Time Of Total Joint Arthroplasty Research Articles

Poster 103: Incidence of postoperative infections in rheumatic disease patients undergoing arthroscopy was not affected by use of immunosuppressive medications

Objectives:Although guidelines exist for perioperative management of immunosuppressive (IS) treatment in rheumatic disease patients around the time of total joint arthroplasty, there are no such guidelines or reports in the literature for arthroscopy. The purpose of this study is to compare the incidence of infectious complications in patients with rheumatic diseases undergoing arthroscopic surgery who either 1) remained on IS perioperatively, 2) held IS perioperatively or 3) were not on IS at baseline.Methods:We conducted a retrospective review of all arthroscopic surgeries in patients with a rheumatic disease diagnosis at our institution over a 10-year period. Inclusion criteria included an underlying diagnosis of one of the following: spondyloarthritis (reactive arthritis, psoriatic arthritis, ankylosing spondylitis, enteropathic arthritis), rheumatoid arthritis, systemic lupus erythematosus, juvenile idiopathic arthritis, polymyalgia rheumatica, dermatomyositis, polymyositis, and sarcoidosis. Patients on IS at baseline (medication classes including conventional synthetic disease-modifying drugs (csDMARDs), biologics, janus kinase (JAK) inhibitors, glucocorticoids, or a combination of two or three of medications) were grouped into those who remained on IS perioperatively versus those who had IS held before the date of their surgery. These two groups were compared to patients who were not on IS at baseline. Demographic data and 90-day postoperative infections (superficial surgical site infections (SSI), deep SSI, septic arthritis, and prosthetic joint infection) were analyzed. Incidence of postoperative complications was calculated for the three cohorts and by medication class. Analysis of variance (ANOVA) was used to determine the statistical significance of between-group differences in postoperative infection incidence.Results:We identified 1,316 rheumatic disease patients undergoing arthroscopy, with 214 of them taking IS medications at baseline. Among patients on IS, patients were most frequently on glucocorticoids (5.2%, n= 69), followed by a combination of 2 or more immunosuppressive medications (3.8%, n=50), csDMARDS (3.6%, n=48), biologics (3.4%, n=45), and JAK inhibitors (0.2%, n=2). Overall, 8.4% (n=110) remained on IS perioperatively, 7.9% (n=104) held IS perioperatively, and 83.7% (n=1102) were not on IS at baseline. There were two cases (1.82%) of infections among patients remaining on IS perioperatively (one on glucocorticoids and the other taking multiple medications), zero cases (0%) of infection in patients who held IS, and four cases (0.36%) of post-operative infection in patients who were not on IS at baseline. There was no statistically significant difference in infection rates among the three cohorts – nor any stratified risk between the various medication classes.Conclusions:This study is the first to suggest that patients with rheumatic diseases undergoing arthroscopy may remain on immunosuppression perioperatively without significant risk for infection.

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

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

Dental Screening in Elective Total Joint Arthroplasty: Risk Factors for Failure

BackgroundActive dental infection at the time of total joint arthroplasty (TJA) or in the acute postoperative period following TJA is thought to increase the risk of periprosthetic joint infection (PJI). Many surgeons recommend preoperative dental screening. This study aimed to identify how many elective TJA patients failed preoperative dental screening and what patient risk factors were associated with failure. MethodsA consecutive series of elective, primary TJA was reviewed from 8/1/2016 to 8/1/2017. We studied 511 operations in 511 patients. All patients were referred for preoperative dental screening per protocol. Dental screening failure was defined as required dental intervention by the dentist. Screening failure rate was calculated for and logistic regression was used to evaluate the relationship between odds of screening failure and patient demographic data. ResultsIn 94 of the 511 total cases (18.5%), patients failed dental screening and required dental procedures prior to TJA. Reasons for failure included tooth extractions, root canals, abscess drainage, and carious lesions requiring filling. Patient characteristics associated with failed dental screening included male gender (odds ratio 1.56, 95% confidence interval 1.0006-2.468, P = .047) and current smoker (odds ratio 3.6, 95% confidence interval 1.650-7.927, P = .001). ConclusionUniversal dental screening prior to primary TJA resulted in 18.5% of patients needing an invasive dental intervention. Universal dental screening results in extra cost and time for patients and providers. Although male gender and active smoking were associated with increased odds of requiring an invasive dental procedure, more work is needed to develop targeted screening to improve perioperative workflow and limit unnecessary dental evaluations for patients.

Preoperative Bariatric Surgery Utilization Is Associated With Increased 90-day Postoperative Complication Rates After Total Joint Arthroplasty.

This study evaluates the incidence of bariatric surgery (BS) before total joint arthroplasty (TJA) in New York State and compares patient comorbidities and 90-day postoperative complications of patients with and without BS before TJA. The NY Statewide Planning and Research Cooperative System database between 2005 and 2014 was reviewed and 343,710 patients with TJA were identified. Patients were stratified into the following three cohorts: group 1 (patients who underwent BS < 2 years before TJA [N = 1,478]); group 2 (obese patients without preoperative BS [N = 60,259]); and group 3 (nonobese patients without preoperative BS [N = 281,973]). Principal outcomes measured were patient comorbidities, 90-day complication rates, length of inpatient stay, discharge disposition, mortality rate, and total hospital costs. BS before TJA incidence increased from 0.11 of 100,000 to 2.4 of 100,000 from 2006 to 2014. Preoperative BS did not notably change the number of patient comorbidities at the time of TJA. Group 1 had more patients with 90-day complications (40.7% versus 36.0%, P < 0.001) than group 2. No difference was found between group 1 and the other groups in home discharge, pulmonary embolism, deep vein thrombosis, and mortality rates. Total hospital costs were higher for group 1 ($18,869 ± 9,022 versus $17,843 ± 8,095, P < 0.001) compared with those for group 2. BS before TJA has increased annually over a 10-year period in New York State and is associated with greater 90-day postoperative complication rates and higher immediate hospital costs when compared with obese patients without BS.

Patients with a History of Treated Septic Arthritis are at High Risk of Periprosthetic Joint Infection after Total Joint Arthroplasty.

In patients undergoing total joint arthroplasty (TJA), increasing attention has been directed recently toward identifying specific patient-related risk factors that may predispose patients to periprosthetic joint infection (PJI). Currently, it is unclear whether having a history of a treated native septic arthritis is a risk factor for PJI after TJA in the same joint. Previous studies have reported contradictory evidence and results varied between a substantially higher rates of PJIs to very low or no reported PJIs. (1) What is the risk of PJI in patients who received TJA and had a history of treated same-joint native joint septic arthritis and (2) What are the associated risk factors for these patients developing PJI? This was a multicenter retrospective analysis of patients who received primary THA or TKA between January 2000 and December 2016 and who had a history of treated native joint septic arthritis in the same joint. Patients were included in the study only if they were considered to have resolved their joint infection based on a preoperative evaluation that included: (1) the absence of clinical symptoms and signs of active infection or local joint inflammation, (2) recent plain radiographs showing only advanced degenerative changes without evidence of active osteolysis or bone infection, (3) preoperative laboratory investigations for infection, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and total leukocyte counts within normal ranges. Patients were reviewed for the occurrence of postoperative PJI. The final cohort included 62 patients who had a mean followup of 4.4 years (range, 3 months-17 years) from the time of TJA. A total of 21 patients (34%) had less than 2 years of followup, including six (10%) mortalities. In total, eight patients (13%) died during the study period, none of which were due to PJI. Patient characteristics, time interval from treatment of septic arthritis to TJA, and Charlson comorbidity index adjusted for age were collected. We used a Kaplan-Meier analysis to estimate the overall survivorship among all TJAs as well as those who underwent THA versus TKA, and we performed a statistical comparison using the Mantel-Cox log-rank test. We performed a Cox regression hazard ratio (HR) survival analysis to identify risk factors for PJI. The PJI odds ratios (OR) for patients who underwent TJA within 2 years of septic arthritis were calculated as an additional temporal analysis. In patients with a history of treated same-joint native septic arthritis, the proportion of PJI was five of 62 patients (8%). The Kaplan-Meier analysis demonstrated an overall survivorship free from PJI of 92% at 14.5 ± 1.14 years (95% confidence interval [CI] = 12.3-16.8 years). All PJI cases occurred only in patients who underwent TKA, which when analyzed separately, yielded a survivorship of 85% at 10.5 ± 0.9 years (95% CI = 8.7-12.3 years) versus 100% in patients who underwent THA (p = 0.068). Mean time to PJI occurrence was 10 months (range, 2-20 months). After controlling for relevant confounding variables, such as age, sex, affected joint and comorbidities, we found smoking (HR, 8.06; 95% CI, 1.33-48.67; p = 0.023) to be associated with increased risk for PJI development. Patients with history of native joint infections are at higher risk of PJI, especially smokers. Despite our limitations, this study suggests careful assessment of several other factors in these patients, including allowing a minimum interval of 2 years from the time of resolving native joint septic arthritis to TJA. Patients who are undergoing TKA seem to be more prone to the PJI risk and may benefit from more aggressive planning. In addition, medical optimization of comorbidities that may confer additional risk, such as diabetes, become exceptionally important in these patients. Level III, therapeutic study.

Tobacco Smoking Independently Predicts Lower Patient-Reported Outcomes: New Insights on a Forgotten Epidemic

BackgroundAlthough smoking is a well-accepted risk factor for surgical complications, the effect of smoking on patient-reported outcomes (PROs) has not been previously investigated. Prompted by an increasingly value-conscious healthcare environment, the purpose of this study is to investigate the association between smoking and PROs in total joint arthroplasty (TJA). MethodsA retrospective review of 713 primary total hip and knee replacements was performed. Two cohorts were compared: (1) current smokers and (2) previous/never smokers at the time of TJA. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Short Form-12 Physical Composite Summary (SF-12 PCS) and Short Form-12 Mental Composite Summary were assessed preoperatively and again at 6 and 12 months postoperatively. The primary outcomes were the net changes and absolute outcome scores at final follow-up. Postoperative patient satisfaction was also assessed as a secondary outcome. Linear mixed-effects regression analysis was performed. ResultsThere were significant demographic and preoperative health disparities as measured by PROs among smokers. After adjusting for baseline differences, smokers achieved significantly lower improvements in WOMAC (P = .002) and SF-12 PCS (P = .03) compared to nonsmokers. For each unit increase in packs per day smoked, the WOMAC scores increased (worsened) by 7.7 points (P = .003) and SF-12 PCS decreased by 4.8 points (P = .001). At final follow up, nonsmokers had significantly better absolute scores for all outcomes (except for mental health) and were more likely to be satisfied with surgery (89% vs 82%, P = .052). ConclusionTobacco smoking is an independent predictor for lower PROs after TJA and this relationship is dose-dependent. The negative impact of smoking does not appear to be related to impaired psychological health. As we transition to value-based care delivery models, this study provides further evidence that smoking cessation should be strongly recommended as a modifiable risk factor before embarking on elective TJA. Studies are still needed to define the optimal window for smoking cessation.

Obesity and racial characteristics drive utilization of total joint arthroplasty at a younger age

BackgroundObesity is a growing public health problem. Obesity increases the risk of requiring total joint arthroplasty (TJA). The purpose of this study was to examine the effect of obesity on the propensity for TJA in patients at our institution. We hypothesized that obese patients would be younger and more likely to be races other than non-Hispanic whites when compared to a normal weight cohort. Methods568 consecutive patients undergoing primary TJA were reviewed. Demographic data and World Health Organization Body Mass Index (BMI) class were compared statistically, with age at time of TJA used as the main outcome of interest. ResultsThe average age at TKA was 68.3 years, while the average age at THA was 67.5 years (p = 0.447 between procedure groups). Increased BMI class was associated with decreased age at TJA: normal weight patients were 12.2 and 11.4 years older than class III obese patients at the time of TKA and THA, respectively (p < 0.001). Among TKA patients, obese patients, when compared to non-obese patients, were significantly less likely to be non-Hispanic whites (p = 0.016). Among THA patients, class III obese patients were significantly less likely to be non-Hispanic whites (p = 0.007). ConclusionsObesity is a risk factor for both TKA and THA at a younger age. For patients in the study, for each unit increase in BMI, the age at TKA decreased by 0.56 years and age at THA decreased by 0.52 years. Obese patients were less likely to be non-Hispanic whites than normal weight patients.

Bariatric Surgery Improves Outcomes After Lower Extremity Arthroplasty in the Morbidly Obese: A Propensity Score-Matched Analysis of a New York Statewide Database

BackgroundThe purpose of this study was to compare risks for revision and short-term complications after total joint arthroplasty (TJA) in matched cohorts of morbidly obese patients, receiving and not receiving prior bariatric surgery. MethodsPatients undergoing elective TJA between 1997 and 2011 were identified in a New York Statewide database, analyzing total knee arthroplasty (TKA) and total hip arthroplasty (THA) separately. Propensity scores were used to match morbidly obese patients receiving and not receiving bariatric surgery prior to TJA. Cox proportional hazard modeling assessed revision risk. Logistic regression evaluated odds for complications. ResultsFor TKA, 2636 bariatric surgery patients were matched to 2636 morbidly obese patients. For THA, 792 bariatric surgery patients were matched to 792 morbidly obese patients. Matching balanced all covariates. Bariatric surgery reduced co-morbidities prior to TJA (TKA P < .0001; THA P < .005). Risks for in-hospital complications were lower for THA and TKA patients receiving prior bariatric surgery (odds ratio [OR] 0.25, P < .001; and OR = 0.69, P = .021, respectively). Risks for 90-day complications were lower for TKA (OR 0.61, P = .002). Revision risks were not different for either THA (P = .634) or TKA (P = .431), nor was THA dislocation risk (P = 1.000). ConclusionAfter accounting for relevant selection biases, bariatric surgery prior to TJA was associated with reduced co-morbidity burden at the time of TJA and with reduced post-TJA complications. However, bariatric surgery did not reduce the risk for revision surgery for either TKA or THA.

Staphylococcus aureus Colonization among Arthroplasty Patients Previously Treated by a Decolonization Protocol: A Pilot Study

Although testing and treatment for Staphylococcus aureus colonization before total joint arthroplasty (TJA) are well described and understood, the durability of decolonization has not been studied extensively. The purpose of this pilot study is to determine the percentage of arthroplasty patients with S. aureus colonization despite previous decolonization at the time of TJA. Over a 2-year period, all patients having TJA by one surgeon were screened and treated for nasal S. aureus. Of 634 patients, 139 had methicillin-sensitive S. aureus (15%) or methicillin-resistant S. aureus (6.6%) colonization before TJA. Fifty-eight of these 139 patients (42%) were retested at 3 to 30months for persistent colonization by nasal culture. Data collection included age at time of TJA, type of TJA, and time from TJA to repeat testing. We performed no clonal analysis for strains. Thirty-nine of the 58 patients (67%) decolonized before surgery were negative on retesting and 19 (33%) were again positive for S. aureus colonization. Of the 19 patients who retested positive for colonization, 17 (89%) were colonized by bacteria with unchanged antibiotic sensitivity. We demonstrate that 33% (19 of 58) of postoperative arthroplasty patients test positive for S. aureus colonization at 3 to 30months after surgery despite preoperative decolonization. Arthroplasty surgeons must be aware that a decolonization treatment does not guarantee that a patient will remain decolonized in the future. Although unchanged antibiotic sensitivity in 89% of these patients suggests a substantial role for persistence as opposed to eradication and repeat colonization, we were unable to retrospectively perform clonal analysis to confirm this conclusion. This group of patients demonstrating continued colonization with S. aureus after arthroplasty deserves further study, because it remains unclear whether there is a higher risk of late infection in this population. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Prevalence of Hepatitis C Virus Infection in the Veteran Population Undergoing Total Joint Arthroplasty

Many orthopedic surgeons train or are employed at the Department of Veterans Affairs (VA) hospitals. We sought to determine the prevalence of hepatitis C antibody–positive and hepatitis C–viremic patients in the VA population undergoing total joint arthroplasty. In this prospective cohort study, 381 of 408 patients undergoing primary total joint arthroplasty for 22 consecutive months were tested for hepatitis C virus (HCV) infection preoperatively. Thirty-two (8.4%) of 381 patients were positive for hepatitis C virus antibody. Seventeen were actually viremic at the time of total joint arthroplasty (4.5%). The prevalence of detectable hepatitis C antibody in VA patients undergoing total joint arthroplasty is about 6 times the general population (1.3%). Surgeons practicing on populations with a high prevalence of hepatitis C such as this should do all they can to minimize the risk of sharps injury.

Expression of smooth muscle actin in osteoblasts in human bone

It is well known that certain connective tissue cells (viz., dermal fibroblasts) can express the gene for a muscle actin – α-smooth muscle actin – and can contract. This process contributes to skin wound closure and is responsible for Dupuytren's contracture. The objective of this study was to determine if human osteoblasts can also express the gene for α-smooth muscle actin. Immunohistochemistry using a monoclonal antibody for α-smooth muscle actin was performed on human cancellous bone samples obtained from 20 individuals at the time of total joint arthroplasty. The percentages of resting and active osteoblasts on the bone surfaces containing this muscle actin isoform were evaluated. Explants of human bone were also studied for the expression of α-smooth muscle actin in the tissue and in the outgrowing cells with time in culture. Western blot analysis was performed to quantify the α-smooth muscle actin content of the outgrowing cells relative to smooth muscle cell controls. Nine ± 2% (mean ± SEM; n=20) of the cells classified as inactive osteoblasts and 69±3% ( n=19) of the cells identified as active osteoblasts on the bone surface contained α-smooth muscle actin. This difference was highly statistically significant (Student's t test, p<0.0001). Similar profiles of α-smooth muscle actin-expressing cells were found in explants cultured for up to 12 weeks. Cells forming a layer on the surface of the explants and growing out from them in monolayer also contained α-smooth muscle actin by immunohistochemistry and Western blot analysis. Human osteoblasts can express the gene for α-smooth muscle actin. This expression should be considered a phenotypic characteristic of this cell type, conferred by its progenitor cells: bone marrow stromal-derived stem cells, and perhaps pericytes and smooth muscle cells.