) were included in the study. We evaluated all clinical records, PROMs, patient satisfaction, and outcome of VC at one-year follow-up. Additionally, we conducted a safety and cost analysis. ResultsThis study included 154 primary joints (70 total knee replacements and 84 total hip replacements) in 148 patients (89 females, 59 males). The mean age at surgery was 65.3 years. Of the patients, 93% completed the postoperative PROMs, whereas <40% completed the PROM during regular clinical follow-up. All the patients had follow-up radiographs. After VC assessment, which included radiographies and PROMs, 59% of the patients were directly discharged. Of the remaining 41% patients who had face-to-face review, one-third were examined for the same arthroplasty issue, and two-thirds were examined for unrelated or other joint problems. Although the postoperative PROM was below the national average, the improvement in PROM (from pre-operative to post-operative scores) was higher than the national average. The cost analysis demonstrated an average cost savings of £10.449 per year and consultant. ConclusionsVC follow-up after primary joint replacement is a safe and cost-effective option to manage postoperative follow-up visits and identify those patients who require additional face-to-face reviews and who can be safely discharged. The discharge criteria included satisfactory improvement in PROM scores, review of follow-up radiographs, and no concerns raised by patients. Considering the increasing number of primary joint arthroplasty and the financial pressure on the National Health Service, VC offers an excellent alternative to conventional clinics.

Is the Preoperative Use of Antidepressants and Benzodiazepines Associated with Opioid and Other Analgesic Use After Hip and Knee Arthroplasty?

Mental health disorders can occur in patients with pain conditions, and there have been reports of an increased risk of persistent pain after THA and TKA among patients who have psychological distress. Persistent pain may result in the prolonged consumption of opioids and other analgesics, which may expose patients to adverse drug events and narcotic habituation or addiction. However, the degree to which preoperative use of antidepressants or benzodiazepines is associated with prolonged analgesic use after surgery is not well quantified. (1) Is the preoperative use of antidepressants or benzodiazepine medications associated with a greater postoperative use of opioids, NSAIDs, or acetaminophen? (2) Is the proportion of patients still using opioid analgesics 1 year after arthroplasty higher among patients who were taking antidepressants or benzodiazepine medications before surgery, after controlling for relevant confounding variables? (3) Does analgesic drug use decrease after surgery in patients with a history of antidepressant or benzodiazepine use? (4) Does the proportion of patients using antidepressants or benzodiazepines change after joint arthroplasty compared with before? Of the 10,138 patients who underwent hip arthroplasty and the 9930 patients who underwent knee arthroplasty at Coxa Hospital for Joint Replacement, Tampere, Finland, between 2002 and 2013, those who had primary joint arthroplasty for primary osteoarthritis (64% [6502 of 10,138] of patients with hip surgery and 82% [8099 of 9930] who had knee surgery) were considered potentially eligible. After exclusion of another 8% (845 of 10,138) and 13% (1308 of 9930) of patients because they had revision or another joint arthroplasty within 2 years of the index surgery, 56% (5657 of 10,138) of patients with hip arthroplasty and 68% (6791 of 9930) of patients with knee arthroplasty were included in this retrospective registry study. Patients who filled prescriptions for antidepressants or benzodiazepines were identified from a nationwide drug prescription register, and information on the filled prescriptions for opioids (mild and strong), NSAIDs, and acetaminophen were extracted from the same database. For the analyses, subgroups were created according to the status of benzodiazepine and antidepressant use during the 6 months before surgery. First, the proportions of patients who used opioids and any analgesics (that is, opioids, NSAIDs, or acetaminophen) were calculated. Then, multivariable logistic regression adjusted with age, gender, joint, Charlson Comorbidity Index, BMI, laterality (unilateral/same-day bilateral), and preoperative analgesic use was performed to calculate odds ratios for any analgesic use and opioid use 1 year postoperatively. Additionally, the proportion of patients who used antidepressants and benzodiazepines was calculated for 2 years before and 2 years after surgery. At 1 year postoperatively, patients with a history of antidepressant or benzodiazepine use were more likely to fill prescriptions for any analgesics than were patients without a history of antidepressant or benzodiazepine use (adjusted odds ratios 1.9 [95% confidence interval 1.6 to 2.2]; p < 0.001 and 1.8 [95% CI 1.6 to 2.0]; p < 0.001, respectively). Similarly, patients with a history of antidepressant or benzodiazepine use were more likely to fill prescriptions for opioids than patients without a history of antidepressant or benzodiazepine use (adjusted ORs 2.1 [95% CI 1.7 to 2.7]; p < 0.001 and 2.0 [95% CI 1.6 to 2.4]; p < 0.001, respectively). Nevertheless, the proportion of patients who filled any analgesic prescription was smaller 1 year after surgery than preoperatively in patients with a history of antidepressant (42% [439 of 1038] versus 55% [568 of 1038]; p < 0.001) and/or benzodiazepine use (40% [801 of 2008] versus 55% [1098 of 2008]; p < 0.001). The proportion of patients who used antidepressants and/or benzodiazepines was essentially stable during the observation period. Surgeons should be aware of the increased risk of prolonged opioid and other analgesic use after surgery among patients who were on preoperative antidepressant and/or benzodiazepine therapy, and they should have candid discussions with patients referred for elective joint arthroplasty about this possibility. Further studies are needed to identify the most effective methods to reduce prolonged postoperative opioid use among these patients. Level III, therapeutic study.

Investigation of Cytotoxicity, Oxidative Stress, and Inflammatory Responses of Tantalum Nanoparticles in THP-1-Derived Macrophages.

Tantalum (Ta) is gaining attention as a biomaterial in bone tissue engineering. Although the clinical advantage of Ta-based implants for primary and revision total joint replacement (TJA) has been well documented, few studies investigated the effect of wear products of Ta implants on peri-implant cells, and their potential contribution to aseptic implant loosening. This study is aimed at examining the cytotoxicity, oxidative stress, and proinflammatory potential of Ta and TiO2 nanoparticles (NPs) on macrophages in vitro. NPs were characterized using scanning electron microscopy, dynamic light scattering, and energy-dispersive X-ray. To test the NP-mediated cellular response in macrophages, THP-1-derived macrophages were challenged with both NPs, and cytotoxicity was analyzed using CCK-8 and LDH assays. Flow cytometry was used to investigate particle uptake and their internalization routes. NP-mediated oxidative stress was investigated by measuring the production of reactive oxygen species, and their proinflammatory potential was determined by quantifying the production of TNFα and IL-1β in cell culture supernatants using ELISA. We found that both Ta and TiO2 NPs were taken up through actin-dependent phagocytosis, although TiO2 NPs did also show some involvement of macropinocytosis and clathrin-mediated endocytosis. Ta NPs caused no apparent toxicity, while TiO2 NPs demonstrated significant cytotoxicity at a concentration of over 100μg/mL at 24 h. Ta NPs induced negligible ROS generation and proinflammatory cytokines (TNFα, IL-1β) in macrophages. In contrast, TiO2 NPs markedly induced these effects in a dose-dependent manner. Our findings indicate that Ta NPs are inert, nontoxic, and noninflammatory. Therefore, Ta could be considered an excellent biomaterial in primary and revision joint arthroplasty implants.

Тренды в первичной артропластике коленного сустава в Национальном медицинском исследовательском центре травматологии и ортопедии им. Р.Р. Вредена и их сравнительный анализ с данными международных национальных регистров: схож ли наш путь?

Introduction Total joint replacement is one of the most effective and successful surgical interventions. Regular monitoring of these surgical interventions is essential and may serve as a system for early detection of defective prosthesis designs or techniques resulting in the complication rate which exceeds the estimated level. The ideal way to conduct this monitoring is a registry of joint replacements. Purpose Assessment of the structure of primary knee joint arthroplasty at the Federal State Budgetary Institution Vreden National Medical Research Centre for Traumatology and Orthopaedics named and it’s comparative analysis with the data from leading foreign registers to improve the work of orthopaedic surgeons, traumatologists and healthcare organizers by optimizing the surgical tactics in the specialized treatment of patients. Methods The authors reviewed the annual reports published by national registers of knee replacements and compared them with the data of the registry of the Vreden National Medical Research Centre for Traumatology and Orthopaedics to make conclusions that would be relevant to current orthopaedic practice. Results Several results of the survey demonstrate the most significant or unexpected conclusions as according to the registry. These include an extremely large gender imbalance and obesity as two thirds of the patients were overweight. The number of patients with tumors and rheumatological diseases in the structure of knee replacements decreased considerably in the recent years. Designs and types of implants used, patellar resurfacing in arthroplasty, time of surgical intervention and options for postoperative administrations of antibiotics at the Vreden Centre are consistent with general European trends in knee arthroplasty. Conclusions The number of primary knee replacements (including unicompartment replacements) has been increasing annually. The patients admitted for primary knee replacement are statistically very similar to patient population from other countries. The main differences are associated with an earlier age at which arthroplasty is performed, an extreme gender imbalance and a relatively low number of patellar resurfacing in primary knee replacement. The problem of overweight among the population leads to an increased number of knee replacements, complications and lower implant survival rate.

Efficacy of universal preoperative decolonization with Polyhexanide in primary joint arthroplasty on surgical site infections. A multicenter before-and after-study

BackgroundSurgical site infections (SSI) are rare but severe complications after total joint arthroplasty (TJA). Decolonization measures prior to elective orthopedic surgeries have shown to reduce the risk of SSI with Staphylococcus aureus (S. aureus).ObjectiveTo determine the efficacy of universal decolonization with Polyhexanide on SSI rates with a focus on Staphylococcus aureus in patients with TJA.MethodsPatients scheduled for elective hip or knee TJA in 5 participating certified orthopedic centers were included between 2015 and 2018 into this before and after study. Data on patients, surgeries and infections were prospectively collected. CDC-criteria were used to define and categorize Infections within 90 days after surgery. From January 2017 on, patients received decolonization sets containing Polyhexanide. Patients performed a 5 day decolonization regimen starting 4 days prior to surgery which included wipes, nasal decontamination and oral solution.ResultsThirteen thousand, three hundred fifteen patients received TJA. During intervention 4437 decolonization sets were distributed among 7175 patients.Overall SSI rates increased from 0.68 /100 surgeries to 0.91/ 100 surgeries after implementation of the intervention (IRR 1.32; 95% CI 0.90–1.96). Time series analysis identified an increasing trend of SSI prior to the intervention. After implementation overall SSI rates plateaued. Regression analysis revealed surgery during intervention period to be an independent risk factor for developing a SSI (OR 1.34; 95%CI 1.18–1.53).Initial SSI rates due to S. aureus were 0.24/100 surgeries and decreased to 0.14/100 surgeries (IRR 0.57; 95% CI 0.25–1.22) after introduction of decolonization. Regression analysis revealed surgery during intervention period to be an independent protective factor for developing a SSI with S. aureus (OR 0.57, 95% CI: 0.33–0.99).Overall deep S. aureus SSI decreased significantly from 0.22/100 surgeries to 0.00/100 surgeries in patients adherent to protocol (IRR 0.00, 95% CI 0.00–.85).ConclusionUniversal decolonization with Polyhexanide did not reduce overall surgical site infections, but was effective in reducing Staphylococcus aureus - surgical site infections following elective joint arthroplasty. Polyhexanide could extend the list of alternatives to already established decolonization strategies.Trial registrationThe trial was registered at the German Registry for clinical studies www.drks.de (DRKS00011505).

Risk factors of allogeneic red blood transfusion following enhanced recovery hip and knee arthroplasty

Objective: To Explore the current status and risk factors of perioperative allogenic red blood cell transfusion following enhanced recovery hip and knee joint arthroplasty. Methods: Patients who have taken their primary unilateral total hip and knee arthroplasty (THA, TKA) or simultaneous primary THA were retrospectively included from January, 2019 to December, 2019 in West China Hospital. The baseline characteristics were compared between patients with allogeneic transfusion and those without. And logistic regression were used to analyze the risk factors of perioperative allogeneic red blood cell transfusion. Results: A total of 2 034 patients (2072 arthroplasties) were included, 705 males and 1 329 females, aged (60±24) years. Of all, 1 137 patients received primary THA (38 simultaneous THA), 897 patients received primary unilateral TKA. Eleven (0.54%) patients received allogeneic red blood cell transfusion, and the mean volume was (2.6±1.2) U. Deep venous thrombosis occurred in 2 patients (0.09%) undergoing primary TKA. The transfusion rate in primary THA patients was 0.79% (9/1 137), and 0.22% (2/897) in TKA. Lower preoperative hemoglobin level (P=0.041) and more hematological comorbidities (P=0.005) were detected in transfused patients. And logistic analysis further revealed that preoperative substandard hemoglobin level was the most important risk factor for transfusion (OR=5.663, P=0.018). Conclusions: Under the intervention of enhanced recovery after surgery concept and modern blood management strategies, the transfusion requirement has been significantly reduced following primary joint arthroplasty. Pre-operative hemoglobin level should be an important threshold for perioperative blood management.

Is Routine Hemoglobin Monitoring Necessary after Elective Hip and Knee Arthroplasty?

BackgroundMany orthopaedic units measure hemoglobin (Hb) levels after primary joint arthroplasty to identify patients with postoperative anemia. With the refinement of surgical techniques, blood loss in primary arthroplasty has decreased. The aim of this study was to investigate the postoperative Hb monitoring and transfusion practices in our own institution after elective hip or knee arthroplasty. MethodsWe conducted a retrospective audit of all patients who underwent elective total hip or knee arthroplasty in Galway University Hospital between March 1 and June 1, 2019. We recorded when they underwent postoperative Hb testing, whether or not they had a drop of Hb, which would indicate transfusion (<8 g/dL), and whether or not they were transfused. In patients who underwent transfusion, a chart review was performed to establish the presence of factors that would have triggered repeat Hb testing. ResultsOne hundred thirty-six patients underwent elective primary hip or knee arthroplasty in the period. All had a full blood count sent on the first postoperative day. None (0%) had a clinically significant (to < 8g/dL) postoperative Hb drop on day 1. Eighteen (13.2%) patients underwent repeat testing on day 2 or subsequently. Eight (5.9%) exhibited a drop in Hb to less than 8 g/dL, with a mean Hb drop of 4.26 (standard error of the mean ± 0.862, standard deviation ± 0.98), and 5 (3.7%) proceeded to undergo allogenic blood product transfusion. All 5 underwent documented indications for repeat Hb testing. ConclusionsThere is no evidence for performing routine Hb testing on day 1 after elective hip or knee arthroplasty. We recommend that postoperative Hb testing should only be carried out on patients with additional indications.

Use of a Modified Rep Model in Primary Joint Arthroplasty: Lessons Learned.

Orthopedic implant device sales representatives ("reps") can provide intraoperative guidance based on their product knowledge, as part of their many responsibilities. However, for experienced high-volume arthroplasty surgeons, a representative may not be required in the room for most primary total knee arthroplasty (TKA) procedures. The goal of this study was to describe the authors' experience with a modified rep model for primary TKA. Between January and December 2017, a total of 100 unilateral primary TKAs were performed with a modified rep model and compared with 100 primary TKAs that were performed before this protocol. The authors adopted 2 additional initiatives to institute this protocol safely: (1) improved education of operating room staff and allocation of responsibilities; and (2) reengineering of the existing surgical trays. No perioperative complications, including readmission, periprosthetic fracture, or infection, occurred in either group. In addition, no difference was found in mean length of stay between the modified rep and conventional cohorts (2.2 and 2.4 days, respectively; P=.49). Mean operating room time was less with the modified rep cohort (102.1 vs 117.8 minutes; P<.001), as was total instrument turnover time in the operating room (13.9 vs 29.7 minutes; P<.0001) and in central sterilization (59.4 vs 126.8 minutes; P<.001). No errors occurred with implant accuracy or trays, and there was no need to change the type of implant with the modified rep model, compared with 6% of trays requiring additional sterilization with the conventional model. The negotiated implant cost with the modified rep model was approximately $2000 less than that for the conventional group. This study found that the modified rep model for primary TKA is safe and has the potential for substantial cost savings. [Orthopedics. 2020;43(6):e538-e542.].

Can the Caprini score predict thromboembolism and guide pharmacologic prophylaxis after primary joint arthroplasty?

AimsVenous thromboembolism (VTE) has a 30-day mortality rate of between 10 and 30%. The Caprini score is a VTE risk assessment model, which assigns points to 20 past medical history and current health factors. We hypothesized that the Caprini score could predict VTE incidence and recommend prophylaxis following total joint arthroplasty. Patients and methodsWe performed a retrospective review of prospectively collected institutional data identifying Caprini scores on 2155 primary hip (n = 840) and knee (n = 1315) arthroplasties. Surgeons were blinded to Caprini scores when prescribing VTE prophylaxis. Patients were separated into prophylaxis groups receiving Aspirin (81 mg BID or 325 mg BID) or other (Rivaroxaban, Warfarin, Enoxaparin, Apixaban, Dabigatran, Heparin). Univariate, multivariate, and Cohen's effect size analyses assessed the predictive power of the Caprini score on VTE incidence. ResultsThe mean Caprini score was 9.49 (5–25). A majority, 83% (1792) of patients were in the Aspirin group, and 17% (363) in the other group. Other prophylaxis patients had statistically significantly higher Caprini scores (10 vs. 9, p < 0.0001). Twenty-five (1.2%) patients developed VTE. Controlling for prophylaxis, higher Caprini scores increased VTE risk, but this wasn't statistically significant (p = 0.16). Multivariate analysis showed a non-significant effect for patients with BMIs >40 or Caprini scores ≥11 to predict VTE incidence in the Aspirin or other prophylaxis groups (p = 0.52 and p = 0.15 respectively). Cohen's effect size was small, comparing Caprini scores in patients who had and had not had a VTE in both Aspirin and other prophylaxis groups (Cohen's d = 0.25 and d = 0.16 respectively). ConclusionSurgeons rely on stronger pharmacologic prophylaxis for a select high risk group of their primary lower extremity total joint arthroplasty patients. When controlling for prophylaxis, the Caprini score had a small effect size and did not have the predictive power necessary to guide treatment

Results of proximal interphalangeal arthroplasty: border digits versus middle digits.

This investigation assessed 106 consecutive primary proximal interphalangeal joint arthroplasties performed on border digits: 73 index or 33 little fingers. This was compared with 193 arthroplasties performed in non-border digits: 121 middle or 72 ring fingers. There were 20 proximal interphalangeal joint arthroplasties in the border digits that required revision surgery for pain and stiffness (10 digits), dislocation (six digits), implant fracture (one digit), and infection (three digits). Risk of revision surgery was not associated with border digit. The 5-year implant survival rate for the border digits was 81%. There was no significant difference in implant revision rate or joint dislocations between border and non-border digits. We conclude that proximal interphalangeal joint arthroplasties performed in border digits had similar pain relief, survivorship, complications, and reoperation rates compared with those performed in non-border digits.Level of evidence: IV.

Detection of α-defensin in synovial fluids by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry as an innovative and cost-effective assay for improved definition of periprosthetic joint infections.

Detection of α-defensins in synovial fluid is gaining more and more interest in the field of correct diagnosis of periprosthetic joint infections (PJIs). At present, they can be assessed by a quantitative enzyme-linked immunosorbent assay which is expensive and time-consuming and by a qualitative lateral flow immunoassay which is rapid but quite expensive and whose clinical sensitivity is debated. Thus, developing an alternative rapid, accurate, and low-cost assay for α-defensins is important to make α-defensins actionable as novel key clinical markers. Synovial fluid (SF) samples were obtained from 18 patients undergoing revision of primary joint arthroplasty. Of these, eight met the 2013 Musculoskeletal Infection Society (MSIS) criteria for PJIs, the remaining were classified as aseptic failure. Microbiological analysis and Synovasure assays were carried out on all samples. Sample preparation and the matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) settings were adjusted to detect human neutrophil peptide (HNP)-1, -2 and -3 and to obtain optimal results in term of sensitivity and stability. MALDI-TOF MS was able to detect HNPs in SF from septic patients. No signals for HNPs were detected in SF from aseptic failure. The limits of detection (LOD) were 2.5 and 1.25 μg/mL for HNP-2 and HNP-1, respectively. The turnaround time of the analysis is 20 min, and SF samples are stable at -20°C for up to 3 days. Assay sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were 100% for all parameters. On the same SF samples, the Synovasure assay showed lower sensitivity specificity, and PPV and NPV of 87.5%, 90%, 87.5% and 90%, respectively. Microbiological analysis of SF confirmed the presence of bacteria only in SF MSIS-positive patients. The reported MALDI-TOF MS assay was able to detect and differentiate HNPs in SF samples and showed a slightly better diagnostic accuracy than the Synovasure assay.