THA Surgery Research Articles

Periprosthetic joint infection is the main reason for failure in patients following periprosthetic fracture treated with revision arthroplasty.

Periprosthetic fracture after primary total hip and knee arthroplasty (THA; TKA) can be challenging, requiring open reduction internal fixation (ORIF), revision, or both. The aim of this study was to evaluate the outcomes and risk factors associated with re-revision surgery following failed revision arthroplasty for periprosthetic fracture. A total of 316 consecutive THA patients and 79 consecutive TKA patients underwent a revision for periprosthetic fracture, of which 68 THA patients (21.5%) and 15 TKA patients (18.9%) underwent re-revision surgery. The most common indication for hip and knee re-revision was periprosthetic joint infection (PJI) in 28 THA patients (46.6%) and 11 TKA patients (47.8%). The complication rates of THA and TKA revision were 24.3% and 25.3% respectively, and 35.0% and 39.1% respectively for re-revision surgery at an average follow-up of 4.5 years. Periprosthetic joint infection was the most common indication for THA and TKA re-revision (46.7%; 47.8%) and third revision surgery (15.0%; 13.0%). Factors significantly contributing to an increased risk of THA and TKA re-revision included revision with plate fixation and revision with combined ORIF. The overall complication rate of THA and TKA re-revision surgery following failed revision surgery for periprosthetic fracture was higher than of revision surgery. The most common indication for re-revision and third revision was periprosthetic joint infection. These findings may assist surgeons in the management and preoperative counseling of patients undergoing THA and TKA revision surgery for a periprosthetic fracture to optimize the outcomes for these patients. Level III, case-control retrospective analysis.

Intersectionality of Net Worth and Race Relative to Utilization of Total Hip and Knee Arthroplasty

BackgroundAlthough the number of total hip arthroplasty and total knee arthroplasty (THA and TKA) increases, individuals of color continue to be less likely to undergo these procedures. Socioeconomic status may be a key influencer of THA and TKA utilization and outcomes. We explore the influence of net worth and race on THA and TKA utilization and outcomes of length of stay and readmissions using a large patient database. MethodsThe StrataSphere data set, an aggregation of 49 health systems representing 209 hospitals, was used for primary THA and TKA procedures performed in the calendar year 2019. Net worth was determined from Market Vue Partners’ data sources. Statistical analyses were performed to investigate relationships between net worth and patients undergoing THA or TKA. ResultsWhen comparing our overall patient cohorts with the US population using Census data, we found differences in the utilization pattern indicated by index ratios most clearly in the lowest net worth categories. In the <$10K net worth category, THA and TKA index ratios were 0.51 and 0.54, respectively. In addition, we found that patients in the $100-250 and $250-500K net worth categories had increased utilization of both THA (index ratios of 1.39, 1.53) and TKA (index ratios of 1.45, 1.47) surgeries. ConclusionNet worth is a strong driver of disparities in utilization of THA and TKA with lower utilization of these surgeries in patients with net worth <$10K and increased utilization in patients with net worth from $100-250 and $250-500K.

Failure to achieve pelvic balance following hip replacement surgery may be a risk factor for development of degenerative scoliosis

IntroductionIn the global alignment of body, the pelvis and spine are strictly and mutually connected. Our hypothesis was that failure to achieve pelvic balance following hip replacement surgery (THA) may be a risk factor for development of degenerative scoliosis. MethodsA retrospective case control study was conducted. Patients who underwent THA followed by spine surgery primarily because of scoliosis (scoliosis group) were compared to patients who only underwent THA (no scoliosis group). Any patient in either group who had spine surgery prior to THA was excluded. Propensity score matching was utilized to match the two groups on age, gender and etiology for THA. ResultsA total of78 patients (39 in each group) were included in the study. The mean age was 63 years in scoliosis group and 64 years in no scoliosis group. The most common etiologies for THA were osteoarthritis, fracture and avascular necrosis. The mean pelvic obliquity as measured by the O’Brien method was 2.9° (0.2–6.5) in scoliosis group and 1.1° (0–4.5) in no scoliosis group. This difference in pelvic obliquity between the two groups was statistically significant (p < 0.01). The mean time interval between THA and spine surgery was 9.5 years. The mean follow-up in scoliosis group was 12 years and 6 years in no scoliosis group. ConclusionAltered pelvic parameters following hip surgery may be a contributing factor in the development of thoracolumbar scoliosis. Our data showed that a small change in pelvic balance following THA could pose a risk for developing degenerative scoliosis.

The effects of patients’ expectations on surgery outcome in total hip and knee arthroplasty: a prognostic factor meta-analysis

ABSTRACT Patients’ expectations are among the most frequently studied psychological prognostic factors in total knee and hip arthroplasty (TKA/THA). So far, however, evidence on the effect of patients’ preoperative expectations on surgery outcome is inconclusive. Heterogeneity of expectation constructs and the use of psychometrically not evaluated measurement instruments have constituted major obstacles for the integration of the current literature. Using a theory-based model of expectation constructs , this meta-analysis set out to disentangle the conflicting results in the current literature. Systematic literature searches yielded k = 46 studies (N = 10,465) that reported associations of preoperative expectations with postoperative pain, functioning and disability, and satisfaction. Random effects meta-analysis revealed a robust small association (r = .16; 95% CI .13, .19) between patients’ positive preoperative expectations and better postoperative outcomes. This effect did not differ between THA and TKA, different outcome categories and different follow-up periods. Studies using psychometrically evaluated expectation measures reported significantly higher effects (r = .19; 95% CI .16, .22). Whether this effect varies among different expectation constructs remains unclear. High-quality studies using validated, multidimensional expectation measures are needed to further understand the role of different expectation constructs in THA and TKA surgery.

Enhanced recovery principles applied to revision hip and knee arthroplasty leads to better patient outcomes

AimsThere is very little published literature on Enhanced Recovery Principles (ERP) used in primary joint replacements applied to revision hip and knee arthroplasty (rTHA, rTKA). MethodsRetrospective series of 268 rTHA and rTKA surgeries from 2010 -2018, treated with ERP, focusing on multimodal pain management, blood management and early functional recovery. ResultsNo patients from the latest cohort required readmission within 6 weeks. Only 20 patients (7.5%) required a blood transfusion. Surgical site local anaesthetic infiltration was associated with lower PCA use in aseptic rTHA and rTKA (p<0.001; p<0.001). Revisions for infection had a longer length of stay (LOS) and increased PCA usage in both rTHA (6.5 vs. 5.2 days) and rTKA (10.1 vs. 5.3 days), similar to our previous study.1 Use of an intra-articular catheter for analgesia in rTKA showed reduced PCA use. Tourniquets were not beneficial for blood loss in rTKA and had greater PCA use post-operatively (p<0.001). ConclusionThe application of ERP to revision THA and TKA surgery is safe and effective.

Validation of a Semiautomated Surveillance Algorithm for Deep Surgical Site Infections After Primary Hip or Knee Arthroplasty

Background: Surgical site infections (SSIs) complicate ~2% of primary total hip (THAs) or total knee arthroplasties (TKAs). Accurate and timely identification through surveillance is essential for targeted implementation and monitoring of preventive interventions. Electronic health records (EHR) facilitate (semi)-automated surveillance and enable upscaling. A validated algorithm is a prerequisite for broader implementation of semiautomated surveillance. Objectives: To validate a previously published algorithm for semiautomated surveillance of deep SSI after THA or TKA in 4 independent regional Dutch hospitals. The algorithm was developed and implemented in the University Medical Centre Utrecht and relies on retrospective routine care data. Methods: For this multicenter retrospective cohort study, the following data required for the algorithm were extracted from the EHR from all patients under THA and TKA surveillance: microbiology results, antibiotics, (re)admissions, and surgical procedures within the 120 days following the primary surgery. Patients were retrospectively classified with a low or high probability of having developed a deep SSI after THA or TKA, according to the algorithm. Sensitivity, positive predictive value (PPV), and workload reduction (defined as the proportion of manuals requiring review) were calculated compared to the traditional (manual) surveillance results, as reported to the national surveillance PREZIES. Discrepancy analyses were performed to understand algorithm results. Results: Data from 8,378 total THA and TKA surgeries (deep SSI n = 95, 1.1%) performed between 2012 and 2018 were extracted by 4 hospitals (Table 1). Sensitivity ranged across centers from 93.6% to 100%, with a PPV from 55.8% to 72.2%. In all hospitals, the algorithm resulted in &gt;98% workload reduction. Cases missed by the algorithm could be explained by incomplete data extraction. Conclusions: This study shows that the surveillance algorithm performance is good in general Dutch hospitals. Broader implementation of this semiautomated surveillance for SSIs after THA or TKA may be possible in the near future and will result in a substantial workload reduction.Funding: This work was supported by the Regional Healthcare Network Antibiotic Resistance Utrecht with a subsidy of the Dutch Ministry of Health, Welfare and Sport (grant number 326835).Disclosures: None

Complications to 6\u2009months following total hip or knee arthroplasty: observations from an Australian clinical outcomes registry

BackgroundTotal hip and total knee arthroplasty (THA/TKA) are increasing in incidence annually. While these procedures are effective in improving pain and function, there is a risk of complications.MethodsUsing data from an arthroplasty registry, we described complication rates including reasons for reoperation and readmission from the acute period to six months following THA and TKA in an Australian context. Data collection at 6 months was conducted via telephone interview, and included patient-reported complications such as joint stiffness, swelling and paraesthesia. We used logistic regression to identify risk factors for complications.ResultsIn the 8444 procedures included for analysis, major complications were reported by 9.5 and 14.4% of THA and TKA patients, respectively, whilst minor complications were reported by 34.0 and 46.6% of THA and TKA patients, respectively. Overall complications rates were 39.7 and 53.6% for THA and TKA patients, respectively. In THA patients, factors associated with increased risk for complications included increased BMI, previous THA and bilateral surgery, whereas in TKA patient factors were heart disease, neurological disease, and pre-operative back pain and arthritis in a separate joint. Female gender and previous TKA were identified as protective factors for minor complications in TKA patients.ConclusionWe found moderate rates of major and high rates of minor postoperative complications following THA and TKA in Australia and have identified several patient factors associated with these complications. Efforts should be focused on identifying patients with higher risk and optimising pre- and post-operative care to reduce the rates of these complications.

Development and early findings of a semiautomated arthroplasty registry in a multi-institutional healthcare network.

The primary aim of this paper was to outline the processes involved in building the Partners Arthroplasty Registry (PAR), established in April 2016 to capture baseline and outcome data for patients undergoing arthroplasty in a regional healthcare system. A secondary aim was to determine the quality of PAR's data. A tertiary aim was to report preliminary findings from the registry and contributions to quality improvement initiatives and research up to March 2019. Structured Query Language was used to obtain data relating to patients who underwent total hip or knee arthroplasty (THA and TKA) from the hospital network's electronic medical record (EMR) system to be included in the PAR. Data were stored in a secure database and visualized in dashboards. Quality assurance of PAR data was performed by review of the medical records. Capture rate was determined by comparing two months of PAR data with operating room schedules. Linear and binary logistic regression models were constructed to determine if length of stay (LOS), discharge to a care home, and readmission rates improved between 2016 and 2019. The PAR captured 16,163 THAs and TKAs between April 2016 and March 2019, performed in seven hospitals by 110 surgeons. Manual comparison to operating schedules showed a 100% capture rate. Review of the records was performed for 2,603 random operations; 2,298 (88.3%) had complete and accurate data. The PAR provided the data for three abstracts presented at international conferences and has led to preoperative mental health treatment as a quality improvement initiative in the participating institutions. For primary THA and TKA surgeries, the LOS decreased significantly (p < 0.001) and the rate of home discharge increased significantly (p < 0.001) between 2016 and 2019. Readmission rates did not correlated with the date of surgery (p = 0.953). The PAR has high rates of coverage (the number of patients treated within the Partners healthcare network) and data completion and can be used for both research purposes and quality improvement. The same method of creating a registry that was used in the PAR can be applied to hospitals using similar EMR systems. Cite this article: Bone Joint J 2020;102-B(7 Supple B):90-98.

The effect of audiovisual distraction on patient-controlled sedation under spinal anesthesia: a prospective, randomized trial.

Audiovisual distraction (AVD) has been used to augment or replace procedural sedation. We investigated whether AVD in patients having total hip (THA) or total knee arthroplasty (TKA) under spinal anesthesia would reduce self-administered propofol consumption during surgery. 50 participants were randomized equally into a patient-controlled sedation (PCS) group or AVD group. All participants were given a spinal block and a propofol PCS device prior to surgery. In addition, Group AVD participants selected and watched a movie or documentary film on a tablet device with noise-cancelling headphones during surgery. The primary outcome of this study was total propofol consumption standardized as mcg/kg/min. Secondary outcomes evaluated increased supplemental oxygen use, rescue airway interventions, hypotension, disruptive movement events during surgery, sedation, and satisfaction with anesthesia scores. Historical clinician-controlled propofol usage at our institution over the previous 2 years were recorded. There was no significant difference in median propofol consumption between Groups PCS and AVD, 8.4mcg/kg/min (1.6-18.9) vs 4mcg/kg/min (0-9) (P = 0.29), respectively. Historical clinician-controlled usage of propofol demonstrated a median of 39.3mcg/kg/min (29.2-51.2). There were few differences in the secondary outcome measures. The use of AVD did not reduce patient-controlled propofol consumption in patients having a THA or TKA surgery under spinal anesthesia.

Bone-to-Bone and Implant-to-Bone Impingement: A Novel Graphical Representation for Hip Replacement Planning

Bone-to-bone impingement (BTBI) and implant-to-bone impingement (ITBI) risk assessment is generally performed intra-operatively by surgeons, which is entirely subjective and qualitative, and therefore, lead to sub-optimal results and recurrent dislocation in some cases. Therefore, a method was developed for identifying subject-specific BTBI and ITBI, and subsequently, visualising the impingement area on native bone anatomy to highlight where prominent bone should be resected. Activity definitions and subject-specific bone geometries, with planned implants were used as inputs for the method. The ITBI and BTBI boundary and area were automatically identified using ray intersection and region growing algorithm respectively to retain the same ‘conical clearance angle’ obtained to avoid prosthetic impingement (PI). The ITBI and BTBI area was then presented with different colours to highlight the risk of impingement, and importance of resection. A clinical study with five patients after 2 years of THA was performed to validate the method. The results supported the study hypothesis, in that the predicted highest risk area (red coloured zone) was completely/majorly resected during the surgery. Therefore, this method could potentially be used to examine the effect of different pre-operative plans and hip motions on BTBI, ITBI, and PI, and to guide bony resection during THA surgery.

Predictors of Failure After Surgical Treatment of Femoroacetabular Impingement: Results of a Multicenter Prospective Cohort of 621 Hips

Objectives: Surgical treatment of femoroacetabular impingement attempts to improve patients’ symptoms through treatment of intra-articular labrochondral pathology and correction of underlying bony deformity. The purpose of the current study was to determine independent predictors of failure after surgical treatment of femoroacetabular impingement in a large prospective multicenter cohort study. Methods: A prospective cohort study of the surgical treatment of FAI was performed. A total of 760 hips undergoing primary surgical treatment of FAI were enrolled across seven surgeons. Patient characteristics, baseline patient reported outcomes (PROs), imaging findings, intraoperative pathology, and surgical treatments were prospectively recorded. A total of 621 hips (81.6%) with minimum one year follow-up were included in the current study (mean 4.3 years). The mHHS was assessed relative to the minimally clinically important difference (MCID, 8 points) and patient acceptable symptom state (PASS, 74 points). Univariate analyses were performed to identify factors significantly associated with failure. Multivariate logistic regression was performed to identify independent predictors of failure. Results: A total of 621 hips undergoing surgical treatment of FAI were assessed at a mean 4.2 years postoperatively. This cohort had a mean age of 29.8 and included 56.8% females. Multivariate logistic regression identified independent predictors of each failure definition. Failure A (THA) was independently associated with increasing age, acetabular microfracture (both p&lt;0.001), and femoral head chondroplasty (p=0.02). Failure B (THA or revision surgery) was independently associated only with lower preoperative mHHS (p&lt;0.001) (p=0.01). A lower failure C (clinical failure) was independently associated with participation in competitive athletics (p=0.01), BMI (p&lt;0.001), and male gender (p&lt;0.001). Conclusion: This large multicenter cohort demonstrates the outcomes of FAI treatment at a mean of 4.3 years postoperative. Rates of THA and revision surgery were 4.0% and 6.9%. An additional 14.8% of patients demonstrates clinical failure based on patient-reported outcomes.

Complications in Patients Undergoing Spinal Fusion After THA.

Patients with lumbar spine and hip disorders may, during the course of their treatment, undergo spinal fusion and THA. There is disagreement among prior studies regarding whether patients who undergo THA and spinal fusion are at increased risk of THA dislocation and other hip-related complications. Is short or long spinal fusion associated with an increased rate of postoperative complications in patients who underwent a prior THA? A retrospective study of New York State's Department of Health database (SPARCS) was performed. SPARCS has a unique identification code for each patient, allowing investigators to track the patient across multiple admissions. The SPARCS dataset spans visit data of patients of all ages and races across urban and rural locations. The SPARCs dataset encompasses all facilities covered under New York State Article 28 and uses measures to further representative reporting of data concerning all races. Owing to the nature of the SPARCS dataset, we are unable to comment on data leakage, as there is no way to discern between a patient who does not subsequently seek care and a patient who seeks care outside New York State. ICD-9-Clinical Modification codes identified adult patients who underwent elective THA from 2009 to 2011. Patients who had subsequent spinal fusion (short: 2-3 levels, or long: ≥ 4 levels) with a diagnosis of adult idiopathic scoliosis or degenerative disc disease were identified. Forty-nine thousand nine hundred twenty patients met the inclusion criteria of the study. In our inclusion and exclusion criteria, there was no variation with respect to the distribution of sex and race across the three groups of interest. Patients who underwent a spinal procedure (short versus long fusion) had comparable age. However, patients who did not undergo a spinal procedure were older than patients who had short fusion (65 ± 12.4 years versus 63 ± 10.7 years; p < 0.001). Multivariate binary logistic regression models that controlled for age, sex, and Deyo/Charlson scores were used to investigate the association between spinal fusion and THA revisions, postoperative dislocation, contralateral THAs, and total surgical complications to the end of 2013. A total of 49,920 patients who had THAs were included in one of three groups (no subsequent spinal fusion: n = 49,209; short fusion: n = 478; long fusion: n = 233). Regression models revealed that short and long spinal fusions were associated with increased odds for hip dislocation, with associated odds ratios (ORs) of 2.2 (95% CI, 1.4-3.6; p = 0.002), and 4.4 (95% CI, 2.7-7.3; p < 0.001), respectively. Patients who underwent THA and spinal surgery also had an increased odds for THA revision, with ORs of 2.0 (95% CI, 1.4-2.8; p < 0.001) and 3.2 (95% CI, 2.1-4.8; p < 0.001) for short and long fusion, respectively. However, spinal fusions were not associated with contralateral THAs. Further, short and long spinal fusions were associated with increased surgical complication rates (OR = 2.8, 95% CI, 2.1-3.8, p < 0.001; OR = 5.3, 95% CI, 3.8-7.4, p < 0.001, respectively). We showed that spinal fusion in adults is associated with an increased frequency of complications and revisions in patients who have had a prior THA. Specifically, patients who had a long spinal fusion after THA had 340% higher odds of experiencing a hip dislocation and 220% higher odds of having to undergo a revision THA. Further research is necessary to determine whether this relationship is associated with the surgical order, or whether more patient-specific surgical goals of revision THA should be developed for patients with a spinal deformity. Level III, therapeutic study.

Gluteal muscle damage leads to higher in vivo hip joint loads 3 months after total hip arthroplasty.

BackgroundTotal hip arthroplasty (THA) is in most cases improving patients´ life quality immediately after surgery. However, a closer look at these patients, especially with modern gait analysis methods, reveals also negative consequences due to the surgical approach related injury to the pelvic muscles. We hypothesized that this damage will have a negative impact on hip joint contact forces during activities of daily living (ADL).Methods10 patients undergoing THA received an instrumented hip joint implant enabling real time in vivo measurements of hip joint loads using a direct lateral approach. Pre- and 3 months postoperative computed tomography (CT) scans were used for evaluation of the periarticular muscle status, using muscle volume, fat ratio and lean muscle volume as parameters. An analysis of in vivo hip contact forces was made 3 months after THA during ADL (walking, stair climbing, chair rising and sitting) and correlated with the morphology of the periarticular muscles.ResultsWe found a significant decrease of volume by 25% (-3 to -45, p = 0.005) and increase in fat ratio of the Gluteus Minimus (Gmin), resulting in a decrease in lean muscle volume of 28% (-48 to 0, p = 0.008). This was accompanied by an inverse development in the Tensor Fasciae Latae (TFL) resulting in a lean muscle volume increase of 34% (-2 to -102, p = 0.013). Changes in Gluteus Medius (Gmed) and Gluteus Maximus (Gmax) have not been observed in the short-term follow up. A decreased Gmin lean muscle volume was found to strongly correlate with high in vivo joint contact forces in all tested ADL.ConclusionThe decrease of Gmin volume can be seen as a direct effect of THA surgery, whereas the increase of TFL might compensate for loss of Gmin volume. Lean muscle volume and fat ratio were better predictors for joint contact forces than total muscle volume. These effects were most pronounced during sitting down and standing up due to the higher demand on the gluteal muscles during these activities.

Mid-term follow-up study of hip arthroplasty for internal fixation failure of femoral intertrochanteric fractures in the elderly

To retrospective analysis the mid-term follow-up effect of hip joint replacement in elderly patients with failure of intertrochanteric fractures of the hip joint internal fixation. From December 2008 to December 2011, 32 elderly patients underwent arthroplasty after intertrochanteric fracture fixation failure, of which, 4 death cases were excluded from the study, and the remaining 28 cases were in the study group. The age of patients ranged from 69 to 83 years old with a mean of 75 years old. The time from the internal fixation to the hip replacement were 8 to 72 months. Among them, 6 patients were Evans I type, 11 patients were Evans II type, 9 patients were Evans III type, and 2 patients were Evans IV type. Nine cases showed fracture of the lateral plate before operation, while 15 cases were femoral head screw cut-out and 4 cases were screw loosening. Harris score was used to compare the changes of hip function before operation with the final follow-up. Imaging results(X-ray) and erythrocyte sedimentation rate(ESR) were performed during the follow-up. All patients were followed up from 4 to 7 years with an average of 5.3 years. Pain was significantly reduced or disappeared in patients compared with pre-operation. And hip function was significantly improved. Two cases had moderate pain after the physical activity and 4 cases had mild pain after the physical activity. At the final follow-up, 19 patients resumed free walking, 8 patients required walking with walking sticks, and 1 patient needed walking aid. The Harris scores improved from preoperative 34.9±2.4 to 83.4±5.7 at the final follow-up, among them, 15 cases were classified as excellent, 10 as good, 2 as fair, and 1 as poor. X-ray examination showed no prosthesis loosening and sinking fracture. Salvage THA surgery could improve the hip function and the quality of life for old patients with intertrochanteric fracture fixation failure, and the middle-term follow-up results support that.

Can the American College of Surgeons Risk Calculator Predict 30-Day Complications After Knee and Hip Arthroplasty?

Accurate risk stratification of patients undergoing total hip (THA) and knee (TKA) arthroplasty is essential in the highly scrutinized world of pay-for-performance, value-driven healthcare. We assessed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator’s ability to predict 30-day complications using 1066 publicly-reported Medicare patients undergoing primary THA or TKA. Risk estimates were significantly associated with complications in the categories of any complication (P = .005), cardiac complication (P < .001), pneumonia (P < .001) and discharge to skilled nursing facility (P < .001). However, predictability of complication occurrence was poor for all complications assessed. To facilitate the equitable provision and reimbursement of patient care, further research is needed to develop accurate risk stratification tools in TKA and THA surgery.

Cost of opioid intravenous patient-controlled analgesia: results from a hospital database analysis and literature assessment.

BackgroundIntravenous patient-controlled analgesia (PCA) equipment and opioid cost analyses on specific procedures are lacking. This study estimates the intravenous PCA hospital cost for the first 48 postoperative hours for three inpatient surgeries.MethodsDescriptive analyses using the Premier database (2010–2012) of more than 500 US hospitals were conducted on cost (direct acquisition and indirect cost for the hospital, such as overhead, labor, pharmacy services) of intravenous PCA after total knee/hip arthroplasty (TKA/THA) or open abdominal surgery. Weighted average cost of equipment and opioid drug and the literature-based cost of adverse events and complications were aggregated for total costs.ResultsOf 11,805,513 patients, 272,443 (2.3%), 139,275 (1.2%), and 195,062 (1.7%) had TKA, THA, and abdominal surgery, respectively, with approximately 20% of orthopedic and 29% of abdominal patients having specific intravenous PCA database cost entries. Morphine (57%) and hydromorphone (44%) were the most frequently used PCA drugs, with a mean cost per 30 cc syringe of $16 (30 mg) and $21 (6 mg), respectively. The mean number of syringes used for morphine and hydromorphone in the first 48 hours were 1.9 and 3.2 (TKA), 2.0 and 4.2 (THA), and 2.5 and 3.9 (abdominal surgery), respectively. Average costs of PCA pump, intravenous tubing set, and drug ranged from $46 to $48, from $20 to $22, and from $33 to $46, respectively. Pump, tubing, and saline required to maintain patency of the intravenous PCA catheter over 48 hours ranged from $9 to $13, from $8 to $9, and from $20 to $22, respectively. Supplemental non-PCA opioid use ranged from $56 for THA to $87 for abdominal surgery. Aggregated mean intravenous PCA equipment and opioid cost per patient were $196 (THA), $204 (TKA), and $243 (abdominal surgery). Total costs, including for adverse events, complications, and intravenous PCA errors, ranged from $647 to $694.ConclusionAlthough there is variation between different types of surgery, the hospital cost of intravenous PCA after major surgery is substantial. Novel technology should demonstrate cost-effectiveness in addition to clinical superiority.

No need to change the skin knife in modern arthroplasty surgery

Earlier studies have found varying contamination rates using separate skin and deep knives in total hip (THA) and total knee (TKA) arthroplasty surgery. Previous studies were primarily conducted in the setting of concomitant use of laminar airflow and/or plastic adhesive draping. This has lead to conflicting conclusions regarding discarding the skin knife or not. This study evaluates the prevalence of contamination of a separate skin knife using modern antiseptic technique in primary THA and TKA without laminar airflow. Three knives from each primary THA and TKA surgery in non-laminar airflow operating rooms were collected: one used for the skin, one used for deeper tissues and one control knife. A total of 831 knife blades from 277 patients were cultured 12 days. Contamination of the skin knife was found in eight patients (2.8 %), contamination of the "deep" knife in five patients (1.8 %) and contamination of the control knife in five patients (1.8 %). No patient developed an infection with 1-year follow-up. Our findings suggest a very low rate of contamination of the skin knife using modern antiseptic technique without laminar airflow and/or plastic adhesive draping and do not support the use of a separate skin knife in arthroplasty surgery.

Professional liability in orthopaedics and traumatology in Italy.

Interest in medical errors has increased during the last few years owing to the number of medical malpractice claims. Reasons for the increasing number of claims may be related to patients' higher expectations, iatrogenic injury, and the growth of the legal services industry. Claims analysis provides helpful information in specialties in which a higher number of errors occur, highlighting areas where orthopaedic care might be improved. We determined: (1) the number of claims involving orthopaedics and traumatology in Rome; (2) the risk of litigation in elective and trauma surgery; (3) the most common surgical procedures involved in claims and indemnity payments; (4) the time between the adverse medical event and the judgment date; and (5) issues related to informed consent. We analyzed 1925 malpractice judgments decided in the Civil Court of Rome between 2004 and 2010. In total, 243 orthopaedics claims were filed, and in 75% of these cases surgeons were found liable; 149 (61%) of these resulted from elective surgery. Surgical teams were sued in 30 claims and found liable in 22. The total indemnity payment ordered was more than €12,350,000 (USD 16,190,000). THA and spinal surgery were the most common surgical procedures involved. Inadequate informed consent was reported in 5.3% of cases. Our study shows that careful medical examination, accurate documentation in medical records, and adequate informed consent might reduce the number of claims. We suggest monitoring of court judgments would be useful to develop prevention strategies to reduce claims.

Free fatty acids are responsible for the hidden blood loss in total hip and knee arthroplasty

Hidden blood loss (HBL), commonly seen post total knee or hip arthroplasty, causes postoperative anemia even after reinfusion or blood transfusion based on the visible blood loss volume. The mechanism of HBL remains unclear although more than one theory had tried to explain it. Free fatty acids, metabolites of fatty emboli that are generated during TKA, THA and other surgery manipulating the medullary canal of femur, had been demonstrated to stimulate the neutrophils in producing reactive oxygen species such (ROS) as hydrogen peroxide and chlorous peroxide. Erythrocytes injury was also shown in parasitic infection, chronic renal disease and paroxysmal nocturnal hemoglobinuria in a mechanism of oxidation of membrane polyunsaturated fatty acids and cytosolic hemoglobin by ROS. Based on these results we hypothesize that free fatty acids generated from fatty emboli in blood circulation are responsible for the hidden blood loss through peroxidating injury of membrane molecules of RBC and hemoglobin. Antioxidants administered intra- or post-operatively are predicted to play a protective role in erythrocytes oxidation and potentially reduce the volume of hidden blood loss after arthroplasty.

Preoperative education addressing postoperative pain in total joint arthroplasty: Review of content and educational delivery methods

Objective: Evaluate content and educational delivery methods of preoperative education in total joint arthroplasties of the hip and knee (THA and TKA) addressing postoperative pain. Data sources: Systematic searches conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect, and Web of Science. Secondary searching (pearling) was undertaken. Data extraction: Data were extracted utilizing the participants, interventions, comparisons, and outcomes approach. Study selection: All randomized controlled trials (RCTs) evaluating the effect of preoperative education on postoperative pain in THA and TKA surgery were considered for inclusion. Limitations: Studies published in English; published within the last 20 years and patients over the age of 18. No limitations were set on specific outcome measures of pain. Data synthesis: This review included 13 RCTs involving a total of 1,017 subjects who underwent THA or TKA. Educational delivery methods comprised verbal one-on-one or group education sessions, delivered within 4 weeks of surgery lasting an average of 30 minutes, and accompanied by other written materials. The educational content centered on descriptions of preoperative preparation, hospital stay, surgical procedure, immediate/intermediate experiences, expectations following surgery, rehabilitation, encouragement/reassurance, and answering common question associated with the surgical experience. Conclusions: Preoperative education centered on a biomedical model of anatomy and pathoanatomy as well as procedural information has limited effect in reducing postoperative pain after THA and TKA surgeries. Preoperative educational sessions that aim to increase patient knowledge of pain science may be more effective in managing postoperative pain.