Primary Joint Arthroplasty Research Articles

Application of Desmopressin and conjugated estrogens to reduce the volume of blood loss during arthroplsty of the hip joint in patients with end stage renal disease

The objective was to determine the possibilities of using desmopressin and conjugated estrogens during primary hip joint arthroplasty in patients receiving renal replacement therapy.Methods and materials. The material for the study was data on 53 patients with pathology of the hip joint, who underwent primary arthroplasty from 2016 to 2018. All patients were divided into 2 groups. Group 1 (n=23) – patients not suffering from kidney diseases. Group 2 (n=30) – patients receiving renal replacement therapy. Each group was divided into 2 subgroups: 1 subgroup – comparisons, where the combination of desmopressin/conjugated estrogens was not used. 2 subgroup – control, where desmopressin was used at a dosage of 0.4 mg/kg 2 hours before the incision, conjugated estrogens was used at a dosage of 0.6 mg / kg of body weight within 5 days before the operation.Results. In group 1 (patients not suffering from kidney disease), there was no statistically significant difference between the subgroups. In group 2 (patients receiving hemodialysis), there was a statistically significant difference in the volume of blood loss. Thus, in the subgroup without using additional techniques, the volume of intraoperative blood loss was 769.5±389.3 ml; in the second subgroup (using desmopressin and estrogens) – 479.1±245.2 ml. The difference was statistically significant, p<0.05. The efficiency was 27.9 %.Conclusion. The additional use of conjugated estrogens at a dose of 0.6 mg/kg of body weight within 5 days before the operation, desmopressin at a dose of 0.4 mg/kg of body weight 2 hours before the incision reduced blood loss by 27.9 %. The use of combination of conjugated estrogens and desmopressin in patients not suffering from kidney disease did not affect the amount of blood loss.

Prognostic risk factors of surgical site infection after primary joint arthroplasty: A retrospective cohort study.

Surgical site infection (SSI) can be a devastating complication in joint arthroplasty. Objective of this study was to identify potential risk factors associated with SSI following primary joint arthroplasty.This retrospective cohort study was performed from January 2016 to October 2017. A total of 986 patients were enrolled. We extracted the patients’ baseline information, treatment-related variables and indexes of laboratory examination during their hospitalization. Receiver operating characteristic (ROC) analysis was performed to find the optimum cut-off value for serum albumin. Univariate and multivariate logistic analysis models were performed respectively to determine independent predictors of SSI.Nine hundred eighty-six patients with complete data were included in the final analysis. There were 314 male and 672 females in this study with a mean age of 64.6 years, and twenty patients developed SSI. The overall incidence of SSI was 2.03%, with 0.20% for deep infection and 1.83% for superficial SSI. Independent predictors of SSI identified by multivariate analysis were ALB < 36.7 g/L (odds ratio = 3.42; 95% CI = 1.24–9.48; P = .018), BMI ≥28 (odds ratio = 5.08; 95%CI = 1.52–17.01; P = .008) and ASA class 3 or higher (odds ratio = 3.36; 95% CI = 1.22–9.30; P = .019). Drain use was demonstrated as a protective factor of postoperative wound healing.The incidence of SSI following primary joint arthroplasty was 2.03%. ASA ≥3, BMI ≥28 and ALB < 36.7 g/L were demonstrated as risk factors of postoperative wound infection. Supplementary nutrition support is necessary to reduce the risk of infection in patients who underwent artificial joint arthroplasty.

Early Deep Periprosthetic Hip Infection of Odontogenic Origin (Case Report)

Deep periprosthetic joint infection (PJI) is a severe complication after primary and revision hip joint arthroplasty resulting in multiple interventions on the joint. The present paper describes a rare case of early deep hip PJI of odontogenic etiology. The patient suffered from early PJI after a planned procedure of left hip joint arthroplasty. Antibacterial therapy without surgical debridement was performed in an outpatient unit which resulted in a late, on day 12th after surgery, admittance of the patient to hospital with continued administration of antibiotics. Treatment tactics was selected upon patient’s admission basing on patient complaints, medical history of the disease, clinical signs and findings of roentgenological, laboratory and bacteriological examinations. Two-stage treatment consisting of revision, removal of implant, debridement, biopsy and wound drainage by a swab was performed and followed by empiric antibacterial therapy (for 5 days). Targeted antibacterial therapy was prescribed basing on bacteriological test findings. Together with dentists the authors examined oral cavity of the patient, identified a site of chronic infection and undertook the focused treatment by dental extraction and sanitation of the oral cavity. Postoperative period after the first stage was uncomplicated. Second stage of revision (re-arthroplasty of left hip joint) was performed on week 36 of the surgical time-out with a good clinical outcome: 80 points on Harris hip score in 40 weeks after the second stage. Presented clinical case illustrates the existence of hematogenous mechanism of postoperative microorganism dissemination from the chronic infection nidus with subsequent progression of inflammation at the surgical site, including PJI. In the present case the Actinomyces odontolyticus was isolated from periprosthetic tissues and parodontal recesses which allowed the authors to suggest a highly probable cause for early PJI by Actinomyces odontolyticus translocation into periprosthetic tissues of the hip joint. However, strain sequencing is required for the complete verification. The described case confirms the need for debridement of chronic infection nidus prior to joint arthroplasty aiming at prevention of hematogenous periprosthetic infection.

The role of multimodal postoperative analgesia after primary hip arthroplasty

Introduction: Due to the increasing number of arthroplasties, the number of post-operative hospital days was reduced and the rate of rehabilitation accelerated. For this, proper postoperative analgesia is essential and the multimodal pain relief is an excellent tool. Aim: The aim of our study was to compare postoperative functional results, postoperative pain levels, and opioid analgesic needs of patients who received conventional and novel analgesic treatments. Method: In our prospective study, 81 patients were enrolled who underwent primary hip prosthesis surgery in our institution between February 2017 and January 2018. Of the randomized patients, 38 were in the control group and 43 in the multimodal pain group. We have tested their analgesic needs and the subjective pain levels of patients with the help of the visual analog scale (VAS). Results: Patients receiving multimodal pain relief had significantly lower opioid analgesic requirements and significantly lower VAS values assessed at 6 hours, and 3 and 4 days postoperatively. In addition, the patients in this group stayed in the hospital for a significantly shorter time after surgery. Conclusions: Based on our experience, multimodal pain relief in one-sided primary hip joint arthroplasty significantly reduced the patients' postoperative subjective pain sensation and pain killer consumptions. Orv Hetil. 2019; 160(52): 2054-2060.

Тест генерации тромбина в оценке адаптационных возможностей системы гемокоагуляции у пациентов с дегенеративно-дистрофическими заболеваниями суставов

Введение. Поиски методов оценки функционального состояния системы гемокоагуляции у пациентов, которые ожидают выполнения эндопротезирования крупных суставов нижних конечностей, обоснованы высокой частотой встречаемости у них тромбоэмболических осложнений. Цель исследования: изучение теста генерации тромбина (ТГТ) с позиции оценки адаптационных возможностей системы гемокоагуляции у больных с дегенеративнодистрофическими заболеваниями крупных суставов нижних конечностей. Материалы и методы. Обследован 141 больной с дегенеративнодистрофическими поражениями тазобедренных и коленных суставов (35 мужчин, 106 женщин), средний возраст 62,6 9,9 лет. Контрольную группу составили 30 условно здоровых доноров, средний возраст 49,7 6,5 лет. Исследовали коагуляционные свой ства крови рутинными методами и регистрировали кривую процесса тромбинообразования в ТГТ, анализируя параметры: tlag латентное время тромбинообразования, ttpeak время достижения максимума тромбина, peak максимальное количество тромбина, VI индекс скорости тромбинообразования, AUC площадь под кривой. Больные были разделены на 2 группы в зависимости от характера изменения временных параметров ТГТ в ответ на инициацию тромбиногенеза активаторами с концентрацией тканевого фактора 2 пмоль/мл (активатор RB) и 5 пмоль/мл (активатор RClow). Результаты. В 1й группе значения параметров tlag и ttpeak в ответ на действие активатора RClow были меньше, чем на действие активатора RB, реакцию системы гемокоагуляции расценивали как адекватную. Во 2й группе значения tlag и ttpeak при использовании активатора RClow превышали величины аналогичных параметров при инициации тромбообразования активатором RB, а корреляционный анализ отразил ослабление связей между параметрами ТГТ, что свидетельствовало об адаптационной перестройке системы на фоне высокого тромбогенного потенциала и повышенном риске развития гемокоагуляционных осложнений у больных 2й группы. Заключение. ТГТ с использованием активаторов RB и RClow ерспективный инструмент выявления больных с высоким риском развития послеоперационных гемокоагуляционных осложнений. Introduction. The search of methods for assessing of hemocoagulation functional state in patients that are waiting endoprosthesis replacement of large joints of lower extremities is justified by the high incidence of thromboembolic complications. Aim: to study thrombin generation assay (TGA) for assessment of hemocoagulation adaptive potential in patients with degenerativedystrophic diseases of the large joints of lower extremities. Materials and methods. We examined 141 patients with degenerativedystrophic lesions of hip and knee joints (35 men, 106 women), average age was 62.6 9.9 years. Control group consisted of 30 relatively healthy donors, average age was 49.7 6.5 years. We investigated blood coagulation properties by routine methods and recorded the curve of thrombin formation by TGA. We analyzed next parameters: tlag is the latent time of thrombin formation, ttpeak is the time to reach the maximum of thrombin, peak is the maximum amount of thrombin, VI is the index of thrombin formation speed, AUC is the area under the curve. Patients were divided into 2 groups according TGA parameters in response to thrombinogenesis initiation by activators with different tissue factor concentrations 2 pmol/ml (RB activator) and 5 pmol/ml (RClow activator). Results. In the 1st group, tlag and ttpeak values in TGA with RClow activator were less than with RB activator, the hemocoagulation response was regarded as adequate. In the 2nd group, tlag and ttpeak values with RClow activator were higher than with RB activator and correlation analysis revealed the weakening of the relationships between TGA parameters. This indicated about system adaptation at a time of high thrombogenic potential and about increased risk of developing hemocoagulation complications in patients of the 2nd group. Conclusion. TGA with RB and RClow activators is a promising tool for identifying patients with a high risk of postoperative hemocoagulation complications.

Treatment Outcomes of Periprosthetic Joint Infection in HIV-positive Patients

Relevance. There is a limited number of publications reporting outcomes of primary large joint arthroplasty in patients with human immunodeficiency virus (HIV). The authors were unable to find papers on revision arthroplasty in patients with periprosthetic infection. Purpose of the study — to evaluate short term outcomes after revision arthroplasty in HIV-positive patients with periprosthetic infection of the hip and knee joint. Materials and methods. 13 HIV-positive patients with periprosthetic infection of the hip (10 cases) and knee (3 cases) joint underwent treatment in the period from 2015 to 2019. Patients were examined by clinical, laboratory and roentgenological methods. Harris Hip Score and Knee Society Score were used for evaluation prior to and after the surgery. Results. Mean follow up period was 21,4±2,6 months. Successful two-stage treatment was performed in two (15,4%) out of 13 patients with periprosthetic infection. In 5 cases (38,5%) control over infection was achieved by resection arthroplasty, and in one case (7,7%) – by arthrodesis. Five patients (38,5%) refused from interchange of spacer to prosthesis. Mean Harris Hip score demonstrated insignificant increase postoperatively — from 45,3±2,2 to 52,2±4,15 (р = 0,2). Conclusion. Despite following the international protocols for treatment of implant-associated infection the infection recurrence rate in HIV-positive patients in the asymptomatic phase remains very high. Efficiency of twostage treatment using antibacterial spacers in the present group of patients amounted only to 15,4%.

Content of blood serum bone tissue metabolism indices in patients with prostheses instability after primary knee joint arthroplasty

Aim. To assess the separate indices of blood serum bone tissue metabolism content in patients with instability of prostheses after the primary knee joint arthroplasty.&#x0D; Materials and methods. The main group joined 40 patients with implant-associated inflammation, the comparison group – 40 patients with primary aseptic instability of prostheses, the control – 20 conditionally healthy donors. The blood serum hPTH and 25-OH Vitamin D content was determined using solid-phase immune-enzyme assay.&#x0D; Results. Among the patients of the main group, blood serum hPTH concentration increased as compared with the control after1 and 12 months following the surgery and compared with each previous observation period; 25-OH Vitamin D level decreased compared with the control before the surgery, after1 and 12 months following the surgical intervention and compared with each previous period of observation. In the patients of the comparison group versus the control values, blood serum hPTH concentration elevated and 25-OH Vitamin D level declined after 1 and 12 months following the surgery and compared with the previous observation period 1 month later.&#x0D; Conclusions. When estimating the blood serum hPTH and 25-OH Vitamin D content in patients with instability of prostheses after the primary knee joint arthroplasty, there were revealed multidirectional changes in their levels, showing bone tissue metabolic disorders.

Factors Affecting Discharge Disposition After Primary Simultaneous Bilateral Joint Arthroplasty.

Predicting discharge destination following total joint arthroplasty (TJA) is important, as discharge destination has major implications for post-operative costs, clinical outcomes, and readmissions. Few studies have looked at factors affecting discharge destination for patients following primary simultaneous bilateral total joint arthroplasty. The purpose of this study was to describe clinical and social factors that relate to a discharge to home versus rehabilitation facility (RF) for patients after primary simultaneous bilateral total hip arthroplasty (PSBTHA) or primary simultaneous bilateral total knee arthroplasty (PSBTKA). The inclusion criteria for this retrospective cohort study were all patients after PSBTHA or PSBTKA at a metropolitan orthopedic specialty hospital between February 1, 2016, and March 31, 2018. Exclusion criteria were revisions, differing weight-bearing status, bed-rest orders, and non-standard hip precautions. Social and clinical demographic data were collected. Multiple regression analysis was conducted to determine which factors related most to discharge plan. Of 253 PSBTHA patients, 153 were discharged home and 100 to an RF. Regression analysis found a posterolateral approach to be the only significant factor associated with an RF discharge. Of 619 PSBTKA patients, 136 were discharged home and 483 to RF. Increased body mass index and older age increased the likelihood of discharge to an RF. Patients with an adductor-only nerve block were more likely to be sent to RF. These findings shed light on the variables that contribute to discharge destination after PSBTHA and PSBTKA. Such information allows for safe pre-operative discharge planning and assists with discharge to the appropriate level of patient care. Future studies might investigate the effect of surgeon experience, surgical technique, and pre-operative discussion with a physical therapist on the discharge disposition of patients undergoing bilateral total joint arthroplasty.

Применение индивидуальных вертлужных компонентов в эндопротезировании тазобедренного сустава при посттравматическом коксартрозе

Introduction The increase in the number of primary hip joint arthroplasties leads to a steady increase in revision interventions. The category of complex arthroplasty also includes patients with extensive acetabular injuries due to high-energy trauma. Amplification of clinical cases requires an individual approach when planning the configuration of the acetabular component. In recent years, clinics have been actively introducing into practice the technology of 3D-modeling of hip replacement components. The purpose of the study was to assess the short and medium-term results of hip joint arthroplasty in posttraumatic coxarthrosis with significant bone defects, using individual acetabular components, with the presentation of clinical cases. Material was five arthroplasty cases operated using customized implants produced with a 3D printer. All five patients were males of working age who suffered high-energy injuries. Three of them had previous operations on the hip joint (from 1 to 5 operations). Anamnesis, characteristics of patients, bone defects types by Paprosky, follow-ups after surgery, X-ray data, the dynamics of the quality of life on the Harris scale were studied. Personalized acetabular components produced on a 3D printer were successfully implanted in four patients; in one case, the installation failed due to excessive lateralization of the rotation center and technical difficulties in adjusting the implant head. The follow-up period of three patients was 16.7 ± 3.7 months; two had operations three and 4 months ago respectfully. Results Dynamic assessment on the Harris scale in all patients showed an increase from 26 ± 5.2 to 77 ± 6.6 points. X-ray monitoring revealed a stable position of the implant components with satisfactory bone integration. Conclusion The study showed good short-and mediumterm results of the use of customized acetabulum components manufactured using a 3D printer in patients with significant bone defects of the acetabulum on the background of post-traumatic coxarthrosis.

Are Hooded, Crosslinked Polyethylene Liners Associated with a Reduced Risk of Revision After THA?

Hooded acetabular liners and head sizes ≥ 32 mm have both shown to have a beneficial effect on the revision rate for dislocation in THA. Experience with noncrosslinked polyethylene (nonXLPE) raised concerns regarding the risk of impingement damage, loosening, and osteolysis with hooded liners; however, the evidence for this in crosslinked polyethylene (XLPE) is inconclusive. The interaction between different femoral head sizes and hooded liners is not well understood, and it is unclear whether hooded XLPE liners have a beneficial effect on overall long-term survivorship. We analyzed a large national joint registry to ask: (1) Is the use of hooded XLPE liners associated with a reduced revision rate for dislocation compared with nonhooded liners? (2) Is there a difference in the revision rate for aseptic loosening/osteolysis? (3) Is head size associated with any difference in the revision rate between hooded and nonhooded liners? The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties with nearly 100% capture. We analyzed all conventional primary THAs performed from registry inception in September 1999 until December 31, 2016 in patients with a diagnosis of osteoarthritis who had nonhooded or hooded XLPE bearings in a cementless acetabular shell. The study group included 192,659 THA procedures with XLPE liners, of which 67,904 were nonhooded and 124,755 were hooded. The mean age of patients receiving nonhooded liners was 70 years (range, 11-100 years); 44% were males. This was similar to the patients with hooded liners, who had a mean age of 70 years (range, 16-100 years); 45% were males. The main outcome measure was the cumulative percent revision at 15 years of the THA using Kaplan-Meier estimates of survivorship. We examined reasons for revision and and performed multivariable analysis to control for the confounding factors of three head size groups (< 32mm, 32mm, and > 32mm) and for the method of femoral fixation. There was a higher revision rate for dislocation for patients with nonhooded liners at all times to 15 years (HR, 1.31; 95% CI, 1.17-1.47; p < 0.001). There was a higher revision rate for the diagnosis of aseptic loosening/osteolysis with patients with nonhooded liners compared with hooded liners (HR, 1.19; 95% CI, 1.05-1.34; p = 0.006). Head sizes of 32 mm or larger were independently associated with a lower comparative revision rate between hooded and nonhooded liners, but this was not apparent for head sizes smaller than 32 mm. It appeared that the main driver of the finding in larger heads was a reduced dislocation risk with hooded liners for 32 mm heads (HR, 1.50; 95% CI, 1.23-1.80; p < 0.001) and for heads larger than 32 mm (HR, 1.50; 95% CI, 1.20-1.89; p < 0.001). Prior research has suggested that hooded acetabular liners may be associated with impingement, loosening, and osteolysis; however, in this large, registry-based report we found that XLPE hooded liners are not associated with an increased revision rate for aseptic loosening/osteolysis. Although there are many potential confounding variables in this registry analysis, if anything, surgeons using larger femoral heads and hooded liners likely did so in patients with a higher perceived dislocation risk. Patients with larger heads and XLPE hooded liners were, however, less likely to experience revision for dislocation. These liners therefore appear reasonable to use in primary THA at the surgeon's discretion. Level III, therapeutic study.

Infection triples the cost of a primary joint arthroplasty

Background: In Europe few studies have analyzed the costs of treating aseptic revisions and prosthetic joint infections with either debridement, antibiotics and implant retention or two-stage revision, as compared to the cost of a primary total joint arthroplasty.Methods: The purpose was to analyze the costs of total joint arthroplasties, aseptic revisions and prosthetic joint infections treated with debridement, antibiotics and implant retention or a two-stage revision. We conducted a retrospective cohort study of patients who had a total joint arthroplasty in the Oulu University Hospital during the three-year period from 2013 to 2015. The costs were divided to specific services (e.g. procedure costs, ward care costs, laboratory). Actual costs obtained from the hospital’s financial database were used for analysis.Results: There were 1708 total joint arthroplasties without complications, 18 aseptic revisions and 42 prosthetic joint infections eligible for analysis. The mean cost of a total joint arthroplasty was €7200, the excess cost of an aseptic revision was €10,900 and the excess cost of a prosthetic joint infection was €18,900 (total joint arthroplasty vs. infection, p < .0001). The excess cost was €12,800 for debridement, antibiotics and implant retention treatment and €44,600 for a two-stage revision (p < .0001). The two most expensive services were ward care and procedures.Conclusions: Infection tripled the cost of a total joint arthroplasty. The cost of two-stage revisions were triple that of debridement, antibiotics and implant retention treatment.

Silver coating on tumour prostheses

Modular endoprostheses, so-called "tumour or megaprostheses" are mainly used for limb salvage surgery after resection of malignant soft tissue or a bone tumour. Sometimes, this type of prosthesis is also used for revision surgeries after failed primary joint arthroplasty. Despite continuously improving techniques and quality management systems, periprosthetic infection is one of the most serious complications. Review of the literature in the PubMed data base with the main focus on silver coatings in joint arthroplasty and their effect on infection rate, outcome and patients' safety. The current literature shows that there is abeneficial role of silver coatings in megaprostheses in terms of revision rates for septic complications, especially following tumour resection with bad soft tissue coverage or in (multimorbid) high-risk patients, compared to uncoated implants. Based on the results of previous publications examining blood or serum silver concentrations or silver levels in urine, silver coatings do not appear to have side effects, except for local argyria. Continuous monitoring of silver levels in blood or serum is still recommended, and additional long-term studies will be necessary to verify the effectiveness and safety of silver coatings.

Impact of Co-Morbidities on the Cost of Care in Primary Elective Joint Arthroplasty

BackgroundThe Comprehensive Care for Joint Replacement model is the newest iteration of the bundled payment methodology introduced by the Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement model, while incentivizing providers to deliver care at a lower cost, does not incorporate any patient-level risk stratification. Our study evaluated the impact of specific medical co-morbidities on the cost of care in total joint arthroplasty (TJA) patients. MethodsA retrospective study was conducted on 1258 Medicare patients who underwent primary elective TJA between January 2015 and July 2016 at a single institution. There were 488 males, 552 hips, and the mean age was 71 years. Cost data were obtained from the Centers for Medicare and Medicaid Services. Co-morbidity information was obtained from a manual review of patient records. Fourteen co-morbidities were included in our final multiple linear regression models. ResultsThe regression models significantly predicted cost variation (P < .001). For index hospital costs, a history of cardiac arrhythmias (P < .001), valvular heart disease (P = .014), and anemia (P = .020) significantly increased costs. For post-acute care costs, a history of neurological conditions like Parkinson’s disease or seizures (P < .001), malignancy (P = .001), hypertension (P = .012), depression (P = .014), and hypothyroidism (P = .044) were associated with increases in cost. Similarly, for total episode cost, a history of neurological conditions (P < .001), hypertension (P = .012), malignancy (P = .023), and diabetes (P = .029) were predictors for increased costs. ConclusionThe cost of care in primary elective TJA increases with greater patient co-morbidity. Our data provide insight into the relative impact of specific medical conditions on cost of care and may be used in risk stratification in future reimbursement methodologies.

Longer Operative Time Results in a Higher Rate of Subsequent Periprosthetic Joint Infection in Patients Undergoing Primary Joint Arthroplasty

BackgroundWhether prolonged operative time is an independent risk factor for subsequent surgical site infection (SSI) and periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) remains a clinically significant and underexplored issue. The aim of this study is to investigate the association between operative time and the risk of subsequent SSI and PJI in patients undergoing primary TJA. MethodsWe retrospectively reviewed 17,342 primary unilateral total knee arthroplasty and total hip arthroplasty performed at a single institution between 2005 and 2016, with a minimum follow-up of 1 year. A multivariate logistic regression model was conducted to identify the association between operative time and the development of SSI within 90 days and PJI within 1 year. ResultsOverall, the incidence of 90-day SSI and 1-year PJI was 1.2% and 0.8%, respectively. Patients with an operative time of >90 minutes had a significantly higher incidence of SSI and PJI (2.1% and 1.4%, respectively) compared to cases lasting between 60 and 90 minutes (1.1% and 0.7%), and those lasting ≤60 minutes (0.9% and 0.7%, P < .01). In the multivariate model, the risk for infection increased by an odds ratio of 1.346 (95% confidential interval 1.114-1.627) for 90-day SSI and 1.253 (95% confidential interval 1.060-1.481) for 1-year PJI for each 20-minute increase in operative time. ConclusionIn patients undergoing primary TJA, each 20-minute increase in operative time was associated with nearly a 25% increased risk of subsequent PJI. We advocate that surgeons pay close attention to this underappreciated risk factor while maintaining safe operative practices, which minimize unnecessary steps and wasted time in the operating room.

Outpatient Joint Arthroplasty: Transitioning to the Ambulatory Surgery Center

The performance of joint arthroplasty in an outpatient setting is expected to rise significantly over the coming decade, with predictions that greater than half of all primary joint arthroplasties will be performed in an outpatient setting by the year 2026. Financial pressures, bundled payment models, and improved understanding of patient recovery have led to discharging patients home the same day as the index procedure. Arthroplasty surgeons are starting to utilize ambulatory surgery centers (ASCs) to perform these outpatient arthroplasty procedures. Our duty as arthroplasty surgeons continues to be to protect our patients' overall care and safety during this transition from a traditional hospital model. Appreciating that postoperative treatment, disposition, physical space, and sterile processing department capabilities are different from traditional hospital models is paramount to success in an ASC.Differences between hospital and ASC models place additional staffing, financial pressure, and time pressure on the arthroplasty surgeon to select and prepare patients before surgery. Adequately preparing patients involves medical optimization, setting patient and family expectations, identifying appropriate caregivers, and establishing effective communication tools after surgery. It is imperative to develop protocols to deal with predictable discharge delays that include blood pressure, oversedation, postoperative urinary retention, postoperative nausea and/or vomiting, pain, and social issues. These protocols are best first developed in a hospital setting where they can be implemented and changed before starting in an ASC. Arthroplasty surgeons will continue to protect patients by developing protocols and preparing patients appropriately for care in an ASC.

Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Primary Hip and Knee Arthroplasty as Reported by American Board of Orthopedic Surgery Part II Candidates

BackgroundMany strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. MethodsThe American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used. ResultsIn total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients. ConclusionIt was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. Level of EvidenceTherapeutic Level III. DisclaimerAll views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.

Revision Surgery in Total Joint Replacement Is Cost-Intensive.

Revisions after total joint replacement increase constantly. In the current study, we analyzed clinical outcome, complication rates, and cost-effectiveness of revision arthroplasty. In a retrospective analysis of 162 revision hip and knee arthroplasties from our institutional joint registry responder rate, patient-reported outcome measures (EQ-5D, WOMAC), complication rates, and patient-individual charges in relation to reimbursement were compared with a matched control group of primary total joint replacements. Positive responder rate one year postoperatively was lower for revision arthroplasties with 72.9% than for primary arthroplasties with 90.1% (OR=0.30, 95%CI=0.18–0.59, p=0.001). Correspondingly, improvement in patient-reported outcome measures one year after surgery was lower in revision than in primary joint arthroplasty with EQ-5D 0.19±0.25 to 0.30±0.24 (p<0.001) and WOMAC 24.3±30.3 to 41.2±21.3 (p<0.001). Infection rate was higher in revision (6.8%) compared to primary replacements (0%, p=0.001). Mean charges in revision arthroplasty were 76.0% higher than in matched primary joint replacements (7110.8±2249.4$ to 4041.1±975.7$, p<0.001), whereas reimbursement was only 23.6% higher (9243.3±2258.4$ in revision and 7477.9±703.1$ in primary arthroplasty, p<0.001). Revision arthroplasty is associated with lower outcome and higher infection rate compared to primary replacements. The high financial expense of revision arthroplasty is only partly covered by a higher reimbursement.

PRIMARY HIP ARTHROPLASTY IN PATIENTS WITH END-STAGE OF CHRONIC KIDNEY DISEASE (LITERATURE REVIEW)

The authors present a review of current national and international literature related to the specifics of primary hip joint arthroplasty in patients with end-stage of chronic kidney disease. epidemiology aspects of such pathology are covered in detail. Screening of the patients with hip joint pathology undergoing substitute renal therapy remains a significant issue. The authors present the outcomes of use of various implant types and their fixation in primary hip joint arthroplasty such as cemented, cementless and monopolar prostheses, as well as consider features and structure of complications following primary replacements in such patients. unfortunately, the national literature lacks sufficient number of publications on the present problem. In addition, the paper presents a promising area for development of specialized care to patients on hemodialysis with hip joint pathology.

Clinical research of debridement with prosthesis retention for periprosthetic joint infection after arthroplasty

To investigate the mid-term effectiveness of debridement with prosthesis retention for periprosthetic joint infection (PJI) after total hip arthroplasty (THA) and total knee arthroplasty (TKA), and analyze the influence factors that affected the effectiveness. A clinical data of 45 cases with PJI after THA (16 cases) and TKA (29 cases) that were treated with debridement with prosthesis retention between January 2011 and January 2015 were collected and analyzed. There were 19 males and 26 females with a mean age of 58.4 years (range, 23-78 years). PJI occurred after primary joint arthroplasty in 40 cases and after revision in 5 cases. The mean time interval between the performance of infection symptoms and the arthroplasty or revision was 15.5 months (range, 0.5-72.0 months). The time interval between the performance of infection symptoms and debridment was 35 days (range, 3-270 days). There were early postoperative infections in 13 cases, acute hematogenous infections in 24 cases, and late chronic infections in 8 cases. X-ray films showed that the location of prosthesis was good. The results of bacilli culture showed that 28 cases were positive and 17 were negative. Twelve cases had sinuses. Length of stay, Hospital for Special Surgery (HSS) score, and Harris score were recorded to evaluate risk factors by using a multivariate logistic regression. The mean length of stay was 22.6 days (range, 5-79 days). All patients were followed up 24-74 months (mean, 52 months). There were 33 cases that retained the prosthesis without further evidence of infection with the success rate was 73.3%. There were significant differences in Harris score and HSS score between pre- and post-operation ( P<0.05). The univariate analysis results showed that the failure of debridement with prosthesis retention had a significant correlation with sinus developing and duration of infection symptoms more than 14 days ( P<0.05). Multivariate logistic regression analysis results showed that sinus developing was an independent risk factor of failure ( P<0.05). Debridement with prosthesis retention plays an important role in treating PJI after THA and TKA. These patients with sinus performing and duration of infection symptoms more than 14 days have higher risk to develop infection again.

Modifiable Risk Factors in Primary Joint Arthroplasty Increase 90-Day Cost of Care

BackgroundRisk factors in demographics and health status have been identified that increase the risk of complications after joint arthroplasty, necessitating additional care and incurring additional charges. The purpose of this study was to identify the number of patients in a hospital network database who had one or more predefined modifiable risk factors and determine their impact on average length of stay, need for additional care during the 90-day postoperative period, and the 90-day charges for care. MethodsAn electronic hospital record query of 6968 lower extremity joint arthroplasty procedures under Diagnosis-Related Group 469/470 performed in 2014-2015 was reviewed, and total 90-day charges were calculated. The case mean was compared to charges for patients with modifiable risk factors: anemia (Hgb < 10 g/dL), malnutrition (albumin < 3.4 g/dL), obesity (body mass index > 45 kg/m2), uncontrolled diabetes (random glucose >180 mg/dL or A1C > 8), narcotic use (prescription filled), and tobacco use (documented within 30 days before surgery). Length of stay, emergency room visits, and hospital readmission were compared. ResultsMean 90-day charges for Diagnosis-Related Group 469/470 were $36,647. Risk factors were associated with a significant increase in 90-day charges: anemia (+$ 15,869/126 patients), malnutrition (+$9270/592), obesity (+$2048/445), diabetes (+$5074/291), narcotic use (+$1801/1943), and tobacco use (+$2034/1882). Intensive care unit admission rate, emergency department visits, and hospital readmission were significantly increased for patients with each risk factor. Length of stay was higher in patients with anemia, malnutrition, diabetes, and tobacco use. When separated by elective vs fracture admission, 90-day charges were significantly higher for each risk factor. ConclusionsMedical strategies to optimize patients before joint arthroplasty are warranted to improve postoperative outcomes.