Revision Total Joint Arthroplasty Research Articles

Return to Cycling After Total Joint Arthroplasty

BackgroundAs total joint arthroplasty (TJA) candidates become younger, patients’ expectations continue to expand. We surveyed our patient population to determine rates of return to cycling after TJA so that we could provide more accurate counseling on performance and safety. MethodsAt our single institution, an online survey was generated and sent out to patients who had at least 3 months of follow-up. Patients were split into 4 categories based on surgery type: single total hip arthroplasty (THA), single total knee arthroplasty (TKA), multiple TJA, and revision TJA. ResultsA total of 1,029 surveys fit the inclusion criteria. The average age of the patient population was 69 years, with an average of 4.08 years from their time of most recent TJA surgery (maximum follow-up of 18.61 years). Nearly all those who were able to bike prior to surgery were able to return to cycling, with only 6% not being able to do so. There were 41.8% who returned to cycling less than 3 months after surgery. Most cyclists were able to return to their previous level. Patients who had a revision TJA had significantly lower rates of returning to cycling in comparison to single TKA, single THA, and multi-TJA (37.3%, 60.3%, 61.9%, and 60.3%, respectively, P < .005). Patients who never returned to cycling had higher revision rates in comparison to those who were able to get back on a bike (14.4 versus 9.2%, P = .01). ConclusionsA large proportion of patients who had prior cycling experience were able to return to bike riding within 3 to 6 months after TJA. Individuals who had revision TJA had lower rates of return to cycling in comparison to single TKA, single THA, and multi-TJA. Returning to cycling did not result in higher rates of revision.

The Use of Aspirin for Venous Thromboembolism Prophylaxis in Patients Who Have Morbid Obesity Undergoing Primary and Revision Total Joint Arthroplasty

BackgroundVenous thromboembolism (VTE) poses a major clinical concern due to its life-threatening nature, and obese and morbidly obese patients are thought to be at an increased risk for VTE. The aims of this study were twofold; first, to explore VTE rates in patients who have a body mass index (BMI) > 40 undergoing primary and revision total joint arthroplasty, and second, to investigate aspirin (ASA) efficacy and safety. MethodsWe identified all patients (n = 4,672) who had a BMI > 40 who underwent primary and revision total joint arthroplasty from 2016 to 2022 at a single academic tertiary care center. Patients were stratified by BMI groups: 40 to 44.9 (n = 3,462), 45 to 49.9 (n = 935), and 50+ (n = 275). The primary outcome was any VTE event within 90 days postoperatively. The secondary outcome consisted of wound complications within 90 days postoperatively. ResultsThe total VTE rate was 0.4% (n = 21) and did not differ statistically between the BMI groups (0.4 versus 0.4 versus 0.7%, P = .669). The VTEs consisted of 6 deep venous thromboses (DVTs), 14 pulmonary embolisms, and one concomitant deep venous thrombosis and pulmonary embolism. The VTE rates were not statistically different between patients who received aspirin 325 mg 0.5% (n = 9), aspirin 81 mg 0.2% (n = 1), aspirin + anticoagulant (AC) 0.5% (n = 6), and AC alone 0.4% (n = 5) (P = .954). In addition, wound complications did not differ significantly between patients who received ASA 325 mg, ASA 81mg, ASA + AC, or AC alone (1.6 versus 1.0 versus 1.8 versus 1.1%, P = .351). ConclusionsThe use of aspirin 325 and 81 mg was found to have similar VTE rates as aspirin + ACs and ACs alone, with no significant increase in wound complications. In patients who have a BMI > 40, the use of aspirin is a safe option for VTE prophylaxis and should be prescribed in the context of the patient who has other risk factors for VTE.

Neighborhood socioeconomic disadvantages associated with prolonged length of stay and non-home discharge following revision total hip and knee joint arthroplasty

BackgroundDischarge disposition and length of stay (LOS) are widely recognized markers of healthcare utilization patterns of total hip and knee joint arthroplasty (TJA). These markers are commonly associated with increased postoperative complications, patient dissatisfaction, and higher costs. Area deprivation index (ADI) has been validated as a composite metric of neighborhood-level disadvantage. This study aims to determine the potential association between ADI and discharge disposition or extended LOS following revision TJA. MethodsThis study conducted a retrospective analysis of a consecutive series of revision hip and knee TJA patients from a single tertiary institution. Univariate and multivariate regression analysis was used to determine the association between ADI and discharge disposition or LOS, adjusting for patient demographics and comorbidities. Results1047 consecutive revision TJA patients were identified across 463 different neighborhoods. 193 (18.4 %) had an extended LOS, and 334 (31.9 %) were discharged to non-home facilities. Compared with Q1 (least deprived cohort), Q2 (odds ratio [OR] = 1.63; p = 0.030) and Q4 (most deprived cohort: OR = 2.04; p = 0.002) cohorts demonstrated higher odds of non-home discharge. Patients in the highest ADI quartile (most deprived cohort) were associated with increased odds of prolonged LOS following revision TJA compared to those in the lowest ADI quartile (OR = 2.63; p < 0.001). ConclusionThis study suggests that higher levels of neighborhood-level disadvantage may be associated with higher odds of non-home discharge and prolonged LOS following revision TJA. Development of interventions based on the area deprivation index may improve discharge planning and reduce unnecessary non-home discharges in patients living in areas of socioeconomic deprivation.

Knotless suture in revision total joint arthroplasty: a prospective randomized controlled trial.

The use of barbed sutures for wound closure in primary total joint arthroplasty (TJA) has been shown to be effective and safe. However, their effectiveness and safety in revision TJA procedures has not been thoroughly studied. This study aims to evaluate the efficacy and safety of using barbed suture closure in revision TJA setting. A total of 80 patients undergoing revision TJA between September 2020 and November 2022 were included in this randomized controlled trial study. Following informed consent, patients were computer-randomized to the treatment arm (barbed suture wound closure) or to the control arm (conventional wound closure). Closure duration, closure rate, number of sutures used and wound related outcomes including complication rates and Patient and Observer Scar Assessment Scale (POSAS) score were compared between groups. The use of barbed sutures decreased closure time by 6min (30.1 vs. 36.1min, P = 0.008) with a higher wound closure rate (6.5 vs. 5.5mm/minute, P = 0.013). Additionally, the number of sutures used for wound closure in the barbed group was significantly lower than in the control group (6.2 vs. 10.1, respectively, P < 0.001). There were no significant differences in the rate of postoperative wound complications (P = 0.556) or patient and observer POSAS scores (P = 0.211, P = 297, respectively) between the two groups at 3-month follow-up. Closure of revision TJA surgical wound utilizing barbed sutures reduced closure time and the number of needles handled by operative staff, with no significant increase in intra- or post-operative complications rate when compared to traditional closure technique. I.

How are Oral Antibiotics Being Used in Total Joint Arthroplasty? A Review of the Literature.

While the role and benefit of perioperative intravenous (IV) antibiotics in patients undergoing total joint arthroplasty (TJA) is well-established, oral antibiotic use in TJA remains a controversial topic with wide variations in practice patterns. With this review, we aimed to better educate the orthopedic surgeon on when and how oral antibiotics may be used most effectively in TJA patients, and to identify gaps in the literature that could be clarified with targeted research. Extended oral antibiotic prophylaxis (EOAP) use in high-risk primary, aseptic revision, and exchange TJA for infection may be useful in decreasing periprosthetic joint infection (PJI) rates. When prescribing oral antibiotics either as EOAP or for draining wounds, patient factors, type of surgery, and type of infectious organisms should be considered in order to optimally prevent and treat PJI. It is important to maintain antibiotic stewardship by administering the proper duration, dose, and type of antibiotics and by consulting infectious disease when necessary.

Mental Health Effects on the Minimal Clinically Important Difference in Total Joint Arthroplasty.

The effect of mental health on patient-reported outcome measures is not fully understood in total joint arthroplasty (TJA). Thus, we investigated the relationship between mental health diagnoses (MHDs) and the Minimal Clinically Important Difference for Improvement (MCID-I) and Worsening (MCID-W) in primary TJA and revision TJA (rTJA). Retrospective data were collected using relevant Current Procedural Terminology and MHDs International Classification of Diseases, 10th Revision, codes with completed Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form, Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form, Patient-reported Outcomes Measurement Information System (PROMIS)-Physical Function Short Form 10a, PROMIS Global-Mental, or PROMIS Global-Physical questionnaires. Logistic regressions and statistical analyses were used to determine the effect of a MHD on MCID-I/MCID-W rates. Data included 4,562 patients (4,190 primary TJAs/372 rTJAs). In primary total hip arthroplasty (pTHA), MHD-affected outcomes for Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (MCID-I: 81% versus 86%, P = 0.007; MCID-W: 6.0% versus 3.2%, P = 0.008), Physical Function Short Form 10a (MCID-I: 68% versus 77%, P < 0.001), PROMIS Global-Mental (MCID-I: 38% versus 44%, P = 0.009), and PROMIS Global-Physical (MCID-I: 61% versus 73%, P < 0.001; MCID-W: 14% versus 7.9%, P < 0.001) versus pTHA patients without MHD. A MHD led to lower rates of MCID-I for PROMIS Global-Physical (MCID-I: 56% versus 63%, P = 0.003) in primary total knee arthroplasty patients. No effects from a MHD were observed in rTJA patients. The presence of a MHD had a prominent negative influence on pTHA patients. Patients who underwent rTJA had lower MCID-I rates, higher MCID-W rates, and lower patient-reported outcome measure scores despite less influence from a MHD. Level III, retrospective comparative study.

Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty

BackgroundPrior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis. MethodsIn total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA. ResultsRates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71). ConclusionsAll patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA. Level of evidenceIII, Retrospective review.

Extended Prophylactic Antibiotics for Primary and Aseptic Revision Total Joint Arthroplasty: A Meta-Analysis

BackgroundThere is growing interest in extended antibiotic prophylaxis (EAP) following total joint arthroplasty (TJA); however, the benefit of EAP remains controversial. For this investigation, both oral and intravenous antibiotic protocols were included in the EAP group. MethodsThe Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, Ovid Embase, Elton B. Stephens CO, and Cumulative Index to Nursing and Allied Health Literature were queried for literature comparing outcomes of primary and aseptic revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients who were treated with either ≤24 hours of postoperative antibiotic prophylaxis (standard of care [SoC]) or >24 hours of EAP. The primary outcome was periprosthetic joint infection (PJI). A pooled relative-risk random-effects Mantel-Haenszel model was implemented to compare cohorts. ResultsThere were 18 studies with a total of 19,153 patients included. There was considerable variation in antibiotic prophylaxis protocols with first-generation cephalosporins being the most commonly implemented antibiotic for both groups. Patients treated with EAP were 35% less likely to develop PJI relative to the SoC (P = .0004). When examining primary TJA, patients treated with EAP were 39% and 40% less likely to develop a PJI for TJA (P = .0008) and THA (P = .02), respectively. There was no significant difference for primary TKA (P = .17). When examining aseptic revision TJA, EAP led to a 36% and 47% reduction in the probability of a PJI for aseptic revision TJA (P = .007) and aseptic revision TKA (P = .008), respectively; there was no observed benefit for aseptic revision THA (P = .36). ConclusionsThis meta-analysis demonstrated that patients treated with EAP were less likely to develop a PJI relative to those treated with the SoC for all TJA, primary TJA, primary THA, aseptic revision TJA, and aseptic revision TKA. There was no significant difference observed between EAP and SoC for primary TKA or aseptic revision THA.

How Many Patients Qualify for Extended Oral Antibiotic Prophylaxis Infection Following Primary and Revision Hip and Knee Arthroplasties?

Extended oral antibiotic prophylaxis (EOAP) has been suggested to reduce rates of periprosthetic joint infection (PJI) postoperatively after total joint arthroplasty (TJA). The purpose of this multicenter study is to define how many TJA patients are considered high risk for developing PJI based on published EOAP criteria and determine whether this status is associated with socioeconomic or demographic factors. All primary and aseptic revision TJAs performed in 2019 at three academic medical centers were reviewed. High-risk status was defined based on prior published EOAP criteria. Area deprivation index (ADI) was calculated as a measure of socioeconomic status. Data were reported as means with standard deviation. Both overall and institutional differences were compared. Of the 2,511 patients (2,042 primary and 469 revision) in this cohort, 73.3% met criteria for high risk (primary: 72.9% [1,490] and revision: 74.6% [350]). Patient's race or age did not have a significant impact on risk designation; however, a larger proportion of high-risk patients were women (p = 0.002) and had higher Elixhauser scores (p < 0.001). The mean ADI for high-risk patients was higher (more disadvantaged) than for standard-risk patients (64.0 [20.8] vs. 59.4 [59.4]) (p < 0.001). Over 72% of primary and revision TJA patients at three medical centers met published criteria for EOAP. These patients were more often women, had more comorbidities, and lived in more disadvantaged areas. Our findings suggest that most patients qualify for EOAP, which may call for more stringent criteria on who would benefit extended antibiotic prophylaxis.

An analysis of risk factors for venous thromboembolism in primary versus revision total joint arthroplasty

BackgroundOne of the most serious complications after primary or revision lower extremity total joint arthroplasty (TJA) is venous thromboembolism disease (VTE). Identifying patients at high risk for VTE allows tailoring of prophylactic anticoagulation regimens to those most vulnerable. This study aimed to identify risk factors for VTE in primary and revision lower extremity TJA. MethodsThe Electronic Medical Record was queried from a single academic institution for all patients who underwent a lower extremity TJA between 2007 and 2020. Demographics, comorbid conditions, perioperative characteristics, and postoperative complications were identified. An Elastic Net Multiple Logistic Regression Model was used to assess 49 covariates and predict those associated with a significant risk of VTE. ResultsWe identified 4900 primary and revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients. There was no significant difference between primary and revision THA. Primary TKA had a higher rate of VTE than revision TKA. Significant risk factors identified for VTE in THA patients include histories of deep vein thrombosis (DVT), pulmonary embolism (PE), metastatic tumors, hemiplegia, and Hispanic ethnicity. Risk factors for VTE in TKA patients include histories of DVT, PE, metastatic tumors, and postoperative warfarin and heparin use. In all patients, age was a significant predictor of VTE risk. ConclusionOur work identifies many risk factors for VTE following TJA. While the increased rate of VTE in some populations may represent selection bias, it also highlights the incomplete understanding of the etiology and prevention of this complication in the joint arthroplasty population and requires further study.

Early Discharge for Revision Total Knee and Hip Arthroplasty: Predictors of Success

BackgroundThe rate of revision total joint arthroplasties is expected to increase drastically in the near future. Given the recent pandemic, there has been a general push toward early discharge. This study aimed to assess for predictors of early postoperative discharge after revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA). MethodsThere were 77 rTKA and 129 rTHA collected between January 1, 2019 and December 31, 2021. Demographic data, comorbidities, a comorbidity index, the modified frailty index (mFI-5), and surgical history were collected. The Common Procedural Terminology codes for each case were assessed. Patients were grouped into 2 cohorts, early discharge (length of stay [LOS] <24 hours) and late discharge (LOS >24 hours). ResultsIn the rTHA cohort, age >65 years, a history of cardiac or liver disease, an mFI-5 of >1, a comorbidity index of >2.7, a surgical time >122 minutes, and the need for a transfusion were predictors of prolonged LOS. Only the presence of a surgical time of >63 minutes or an mFI-5 >1 increased patient LOS in the rTKA cohort. In both rTHA and rTKA patients, periprosthetic joint infection resulted in a late discharge for all patients, mean 4.8 and 7.1 days, respectively. Dual component revision was performed in 70.5% of rTHA. Only 27.6% of rTKA were 2-component revisions or placements of an antibiotic spacer. ConclusionsSeveral patient and surgical factors preclude early discharge candidacy. For rTHA, an mFI-5 of >2/5, comorbidity index of >4, or a surgical time of >122 minutes is predictive of prolonged LOS. For rTKA, an mFI-5 of >2/5, Charlson Comorbidity Index of >5, or a surgical time of >63 minutes predicts prolonged LOS.

Does Participation in Virtual or In-Person Preoperative Education Relate to Reduced Length of Stay After Total Joint Arthroplasty?

Advancements in surgical procedures for total joint arthroplasty (TJA) have resulted in more effective procedures with more rapid recovery. To prepare patients for surgery, many organizations offer a preoperative "joint class," which has been associated with reduced length of stay (LOS). Virtual modes of education are increasingly favored for those having TJA. To determine whether participation in an individually administered preoperative educational session ("Prehab") relates to reduced LOS or increased likelihood of same-day discharge (SDD) for those undergoing TJA. Additionally, to establish whether and the virtual mode of education provision is superior or inferior to the in-person mode with regards to LOS benefits. The author conducted a case-control study of 2532 patients who had a primary or revision TJA between January 2022 and August 2022 at a single institution. Data were obtained from the electronic medical record. A total of 1118 patients attended Prehab; 1414 patients did not. Patients were included if they were over the age of 18 and had a total hip arthroplasty (THA) or total knee arthroplasty (TKA) during the study period. T-tests, chi-square χ2 tests, and binomial logistic regression were used to evaluate the LOS and SDD outcomes for those who participated in Prehab compared with those who did not. Those receiving Prehab in any form had shorter LOS than those who had not. Those receiving virtual Prehab had the shortest LOS. There was no difference in the rate of SDD for outpatient-class patients. Preoperative education is associated with LOS benefits to patients undergoing TJA. The virtual mode of education provision is at minimum non-inferior, and may be superior, to the in-person mode. The lack of statistically significant between-group differences for SDD outcomes may be explained by a lack of SDD-specific educational content provided during Prehab.

A Comparison of the Caprini Score With an Institutional Risk Assessment Tool for Prediction of Venous Thromboembolism After Total Joint Arthroplasty at an Urban Tertiary Care Health Safety Net Hospital.

Patients undergoing total joint arthroplasty (TJA) are at increased risk for venous thromboembolism (VTE). Prediction tools such as the Caprini Risk Assessment Model (RAM) have been developed to identify patients at higher risk. However, studies have reported heterogeneous results when assessing its efficacy for TJA. Patients treated in an urban health safety net hospital have increased medical complexity, advanced degenerative joint disease, and severe disability prior to TJA increasing the risk of VTE. We hypothesize that use of a tool designed to account for these conditions-the Boston Medical Center (BMC) VTE score-will more accurately predict VTE in this patient population. A retrospective case-control study was performed including subjects 18 years of age and older who underwent primary or revision TJA in an urban academic health safety net hospital. Patients with hemiarthroplasties, simultaneous bilateral TJA, and TJA after acute trauma were excluded. A total of 80 subjects were included: 40 who developed VTE after TJA (VTE+) and 40 who did not develop VTE (controls). Subjects were matched by age, gender, and surgical procedure. There was a statistically significant difference between the mean BMC VTE score for VTE+ and controls (4.40 and 3.13, respectively, P = .036). Conversely, there was no statistical difference between the mean Caprini scores for VTE+ and controls (9.50 and 9.35, respectively, P = .797). In a health safety-net patient population, an institutional RAM-the BMC VTE score-was found to be more predictive of VTE than the modified Caprini RAM following TJA. The BMC-VTE score should be externally validated to confirm its reliability in VTE prediction in similar patient populations.

The Use of Oral Antibiotics After Total Joint Arthroplasty: A Critical Analysis Review.

» There is conflicting and insufficient evidence that extended oral antibiotic (EOA) therapy prevents infection in high-risk patients undergoing primary total joint arthroplasty (TJA), limiting recommendation for or against the practice.» In the case of aseptic revision TJA, the evidence is also conflicting and limited by underlying confounders, preventing recommendation for use of EOA.» There is fair evidence that use of EOA after debridement antibiotic therapy and implant retention of the prosthesis prolongs infection-free survival, but randomized controlled trials are needed. On the other hand, there is strong evidence that patients undergoing 2-stage revision should receive a period of suppressive oral antibiotics after the second stage.» The optimal duration of EOA in primary TJA, aseptic revision, and debridement antibiotic therapy and implant retention of the prosthesis is unknown. However, there is strong evidence that 3 months of EOA suppression may be appropriate after reimplantation as part of 2-stage exchange arthroplasty.» Complications secondary to EOA are reported to be between 0% and 13.7%, yet are inconsistently reported and poorly defined. The risks associated with antibiotic use, including development of antimicrobial resistance, must be weighed against a possible decrease in infection rate.

Unplanned Emergency Department Visits Following Revision Total Joint Arthroplasty: Incidences, Risk Factors, and Mortalities

BackgroundThe incidence of unplanned emergency department (ED) visits following revision total joint arthroplasty is an indicator of the quality of postoperative care. The aim of this study was to investigate the incidences, timings, and characteristics of ED visits within 90 days after revision total joint arthroplasty. MethodsA retrospective review of 457 consecutive cases, including 254 revision total hip arthroplasty (rTHA) and 203 revision total knee arthroplasty (rTKA) cases, was conducted. Data regarding patient demographics, timings of the ED encounter, chief complaints, readmissions, and diagnoses indicating reoperation were analyzed. ResultsThe results showed that 41 patients who had rTHA (16.1%) and 14 patients who had rTKA (6.9%) returned to the ED within 90 days postoperatively. The incidence of ED visits was significantly higher in the rTHA group than in the rTKA group (P = .003). The most common surgery-related complications were dislocation among rTHA patients and wound conditions among rTKA patients. Apart from elevated calculated comorbidity scores, peptic ulcer in rTHA patients and cerebral vascular events and chronic obstructive pulmonary disease in rTKA patients might increase chances of unplanned ED visits. Patients who had ED visits showed significantly higher mortality rates than the others in both rTHA and rTKA cohorts (P = .050 and P = .008, respectively). ConclusionsThe ED visits within 90 days are more common after rTHA than after rTKA. Patients in both ED visit groups after rTHA and rTKA demonstrated worse survival. Efforts should be made to improve quality of care to prevent ED visits.

Defining Patient-relevant Thresholds and Change Scores for the HOOS JR and KOOS JR Anchored on the Patient-acceptable Symptom State Question.

When evaluating the results of clinical research studies, readers need to know that patients perceive effect sizes, not p values. Knowing the minimum clinically important difference (MCID) and the patient-acceptable symptom state (PASS) threshold for patient-reported outcome measures helps us to ascertain whether our interventions result in improvements that are large enough for patients to care about, and whether our treatments alleviate patient symptoms sufficiently. Prior studies have developed the MCID and PASS threshold for the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) anchored on satisfaction with surgery, but to our knowledge, neither the MCID nor the PASS thresholds for these instruments anchored on a single-item PASS question have been described. (1) What are the MCID (defined here as the HOOS/KOOS JR change score associated with achieving PASS) and PASS threshold for the HOOS JR and KOOS JR anchored on patient responses to the single-item PASS instrument? (2) How do patient demographic factors such as age, gender, and BMI correlate with MCID and PASS thresholds using the single-item PASS instrument? Between July 2020 and September 2021, a total of 10,970 patients underwent one primary unilateral THA or TKA and completed at least one of the three surveys (preoperative HOOS or KOOS JR, 1-year postoperative HOOS or KOOS JR, and 1-year postoperative single-item anchor) at one large, academic medical center. Of those, only patients with data for all three surveys were eligible, leaving 13% (1465 total; 783 THAs and 682 TKAs) for analysis. Despite this low percentage, the overall sample size was large, and there was little difference between completers and noncompleters in terms of demographics or baseline patient-reported outcome measure scores. Patients undergoing bilateral total joint arthroplasty or revision total joint arthroplasty and those without all three surveys at 1 year of follow-up were excluded. A receiver operating characteristic curve analysis, leveraging a 1-year, single-item PASS (that is, "Do you consider that your current state is satisfactory?" with possible answers of "yes" or "no") as the anchor was then used to establish the MCID and PASS thresholds among the 783 included patients who underwent primary unilateral THA and 682 patients who underwent primary unilateral TKA. We also explored the associations of age at the time of surgery (younger than 65 years or 65 years and older), gender (men or women), BMI (< 30 or ≥ 30 kg/m 2 ), and baseline Patient-Reported Outcome Measure Information System-10 physical and mental component scores (< 50 or ≥ 50) for each of the MCID and PASS thresholds through stratified analyses. For the HOOS JR, the MCID associated with the PASS was 23 (95% CI 18 to 31), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 81 (95% CI 77 to 85), with an area under the receiver operating characteristic curve of 0.81. For the KOOS JR, the MCID was 16 (95% CI 14 to 18), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 71 (95% CI 66 to 73) with an area under the receiver operating characteristic curve of 0.84. Stratified analyses indicated higher change scores and PASS threshold for younger men undergoing THA and higher PASS thresholds for older women undergoing TKA. Here, we demonstrated the utility of a single patient-centered anchor question, raising the question as to whether simply collecting a postoperative PASS is an easier way to measure success than collecting preoperative and postoperative patient-reported outcome measures and then calculating MCIDs and the substantial clinical benefit. Level III, therapeutic study.

Unexpected positive cultures in patients with arthrofibrosis following total hip and total knee arthroplasty.

It has been suggested that low-grade infections could be the cause of arthrofibrosis. However, this hypothesis has not been conclusively proven. The aim of this study is to assess the incidence of unexpected positive cultures (UPC) in patients undergoing revision total joint arthroplasty for a diagnosis of arthrofibrosis. A retrospective single-centre review was performed. All patients who underwent an aseptic revision due to histologically confirmed arthrofibrosis (based on the synovial-like interface membrane (SLIM) criteria) were included. The incidence of UPC was then calculated. A total of 147 patients were included. Of these, 100 underwent a total knee arthroplasty (TKA) procedure and 46 a total hip arthroplasty (THA) surgery. One patient had a periprosthetic joint infection and was therefore excluded. Of the 146 included patients, 6 had confirmed UPC (4.08%). The following bacteria were identified: Anaerococcus octavius, Staphylococcus epidermidis, Enterobacter cloacae, Staphylococcus hominis, Streptococcus pluranimalium, Staphylococcus pettenkoferi. Our results suggest that the incidence of UPC in patients with arthrofibrosis is low. It is lower than that of UPC in patients that undergo a revision for other causes. There is no proven relationship between histologically confirmed arthrofibrosis following total joint arthroplasty and prosthetic joint infection.

The Diagnostic Utility of Fast Tests for Detecting C-Reactive Protein in Synovial Fluid in Periprosthetic Joint Infections.

Despite the fact that many synovial fluid biomarkers have found application in the routine diagnosis of periprosthetic joint infection (PJI), this process still remains a challenge for orthopaedic surgeons. To simplify this process, fast point-of-care (POC) tests can be used during ambulatory visits and in operating room conditions. However, before such tests can be routinely used in clinical practice, they require validation. The purpose of the present study was to evaluate the diagnostic accuracy of different fast POC tests for detecting C-reactive protein (CRP) in synovial fluid for the diagnosis of PJI. Synovial fluid samples were collected from 120 consecutive patients who underwent revision total joint arthroplasty (TJA). The patients were divided into 2 groups. The first group included 76 patients who underwent revision for reasons other than infection (the aseptic revision TJA [arTJA] group), and the second group included 44 patients who underwent revision because of periprosthetic joint infection (PJI). The diagnosis of infection was made according to the International Consensus Meeting (ICM) 2018 criteria. All patients were operatively treated at a single orthopaedic center from January 2022 to February 2023. Four fast CRP tests with different cutoff values (1 and 3 mg/L, ≥8 mg/L, ≥10 mg/L [cassette], ≥10 mg/L [strip]) were used off-label for synovial fluid testing. Tests were performed on the same synovial fluid samples, and the results of these tests were compared with those obtained with the laboratory method. The cassette test with a minimum cutoff value of ≥8 mg/L demonstrated the best accuracy for the diagnosis of chronic PJI, with a sensitivity and specificity of 90.9% and 90.8%, respectively. For the cassette test with a cutoff value of >3 mg/L, the sensitivity and specificity were 68.2% and 77.6%, respectively. For the tests with a minimum cutoff value of ≥10 mg/L, the sensitivity and specificity were 77.3% and 94.7%, respectively, for the cassette test and 77.3% and 96.1%, respectively, for the strip test. The laboratory method with the statistically calculated threshold (2.7 mg/L) revealed the highest AUC (area under the receiver operating characteristic curve) value (0.95), with 90.9% sensitivity and 94.7% specificity. The cassette POC test with the minimum cutoff value of ≥8 mg/L had very good accuracy for the diagnosis of chronic PJI. This test had comparable sensitivity and slightly lower specificity in comparison with the laboratory method with the calculated threshold of 2.7 mg/L. Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Large Variation in Listed Chargemaster Price for Total Joint Arthroplasty Among Top Orthopaedic Hospitals in the United States.

Chargemasters are lists of all services offered by a hospital and their associated cost. This study analyzes chargemaster data to determine price differences among different hospitals for total joint arthroplasty. In May 2020, the chargemaster data for highly rated orthopaedic hospitals were accessed, and the diagnostic-related group (DRG) codes related to primary and revision total joint arthroplasty were analyzed (DRGs 466, 467, 468, 469, and 470). The prices listed for each hospital were averaged, and descriptive statistics were calculated. Furthermore, Medicare reimbursement was collected. A subanalysis was performed to determine relationships between geographic and demographic information. The median price for a major hip or knee joint arthroplasty without complications was $68,016 (range: $39,927 to $195,264). The median price of a revision of hip or knee arthroplasty without complications was $90,966 (range: $58,967 to $247,715). The cost of living in the city in which the hospitals are located was weakly correlated with procedure pricing, whereas the median income had no notable relationship to chargemaster pricing. The published cost of DRG codes in arthroplasty is widely variable among the top 20 US orthopaedic hospitals, with little correlation to the cost of living or median income of the area.

Medicaid Patients Travel Disproportionately Farther for Revision Total Joint Arthroplasty

BackgroundAccess to high-quality care for revision total joint arthroplasty (rTJA) is poorly understood but may vary based on insurance type. This study investigated distance traveled for hip and knee rTJA based on insurance type. MethodsA total of 317 revision hips and 431 revision knees performed between 2010 and 2020 were retrospectively reviewed. Cluster sampling was used to select primary hips and knees for comparison. Median driving distance was compared based upon procedure and insurance type. ResultsRevision hip and knee patients traveled 18.2 and 11.0 miles farther for surgery compared to primary hip and knee patients (P ≤ .001). For hip rTJA, Medicaid patients traveled farther than Medicare patients followed by commercially insured patients with median distances traveled of 98.4, 67.2, and 35.6 miles, respectively (P = .016). Primary hip patients traveled the same distance regardless of insurance type (P = .397). For knee rTJA, Medicaid patients traveled twice as far as Medicare and commercially insured patients (medians of 85.0, 43.5, and 42.2 miles respectively, P ≤ .046). Primary knee patients showed a similar pattern (P = .264). Age and ASA-PS classification did not indicate greater comorbidity in Medicaid patients. ConclusionInsurance type may influence rTJA referrals, with disproportionate referral of Medicaid and Medicare patients to nonlocal care centers. In addition to patient burden, these patterns potentially present a financial burden to facilities accepting referrals. Strategies to improve equitable access to rTJA, while maintaining the highest and most economical standards of care for patients, providers, and hospitals, are encouraged.