Total Joint Surgery Research Articles

Assessing osteoporosis screening compliance in total joint surgery: a retrospective chart review.

Osteoporosis is a prevalent concern, particularly among aging populations, leading to increased risk of fractures, including those related to hip and knee arthroplasty procedures. Screening for osteoporosis, especially with dual X-ray absorptiometry (DXA) scans, is crucial for early detection and management. This study aimed to assess adherence to osteoporosis screening guidelines among patients aged 65 and older undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) within a single health network. Factors influencing screening adherence were also explored. A retrospective chart review of 2,160 patients undergoing elective THA or TKA between January 2019 and January 2023 was conducted. Demographic data, osteoporosis screening status, and occurrence of periprosthetic fractures were analyzed. Statistical analysis included descriptive statistics and chi-square tests. Only 24.1 % of eligible patients underwent a DXA scan prior to surgery. Females were more likely to undergo screening than males, and race was also associated with screening status. A total of 45 periprosthetic fractures were identified, with no significant correlation between osteoporosis status, DXA screening, and fracture occurrence. Adherence to osteoporosis screening guidelines among geriatric patients undergoing elective total joint arthroplasty remains low within the studied health network. Despite the lack of correlation between screening and fracture occurrence in this study, the importance of screening and potential optimization in high-risk patients is emphasized. Further research is needed to assess outcomes associated with different care pathways in bone health screening and management for elective geriatric total joint patients.

Foot complaints pre-operative to primary total hip or knee arthroplasty

Purpose of the Study: Aim of the study was to determine the prevalence of foot and ankle complaints and radiographic abnormalities, and their association in patients planned for total joint surgery. Methods: A cross-sectional cohort study of 183 patients, planned for total hip or knee arthroplasty (THA, TKA). Assessments included recording of polyneuropathy, previous trauma, foot deformities, and ankle range of motion (ROM); self-reported foot and ankle complaints; and radiographic severity of the foot and ankle joints OA. Results: In patients planned for THA and TKA, the proportions of patients with risk factors or using bespoke footwear ranged from 21-41%, whereas the proportions with clavus, hammertoes, and/or hallux valgus or rigidus varied between 1-17%. Although the mean foot function scores were good (median FAOS >93 and FFI-5pt 0), up to 24% of patients had a low score on one or more of the subscale scores. Prevalence of patients with signs of radiographic OA in foot and ankle were lower in THA than TKA patients, respectively. For the TKA group, we found an association between radiological scores and both self-reported measures of foot and ankle complaints. Conclusion: About a quarter of patients undergoing THA and TKA report some foot complaints, whereas 32-45% have signs of radiographic OA of foot and/or ankle. Since foot and ankle complaints have shown to have a negative effect on outcome of THA and TKA surgery, pre-operative optimisation concerning the foot complaints should be considered to support a more favourable outcome.

Leveraging Technology Across the Patient Care Journey to Reduce Length of Stay After Total Joint Surgery.

Leveraging Technology Across the Patient Care Journey to Reduce Length of Stay After Total Joint Surgery.

Exceedingly High Rate of Venous Thromboembolism after Laparoscopic Splenectomy Warrants a Chemoprevention Guideline

INTRODUCTION: Venous thromboembolism (VTE) after elective laparoscopic splenectomy (LS) historically ranges from 0.8% to 3%, which is higher than other types of elective noncardiac procedures. These patients often have multiple risk factors for VTE. However, no guideline exists to aid surgeons in minimizing VTE. The purpose of this study is to define the associated risk and rate of VTE after LS. METHODS: The American College of Surgeons NSQIP database was queried from 2005 to 2020. Patients were identified based on the CPT code 38120. Patients were further excluded if they were coded as emergent or being transported to the hospital from any location other than home. Analysis of the data was performed with RStudio and Microsoft Excel. RESULTS: A total of 5,176 patients underwent LS with a VTE rate of 3.6% and average Caprini score of 4. Among these, 67% had surgical indication or a postoperative diagnosis that confers increased risk of VTE, such as active malignancy or autoimmune disease. 100% of patients had full data available for all relevant outcomes except for postoperative diagnosis, in which 97% of patients had this information recorded (Table),TableCONCLUSION: LS patients are very high risk for VTE, even more so than patients undergoing bariatric or total joint surgery. These patients should be strongly considered for both preoperative and postoperative VTE chemoprophylaxis. Additional research should be performed investigating the role of prolonged postoperative VTE chemoprophylaxis after discharge.

CORR Insights®: What was the Prevalence of COVID-19 in Asymptomatic Patients Undergoing Orthopaedic Surgery in One Large United States City Mid-pandemic?

CORR Insights®: What was the Prevalence of COVID-19 in Asymptomatic Patients Undergoing Orthopaedic Surgery in One Large United States City Mid-pandemic?

246. Medical optimization after orthopedic spine and total joint arthroplasty decreases readmission

BACKGROUND CONTEXT Over the past decade, new health care reforms, due to the Patient Protection and Affordable Care Act, have introduced all-cause hospital readmission as a determinate metric for quality of care. Concurrently, payers have started to implement bundled payment systems, in which hospitals will be accountable for the costs of readmissions for any reason, up to 90 days from discharge. Therefore, decreasing the readmission rate will allow for cost savings. PURPOSE The aim of the current study was to assess factors associated with 30-90 day readmission after spine and total joint replacement surgeries. STUDY DESIGN/SETTING We compiled a randomized list of 999 spine and total joint patients who underwent surgery at our institution between 2014-2015. From this, we compiled a database with information regarding the length of stay, number of consults, 30- and 90-day readmission, medical comorbidities, and patient demographics. Pearson correlation coefficients were calculated between the variables of interest. PATIENT SAMPLE We compiled a randomized list of 999 spine and total joint patients who underwent surgery at our institution between 2014-2015. OUTCOME MEASURES A database with information regarding the length of stay, number of consults, 30- and 90-day readmission, medical comorbidities, and patient demographics was compiled. Outcomes measures included 30- and 90-day readmission rates. METHODS A randomized study including 999 spine procedures and total joint arthroplasties were collected from 2014-2015. A retrospective chart review was then performed. RESULTS A 90-day readmission correlation coefficient of -0.13 was observed when compared to the number of consults obtained after surgery (P CONCLUSIONS Our results indicate that those patients who are optimized medically for discharge, following spine or total joint surgery, have a significantly lower likelihood of readmission at 30 and 90 days. Furthermore, our results demonstrate that patients with longer lengths of stay necessary, for medical optimization, will lead to a lower likelihood of readmission. Based on the findings of the current study, the authors recommend, medically optimizing patients prior to discharge to decrease readmission and the associated penalties. This may require more consults and longer length of hospital stay. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections

Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections. This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004). Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections. ClinicalTrials.gov Identifier: NCT03638947.

ASA noninferior to rivaroxaban after total joint surgery

ASA noninferior to rivaroxaban after total joint surgery

P3. Perioperative immunonutrition in spine and total joint surgery

BACKGROUND CONTEXT In the current era of adding value to health care, modifiable risk factors have become a major focus. Quality and outcomes are now measured, reported, and tied to reimbursement. Recent studies in orthopedic surgery and spine surgery have shown nutritional status to be one of the most significant risk factors for post-operative complications. Our purpose for this study is to evaluate if perioperative nutritional support can reduce post-operative complications and improve outcomes in orthopedic and spine surgery patients. PURPOSE To evaluate if perioperative nutritional support with immunonutrition containing arginine, glutamine, omega 3 fatty acids, and nucleotides can reduce post-operative complications and improve outcomes in orthopedic and spine surgical patients. STUDY DESIGN/SETTING For a 12-month period from November 2016 to October 2017 we prospectively collected data for inpatient total joint replacements and spine surgeries occurring at two hospitals. Surgeries were performed by one of two fellowship trained Orthopedic spine surgeons. PATIENT SAMPLE A total of 125 patients were included. Patients were excluded from the study if they were receiving radiation, or chemotherapy, at the time of surgery or were non compliant with the nutritional protocol. Included patients were adults over the age of 18 undergoing elective spine or total joint replacement surgery OUTCOME MEASURES Postoperative complications, readmissions, reoperations were recorded. Number needed to treat and absolute risk reduction were calculated to evaluate results. METHODS Data were prospectively collected for inpatient total joint replacements and spine surgeries for 12 months beginning November 2016 and ending October 2017. All patients were followed a minimum of 90 days after surgery. The immunonutrition group was instructed to consume two 8 oz bottles of Ricochet Nutrition (Revive Medical, Brighton, MO USA) each day for 6 days before, and 6 days after, surgery. Outcome data was collected on reoperations, readmissions, and complications including: surgical site infections, Pneumonia, UTI, sepsis, and acute MI. RESULTS A total of 125 patients (62 in immunonutrition group and 63 in the control group) were included and no difference was found between the two groups regarding surgery type, comorbidities, sample size, and demographics. The control group had a total of 8 patients with complications after surgery: 1 pneumonia, 3 UTIs, 1 incisional hernia, and 2 deep surgical site infections. There was a total of 3 reoperations and 4 readmissions in the control group. The immunon trition group had no reoperations, no readmissions, and no complications. CONCLUSIONS Our study provides strong evidence that perioperative immunonutrition (containing Arginine, Glutamine, Omega 3 FAs and Nucleotides) reduces complications, reoperations and readmission for inpatient orthopedic and spine surgery patients.; Patient optimization prior to surgery should include optimizing nutritional status with immunonutrition. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Preoperative rehabilitation care in total hip joint replacement by rapid recovery approach in Slovakia

Relevance of research: Hip fractures and arthrosis are currently one of the serious illnesses presenting as a serious health problem faced by the aging population. The health problem is not just the wound itself or arthrotic changes accompanied by severe pains and difficulties to get up and walk on the affected lower limb, but also the risk of inadequate healing after surgery. Also, significant disability and reduced ADL performance may continue despite the immense advances in surgical techniques, nursing care and rehabilitation. Nowadays, which is primarily aimed at reducing the cost of health care, it is necessary to ensure that this reduction in costs is not at the expense of the quality of health care and future medical success. In general, physiotherapy for total hip joint replacement is considered to be a routine matter that deals mainly with mobility training, increased muscular strength, and basic day-to-day activities such as bed-to-chair transition, standing and walking. In addition to these attributes, physiotherapists also need the patient's own experiences and psychological responses such as anxiety and fear. Goal and methods of research: The aim of the thesis is to point out the importance of preoperative preparation of the patient for total replacement of the hip joint and its impact on the reduction of recovery after surgery. As a method, a case study of the 33 year patient indicated for total hip replacement was selected. The patient underwent a comprehensive preoperative three-month preoperative treatment (from the moment of indication to surgery to performance itself) and subsequent post-operative rehabilitation treatment of three and a half months. Results: A comprehensive rehabilitation program was developed taking into account the patient's health and Rapid recovery recommendations in preoperative and postoperative care. During the preparatory phase of the operation, the patient was modified by motor stereotype walking, strengthened lower limb muscles, especially musculus quadratus femoris and pelvis stabilizers. Lower limb circumference values increased by 2 cm, hip muscle strength increased from grade 3 to grade 4 of the Janda muscle tests, and shortened muscles iliopsos were released on the affected side. Taking into account the operational complications and subsequent comprehensive care according to Rapid Recovery recommendations, the stay in the hospital was reduced from 12 days to 5 and the patient returned to normal working life from 6 months to 4 months. Conclusion: Rapid recovery program requires the development of a new culture not only in normal orthopedic outpatient clinics but also in hospitals. In the past, and nowadays in some regions of the world, slow recovery with extended acute hospitalization for several weeks has been thought to be the best way for patients to recover and achieve a good result after complete replacement of either the hip or knee joint. The results of total hip joint surgery studies showed a significant reduction in hospital stay without increasing the remission rate. Subsequently, patient satisfaction increased, accompanied by a reduction in health care costs and a faster return to normal daily life.

Intraoperative Ketamine Versus Saline in Patients With Major Depressive Disorder Undergoing Anesthesia for Total Joint Surgery

Intraoperative Ketamine Versus Saline in Patients With Major Depressive Disorder Undergoing Anesthesia for Total Joint Surgery

Medical therapy for atherosclerotic cardiovascular disease in patients with myocardial injury after non-cardiac surgery

BackgroundMyocardial injury after non-cardiac surgery (MINS) is a common post-operative cardiovascular complication and is associated with short and long-term mortality. The objective of this study was to describe the contemporary management of patients with and without MINS after total joint and spine orthopedic surgery at a large urban health system in the United States. MethodsAdults admitted for total joint and major spine surgery from January 2013 through December 2015 with ≥1 cardiac troponin (cTn) measurement during their hospitalization were identified. MINS was defined by a peak cTn above the 99th percentile of the upper reference limit. Demographics, medical comorbidities, and admission and discharge medications were reviewed for all patients. ResultsA total of 2561 patients underwent 2798 orthopedic surgeries, and 236 cases of MINS were identified. Patients with MINS were older (71.9 ± 10.9 vs. 67.0 ± 10.0, p < 0.001) and more likely to have cardiovascular risk factors, including hypertension, chronic kidney disease, prior stroke, coronary artery disease, prior MI, and a history of heart failure. Among patients with MINS, only 112 (47.5%) were discharged on a combination of aspirin and statin. Patients with MINS were more likely to be prescribed a statin (154 [65.3%] vs. 1463 [57.1%], p = 0.018), beta-blocker (147 [62.3%] vs. 1194 [46.6%], p < 0.001), and oral anticoagulation (65 [27.5%] vs. 436 [17.0%], p < 0.001) than patients without MINS. ConclusionsThe proportion of patients with MINS who were prescribed medical therapy for atherosclerotic cardiovascular disease was low. Additional efforts to determine optimal management of MINS are warranted.

Prevalence of iron deficiency in a total joint surgery population

ABSTRACTBackground: Iron deficiency without anemia has been associated with decreases in functional work capacity and fatigue. The aim of this study was to determine the prevalence of iron deficiency without anemia in a preoperative cohort of orthopedic patients and to determine if iron deficiency is a condition which warrants inclusion into a prehabilitation program prior to surgery.Methods: One hundred consecutive patients going through preoperative testing for total joint replacement were enrolled in the study. In addition to the standard preoperative complete blood count, a ferritin concentration was also measured before the patients had their surgeries performed. Iron deficiency was defined as a ferritin concentration <50. Patients were then followed for 30 days following their surgical procedure to determine if any complications ensued, or if red blood cell transfusions were required.Results: The average age of the patients in this study was 65.2 ± 11.8 years and there were 41/100 males. Overall, 16 patients had anemia of which 6 patients also had low ferritin levels. Twenty-two other patients had ferritin levels consistent with iron deficiency but were not anemic. There was no association between iron deficiency and length of stay, complications, and transfusion.Discussion: No association was found between simple iron deficiency and any perioperative complications. Only a ferritin level was assessed so other measures of iron deficiency may have revealed a higher prevalence of iron deficiency. A study with a larger sample size is warranted in order to further understand iron deficiency in a preoperative setting.

Safety and efficacy of resistive polymer versus forced air warming in total joint surgery

BackgroundForced-air warming is used as a mechanism to prevent hypothermia and adverse outcomes associated with hypothermia among patients undergoing surgery. Patient safety in healthcare includes the use of devices and technology that minimize potential adverse events to patients. The present study sought to compare the capabilities of patient warming between two different devices that use different mechanisms of warming: forced-air warming and non-air warming.MethodsOne hundred twenty patients undergoing total hip or total knee arthroplasty received patient warming via a forced warming device or non-air warming fabric conductive material. The project was part of a quality improvement initiative to identify warming devices effective in maintaining normothermic patient core temperatures during orthopedic surgery.ResultsForced-air warming and non-air warming achieved similar results in maintaining the core temperature of patients undergoing total knee or hip arthroplasty. No adverse events were reported in either group. Operating room staff observed that the non-air warming device was less noisy and appreciated the disposable covers that could be changed after each surgical case.ConclusionsThese findings demonstrate that hypothermia is achieved by both forced-air and non-forced air warming devices among total knee and hip arthroplasty patients. The potential for airflow disruption is present with the forced-air warming device and does not exist with the non-forced air device. The disruption of laminar airflow may be associated with surgical site infections. The disposable covers used to protect the device and patient have potential implications for surgical site infection. Quality improvement efforts aimed to enhance patient safety should include the implementation of healthcare equipment with the least known or suspected risk.

Study on the improvement effect of rehabilitation nursing on joint swelling and pain after total knee arthroplasty

Objective To explore the improvement effect of rehabilitation nursing on joint swelling and pain after total knee arthroplasty. Methods According to the digital table, 100 patients with total knee arthroplasty were randomly divided into observation group and control group, 50 cases in each group.The control group after operation used routine nursing care, the observation group was given targeted rehabilitation nursing.They were compared with visual analogue scale(VAS), American Knee Society Score(AKSS), range of motion(ROM), length of hospital stay, joint swelling degree. Results After treatment, the VAS score of the observation group was lower than the control group[(2.43±0.51)points vs.(4.58±0.81)points, t=15.882, P<0.05], AKSS scores and ROM were higher than those in the control group[(69.94±14.23)points vs.(53.23±12.91)points, (103.47±14.84)° vs.(91.23±12.53)°, t=6.149, 4.456, all P<0.05]. The hospitalization time of the observation group was shorter than that of the control group[(14.23±3.81)d vs.(17.82±4.03)d, t=4.577, P<0.05]. At 3d and 7d after operation, the swelling degree of the observation group was lower than those of the control group[(1.23±0.26)mm vs.(1.97±0.38)mm, (0.62±0.21)mm vs.(1.38±0.35)mm, t=11.364, 13.166, all P<0.05]. Conclusion The application of rehabilitation nursing after total knee joint surgery can effectively relieve joint swelling and pain, and it is worth to be popularized. Key words: Arthroplasty, replacement, knee; Rehabilitation nursing; Postoperative complications

The use of the Risk Assessment and Prediction Tool in surgical patients in a bundled payment program

ObjectivesThe purpose of this study was to evaluate the relationship between the Risk Assessment and Predictor Tool (RAPT) and patient discharge disposition in an institution participating in bundled payment program for total joint replacement, spine fusion and cardiac valve surgery patients. MethodBetween April 2014 and April 2015, RAPT scores of 767 patients (535 primary unilateral total joint arthroplasty; 150 cardiac valve replacement; 82 spinal fusions) were prospectively captured. Total RAPT scores were grouped into three levels for risk of complications: <6 = ‘high risk’, between 6 and 9 = ‘medium risk’, and >9 = ‘low risk’ for discharge to a post-acute facility. Associations between RAPT categories and patient discharge to home versus any facility were conducted. Multivariate analysis was performed to determine if there was any correlation between RAPT score and discharge to any facility. Results70.5% of total joint patients, 80.7% of cardiac valve surgery patients and 70.7% of spine surgery patients were discharged home rather than to a post-acute facility. RAPT risk categories were related to discharge disposition as 72% of those in the high risk group were discharged to a facility and 91% in the low risk group were discharged to home in the total joint replacement cohort. In the cardiac cohort, only 33% of the high risk group was discharged to a facility, and 94% of the low risk group was discharged to home. In the spinal fusion cohort, 60% of those in the high risk group were discharged to a facility and 86% in the low risk group were discharged to home. Multivariate analysis showed that being in the high risk category versus low risk category was significantly associated with substantially increased odds of discharge to a facility. ConclusionThe RAPT tool has shown the ability to predict discharge disposition for total joint and spine surgery patients, but not cardiac valve surgery patients, where the majority of patients in all categories were discharged home, at an institution participating in a bundled payment program. The ability to identify discharge disposition pre-operatively is valuable for improving care coordination, directing care resources and establishing and maintaining patient and family expectations.

PMS4 - Incidence and Comparative In-Hospital Outcomes For Periprosthetic Fracture: Orif Versus Revision Total Joint Surgery

PMS4 - Incidence and Comparative In-Hospital Outcomes For Periprosthetic Fracture: Orif Versus Revision Total Joint Surgery

Defining the Cause of Post-Operative Hyponatremia in the Orthopedic Patient

Background: Post-operative hyponatremia occurs after 30% of orthopedic surgeries, increasing morbidity, mortality and hospital length of stays and hospital costs. The cause of the hyponatremia can be varied, hard to diagnose and impact management. The goal of this study was to determine the causes of post-operative orthopedic hyponatremia and to evaluate the accuracy with which nephrologists and internists interpret the data. Methods: This was a retrospective chart review of patients >21 years old on the adult total joint service who developed postoperative hyponatremia. A hyponatremic order set was developed and patient fluid status was charted by the presence or absence of edema in non-surgical extremities. The patients were treated by their managing physicians. After one year, data on 51 patients were assembled and sent to three nephrologists and three internists to analyze and diagnose the etiology of the hyponatremia. Results: The most common causes of post-operative hyponatremia were hypovolemia (33.7%), the syndrome of inappropriate antidiuretic hormone, SIADH (32.4%), hypotonic fluid (8.2%), acute kidney injury (5.2%) and medications (5.9%). The interrater agreement, measured by kappa coefficient, was moderate (0.43; 95% CI 0.34, 0.53) for the nephrologists and fair (0.38; 95% CI 0.30, 0.46) for the internists. Conclusions: The majority of post-operative hyponatremia following total joint surgery in adults is from hypovolemia and SIADH. The treatment for these is very different: the first requires fluid resuscitation and the latter, free water restriction. Due to an interplay of peri-operative factors, the diagnosis can be difficult for both internists as well as nephrologists.

Preparation for Total Joint Surgery: Patient Education and Documentation Tools for Home

Preparation for Total Joint Surgery: Patient Education and Documentation Tools for Home