Revision Total Knee Arthroplasty Research Articles

Suction drain usage has no benefit following revision total hip and knee arthroplasty.

The use of drains after primary total joint arthroplasty (TJA) has shown little benefit. Few studies have investigated drain usage after revision TJA. The purpose of this study was to determine whether utilizing suction drains is beneficial for patients undergoing revision arthroplasty. We performed a comprehensive literature review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines from the PubMed, Embase, Web of Science, and Cochrane Library. Inclusion criteria of this review were all original articles written in English investigating the efficacy and safety of closed suction drainage in revision TKA or THA, reporting at least one of the following outcome measures: (1) estimated blood loss (EBL), (2) perioperative hemoglobin change, (3) needs for transfusion, (4) postoperative infection, and (5) wound complications. Articles were excluded if they are not available in English or they included case reports, systematic reviews, comments, editorials, surveys, or animal studies prior to July 22, 2023. A total of six studies met inclusion criteria. In total, 655 patients had a drain while 1765 patients did not have a drain after revision total hip or knee arthroplasty. Primary outcomes included for meta-analysis included estimated blood loss (EBL), postoperative hemoglobin, need for transfusion. Other data extracted includes postoperative infections, and wound complications. Six studies met the inclusion criteria. In total, 655 patients had drains, while 1765 patients did not after revision total hip or knee arthroplasty. The average age of the patients was 66.1+/- 3.4 years, and the average BMI was 30.3 +/-0.8. There was no difference in postoperative infections (p = 0.14), wound complications (p = 0.621) or need for transfusion (p = 0.521) between the two groups. There was also no difference in EBL (Hedges' g CI[-3.52, 2.77]) or postoperative Hb (Hedges' g CI[-1.65, 2.41]) between patients with and without drains. Our results do not show any benefit from drain placement after revision total hip or knee arthroplasty. With the increased cost, time and need for drain removal, this is likely an unnecessary intervention. Level III, systematic review and meta-analysis.

Unexpected positive cultures in revision total knee arthroplasty after unicompartmental knee arthroplasty.

Unexpected positive cultures are defined as a single positive culture in intraoperative samples taken during revision surgery after prosthetic joint infection was preoperatively ruled out. This study aims to determine the prevalence of unexpected positive cultures (UPC) in revision total knee arthroplasty (TKA) after unicompartmental knee arthroplasty (UKA). As a secondary objective, this study aims to compare the re-intervention rate in this specific group, between UPC and non-UPC patients. The hypothesis is that the UPC prevalence in patients who undergo a revision TKA after UKA is not higher than in other TKA revision cases and this does not increase the risk of re-intervention. This is a retrospective study where all patients who underwent a UKA revision from January 2016 to February 2023 in a high-volume arthroplasty centre, were analyzed. Unexpected positive culture prevalence in this group of patients was obtained. During the included period, 270 UKA revision surgeries were performed. Eight cases had at least two positive cultures and were therefore excluded. The final analysis included 262 patients. Of these, 8 (3.05%) patients presented UPCs and the isolated microorganisms were low-virulence organisms. None of the UPC patients received any treatment. No statistical differences were found between UPC and non-UPC groups in the analyzed variables. The prevalence of unexpected positive cultures in patients following revision of unicompartmental knee arthroplasty is lower than in patients who undergo a revision of total knee arthroplasty. In UKA patients a UPC does not seem to increase the risk of a re-intervention, so it can be safely ignored if ICM criteria are not met.

High Rates of Early Septic Failure, but Low Rates of Aseptic Loosening After Revision Total Knee Arthroplasty With Contemporary Rotating-Hinge Prostheses

BackgroundThe purpose of this study was to determine implant survivorship and functional outcomes for revision total knee arthroplasty (rTKA) with contemporary rotating-hinge knee implants. MethodsA retrospective review identified 115 rTKAs using contemporary rotating-hinge implants from 2014 to 2018 for the treatment of instability (34, 30%), reimplantation after periprosthetic joint infection (PJI) (33, 29%), aseptic loosening (25, 22%), arthrofibrosis (14, 12%), periprosthetic fracture (4, 3%), osteolysis (4, 3%), and femoral component fracture (1, 1%). There were 70 women (61%), and the mean age was 67 years (range, 27 to 94). The mean follow-up was 3 years (range, 2 to 6). Kaplan-Meier analysis and Cox proportional hazard models estimated survivorship. ResultsThe re-revision rate was 20% (23 of 115) at an average of 18 months postoperatively. Re-revision indications included PJI (n = 14), aseptic loosening (n = 4), arthrofibrosis (n = 2), instability/malalignment (n = 1), femoral stem fracture (n = 1), and hinge mechanism disruption (n = 1). At 2 and 5 years, survivorship free from all-cause re-revision was 86 and 64%, and survivorship free from re-revision for aseptic loosening was 100 and 87%, respectively. Use of a rotating-hinge implant in reimplantation after PJI was a risk factor for subsequent re-revision (hazard ratio = 2.4, P = 0.046). On a radiographic review of unrevised rotating-hinges, there were major radiolucent lines around 2 femoral and 5 tibial components. The mean Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement increased from 43 preoperatively to 60 at 1 year (P < 0.001). ConclusionsIn patients treated with a rotating-hinge implant for rTKA, there were relatively poor 2-year (86%) and 5-year (64%) survivorship free from all-cause re-revision, most commonly due to PJI. Midterm survivorship free from re-revision for aseptic loosening was modest (87%). There should be a goal to mitigate complications in complex rTKAs with rotating-hinge implants, namely PJI.

Rotating Hinge Revision Total Knee Arthroplasty Provides Greater Arc of Motion Gains for Patients Who Have Severe Arthrofibrosis

BackgroundArthrofibrosis is a common postoperative total knee arthroplasty (TKA) complication that results in limited range of motion (ROM). There is limited literature on outcomes after revision TKA (rTKA) for arthrofibrosis based on preoperative ROM restriction. The aims of this study were to: (1) examine ROM trajectory after rTKA for arthrofibrosis patients who have severe versus nonsevere limitations; (2) compare ROM gains and final arc of motion (AOM) between severe and nonsevere cohorts; (2a) compare ROM gain in a severe cohort treated with a rotating hinge (RH) versus a non-RH (NRH) construct; and (3) assess the impact of arthrofibrosis severity on patient-reported outcome measures. MethodsPatients were divided into 2 groups: group A had preoperative ROM < 70° (severe), and group B had preoperative ROM > 70° (non-severe). Patients were assessed clinically using AOM gain, absolute ROM, Knee injury and Osteoarthritis Outcomes Score for Joint Replacement, lower extremity activity scale, and pain scores. Postoperative gains in AOM were compared between both groups. ResultsA total of 56 rTKAs (group A (severe): n = 36, group B (non-severe): n = 20) were performed for patients who have postoperative fibrosis. Group B had better ROM at the 1-year time point (group B: 95.9 ± 22.5 degrees versus group A: 83.2 ± 25.7 degrees). Group A had significantly better improvement in absolute AOM than group B (31.1 ± 20.9 versus 11.4 ± 25.0 degrees, P < 0.01). The RH group demonstrated significantly better absolute AOM gain than the NRH group (41.3 ± 19.4 versus 18.3 ± 15.2 degrees, P < 0.001). However, there were no significant differences in patient-reported outcome measures between groups A and B or between RH and NRH groups at the final follow-up. ConclusionsFinal ROM achieved between severe and nonsevere arthrofibrosis groups was similar, and patients who have severe arthrofibrosis can expect greater absolute ROM gains and similar functional outcomes than nonsevere arthrofibrosis patients. The RH rTKAs provided greater AOM gains for patients who have severe arthrofibrosis, with equivalent functional outcomes to non-RH implants. For severe arthrofibrosis patients, RH designs provided twice the overall ROM gain; however, longer follow-up is necessary to determine whether RH designs have inferior overall implant survivorship.

Serum albumin-to-globulin ratio and CRP-to-albumin ratio did not outperform serum CRP in diagnosing periprosthetic joint infections.

Serum inflammatory parameters are widely used to aid in diagnosing a periprosthetic joint infection (PJI). Due to their limited performances in the literature, novel and more accurate biomarkers are needed. Serum albumin-to-globulin ratio (AGR) and serum CRP-to-albumin ratio (CAR) have previously been proposed as potential new parameters, but results were mixed. The aim of this study was to assess the diagnostic accuracy of AGR and CAR in diagnosing PJI and to compare them to the established and widely used marker CRP. From 2015 to 2022, a consecutive series of 275 cases of revision total hip (n = 129) and knee arthroplasty (n = 146) were included in this retrospective cohort study. Based on the 2021 European Bone and Joint Infection Society (EBJIS) definition, 144 arthroplasties were classified as septic. Using receiver operating characteristic curve (ROC) analysis, the ideal thresholds and diagnostic performances were calculated. The areas under the curve (AUCs) were compared using the z-test. AGR, CAR, and CRP were associated with PJI (p < 0.001). Sensitivities were 62.5% (95% CI 54.3 to 70.0), 73.6% (95% CI 65.8 to 80.1), and 71.5% (95% CI 63.6 to 78.3), respectively. Specificities were calculated with 84.7% (95% CI 77.5 to 89.9), 86.3% (95% CI 79.2 to 91.2), and 87.8% (95% CI 80.9 to 92.4), respectively. The AUC of CRP (0.797 (95% CI 0.750 to 0.843)) was significantly higher than the AUC of AGR (0.736 (95% CI 0.686 to 0.786), p < 0.001), and similar to AUC of CAR (0.799 (95% CI 0.753 to 0.846), p = 0.832). Decreased sensitivities were observed in PJIs caused by low-virulence organisms (AGR: 60%, CAR: 78%) compared to high-virulence pathogens (AGR: 80%, p = 0.042; CAR: 88%, p = 0.158). Higher sensitivities were seen in acute haematogenous (AGR: 83%, CAR: 96%) compared to chronic PJIs (AGR: 54%, p = 0.001; CAR: 65%, p < 0.001). Serum AGR and CAR showed limited diagnostic accuracy (especially in low-grade and chronic infections) and did not outperform the established marker CRP in our study. Hence, neither parameter can be recommended as an additional tool for diagnosing PJI.

Revision Total Knee Arthroplasty Achieves Minimal Clinically Important Difference Faster Than Primary Total Knee Arthroplasty

BackgroundRevision total knee arthroplasty (rTKA) remains underexplored regarding patient-reported outcome measures (PROMs), particularly in terms of time to reach minimal clinically important difference (MCID). This study addresses this gap by comparing the time to achieve MCID between primary TKA (pTKA) and rTKA patients, providing valuable insights into their recovery trajectories. MethodsA total of 8,266 TKAs (7,618 pTKA and 648 rTKA) were retrospectively studied in a multi-institutional arthroplasty registry. Patients who completed the patient-reported outcomes measurement information system (PROMIS) global physical, PROMIS physical function short form 10a (PF-10a), and knee injury and osteoarthritis outcome score physical function short form (KOOS-PS) questionnaires were identified by Current Procedural Terminology codes. Survival curves with and without interval censoring were utilized to evaluate the time to achieve MCID. ResultsComparing the time to achieve MCID, rTKAs were significantly faster than pTKA for PROMIS global physical (3.5 versus 3.7 months, P = 0.004) and KOOS-PS (3.3 versus 4.2 months, P < 0.001), but similar for PROMIS PF-10a (4.4 versus 4.8 months, P = 0.057). Interval censoring also showed similar trends with earlier times to achieve MCID for rTKAs for PROMIS global physical (0.6 to 0.61 versus 0.97 to 0.97 months, P = 0.009) and KOOS-PS (0.97 to 0.97 versus 1.47 to 1.47 months, P < 0.001), but not for PROMIS PF-10a (2.43 to 2.54 versus 1.90 to 1.91 months, P = 0.92). ConclusionsThe present study revealed that the time to achieve MCID was faster in patients undergoing rTKA compared to those undergoing pTKA. These findings allow surgeons to reassure preoperative rTKA patients that their recovery to a MCID postoperatively may be quicker than expected, especially when compared to their initial recovery after primary TKA. Level of EvidenceLevel III.

Knee fusion versus above knee amputation as two options to deal with knee periprosthetic joint infection.

Periprosthetic joint infection (PJI) poses a significant challenge in total knee arthroplasty (TKA), with recurrence rates as high as 14-28%, leading to substantial morbidity and treatment costs. When conventional treatments fail, knee fusion and above-the-knee amputation (AKA) emerge as alternative options. Existing literature offers conflicting views on the efficacy and impact of knee fusion versus AKA with varied outcomes and limitations. This retrospective national study spanning 2010-2022 investigates Knee Fusion and AKA as options for addressing Knee PJI. Utilizing PearlDiver Patient Records Database, procedural, and reimbursement data on over 100million individuals from all the US was evaluated. Readmission rates, costs, and complications of the mentioned procedures were assessed using ICD-9 and ICD-10 codes within a 90-day period and one-year post-operation. Statistical analyses, including chi-square tests and regression models, were conducted using integrated R software. The study reveals a substantial escalation (p < 0.0001) in the proportion of patients opting for AKA compared to arthrodesis. While age as a demographic factor showed no significant difference, arthrodesis patients exhibited lower comorbidity scores (3.6 ± 2.9 vs. 4.6 ± 3.4, p < 0.001). Arthrodesis correlated with higher 90-day thromboembolism rates (9.2% vs. 7.3%, p < 0.001), blood transfusion requirements (23.2% vs. 14.4%, p < 0.001), and acute renal failure incidence (p = 0.008) but demonstrated lower rates of urinary tract infections (p = 0.047) and cerebrovascular accidents (p < 0.001). At 1 year, arthrodesis was associated with higher infection rates (38.7% vs. 36.4%, p < 0.001). Arthrodesis patients had significant increased 90-day and 1-year readmission rates and hospitalization costs ($12,732 vs. $18,826, p < 0.001). We found higher rates of 1-year thromboembolism, infection, acute renal failure, and readmission in the arthrodesis group. AKA patients had more sepsis and cerebrovascular accidents. A patient-centered conversation is best for persistent infections and failed revision TKA. Considering the patient's quality of life, goals, and health status, this discussion should cover each procedure's risks and complications.

Clinical outcomes of two-stage revision arthroplasty using a spiked tibial cement spacer in infected total knee arthroplasty.

A tibial cement spacer (TCS) with spikes offers better initial stability than a conventional TCS and reduces spacer-related problems in two-stage revision total knee arthroplasty (R-TKA) for infection. We compared the clinical outcomes of two-stage revision arthroplasty for infected TKA using spiked TCS with that of conventional TCS. This retrospective cohort study included 29 patients who underwent two-stage revision arthroplasty using an articulating cement spacer and who could be followed up for at least one year. Group S comprised 14 patients using spiked TCS, whereas Group C comprised 15 patients using conventional TCS. Demographic data, the interval from first to second stage revision, motion arc, numerical rating scale (NRS), Knee Society (KS) score, serum levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and frequency of repeating the first-stage and infection recurrence after R-TKA between the groups were analyzed. No significant differences were observed in the female ratio and mean age between both groups. The mean interval between the first and second stage revision was significantly shorter in Group S than in Group C. The mean motion arc was significantly larger in Group S than in Group C. The mean NRS was significantly lower in Group S than in Group C. The mean KS score in Group S was significantly higher than that in Group C. Serum ESR and CRP levels did not differ between the groups. The frequency of repeating the first stage was lower in Group S than in Group C. However, the recurrence rate after R-TKA was higher in Group S than in Group C. Compared with conventional TCS, spiked TCS shortened the period until R-TKA and improved pain and function levels. However, no significant difference existed in the rate of infection recurrence after R-TKA.

Biomechanical analysis of patient specific cone vs conventional stem in revision total knee arthroplasty

BackgroundIn revision total knee arthroplasty, addressing significant bone loss often involves the use of cemented or press-fit stems to ensure implant stability and long-term fixation. A possible alternative to stem was recently introduced utilizing custom-made porous metaphyseal cones, designed to reconstruct the missing tibial and femoral geometries. Early clinical and radiological assessments have shown promising results. The objective of this research was to biomechanically evaluate the performances of these custom-made cones.MethodsThe biomechanical study was conducted using a validated finite element model. The bone geometries of a patient (selected for their history of four knee revisions due to infection and periprosthetic fractures, followed by a successful treatment with custom-made 3D-printed metaphyseal cones) were employed for the study. On these bone models, different revision scenarios were simulated and examined biomechanically: (A) custom-made cementless metaphyseal cones; (B) cemented stems; (C) press-fit stems; (D) distal femoral reconstruction with press-fit stem. All the models were analyzed at 0 °and 90 °of flexion, under physiological load conditions simulating daily activities; stress distribution, average Von-Mises stresses and risk of fracture were then analyzed and compared among configurations.ResultsThe use of custom-made 3D-printed cones exhibited the most favorable stress distribution in both femoral and tibial bones. Tibial bone stress was evenly distributed in custom-made cone configurations, while stress concentration was observed in distal regions for the other scenarios. Additionally, custom-made cones displayed overall homogeneity and lower stress levels, potentially contributing to limit pain. Symmetrical stress distribution was observed between the lateral and medial proximal tibia in custom-made cone models, whereas other scenarios exhibited uneven stress, particularly in the anterior tibial bone.ConclusionsThe biomechanical analysis of porous custom-made metaphyseal cones in re-revision arthroplasties is in agreement with the positive clinical and radiological outcomes. These findings provide valuable insights into the potential benefits of using custom-made cones, which offer more uniform stress distribution and may contribute to improve patient outcomes in revision TKA procedures. Further studies in this direction are warranted to validate these biomechanical findings.

Does previous total hip arthroplasty affect the outcomes of total knee arthroplasty? A one- and five-year follow-up registry study in a monocentric hospital

BackgroundOsteoarthritis in the lower extremities becomes more common as people age. In addition to conservative treatments, hip or knee arthroplasty is often needed. The aim of this study was to evaluate total knee arthroplasty (later TKA) in patients, comparing those who had previously undergone THA (later THA/TKA), with those who had not undergone such procedure. Pain, walking ability and functional capacity were assessed.MethodsPatients who underwent primary TKA between 1987 and 2017 at a single orthopaedic hospital was included in this study. The patients participated in clinical preoperative and postoperative examinations by an orthopaedic surgeon after one- and five- years. The final study group consisted of 418 patients who had undergone 502 knee arthroplasties. Of these 502 TKA cases, 462 had not undergone previous THA and 40 had undergone previous THA. To evaluate the patients’ physical function and walking ability, a structure form for knee arthroplasty based on the Hungerford score was used. The registry data from the Finnish National Institute of Health and Welfare was used. The data included TKA revision(s) and mortality events.ResultsAt the baseline and after one- and five- years primary TKA, no statistical differences were found in the total Hungerford score between TKA patients and THA/TKA patients. In both groups, the total score increased per surgery year. However, when analysing the relationship between the year of operation and the total score, no statistical differences were found between the groups (TKA and THA/TKA) at five years (p = 0.61). The only statistical difference found between the groups was in walking distance points after one year; THA/TKA patients (mean 83 [SD 17]) could walk remarkably shorter distances than TKA patients (91 [14]) one year after arthroplasty (p < 0.001).ConclusionsIn conclusion, walking distance improved more rapidly in TKA patients than in THA/TKA patients. However, patients who underwent more than one arthroplasty in their lower extremities managed their lives, activities, and pain almost as well as those who underwent only one knee arthroplasty.

Current Evidence Does Not Support the Use of Tibial Stem Extension in Total Knee Arthroplasty of Obese Patients: A Systematic Review

BackgroundObesity rates have been increasing globally, leading to a higher incidence of knee osteoarthritis and a surge in primary and revision total knee arthroplasty (TKA). The debate continues on the impact of obesity on TKA success, particularly regarding the use of stemmed tibial components in obese patients. This systematic review aimed to compare the effectiveness of stemmed tibial components versus standard keeled tibial components in obese patients undergoing TKA. MethodsA systematic review was conducted using databases including PubMed, Embase, Scopus, and Web of Science from inception to December 2023. The eligibility criteria were Participants: Patients who have obesity undergoing TKA; Intervention: stemmed TKA; Comparator: standard keeled tibial TKA; Outcomes: aseptic loosening, patient-reported outcome measures (PROMs), and overall revision. Data extraction and quality assessment were performed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane risk-of-bias tool for randomized trials. ResultsThe search yielded 470 studies, with 10 studies (42,533 knees) meeting the inclusion criteria. These studies included 3 randomized controlled trials and 7 retrospective cohorts. The primary outcomes measured were aseptic loosening and overall revision rates, while secondary outcomes included PROMs. Results indicated mixed findings, with some studies suggesting improved outcomes with stemmed components in cases of aseptic loosening and mechanical failure, while others showed no significant difference. The PROMs did not show a significant difference between groups post-TKA. The certainty of the evidence was graded as “very low” using the Grading of Recommendations, Assessment, Development, and Evaluations framework. ConclusionsCurrent literature does not provide conclusive evidence to support the routine use of stemmed tibial components in TKA for obese patients. The decision to use stem extensions should not solely rely on the patient’s obesity status. Further high-quality studies are needed to clarify the role of stemmed components in TKA for this patient population. Level of EvidenceIII.

Cement loaded with high-dose gentamicin and clindamycin does not reduce the risk of subsequent infection after aseptic total hip or knee revision arthroplasty: a preliminary study

PurposeThe aim of this study was to quantify the prophylactic effect of high-dose gentamicin and clindamycin antibiotic-loaded bone cement (ALBC) during revision total hip (rTHA) or knee (rTKA) arthroplasty for aseptic reasons. The hypothesis was that the raw surgical site infection (SSI) rate is lower when this particular cement is used in comparison with cement loaded with standard-dose gentamicin during rTHA or rTKA for aseptic reasons.MethodsThis retrospective study included 290 consecutive patients undergoing aseptic rTHA or rTKA. Two consecutive cohorts were defined: the first (control group) involved 145 patients where ALBC with gentamicin only was used; the second (study group) involved 145 patients where ALBC with high-dose gentamicin and clindamycin was used. The primary endpoint was the raw SSI rate after 24 months.ResultsThe raw SSI rate was 8/145 (6%) in the control group and 13/145 (9%) in the study group (odds ratio 0.62, p = 0.26). There was a significant impact of the presence of any risk factor on the SSI rate (15/100 versus 6/169, odds ratio = 4.25, p = 0.002), but no significant impact of any individual risk factor. No complication or side effect related to ALBC was observed in either group.ConclusionThese results do not support the routine use of gentamicin and clindamycin ALBC for fixation of revision implants after rTHA and rTKA for aseptic reasons.

Midterm results for revision total knee arthroplasty for component malrotation

IntroductionAccurate positioning of components in total knee arthroplasty (TKA) is essential to a satisfactory outcome. Significant malrotation may lead to chronic pain, stiffness, and dysfunction. This study aims to quantify improvements in functional outcomes following revision surgery for malrotation of either one or both components in TKA versus revision for aseptic loosening. MethodsThis was a retrospective review of TKAs that matched and compared the two-year functional outcomes of the malrotation group to a functionally similar aseptic loosening group. Functional outcomes were compared between groups using Short Form (SF-12), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and Knee Society Functional Score (KSFS). Student t-tests and chi-squared or Fisher’s tests were used for statistical analysis. ResultsOf the patients revised, 24 had malrotation and 57 had aseptic loosening. A total of 16 femoral and 17 tibial components were revised for malrotation. All 16 femoral components were internally malrotated (mean –4.8 ± 4.1 degrees; range, −0.5 to −16.6). Of the tibial components, 15 were internally malrotated, (mean −9.5 ± 6.6 degrees; range, −2.2 to –23.5) and 2 were externally malrotated (mean 4.6 ± 2.1 degrees; range, 3.1 to 6.0). All functional outcome measures significantly improved comparably within both groups preoperatively to 24 months postoperatively. At 24 months, functional outcome measures were comparable between the groups and WOMAC function scores were significantly higher in the malrotation group. ConclusionRevision TKA for malrotation can yield clinically and statistically significant functional improvements, similar in magnitude to those seen following revision TKA for aseptic loosening. Level of EvidenceLevel III

Rising Costs and Diminishing Surgeon Reimbursement From Primary to Revision Total Hip and Knee Arthroplasty: An Analysis of Medicare Advantage and Commercial Insurance.

Revision total joint arthroplasty (rTJA) is a resource-intensive procedure addressing failed primary total joint hip (total hip arthroplasty [THA]) and knee arthroplasty (total knee arthroplasty [TKA]). Despite predictions of increased demand, reimbursement for rTJA has not kept pace with increasing costs and may be insufficient compared with primary procedures. The study aimed to highlight the diminishing surgeon reimbursement between primary and revision THA (rTHA) and TKA. This study is a retrospective analysis of billing data for primary and rTHA and TKA procedures from a single institution between 2019 and 2022. Insurance claims and charges data were provided by a local affiliate of a major national carrier which includes Medicare Advantage (MA) and commercial patients. Using insurance data, the study evaluates the total surgery costs for primary and rTHA and TKA and the individual charges that make up the total surgery cost. Nine hundred five patients insured by the same carrier, who underwent a primary or rTJA, were identified. Irrespective of MA or commercial insurance, the average surgery cost for a primary THA was $26,043, compared with $53,456 for rTHA. Surgeon reimbursement for primary THA was 20% ($5,323) of the total surgery cost. Despite the doubled surgery cost for rTHA, surgeon reimbursement was 10% ($5,257) of the total surgery cost. Primary TKA surgery costs were $24,489, while revision costs were $43,074. Surgeon reimbursement for primary TKA was 20% ($4,918) of the total surgery cost, while reimbursement for revision TKA was 13% ($5,560). MA reimbursement was markedly lower than commercial reimbursement for primary and revision cases. Despite the higher total costs for rTJA, surgeon reimbursement is disproportionately diminished. The findings highlight the lack of incentive for revision cases. Surgeon reimbursement from MA and commercially insured patients for rTJA remains inadequate. This may limit patient access-to-care, leading to suboptimal outcomes and increased healthcare utilization.

Antibiotic-loaded bone cement is associated with a reduction of the risk of revision of total knee arthroplasty: Analysis of the Catalan Arthroplasty Register.

The purpose of this study was to analyse the impact on peri-prosthetic joint infection (PJI) rate and prosthetic survival using antibiotic-loaded bone cement (ALBC) versus plain cement during total knee arthroplasty (TKA). A retrospective cohort study was conducted. The main data source was the Catalan Arthroplasty Register (RACat). TKAs with surgery date between 1 January 2011 and 31 December 2020 were analysed and followed up until 31 December 2023. The main variable of interest was the type of cement (ALBC vs. plain cement), and several endpoints (septic revision, aseptic revision, and all-cause revision) were considered. The analysed outcomes were revision rates, survival rates and risk factors' hazard ratios (HR). A total of 22,781 TKAs were analysed, 13,125 (57.6%) of them with plain cement and 9656 (42.4%) with ALBC. The septic revision rate was lower in the ALBC group after 3 months of follow-up (0.52% vs. 0.78%, p value = 0.04). Prosthetic survival with respect to the aseptic revision endpoint was also higher for the ALBC group during the whole follow-up period (~158 months). Regarding risk factors for infection, ALBC showed a protective effect, HR: 0.53 (0.44, 0.63), while sex (being male) and the analysed comorbidities increased the risk. ALBC is associated with a reduction in both the septic revision and the aseptic revision rate after TKA, and thus with higher prosthetic survival. Level III, Therapeutic, retrospective.

Factors Affecting Operating Room Scheduling Accuracy for Primary and Revision Total Knee Arthroplasty: A Retrospective Study.

Optimizing operating room (OR) scheduling accuracy is important for improving OR efficiency and maximizing value of total knee arthroplasty (TKA). However, data on factors that may impact TKA OR scheduling accuracy are limited. A retrospective review of 7655 knee arthroplasties (6999 primary TKAs and 656 revision TKAs) performed between January 2020 and May 2023 was conducted. Patient baseline characteristics, surgeon experience (years in practice), as well as actual vs scheduled OR times were collected. Actual OR times that were at least 15% shorter or longer than scheduled OR times were considered to be clinically important. Logistic regression analyses were employed to assess the influence of specific patient and surgeon factors on OR scheduling inaccuracies. Using adjusted odds ratio, patients with primary TKA who had a lower body mass index (P<.001) were independently associated with overestimation of scheduled surgical time. Conversely, younger age (P<.001), afternoon procedure start time (P<.001), surgeons with less than 10 years of experience (P=.037), and higher patient body mass index (P<.001) were associated with underestimation of scheduled surgical time. For revision TKA, female sex (P=.021) and morning procedure start time (P=.038) were associated with overestimation of scheduled surgical time, while surgeons with less than 10 years of experience (P=.014) and patients who underwent spinal/epidural/block anesthesia (P=.038) were associated with underestimation of scheduled surgical time. This study highlights patient, surgeon, and intraoperative variables that impact the accuracy of scheduling for TKA procedures. Health systems should take these variables into consideration when creating OR schedules to fully optimize resources and available space. [Orthopedics. 2024;47(5):313-319.].

The role of BioFire Joint Infection Panel in diagnosing periprosthetic hip and knee joint infections in patients with unclear conventional microbiological results.

This study aimed to evaluate the BioFire Joint Infection (JI) Panel in cases of hip and knee periprosthetic joint infection (PJI) where conventional microbiology is unclear, and to assess its role as a complementary intraoperative diagnostic tool. Five groups representing common microbiological scenarios in hip and knee revision arthroplasty were selected from our arthroplasty registry, prospectively maintained PJI databases, and biobank: 1) unexpected-negative cultures (UNCs), 2) unexpected-positive cultures (UPCs), 3) single-positive intraoperative cultures (SPCs), and 4) clearly septic and 5) aseptic cases. In total, 268 archived synovial fluid samples from 195 patients who underwent acute/chronic revision total hip or knee arthroplasty were included. Cases were classified according to the International Consensus Meeting 2018 criteria. JI panel evaluation of synovial fluid was performed, and the results were compared with cultures. The JI panel detected microorganisms in 7/48 (14.5%) and 15/67 (22.4%) cases related to UNCs and SPCs, respectively, but not in cases of UPCs. The correlation between JI panel detection and infection classification criteria for early/late acute and chronic PJI was 46.6%, 73%, and 40%, respectively. Overall, the JI panel identified 12.6% additional microorganisms and three new species. The JI panel pathogen identification showed a sensitivity and specificity of 41.4% (95% confidence interval (CI) 33.7 to 49.5) and 91.1% (95% CI 84.7 to 94.9), respectively. In total, 19/195 (9.7%) could have been managed differently and more accurately upon JI panel evaluation. Despite its microbial limitation, JI panel demonstrated clinical usefulness by complementing the traditional methods based on multiple cultures, particularly in PJI with unclear microbiological results.

The Impact of Culture Negativity on the Outcomes of Revision Total Knee Arthroplasty for Chronic PJI.

Culture-positive (CP) and culture-negative (CN) periprosthetic joint infections (PJI) remain a crucial area of research; however, current studies comparing these infections rely on unstandardized outcome reporting tools. Our study aimed to compare the outcomes of two-stage revision of CP and CN PJI using the standardized Musculoskeletal Infection Society (MSIS) outcome reporting tool. We retrospectively reviewed 138 patients who were diagnosed with PJI and indicated for two-stage revision total knee arthroplasty (rTKA). The majority of patients in both CP and CN cohorts achieved infection control without the need for reoperation (54.1% and 62.5%, respectively). There was a significant difference in the overall distribution of MSIS outcomes (p = 0.043), with a significantly greater rate of CN patients falling into Tier 1 (infection control without the use of suppressive antibiotics) (52.5% versus 29.6%, p = 0.011). There was also a significant difference in the distribution of septic versus aseptic reoperations after 2nd stage (p = 0.013), with more CP reoperations being septic and more CN reoperations being aseptic. The duration from first to second stage was significantly shorter in the CN cohort (p = 0.002). While overall infection control was similar between cohorts, these data suggest that the outcomes of two-stage rTKA are favorable in cases of CN PJI.

Synovial calprotectin in prosthetic joint infection. A systematic review and meta-analysis of the literature.

Calprotectin is a protein endowed with antimicrobial properties, rendering it a distinctive marker for infection. Two methods are currently available for the assay of calprotectin: the enzyme-linked immunosorbent assay (ELISA) and the lateral flow test (LFT). We aimed to assess the diagnostic accuracy of synovial fluid calprotectin and to compare the accuracy of the laboratory-based test and the qualitative assessment for the diagnosis of hip and knee prosthetic infection. We searched (from inception to November 2023) MEDLINE, Scopus, EMBASE, Web of Science, and Cochrane for studies on calprotectin in the diagnosis of periprosthetic joint infection (PJI). Sensitivity, specificity, positive and negative likelihood ratio (LR), and diagnostic odds ratio were analyzed. The receiver-operating curve for each method was calculated. We included 14 articles in our meta-analysis, including 902 patients who underwent total hip and knee arthroplasties revision; 331 (37%) had a joint infection according to MSIS, MSIS-modified criteria, ICM 2018 and EBJIS 2021. Considering the false-positive result rate of 6% and false-negative result rate of 7%, pooled sensitivity and specificity were 0.92 (95% CI 0.89-0.94) and 0.93 (0.91-0.95), respectively. The area under the curve (AUC) was 0.93 (95% CI 0.91-0.94). No statistical differences in terms of sensitivity and specificity were found between ELISA and LFT. The pooled sensitivity and specificity of the two calprotectin assessment methods were: LFT 0.90 (95% CI 0.869-0.935) and 0.92 (95% CI 0.894-0.941), respectively; ELISA 0.96 (95% CI 0.914-0.986) and 0.97 (95% CI 0.934-0.988), respectively. The diagnostic odds ratio of the ELISA was superior to that of the LFT (906.6667, 95% CI 271.2686-3030.3712 versus 113.8886, 95% CI 70.4001-184.2414; p < 0.001). The AUC for ELISA and LFT was 0.968 (95% CI 0.944-0.984) and 0.915 (95% CI 0.895-0.933), respectively. Detection of synovial calprotectin is an accurate test for diagnosis of hip and knee prosthetic infections. The diagnostic accuracy of the two calprotectin assessment methods is almost comparable. The LFT is a valid, rapid, and more available diagnostic tool, particularly to rule out PJI.

Are social determinants of health associated with an increased length of hospitalization after revision total hip and knee arthroplasty? A comparison study of social deprivation indices.

Length of stay (LOS) has been extensively assessed as a marker for healthcare utilization, functional outcomes, and cost of care for patients undergoing arthroplasty. The notable patient-to-patient variation in LOS following revision hip and knee total joint arthroplasty (TJA) suggests a potential opportunity to reduce preventable discharge delays. Previous studies investigated the impact of social determinants of health (SDoH) on orthopaedic conditions and outcomes using deprivation indices with inconsistent findings. The aim of the study is to compare the association of three publicly available national indices of social deprivation with prolonged LOS in revision TJA patients. 1,047 consecutive patients who underwent a revision TJA were included in this retrospective study. Patient demographics, comorbidities, and behavioral characteristics were extracted. Area deprivation index (ADI), social deprivation index (SDI), and social vulnerability index (SVI) were recorded for each patient, following which univariate and multivariate logistic regression analyses were performed to determine the relationship between deprivation measures and prolonged LOS (greater than five days postoperatively). 193 patients had a prolonged LOS following surgery. Categorical ADI was significantly associated with prolonged LOS following surgery (OR = 2.14; 95% CI = 1.30-3.54; p = 0.003). No association with LOS was found using SDI and SVI. When accounting for other covariates, only ASA scores (ORrange=3.43-3.45; p < 0.001) and age (ORrange=1.00-1.03; prange=0.025-0.049) were independently associated with prolonged LOS. The varying relationship observed between the length of stay and socioeconomic markers in this study indicates that the selection of a deprivation index could significantly impact the outcomes when investigating the association between socioeconomic deprivation and clinical outcomes. These results suggest that ADI is a potential metric of social determinants of health that is applicable both clinically and in future policies related to hospital stays including bundled payment plan following revision TJA.