MicroRNA expression analysis in peripheral blood and soft-tissue of patients with periprosthetic hip infection

Aims

Current diagnostic tools are not always able to effectively identify periprosthetic joint infections (PJIs). Recent studies suggest that circulating microRNAs (miRNAs) undergo changes under pathological conditions such as infection. The aim of this study was to analyze miRNA expression in hip arthroplasty PJI patients.

Methods

This was a prospective pilot study, including 24 patients divided into three groups, with eight patients each undergoing revision of their hip arthroplasty due to aseptic reasons, and low- and high-grade PJI, respectively. The number of intraoperative samples and the incidence of positive cultures were recorded for each patient. Additionally, venous blood samples and periarticular tissue samples were collected from each patient to determine miRNA expressions between the groups. MiRNA screening was performed by small RNA-sequencing using the miRNA next generation sequencing (NGS) discovery (miND) pipeline.

Results

Overall, several miRNAs in plasma and tissue were identified to be progressively deregulated according to ongoing PJI. When comparing the plasma samples, patients with a high-grade infection showed significantly higher expression levels for hsa-miR-21-3p, hsa-miR-1290, and hsa-miR-4488, and lower expression levels for hsa-miR-130a-3p and hsa-miR-451a compared to the aseptic group. Furthermore, the high-grade group showed a significantly higher regulated expression level of hsa-miR-1260a and lower expression levels for hsa-miR-26a-5p, hsa-miR-26b-5p, hsa-miR-148b-5p, hsa-miR-301a-3p, hsa-miR-451a, and hsa-miR-454-3p compared to the low-grade group. No significant differences were found between the low-grade and aseptic groups. When comparing the tissue samples, the high-grade group showed significantly higher expression levels for 23 different miRNAs and lower expression levels for hsa-miR-2110 and hsa-miR-3200-3p compared to the aseptic group. No significant differences were found in miRNA expression between the high- and low-grade groups, as well as between the low-grade and aseptic groups.

Conclusion

With this prospective pilot study, we were able to identify a circulating miRNA signature correlating with high-grade PJI compared to aseptic patients undergoing hip arthroplasty revision. Our data contribute to establishing miRNA signatures as potential novel diagnostic and prognostic biomarkers for PJI.

Total Knee Arthroplasty Periprosthetic Joint Infection with Concomitant Extensor Mechanism Disruption and Soft-Tissue Defect: The Knee Arthroplasty Terrible Triad

BACKGROUND

Periprosthetic infection (PJI) with concomitant extensor mechanism disruption (EMD) and soft-tissue defect - hereinafter termed the "Terrible Triad" - is a devastating complication following total knee arthroplasty (TKA). The purpose of this study was to define the surgical and clinical outcomes following management of a cohort of patients who have the Terrible Triad.

METHODS

From 2000 to 2022, 127 patients underwent operative management for PJI alone, 25 for PJI with soft-tissue defects (defined as defects requiring flap reconstruction or being a factor contributing to the decision of performing above-knee amputation (AKA) or arthrodesis), 14 for PJI with EMD, and 22 for the Terrible Triad. A composite outcome of infection status, range of motion, extensor lag, and ambulatory status at final follow-up was used to compare the proportion of patients in each group with a favorable overall knee outcome. Differences between groups were determined using one-way analyses of variance with post hoc Tukey's tests and Pearson's Chi-square tests or Fisher's exact tests with post hoc Bonferroni adjustments, where applicable. Odds ratios (OR) were calculated for comparison of the overall knee outcome between groups. A Kaplan-Meier survival analysis for patient mortality was performed.

RESULTS

The mean follow-up was 8.4 years and similar between groups (P = 0.064). Patients who had the Terrible Triad had a 45.5% incidence of AKA, or arthrodesis, and an 86.4% incidence of an unfavorable outcome. Compared to patients in the PJI group, patients in the PJI who had a soft-tissue defect (OR=5.8, 95%CI [confidence interval] 2.2 to 15.7), PJI with EMD (OR=3.7, 95%CI 1.0 to 12.9), and Terrible Triad groups (OR=11.6, 95%CI 3.3 to 41.5) showed higher odds of an unfavorable knee outcome.

CONCLUSIONS

This study demonstrates that the TKA Terrible Triad is a dreaded diagnosis with poor outcomes. Clinicians and patients might consider early treatment with amputation or arthrodesis.

Methodological Assessment of the 100 Most-Cited Articles in Total Knee Arthroplasty in the Last Decade Compared to the All-Time List

BACKGROUND

Recent advances in total knee arthroplasty (TKA) have been driven by a growing focus on evidence-based medicine. This transition is reflected in the critical appraisal of both, the quality of work and the potential impact on the orthopedic community. The purpose of our study was to (1) identify the top 100 most-cited articles in TKA in the last decade and from all-time, and (2) compare methodological rigor of the most-cited articles in TKA in the last decade to articles all-time by level of evidence.

METHODS

The top 100 cited articles were recorded for manuscripts from the last decade, January 1, 2012 to December 31, 2022, and manuscripts from all-time for TKA. We collected authors, year of publication, journal of the article, country of origin of authors, article type (basic science article, clinical research article), level of evidence, methodological index for non-randomized studies score, physiotherapy evidence database scale, and citation density (total citations/years published).

RESULTS

The largest number of studies for all-time TKA (53.0%) and decade TKA (42.0%) were Level III. The average methodological index for non-randomized studies score for comparative studies was 18.7 for all-time TKA and 20.7 for decade TKA (P < .001). The average physiotherapy evidence database score was 6.1 for all-time TKA and 8.1 for decade TKA (P > .05). The highest citation density for all-time TKA was 111 and for past decade was 63. The number of level II studies in TKA increased from 19.0% from all time to 38.0% from the last decade (P < .05).

CONCLUSIONS

Our findings of improved methodologies over time reflect positive steps toward evidence-based practice in TKA. A continued focus on producing methodologically sound studies may guide evidence-based clinical decision-making.

Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit

PURPOSE

We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents.

METHODS

A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test.

RESULTS

The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal.

CONCLUSION

Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

Risk factors for peri-megaprosthetic joint infections in tumor surgery: A systematic review

BACKGROUND

Peri-megaprosthetic joint infections (PJI) in tumor surgery are complex and challenging complications that significantly impact the outcomes of the patients. The occurrence of PJI poses a substantial threat to the success of these operations. This review aims to identify and summarize the risk factors associated with PJI in tumor surgery with megaprosthetic reconstruction as well as to determine the overall risk of PJI in limb salvage surgery.

METHODS

A thorough examination of published literature, scrutinizing the incidence of PJI in tumor prostheses after limb salvage surgery was done. Research studies that documented the incidence of PJI in tumor patients who underwent limb salvage surgery, and explored the risk factors associated with the occurrence of PJI were deemed eligible.

RESULTS

A total of 15 studies were included in the analysis and underwent comprehensive examination. After the exploration of key parameters, several significant risk factors for PJI concerning the type of implant coating, surgical site characteristics, patient demographics, and procedural factors were recorded.

DISCUSSION

The findings underscore the need for a nuanced approach in managing tumor patients undergoing limb salvage surgery and megaprosthetic reconstruction, with emphasis on individualized risk assessments and individualized preventive strategies.

Comparable Results of Single and Two-Stage Exchange for Select Periprosthetic Hip and Knee Infection

INTRODUCTION

Although two-stage exchange has been the standard of care for periprosthetic joint infection (PJI) in the United States, single-stage exchange is emerging as an option in select patients. The purpose of this study was to compare outcomes of patients undergoing single-stage and two-stage exchange using strict surgical indications.

METHODS

We reviewed a consecutive series of 196 patients with diagnosed PJI undergoing revision total knee and hip arthroplasty from 2017 to 2021. Patients were excluded if they had PJI history, plastic surgery coverage, or extensive bone loss requiring endoprosthesis. We compared the number of patients PJI-free at 1-year follow-up using MusculoSkeletal Infection Society criteria and patients requiring re-revision between the single-stage and two-stage groups.

RESULTS

In total, 126 patients met inclusion criteria. Of 61 knee patients (48.4%), 22 underwent single-stage (36%) and 39 underwent two-stage (63.9%). Of 65 hip patients (51.6%), 38 underwent single-stage (58.5%) and 27 underwent two-stage (41.5%). At a mean follow-up of 1.95 ± 0.88 years, a higher rate of knee patients were classified as having treatment success in the single-stage group (77.3% versus 69.2%, P = 0.501), however with comparable septic failure rates (18.1% single-stage versus 17.9% two-stage; P = 0.982). At a mean follow-up of 1.81 ± 0.9 years, a higher rate of hip patients were classified as having treatment success in the single-stage group (94.7% versus 81.5%, P = 0.089), and more patients had septic failures in the two-stage group (18.5% versus 5.3%; P = 0.089). No differences were observed in the microorganism profile. More total complications (P = 0.021) and mortalities were found in the single-stage knee cohort than in the two-stage cohort (22.7% versus 2.6%; P = 0.011).

CONCLUSION

Single-stage arthroplasty is a viable alternative to standard two-stage exchange in patients with PJI without a history of infection and with no bone or soft-tissue compromise. Additional studies with longer term follow-up are needed to evaluate its efficacy.

Is there sufficient evidence to support the use of antibiotic holiday just before the second stage of an infected total hip or knee arthroplasty revision surgery?

The practice of implementing an antibiotic holiday before the second stage of hip or knee arthroplasty is currently controversial due to limited evidence for this approach, as per the International Consensus Meeting 2018 on Musculoskeletal Infection. A greater understanding of this issue could augment the quality of Alrayes and Sukeik's mini-review (2023) on diagnosing, managing, and treating periprosthetic knee infections. However, a significant lack of literature exists concerning the optimal duration for the antibiotic holiday, calling for more research before establishing any clinical guidelines.

Compare the Quadriceps Activity between Mini-Midvastus and Mini-Medial Parapatellar Approach in Total Knee Arthroplasty with Electromyography

Background: The comparison between the mini-midvastus (mini-MV) and mini-parapatellar (mini-MPP) approach in total knee arthroplasty (TKA) remains a subject of debate. The present study compared quadriceps activation, pain levels, and clinical outcomes between the two approaches; quadricep activation was assessed using surface electromyography (sEMG). Methods: This retrospective cross-sectional study comprised a total of 78 patients aged between 50 and 85 years with primary osteoarthritis. Patients were divided into a mini-MV (n = 38) group and a mini-MPP (n = 40) group according to the surgical approach. Results: The two groups exhibited no significant differences in sEMG for the vastus medialis (VM) or rectus femoris (RF) at the follow-up time points, with the exception that the mini-MV group exhibited superior strength of RF during extensions at the 2-week follow-up. However, the mini-MPP group had superior Western Ontario and McMaster Universities Index (WOMAC) total and function scores at the 2- and 6-week follow-ups. The mini-MPP group also had superior WOMAC stiffness scores at the 2-week follow-up. The two groups did not differ significantly in terms of pain levels or morphine consumption. Conclusions: The sEMG data of quadriceps muscle would not differ significantly between the mini-MV and mini-MPP approaches for TKA. Moreover, the mini-MPP approach may yield superior WOMAC scores when compared with the mini-MV approach.

No Difference in Revision Rates or Patient-Reported Outcome Measures Between Surgical Approaches for Total Hip Arthroplasty Performed for Femoral Neck Fracture: An Analysis of 5,025 Primary Total Hip Arthroplasties From the New Zealand Joint Registry

BACKGROUND

Total hip arthroplasty (THA) for femoral neck fracture (FNF) can be performed through different surgical approaches. This study compared the revision rates and patient-reported outcome measures by surgical approach.

METHODS

Data from the New Zealand Joint Registry were analyzed for patients undergoing primary THA for FNF from January 2000 to December 2021. A total of 5,025 THAs were performed for FNF; the lateral approach was used in 2,499 (49.7%), the posterior in 2,255 (44.9%), and the anterior in 271 (4.3%). The primary outcome measure was the all-cause revision rate. Secondary outcome measures included revision rates for: dislocation, aseptic femoral component loosening, periprosthetic fracture, and infection. Oxford Hip Scores (OHS) were also collected. Age, sex, body mass index, American Society of Anesthesiologists score, femoral head size, dual mobility use, femoral fixation, and surgeon experience were assessed as potential confounding variables.

RESULTS

There was no difference in the revision rates between lateral and posterior (P = .156), lateral and anterior (P = .680), or posterior and anterior (P = .714) approaches. There was no difference in the reasons for revision between the lateral and posterior approaches or 6-month OHS (P = .712). There was insufficient data to compare the anterior approach.

CONCLUSIONS

There is no difference in the overall revision rates, reasons for revision, or OHS between the lateral and posterior surgical approaches for THA performed for FNF. Insufficient data on the anterior approach is available for an accurate comparison.

LEVEL OF EVIDENCE

Level III.

Tranexamic acid decreases transfusion requirements during the modified pi-plasty procedure for sagittal craniosynostosis

The aim of our study was to evaluate the effectiveness of intraoperative tranexamic acid (TXA) administration in decreasing transfusion needs in patients undergoing modified pi-plasty. A retrospective study was performed using a population of 59 patients who underwent modified pi-plasty, wherein patients who received TXA during surgery (study group, n = 26) were compared with patients who did not receive TXA (control group, n = 33). The primary study endpoints were intraoperative red blood cell substitution (%), postoperative red blood cell substitution (%), total red blood cell substitution (%), and hematocrit variation. Perioperative administration of TXA significantly decreased the total red blood cell substitution (62.90% vs 86.70%; p = 0.002) and resulted in a higher postoperative hematocrit (29.47% vs 27.53%; p = 0.060). In conclusion, perioperative administration of TXA significantly decreased blood transfusion requirements in patients with sagittal craniosynostosis undergoing modified pi-plasty.

Intravenous tranexamic acid reduces complications following surgical treatment of pathologic fractures of the lower extremity

BACKGROUND AND OBJECTIVES

This study aimed to evaluate the postoperative complications associated with administering intravenous (IV) tranexamic acid (TXA) in patients undergoing surgical fixation for neoplastic pathologic fractures of the lower extremities.

METHODS

Patients ≥18 years old who underwent surgical intervention for neoplastic pathologic lower extremity fractures from 2015 to 2021 were identified using the Premier Healthcare Database. This cohort was divided by TXA receipt on the index surgery day. Patient demographics, hospital factors, patient comorbidities, and 90-day complications were assessed and compared between the cohorts.

RESULTS

From 2015 to 2021, 4497 patients met inclusion criteria (769 TXA[+] and 3728 TXA[-]). Following propensity score matching, patients who received TXA had a significantly shorter length of stay than those who did not (7.6 ± 7.3 days vs. 9.0 ± 15.2, p = 0.036). Between the two cohorts, there were no significant differences in comorbidities. Regarding differences in postoperative complications, TXA(+) patients had significantly decreased odds of deep vein thrombosis (DVT) (1.87% vs. 5.46%; odds ratio [OR]:0.33; 95% confidence interval: 0.17-0.62; p = 0.001).

CONCLUSION

Administration of IV TXA may be associated with a decreased risk of postoperative DVT without an increased risk of other complications. Orthopedic surgeons should consider the utilization of IV TXA in patients treated surgically for neoplastic pathologic fractures of the lower extremity.

Anterior Minimally Invasive Approach (AMIS) for Total Hip Arthroplasty: Analysis of the First 1000 Consecutive Patients Operated at a High Volume Center

(1) Background: Direct anterior approach (DAA) has recently acquired popularity through improvements such as the anterior minimally invasive surgical technique (AMIS). This retrospective study examines the first 1000 consecutive THAs performed utilizing the AMIS approach in a high-volume center between 2012 and 2017. (2) Methods: 1000 consecutive THAs performed at a single institution utilizing the AMIS approach were retrospectively analyzed with a minimum five-year follow-up. Full evaluation of demographic information, clinical parameters, intraoperative complications, and radiological examinations are reported. (3) Results: Overall complication rate was 9.4% (94/1000), including 8 dislocations, 57 femoral-cutaneous nerve injuries, 12 intraoperative femoral fractures, 9 infections and 8 leg length discrepancy. Implant survival rates were 98.5% at 1 year, 97.5% at 3 years, 97% at 5 years, and 95.3% at 7 years. Causes of failure included periprosthetic fractures (0.8%), implant dislocations (0.6%), septic loosening (0.5%), aseptic mobilizations (0.2%), and symptomatic limb length discrepancies (0.2%). (4) Conclusions: Controversies persist around the direct anterior approach (DAA) for THA, primarily regarding the increased complications rate during the learning curve. However, this study advocates for widespread adoption of the DAA approach. The results demonstrate acceptable complication rates and remarkable functional outcomes, affirming its viability in the broader orthopedic patient population.

Safety of tranexamic acid in surgically treated isolated spine trauma

BACKGROUND

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown. This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma.

AIM

To assess the safety of TXA in isolated spine trauma. The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion, respectively.

METHODS

This prospective observational study included patients aged ≥ 17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom.

RESULTS

We identified 67 patients: 26 (39%) and 41 (61%) received and did not receive TXA, respectively. Both groups were matched in terms of age, gender, American Society of Anesthesiologists grade, and mechanism of injury. A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score > 4 (74% vs 56%). All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min, compared with 24 patients (58%) in the non-TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min. Among patients who received TXA, blood loss was < 150 and 150-300 mL in 8 (31%) and 15 (58%) patients, respectively. There were no cases of thromboembolic events in any patient who received TXA.

CONCLUSION

Our study demonstrated that TXA is safe for isolated spine trauma. It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases. Further, larger studies are necessary to explore the rate, dosage, and mode of administration of TXA.

Debridement, Antibiotic Pearls, and Retention of the Implant (DAPRI) in the Treatment of Early Periprosthetic Knee Joint Infections: A Literature Review

(1) Background: Periprosthetic joint infections (PJIs) are severe and frightening complications in orthopaedic surgery, and they are generally divided into three categories: early infections (those occurring within the first 4-6 weeks), delayed infections (those occurring between 3 and 24 months), and late infections (those occurring more than 2 years after surgery). PJI treatment comprises "debridement, antibiotics, and implant retention" (DAIR), single-stage revision, and double-stage revision. Nowadays, to improve the chances of retaining an infected implant and to improve the traditional DAIR method, a modified surgical technique has been developed, named DAPRI (debridement, antibiotic pearls, and retention of the implant). Our study aims to present an up-to-date concept evaluation of the DAPRI technique and its success rate. (2) Methods: Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards were followed, applying a protocol defined by the authors: a total of 765 articles were identified, and at the end of the screening process only 7 studies were included. (3) Results: Currently, the DAPRI procedure can be performed only on patients who have had PJI symptoms for less than 4 weeks, and in order to achieve the highest success rate, indications are quite strict: it is appropriate in patients with acute, superficial infections without sinus tract presence, and well-fixed implants with known sensitive bacteria. The DAPRI surgical method follows a step-by-step process consisting of a first phase of biofilm identification with intra-articular injection of methylene blue, followed by biofilm removal (thermic, mechanical, and chemical aggression), and a last step consisting of prevention of PJI recurrence by using calcium sulphate antibiotic-added beads. (4) Conclusions: The DAPRI approach improves the traditional DAIR technique. It is a correct treatment for acute and early haematogenous PJI, and improves the DAIR success rate.

Ankle and hindfoot motion of healthy adults during running revealed by dynamic biplane radiography: Side-to-side symmetry, sex-specific differences, and comparison with walking

This study aimed to characterize ankle and hindfoot kinematics of healthy men and women during overground running using biplane radiography, and to compare these data to those previously obtained in the same cohort during overground walking. Participants ran across an elevated platform at a self-selected pace while synchronized biplane radiographs of their ankle and hindfoot were acquired. Motion of the tibia, talus, and calcaneus was tracked using a validated volumetric model-based tracking process. Tibiotalar and subtalar 6DOF kinematics were obtained. Absolute side-to-side differences in ROM and kinematics waveforms were calculated. Side-to-side and sex-specific differences were evaluated at 10 % increments of stance phase with mixed model analysis. Pearson correlation coefficients were used to assess the relationship between stance-phase running and walking kinematics. 20 participants comprised the study cohort (10 men, mean age 30.8 ± 6.3 years, mean BMI 24.1 ± 3.1). Average absolute side-to-side differences in running kinematics waveforms were 5.6°/2.0 mm or less at the tibiotalar joint and 5.2°/3.2 mm or less at the subtalar joint. No differences in running kinematics waveforms between sides or between men and women were detected. Correlations were stronger at the tibiotalar joint (42/66 [64 %] of correlations were p < 0.05), than at the tibiotalar joint (38/66 [58 %] of correlations were p < 0.05). These results provide a normative reference for evaluating native ankle and hindfoot kinematics which may be informative in surgical or rehabilitation contexts. Sex-specific differences in ankle kinematics during overground running are likely not clinically or etiologically significant. Associations seen between walking and running kinematics suggest one could be used to predict the other.

A Meta-Analysis of Success Rates of One-Stage Versus Two-Stage Revisions in Knee Prosthetic Joint Infections

Prosthetic joint infections (PJIs) pose significant challenges following total joint arthroplasties and cause profound complications. They are associated with significant morbidity and mortality. One-stage revision involves the removal of the infected implant and simultaneous re-implantation of a new prosthesis in a single surgical procedure. The two-stage approach is traditionally more common in the United States and follows a deliberate sequence: the infected implant is first removed, followed by a period of antibiotic therapy, and then a second surgery for implant reinsertion. While two-stage revisions were traditionally considered the gold standard, recent advancements have introduced one-stage revisions as a viable alternative. One-stage revision offers the advantage of being a single procedure, significantly reducing the patient's downtime without a functioning knee. Currently, there has not been a comprehensive exploration of the comparative outcomes between two-stage revisions and one-stage revisions. This systematic review and meta-analysis aimed to assess the outcomes of both one- and two-stage revisions for total knee arthroplasties (TKAs), by utilizing comparison studies as the foundation for analysis. Our search encompassed databases such as MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, and Cochrane to identify articles examining the comparative efficacy and outcomes of one- and two-stage revision procedures between January 2000 and June 2023. We employed keywords relevant to knee PJIs to identify comparative studies reporting on success rates, reinfection rates, microbiological findings, and other pertinent outcomes. Statistical analysis for this investigation was performed using Review Manager 5.4 (The Cochrane Collaboration, 2020) with a standard significance threshold set at a p-value less than .05. This meta-analysis incorporated six comparison articles and 802 patients. Two-stage revisions (547 patients) were associated with greater success rates (i.e., infection eradication) than one-stage revisions (255 patients) (p = .03). The studies did not suggest a difference in the microbiology of the infections. Two-stage revisions are associated with higher success rates than one-stage revisions in the treatment of knee PJIs. Future randomized controlled trials should evaluate the optimization of the management of these complications.

The Financial Burden of Aspirin versus Oral Factor Xa Inhibitors for Thromboprophylaxis Following Total Knee Arthroplasty

BACKGROUND

Aspirin and oral factor Xa inhibitor thromboprophylaxis regimens are associated with similarly low rates of venous thromboembolism following total knee arthroplasty (TKA). However, the rate of prosthetic joint infection (PJI) is lower with aspirin use. This study aimed to compare the cost differential between aspirin and factor Xa inhibitor thromboprophylaxis with respect to PJI management.

METHODS

We used previously published rates of PJI following aspirin and factor Xa inhibitor thromboprophylaxis in primary TKA patients at a single, large institution. Prices for individual drugs were obtained from our hospital's pharmacy service. The cost of PJI included that of 2-stage septic revision, with or without the cost of 1-year follow-up. National data were obtained to determine annual projected TKA volume.

RESULTS

The per-patient costs associated with a 28-day course of aspirin versus factor Xa inhibitor thromboprophylaxis were $17.36 and $3,784.20, respectively. Including cost of follow-up, per-patient costs for a 28-day course of aspirin versus factor Xa inhibitors increased to $73,358.76 and $77,125.60, respectively. The weighted average per-patient costs for a 28-day course were $237.38 and $4,370.93, respectively. The annual cost difference could amount to over $14.1 billion in the United States by 2040.

CONCLUSIONS

The per-patient cost associated with factor Xa inhibitor thromboprophylaxis is as much as 1,980.6% higher than that of an aspirin regimen due to increased costs of primary treatment, differential PJI rates, and high costs of management. In an era of value-based care, the use of aspirin is associated with major cost advantages.

Application of the New Irrigation Protocol to Reduce Recurrence Rate in the Management Of Periprosthetic Joint Infection

OBJECTIVE

Irrigation is a conventional treatment for acute and chronic periprosthetic joint infections (PJI). However, there has been no unified standard for irrigation during surgery for PJI in the past, and the efficacy is uncertain. The purpose of this study is to create a new irrigation protocol to enhance the infection control rate and reduce the postoperative recurrence rate of PJI patients.

METHODS

We conducted a single-institution retrospective review with a total of 56 patients who underwent revision total hip or knee arthroplasties due to PJI from January 2011 to January 2022. Conventional irrigation (CI) was used in 32 cases, and standard operating procedure of irrigation (SOPI) was used in 24. The CI protocol carries out an empirical irrigation after debridement, which is quite random. Our SOPI protocol clearly stipulates the soaking concentration and time of hydrogen peroxide and povidone-iodine. The irrigation is carried out three times, and tissue samples are taken from multiple parts before and after irrigation, which are sent for microbial culture. The important statistical indicators were the rate of positive microbiological culture and postoperative recurrence rate with an average follow-up of 24 average months.

RESULTS

The drainage volume was lower in the SOPI group than in the CI group on postoperative day 3 (p < 0.01) and 7 (p = 0.016). In addition, the percentage of positive microbiological cultures after the third irrigation was less than that before (p < 0.01) and after (p < 0.01) the first irrigation. The most common causative organism was Staphylococcus aureus, which was detected in 25.0% and 12.5% of the SOPI and CI groups, respectively. The failure rate at the final follow-up was 8.3% and 31.3% (p = 0.039) for the SOPI and CI groups, respectively.

CONCLUSION

Compared with the traditional CI method, SOPI standardized the soaking time of hydrogen peroxide and povidone-iodine, increased the frequency of and irrigation, and proved that microorganisms were almost completely removed through the microbial culture of multiple tissues. SOPI has the potential to become a standardized irrigation process worthy of promotion, effectively reducing the postoperative recurrence rate of PJI patients.

Do one-stage indications predict success following two-stage arthroplasty for chronic periprosthetic joint infection?

Introduction: The 2018 International Consensus Meeting (ICM) proposed criteria for one-stage exchange arthroplasty in treating periprosthetic joint infection (PJI). Our study aimed to determine what proportion of PJI patients met the 2018 ICM criteria and how this affected infection-free survivorship for patients. Methods: All chronic PJI patients treated with two-stage exchange within our institution between 2017-2020 were retrospectively reviewed. Included cases met 2011 Musculoskeletal Infection Society (MSIS) criteria for PJI and had a 2-year minimum follow-up. Treatment success was defined as Tier 1A in the 2019 MSIS working group definition. ICM one-stage criteria included non-immunocompromised host, absence of sepsis, adequate soft tissue for closure, known preoperative pathogen, and susceptibility. Immunocompromised host was analyzed as two separate definitions. Kaplan-Meier survivorship, Cox regression, and univariate analyses were performed. Results: A total of 293 chronic PJI patients were included. Overall, treatment failure occurred in 64 / 293 (21.8 %) patients. Only 13 % (n = 37 ) met ICM criteria definition no. 1 for one-stage exchange; 12 % (n = 33 ) met definition no. 2. In both definitions, infection-free survivorship at 2 years did not differ between patients who met and did not meet criteria (p > 0.05 ). Cox proportional hazard regression analyses demonstrated that the only variable predicting treatment failure was knee joint involvement (p = 0.01 ). Conclusions: We found that a very limited number of chronic PJI patients were suitable for a one-stage exchange. Furthermore, the supposition that healthier hosts with known pathogens (the basis of the ICM criteria) yield better PJI treatment outcomes was not observed. These results justify the ongoing multicenter randomized control trial comparing one-stage versus two-stage treatment for chronic PJI.

Intramedullary Positive Tissue Culture Increases the Risk of Reinfection Following One-Stage Septic Revision Total Knee Arthroplasty

BACKGROUND

Intraoperative acquisition of representative tissue samples is essential during revision arthroplasty of the infected total knee arthroplasty (TKA). While the number of intraoperative tissue samples needed to identify the organism is well described in the literature, there is still a paucity of evidence regarding the location of positive intraoperative samples and their correlation to postoperative outcomes.

METHODS

There were forty-two patients who had septic failure following one-stage revision TKA for periprosthetic joint infection who were identified between January 2009 and December 2017. They were matched to a control group of patients who had successful one-stage revision TKA without septic failure. The location of positive intraoperative tissue samples was categorized as: 1) soft tissue; 2) interface between bone and prosthesis; and 3) intramedullary (IM). Chi-square, Student's t-, and Wilcoxon Mann-Whitney U-tests were used as appropriate. Univariate and multivariate logistic regression analyses were performed to evaluate predictors of septic failure.

RESULTS

Weight > 100 kilograms (P = .033), higher Charlson Comorbidity Index (P < .001), and positive IM cultures (P < .001) were associated with a higher risk of reinfection after one-stage revision TKA. A positive IM sample carried a nearly five-fold increase in odds of reinfection (odds ratio 4.86, 95% confidence interval 1.85 to 12.78, P = .001).

CONCLUSIONS

A positive IM culture sample is significantly associated with septic failure after one-stage exchange for periprosthetic joint infection of the knee. Patients who had positive IM cultures may benefit from longer postoperative antibiotic therapy for the treatment of one-stage exchange arthroplasty to minimize the risk of reinfection.

Systematic review and meta-analysis of single-stage vs two-stage revision for periprosthetic joint infection: a call for a prospective randomized trial

BACKGROUND

Periprosthetic joint infection (PJI) is a severe complication of joint arthroplasty that causes significant pain and economic loss. This study aimed to determine whether the current evidence supports single-stage revision for PJI based on reinfection and reoperation rates.

METHODS

We searched the PubMed, EBSCO, Medline, and Cochrane Library databases from inception to 30 May 2023 to identify studies that compared single-stage revision and two-stage revision for PJI. Data on reinfection and reoperation rates were pooled.

RESULTS

This meta-analysis included a total of 40 studies with 8711 patients. Overall, there was no significant difference between single- and two-stage revision regarding the postoperative reinfection rate and reoperation rate. Subgroup analysis by surgery period and different surgical sites revealed no difference between the two groups in the reinfection and reoperation rates.

CONCLUSIONS

Based on the available evidence, our study did not identify a significant difference in reinfection and reoperation rates between single- and two-stage revision for PJI. Given the limitations in inclusion/exclusion criteria and the observed heterogeneity, we acknowledge the complexity of drawing strong conclusions. Therefore, we suggest that the choice between single- and two-stage revision should be carefully considered on an individual basis, taking into account patient-specific factors and further research developments.

Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review

PURPOSE

Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI.

METHODS

This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported.

RESULTS

The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%).

CONCLUSION

Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.

Ankle Telemedicine Planning Considerations

A virtual medical visit, also known as telemedicine or telehealth, is a valuable alternative method of providing health care to patients who do not have easy access to a hospital, or during times when limited social interaction is crucial such as our current COVID-19 pandemic. A virtual approach to evaluating musculoskeletal system ailments is particularly challenging, for diagnosis of these conditions generally rely greatly on physical examination, which may be challenging. However, a properly planned and executed telemedicine visit will yield successful results in most cases. Our aim is to produce a document with instructions and suggestions, including physical examination maneuvers, to help physicians carry out a proper virtual medical visit with patients complaining of ankle musculoskeletal problems. Virtual visits should not be thought of as a replacement for traditional face-to-face medical consultations, but rather a complementary method to provide health care when deemed appropriate. By following this guide, and tailoring it to the specific case at hand, medical providers should be able to effectively carry out a successful telemedicine consultation for musculoskeletal ailments relating to the ankle.Levels of Evidence: Level V.

The Efficacy and Safety of Tranexamic Acid in Total Hip and Knee Arthroplasty: A Literature Review

Historically, total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been associated with significant perioperative blood loss and a relatively high rate of allogeneic blood transfusions. However, in recent years, tranexamic acid (TXA), a competitive inhibitor of tissue plasminogen activator, inhibiting fibrinolysis of existing thrombi, has substantially decreased the need for blood transfusion in THA and TKA. Various administration strategies have been studied, but there remains a lack of consensus on an optimal route and dosing regimen, with intravenous and topical regimens being widely used. A growing body of literature has demonstrated the safety and efficacy of TXA in primary and revision THA and TKA to reduce blood loss, allogeneic transfusions, and complications; it is associated with lowered lengths of stay, costs, and readmission rates.

The influence of gut microbiome on periprosthetic joint infections: State-of-the art

Early periprosthetic joint infection constitutes one of the most frightening complications of joint replacement. Recently, some evidence has highlighted the potential link between dysregulation of the gut microbiota and degenerative diseases of joints. It has been hypothesized that microbiome dysbiosis may increase the risk of periprosthetic joint infection by facilitating bacterial translocation from these sites to the bloodstream or by impairing local or systemic immune responses. Although the processes tying the gut microbiome to infection susceptibility are still unknown, new research suggests that the presurgical gut microbiota-a previously unconsidered component-may influence the patient's ability to resist infection. Exploring the potential impact of the microbiome on periprosthetic joint infections may therefore bring new insights into the pathogenesis and therapy of these disorders. For a successful therapy, a proper surgical procedure in conjunction with an antibacterial concept is essential. As per the surgical approach, different treatment strategies include surgical irrigation, debridement, antibiotic therapy, and implant retention with or without polyethylene exchange. Other alternatives could be one-stage or two-stage revisions surgery. Interventions that either directly target gut microbes as well as interventions that modify the composition and/or function of the commensal microbes represent an innovative and potentially successful field to be explored. In recent times, innovative therapeutic methods have arisen in the realm of microbiome restoration and the management of gut-related ailments. These progressive approaches offer fresh perspectives on tackling intricate microbial imbalances in the gastrointestinal tract. These emerging therapies signify a shift towards more precise and individualized approaches to microbiome restoration and the management of gut-related disorders. Once a more advanced knowledge of the pathways linking the gut microbiota to musculoskeletal tissues is gained, relevant microbiome-based therapies can be developed. If dysbiosis is proven to be a significant contributor, developing treatments for dysbiosis may represent a new frontier in the prevention of periprosthetic joint infections.

Which approach of total hip arthroplasty is the best efficacy and least complication?

BACKGROUND

Total hip arthroplasty is as an effective intervention to relieve pain and improve hip function. Approaches of the hip have been exhaustively explored about pros and cons. The efficacy and the complications of hip approaches remains inconclusive. This study conducted an umbrella review to systematically appraise previous meta-analysis (MAs) including conventional posterior approach (PA), and minimally invasive surgeries as the lateral approach (LA), direct anterior approach (DAA), 2-incisions method, mini-lateral approach and the newest technique direct superior approach (DSA) or supercapsular percutaneously-assisted total hip (SuperPath).

AIM

To compare the efficacy and complications of hip approaches that have been published in all MAs and randomized controlled trials (RCTs).

METHODS

MAs were identified from MEDLINE and Scopus from inception until 2023. RCTs were then updated from the latest MA to September 2023. This study included studies which compared hip approaches and reported at least one outcome such as Harris Hip Score (HHS), dislocation, intra-operative fracture, wound complication, nerve injury, operative time, operative blood loss, length of hospital stay, incision length and VAS pain. Data were independently selected, extracted and assessed by two reviewers. Network MA and cluster rank and surface under the cumulative ranking curve (SUCRA) were estimated for treatment efficacy and safety.

RESULTS

Finally, twenty-eight MAs (40 RCTs), and 13 RCTs were retrieved. In total 47 RCTs were included for reanalysis. The results of corrected covered area showed high degree (13.80%). Among 47 RCTs, most of the studies were low risk of bias in part of random process and outcome reporting, while other domains were medium to high risk of bias. DAA significantly provided higher HHS at three months than PA [pooled unstandardized mean difference (USMD): 3.49, 95% confidence interval (CI): 0.98, 6.00 with SUCRA: 85.9], followed by DSA/SuperPath (USMD: 1.57, 95%CI: -1.55, 4.69 with SUCRA: 57.6). All approaches had indifferent dislocation and intraoperative fracture rates. SUCRA comparing early functional outcome and composite complications (dislocation, intra-operative fracture, wound complication, and nerve injury) found DAA was the best approach followed by DSA/SuperPath.

CONCLUSION

DSA/SuperPath had better earlier functional outcome than PA, but still could not overcome the result of DAA. This technique might be the other preferred option with acceptable complications.

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Distal Femoral Osteotomy for the Management of Coronal Deformity Following Total Knee Arthroplasty: A Report of 2 Cases

CASE

We present 2 cases demonstrating the management of coronal malalignment with an existing total knee arthroplasty using opening wedge distal femur osteotomy. The mechanical axis was corrected, and the primary total knee implants were maintained. Patients resumed full activity 3 to 4 months after surgery.

CONCLUSION

In certain cases, opening wedge distal femoral osteotomy is an option to correct coronal malalignment with an existing total knee arthroplasty without revising the implant.

Hemiarthroplasty through SuperPATH versus hemiarthroplasty through conventional approaches in patients with femoral neck fractures: a systematic review and meta-analysis of randomized controlled trials

The aim was to conduct a systematic review of literature and meta-analysis of randomized controlled trials (RCTs) comparing short-term outcomes of bipolar hemiarthroplasty (HA) through SuperPATH and bipolar HA through conventional approaches (CAs) in patients with femoral neck fractures. The following PICO question was formulated: In human participants with femoral neck fractures, are the short-term outcomes of SuperPATH HA better than the short-term outcomes of CAs HA? The following databases were searched until 25 August 2023: PubMed, CNKI, CENTRAL of The Cochrane Library, Clinical trials, and Google Scholar. Quality assessment of the RCTs was performed, according to the Cochrane's Risk of Bias 2 tool and the recommendations of the GRADE system. Furthermore, we evaluated publication bias with funnel plots. Mean differences (MDs) with 95% confidence intervals (CIs) were calculated for continuous variables using the Hartung-Knapp-Sidik-Jonkman method and a random effects model. Nine RCTs with overall 762 patients were included in this meta-analysis. All 9 RCTs were rated with a moderate risk of bias. The quality of evidence of the outcome parameters was rated moderate to very low. The funnel plots were overall broadly symmetrical, possibly indicating low to moderate publication bias. SuperPATH had a longer operation time compared to CAs (MD = 21.79, 95% CI 12.57 to 31.02). SuperPATH decreased incision length (MD = - 4.50; 95% CI - 5.80 to - 3.20), intraoperative blood loss (MD = - 103.96, 95% CI - 150.27 to - 55.66), postoperative drainage volume (MD = - 137.30, 95% CI - 178.74 to - 95.86), time to mobilization (MD = - 3.86; 95% CI - 5.96 to - 1.76), pain VAS ≤ 1 week postoperatively (MD = - 1.81; 95% CI - 2.17 to - 1.45), and hospitalization time (MD = - 4.05; 95% CI - 4.96 to - 3.15). SuperPATH improved HHS ≤ 1 week postoperatively (MD = 11.10; 95% CI 1.65 to 20.54) and HHS 3 months postoperatively (MD = 6.33; 95% CI 3.97 to 8.69). There was no difference in pain VAS 1-3 months postoperatively (MD = - 0.08; 95% CI - 0.22 to 0.05) and HHS 6 months postoperatively (MD = 0.44; 95% CI - 0.11 to 1.00). This is the first meta-analysis comparing SuperPATH HA with CAs HA in patients with femoral neck fractures. SuperPATH HA was superior in the early short-term functional outcome (HHS) compared to CAs HA, reaching minimal clinically important differences. Furthermore, SuperPATH HA showed significantly better results in incision length, blood loss, time to mobilization, pain intensity (VAS), and hospitalization time than CAs HA.

Effect of barbed versus standard sutures on wound complications in total knee arthroplasty: A meta-analysis

A barbed suture has been demonstrated to be effective in shortening the stitching time and improving the aesthetic appearance of the stitches during the entire knee replacement. However, no meta-analyses have been conducted specifically to evaluate the effect of the barbed thread on wound complications relative to the conventional suture. A comprehensive search of the PubMed database, the Embase database, the Cochrane Library and the Web of Science was performed to obtain search data up to June 2023, and only randomised controlled trials were included in this meta-analysis. We used Review Manager 5.3 for data synthesis and analysis. This meta-analysis included eight studies. It was found that the use of barbed sutures did not improve the incidence of the disease, the infection of the wound, the closure of the abscess and the injury. However, because of the limited sample size of the randomised controlled trials for this meta-analysis, the data should be handled with caution. More high-quality, large-sample studies will be required to confirm the results.

Early return to activity of daily living after total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

Total hip arthroplasty (THA) is an orthopaedic procedure that improves the quality of life in patients suffering from hip pain related to osteoarthritis, fractures, and avascular osteonecrosis of the femoral head. Different surgical approaches can be used for THA leading to different recovery times. Because of the lowering medium age of people undergoing THA, it is important to focus on the earlier return of physiological activity after surgery.

AIM

To evaluate the best approach for THA in terms of earlier return to activity.

METHOD

Studies comparing the postoperative outcomes in patients who underwent THA through different approaches were analysed focusing on patients' self-reported outcomes, ADL score and UCLA activity score with a short follow-up.

RESULTS

A total of 1990 articles were identified in the search, and 14 met the inclusion criteria. The Review Manager software version 5.4 was used to conduct a meta-analysis to compare the direct anterior (DAA) and posterior (PA) approaches, which are the most adopted approaches. An earlier return to walk without aids and to independent ADLs were reported with DAA, but without statistical significance (respectively p = 0.06 and p = 0.10). The time to return to drive was similar among the 2 groups (p = 0.88). The return to work was faster with PA, but no statistical significance was reported (p = 0.47).

CONCLUSIONS

Further studies are needed with a larger number of patients, that present homogeneous outcomes, follow-ups and rehabilitation programmes, and that compare similar surgical approaches to assess the early return to activity of daily living after THA.

The Practice Patterns of American Association of Hip and Knee Surgeons for the Management of Chronic Periprosthetic Joint Infection After Total Knee Arthroplasty

BACKGROUND

The management of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) has considerable variation. In order to better capture current preferences for the management of PJI, this study sought to poll the current members of American Association of Hip and Knee Surgeons (AAHKS) first to characterize the distribution of practice patterns.

METHODS

There were 32 questions in an online survey distributed to members of AAHKS. The questions were multiple choice regarding the management of PJI for TKA. There were 844 out of 2,752 members who completed the survey (response rate of 31%).

RESULTS

Most of the members were in private practice (50%) compared to 28% being in an academic setting. On average, members were performing between 6 to 20 PJI cases per year. Two-stage exchange arthroplasty was performed in over 75% of the cases with either a cruciate retaining (CR) or posterior stabilized (PS) primary femoral component used in over 50% of the cases and 62% using an all-polyethylene tibial implant. Most of the members were using vancomycin and tobramycin. Typically, 2 to 3 grams of antibiotics were added per bag of cement regardless of the cement type. When indicated, amphotericin was the most often-used antifungal. Post-operative management had major variability with range of motion, brace use, and weight-bearing restrictions.

CONCLUSION

There was variability in the responses from the members of AAHKS, but there was a preference toward performing a two-stage exchange arthroplasty with an articulating spacer using a metal femoral component and an all-polyethylene liner.

Midvastus Versus Medial Parapatellar Approach in Simultaneous Bilateral Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to compare the postoperative outcomes over a period of 3 years in patients who underwent bilateral total knee arthroplasty (TKA) using midvastus (MV) versus medial parapatellar (MPP) approaches.

METHODS

In this retrospective study, 2 propensity-matched cohorts of patients who underwent simultaneous bilateral TKA via MV (n = 100) and MPP (n = 100) approaches from January 2017 to December 2018 were compared. Surgical parameters compared were surgery time and the incidence of lateral retinacular release (LRR). Clinical parameters including the visual analog score for pain, time for straight leg raise (SLR), range of motion, the Knee Society Score, and the Feller patellar score were assessed in the early postoperative and follow-up periods up to 3 years. Radiographs were evaluated for alignment, patellar tilt, and displacement.

RESULTS

LRR was performed on 17 knees (8.5%) in the MPP group and 4 knees (2%) in the MV group which was significant (P = .03). The time to SLR was significantly lower in the MV group. There was no statistically significant difference in the length of hospital stay between the groups. The visual analog score, range of motion, and Knee Society Score were better in the MV group within 1 month (P < .05), but no statistically significant differences were found later. Patellar scores, radiographic patellar tilt, and displacements were similar at all follow-up periods.

CONCLUSION

In our study, the MV approach had faster SLR, less LRR, and better pain and function scores in the first few weeks after TKA. However, its effect on different patient outcomes has not been sustained at 1 month and further follow-up points. We recommend that surgeons use the surgical approach with which they are most familiar.

Trends in Revision Knee Arthroplasty for Prosthetic Joint Infection: A Single-Center Study of 384 Knees at a High-Volume Center Between 2008 and 2021

BACKGROUND

Prosthetic joint infection (PJI) is one of the most devastating complications after total knee arthroplasty (TKA), and comorbidities increase the risk. We examined whether a temporal change has occurred in the demographics, especially regarding comorbidities, of patients who have PJI and were treated at our institution over a 13-year study period. In addition, we assessed the surgical methods used and the microbiology of the PJIs.

METHODS

Revisions (n = 384, 377 patients) due to PJI of the knee performed at our institution between 2008 and September 2021 were identified. All included PJIs fulfilled the 2013 International Consensus Meeting diagnostic criteria. The surgeries were categorized into one of the following categories: debridement, antibiotics, and retention (DAIR), 1-stage revision, and 2-stage revision. Infections were classified as early, acute hematogenous, and chronic.

RESULTS

No changes in the median age of the patients nor comorbidity burden were observed during the study period. However, the proportion of 2-stage revisions decreased remarkably from 57.6% in 2008 to 2009 to 6.3% in 2020 to 2021. A DAIR was the most used treatment strategy, but the proportion of 1-stage revisions increased the most. In 2008 to 2009, 12.1% of the revisions were 1-stage, but in 2020 to 2021, the proportion was 43.8%. The most common pathogen was Staphylococcus aureus (27.8%).

CONCLUSION

The comorbidity burden remained at the same level with no trends. A DAIR was the most used strategy, but the proportion of 1-stage revisions rose to almost the same level. The incidence of PJI varied between the years, but remained relatively low.

Enhanced antibiotic release from bone cement spacers utilizing dual antibiotic loading with elevated vancomycin concentrations in two-stage revision for periprosthetic joint infection

PURPOSE

Antibiotic loaded bone cement spacers provide high local antibiotic concentrations, preserve bone stock, and reduce soft tissue contractions. The objective of this in-vitro study was to compare antibiotic release from spacers, aiming to discover the most optimal preparation and identify modifiable factors that can further enhance antibiotic release.

METHODS

Six distinct spacer preparation were created using three different bone cements and manual incorporation of antibiotics. During a six-week period, the release of antibiotics from each spacer was measured individually at ten predetermined time points using a chemiluminescent immunoassay.

RESULTS

Manually adding 4 g of vancomycin to every 40 g of "Palacos R + G" yielded the most favorable release profile. Throughout all preparations, antibiotic release consistently and significantly decreased over the six-week period. When incorporating a higher concentration of vancomycin, a significantly higher cumulative release of vancomycin was observed, with varying effects on the release of gentamicin. The choice of bone cement had a significant impact on antibiotic release.

CONCLUSION

To enhance antibiotic release from spacers, surgeons should manually incorporate high antibiotic concentrations into the most appropriate bone cement and keep the interim period as short as possible. Specifically, we suggest manual incorporation of 4 g of vancomycin to every 40 g of gentamicin premixed "Palacos R + G" to create bone cement spacers.

Plus Sutures for preventing surgical site infection: a systematic review of clinical outcomes with economic and environmental models

BACKGROUND

Surgical site infections (SSIs) represent ~ 20% of all hospital-acquired infections in surgical patients and are associated with prolonged hospital stay, admission to intensive care, and mortality. We conducted a systematic review with economic and environmental models to assess whether triclosan-coated sutures (Plus Sutures) provide benefits over non-coated sutures in the reduction of SSI risk.

METHODS

Searches were conducted in fifteen databases. A total of 1,991 records were retrieved. Following deduplication and screening by two independent reviewers, 31 randomized controlled trials in adults and children were included in the review. Similarity of the studies was assessed by narrative review and confirmed by quantitative assessment. A fixed effects meta-analysis of SSI incidence model including all groups of patients estimated a risk ratio of 0.71 (95% confidence interval: 0.64 to 0.79) indicating those in the Plus Sutures group had a 29% reduction in the risk of developing an SSI compared with those in the control group (p < 0.001). Safety outcomes were analysed qualitatively.

RESULTS

The economic model estimated the use of Plus Sutures to result in average cost savings of £13.63 per patient. Plus Sutures remained cost-saving in all subgroup analyses with cost-savings ranging between £11 (clean wounds) and £140 (non-clean wounds). The environmental impact of SSI is substantial, and the model suggests that the introduction of Plus Sutures could result in potential environmental benefits.

CONCLUSIONS

The evidence suggests that Plus Sutures are associated with a reduced incidence of SSI across all surgery types alongside cost savings when compared with standard sutures.

Tranexamic acid is safe with respect to the risk of deep venous thrombosis in patients with hemophilic arthritis undergoing total knee arthroplasty without chemoprophylaxis: A prospective study

BACKGROUND

Pharmacologic thromboprophylaxis is controversial for hemophiliacs who undergo total joint replacements. The purpose of this study was to assess the safety of tranexamic acid (TXA) utilization with respect to the incidence of deep venous thrombosis (DVT) in hemophiliacs undergoing total knee arthroplasty (TKA).

METHODS

A total of 104 patients with hemophilic arthritis were included in the study. The patients were randomly divided into two groups of 52 subjects. All patients received a modified coagulation factor substitution regimen. In the TXA group, 1 g of TXA was injected intravenously 15 min before incision and 2 g of TXA was intra-articularly injected in the surgical area. A routine mechanical prophylaxis was administered to all patients under a standardized postoperative protocol. Thromboembolic complications in both groups were followed up for 2 years.

RESULTS

All patients were male and underwent 146 arthroplasties. There was a mean age of 33.2 ± 8.8 years and a mean body mass index of 22.2 ± 5.1 kg/m2. A 100% compliance rate was observed with mechanical prophylaxis. No asymptomatic DVT was detected on postoperative ultrasound in all patients. We also failed to find any proof of clinical venous thromboembolism in our patients during a 2-year follow up. Only two cases in the TXA group underwent blood transfusions (4.0%), while 29.2% of the patients in the non-TXA group needed transfusion.

CONCLUSIONS

This prospective study showed that TXA could be safely utilized in patients with hemophilic arthritis who underwent TKA without increasing the incidence of DVT and routine chemoprophylaxis may not be necessary.

Use of monofilament sutures and triclosan coating to protect against surgical site infections in spinal surgery: a laboratory-based study

PURPOSE

We investigated bacterial propagation through multifilament, monofilament sutures and whether sutures coated with triclosan would exhibit a different phenomenon.

METHODS

One centimetre (cm) wide trenches were cut in the middle of Columbia blood Agar plates. We tested a 6 cm length of two Triclosan-coated (PDS plus®, Vicryl plus®) and two uncoated (PDS ®, Vicryl ®) sutures. Each suture was inoculated with a bacterial suspension containing methicillin-sensitive Staphylococcus aureus (MSSA), Escherichia coli (E. coli), Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus (MRSA) at one end of each suture. The plates were incubated at 36C for 48 h, followed by room temperature for a further 5 days. We established bacterial propagation by observing for any bacterial growth on the Agar on the opposite side of the trench.

RESULTS

Bacterial propagation was observed on the opposite side of the trench with both suture types, monofilament PDS and multifilament Vicryl, when tested with the motile bacterium (E. coli). Propagation was not observed on the other side of the trench with the monofilament PDS suture following incubation with MSSA and S. epidermidis, and in 66% of MRSA. With multifilament suture Vicryl, propagation was observed on the other side of the trench in 90% (MSSA), 80% (S. epidermidis), and 100% (MRSA) of plates tested. No bacterial propagation was observed in any of the triclosan-coated sutures (monofilament or multifilament).

CONCLUSIONS

Monofilament sutures are associated in vitro with less bacterial propagation along their course when compared to multifilament sutures. Inhibition in both sutures can be further enhanced with a triclosan coating.

Characterizing recurrent infections after one-stage revision for periprosthetic joint infection of the knee: a systematic review of the literature

BACKGROUND

Periprosthetic joint infection (PJI) of the knee represents a severe complication after 1.5% to 2% of primary total knee replacement. Although two-stage revision was considered the gold-standard treatment for PJI of the knee, in the last decades, more studies reported the outcomes of one-stage revisions. This systematic review aims to assess reinfection rate, infection-free survival after reoperation for recurrent infection, and the microorganisms involved in both primary and recurrent infection.

MATERIAL AND METHODS

A systematic review of all studies reporting the outcome of one-stage revision for PJI of the knee up to September 2022, according to PRISMA criteria and AMSTAR2 guidelines, was performed. Patient demographics, clinical, surgical, and postoperative data were recorded.

PROSPERO ID

CRD42022362767.

RESULTS

Eighteen studies with a total of 881 one-stage revisions for PJI of the knee were analyzed. A reinfection rate of 12.2% after an average follow-up of 57.6 months was reported. The most frequent causative microorganism were gram-positive bacteria (71.1%), gram-negative bacteria (7.1%), and polymicrobial infections (8%). The average postoperative knee society score was 81.5, and the average postoperative knee function score was 74.2. The infection-free survival after treatment for recurrent infection was 92.1%. The causative microorganisms at reinfections differed significantly from the primary infection (gram-positive 44.4%, gram-negative 11.1%).

CONCLUSION

Patients who underwent a one-stage revision for PJI of the knee showed a reinfection rate lower or comparable to other surgical treatments as two-stage or DAIR (debridement, antibiotics, and implant retention). Reoperation for reinfection demonstrates a lower success compared to one-stage revision. Moreover, microbiology differs between primary infection and recurrent infection. Level of evidence Level IV.

Die perioperative Gabe von Tranexamsäure

The application of tranexamic acid (TXA) during endoprosthetic surgical procedures has significantly increased in recent years. Due its ability to reduce perioperative blood loss and avert the need for blood transfusions as well as wound drainage, TXA is becoming part of a 'standard practice'. However, TXA is currently not approved for the application during endoprosthetic procedures and therefore, a benefit-risk analysis should always be conducted. Prophylactic administration of TXA without prior patient consent is only justified if fibrinolytic bleeding is expected and there are no contraindications or relevant risk factors for thromboembolic complications. Respectively, no patient consent is required when a therapeutic dose of TXA is administered in the context of fibrinolytic bleeding. The following guidelines provide updated recommendations based on the current state of knowledge on TXA optimal timing, routes of administration and dosing regimen.

A Bio-Inspired Arched Foot with Individual Toe Joints and Plantar Fascia

This paper presents the design and testing of an arched foot with several biomimetic features, including five individual MTP (toe) joints, four individual midfoot joints, and plantar fascia. The creation of a triple-arched foot represents a step further in bio-inspired design compared to other published designs. The arched structure creates flexibility that is similar to human feet with a vertical deflection of up to 12 mm. The individual toe joints enable abduction-adduction in the forefoot and therefore a natural pronation motion. Adult female bone data was obtained and converted into a CAD model to accurately identify the location of bones, joints, and arches. An analytical model is presented that gives the relationship between the vertical stiffness and horizontal stiffness of the longitudinal arches and therefore allows the optimization of stiffness elements. Experimental tests have demonstrated a vertical arch stiffness of 76 N/mm which is similar to adult human feet. The range of movement of the foot is similar to human feet with the following values: dorsi-plantarflexion (28°/37°), inversion-eversion (30°/15°), and abduction-adduction (30°/39°). Tests have also demonstrated a three-point contact with the ground that is similar to human feet.

Minimally invasive medial femoral approach to total knee arthroplasty improves short-term outcomes compared to the standard medial parapatellar approach: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to conduct a comprehensive evaluation of the effectiveness of the medial parapatellar approach via the vastus medialis obliquus muscle in comparison with the standard medial parapatellar approach for total knee arthroplasty, using a systematic approach.

METHODS

A computer search was conducted on PubMed, EMBASE, Medline, Cochrane libraries, and Web of Science databases to comprehensively collect randomized controlled studies on minimally invasive (MMV) approaches for knee arthroplasty, specifically the vastus and medial parapatellar (MP) approaches. Two authors independently screened the literature based on inclusion and exclusion criteria, evaluated the quality of the included studies using the Cochrane systematic review method, and performed a meta-analysis using RevMan 5.3 software.

RESULTS

A total of twelve randomized controlled studies were ultimately included, comprising 788 knees. The small incision medial femoral muscle approach (MMV) group consisted of 398 cases, while the traditional parapatellar approach (MP) group consisted of 390 cases. Data analysis showed that in the comparison of KSS, VAS, and ROM score at 3 months after surgery, MMV approach was superior to MP approach [MD = 2.89, 95%CI (0.33, 5.46), P = 0.03], [MD = - 0.22, 95%CI (- 0.36, - 0.09), P = 0.001], and [MD = 1.08, 95%CI (0.04, 2.12), P = 0.04]. However, there was no significant difference in the postoperative KSS, VAS, and ROM score between the MMV and MP approaches at 6 and 12 months after surgery. The operation time of the MMV group was longer than that of the MP group [MD = 8.98, 95%CI (4.64, 13.32), P < 0.0001], and the number of days of straight leg raising after surgery was shorter in the MMV group than in the MP group [MD = - 1.91, 95%CI (- 3.45, - 0.37), P = 0.01], with statistically significant differences. There was no significant difference in the lateral support band release rate [OR = 0.72, 95%CI (0.23, 2.28), P = 0.58], length of hospital stay [MD = 0.07, 95%CI (- 0.18, 0.31), P = 0.58], postoperative complications [MD = 0.62, 95%CI (0.33, 1.18), P = 0.15], and intraoperative blood loss [MD = 70.50, 95%CI (- 57.51, 198.72), P = 0.28].

CONCLUSION

Most of the approaches have similar length of stay and incidence of complications compared to standard approaches. However, the minimally invasive midvastus approach has shown potential to improve short-term outcomes.

STUDY REGISTRATION

PROSPERO registration number CRD42023410583.

Hypoalbuminemia increases the risk of failure following one-stage septic revision for periprosthetic joint infection

PURPOSE

Malnutrition is a potentially modifiable risk factor of periprosthetic joint infection (PJI). The purpose of this study was to analyze the role of nutritional status as a risk factor for failure after one- stage revision hip or knee arthroplasty for PJI.

METHODS

Retrospective, single-center, case-control study. Patients with PJI according to the 2018 International Consensus Meeting criteria were evaluated. Minimum follow-up was 4 years. Total lymphocyte count (TLC), albumin values, hemoglobin, C-reactive protein, white blood cell (WBC) count and glucose levels were analyzed. An analysis was also made of the index of malnutrition. Malnutrition was defined as serum albumin < 3.5 g/dL and TLC < 1500/mm3. Septic failure was defined as the presence of local or systemic symptoms of infection and the need of further surgery as a result of persistent PJI.

RESULTS

No significant differences were found between increased failure rates after a one-stage revision hip or knee arthroplasty for PJI and TLC, hemoglobin level, WBC count, glucose levels, or malnutrition. Albumin and C-reactive protein values were found to have a positive and significant relationship with failure (p < 0.05). Multivariate logistic regression identified only hypoalbuminemia (serum albumin < 3.5 g/dL) (OR 5.64, 95% CI 1.26-25.18, p = 0.023) as a significant independent risk factor for failure. The receiver operating characteristic (ROC) curve for the model yielded an area under the curve of 0.67.

CONCLUSION

TLC, hemoglobin; WBC count; glucose levels; and malnutrition, understood as the combination of albumin and TLC, were not found to be statically significant risk factors for failure after single-stage revision for PJI. However, albumin < 3.5 g/dL, alone was a statically significant risk factor for failure after single-stage revision for PJI. As hypoalbuminemia seems to influence the failure rate, it is advisable to measure albumin levels in preoperative workups.

Knee and hip arthroplasty joint surgical site wound infection in end-stage renal disease subjects who underwent dialysis or a kidney transplant: A meta-analysis

A meta-analysis study to assess the knee and hip arthroplasty joint surgical site wound infection (SSWI) in end-stage renal disease (ESRD) subjects who underwent dialysis or a kidney transplant (KT). A comprehensive literature examination till February 2023 was implemented and 1046 linked studies were appraised. The picked studies contained 5 471 898 subjects with total joint arthroplasty (TJA) at the baseline, 13 049 of them were haemodialysis or renal transplant, and 5 458 849 were control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of knee and hip arthroplasty SSWI in ESRD subjects who underwent dialysis or a KT by the dichotomous and continuous styles and a fixed or random model. Haemodialysis or renal transplant had a significantly higher postoperative SSWI (OR, 2.13; 95% CI, 1.73-2.62, P < .001) compared with control in TJA subjects. However, no significant difference was observed between haemodialysis and renal transplant in postoperative SSWI (OR, 0.93; 95% CI, 0.16-5.54, P = .94) and between haemodialysis or renal transplant and control in prosthetic joint infection (OR, 1.07; 95% CI, 0.25-4.55, P = .93) in TJA subjects. Haemodialysis had a significantly higher prosthetic joint infection (OR, 1.92; 95% CI, 1.21-3.03, P = .005) compared with renal transplant in TJA subjects. Haemodialysis or renal transplant had a significantly higher postoperative SSWI in TJA subjects. Also, haemodialysis had a significantly higher prosthetic joint infection compared with renal transplant in TJA subjects. Although precautions should be taken when commerce with the consequences because a low number of selected studies was picked for certain comparisons in this meta-analysis.

Articulating Hip Spacers with a Constrained Acetabular Liner: Effect of Acetabular Bone Loss and Cementation Quality

Articulating hip spacers for periprosthetic joint infection (PJI) offer numerous advantages over static spacers such as improved patient mobilization, hip functionality, and soft tissue tension. Our study aimed to determine complication rates of a functional articulating spacer using a constrained liner to determine the role of acetabular cementation mantle and bone loss on the need for second-stage surgery. A retrospective review of 103 patients was performed and demographic information, spacer components and longevity, spacer-related complications, reinfection rates, and grade of bone loss and acetabular cement mantle quality were determined. There was no significant difference in spacer-related complications or reinfection rate between PJI and native hip infections. 33 of 103 patients (32.0%) elected to retain their spacers. Between patients who retained their initial spacer and those who underwent reimplantation surgery, there was not a significant difference in cement mantle grade (p = 0.52) or degree of bone loss (p = 0.78). Functional articulating antibiotic spacers with cemented constrained acetabular liners demonstrate promising early results in the treatment of periprosthetic and native hip infections. The rate of dislocation events was low. Further efforts to improve cement fixation may help decrease the need for second-stage reimplantation surgery.

Clinical Outcomes and Infection Rates Following Revision Total Knee Arthroplasty: Aseptic Failure versus Septic Failure

Background

It is controversial whether revision total knee arthroplasty (TKA) due to septic failure shows inferior clinical outcomes compared with TKA due to aseptic failure. Moreover, few studies have compared the infection rates after revision TKA between aseptic and septic failure. We aimed to compare the clinical outcomes and infection rates after aseptic and septic revision TKA.

Methods

Between April 2006 and May 2019, 68 and 26 patients underwent revision TKA due to aseptic failure (aseptic group) and septic failure (septic group), respectively. The postoperative range of motion (ROM), Western Ontario and McMaster Universities Osteoarthritis index, Knee Society Knee Score (KSKS), Knee Society Function Score (KSFS), and infection rates were compared between the two groups.

Results

The mean follow-up durations in the aseptic and septic groups were 44.4 and 54.8 months, respectively. The septic group showed inferior postoperative ROM (124.1° and 109.4°, p = 0.004), KSKS (88.9 and 78.8, p = 0.001), and KSFS (72.8 and 59.0, p = 0.001). Three patients of aseptic group had infection. Three patients of septic group had recurred infection (same pathogen with the first infection) and 1 patient had a new infection (different pathogen). The septic group showed slightly higher but not significantly different infection rates (4.4% and 15.4%, p = 0.089).

Conclusions

Revision TKA with septic failure showed inferior postoperative clinical outcomes compared with aseptic revision surgery. A slightly higher infection rate was observed in the septic group but it was not significantly different.

Antibiotic release from PMMA spacers and PMMA beads measured with ELISA: Assessment of in vitro samples and drain fluid samples of patients

For prosthetic joint infections, antibiotic loaded poly methyl methacrylate (PMMA) spacer or beads can be used to release high concentrations of antibiotics locally at the infection site, while minimizing systemic toxicity. The aim of this study is to determine in vitro and in vivo pharmacokinetic release profile of antibiotics from PMMA spacers and PMMA beads. For the in vitro experiment, the PMMA spacers or beads were submerged in phosphate-buffered saline and gentamicin concentrations were determined from collected specimen at several times points, measured with enzyme-linked immunosorbent assays (ELISA). To assess the in vivo antibiotic release profile of different spacers, wound drainage fluid samples were collected after implantation of a spacer over a period of maximum 14 days. After 48 h, the burst gentamicin concentration elution was 9862 ± 1782 ng/ml (mean ± SD) from spacers versus 38,394 ± 7071 ng/ml (mean ± SD) for beads. Over 35 days, spacers had eluted a cumulative mean concentration of 13,812 ± 3548 versus 55,048 ± 12,006 ng/ml for beads (p < 0.001). Clinical samples of patients with a Vancogenx® spacer showed higher gentamicin release than Refobacin™ spacers (p < 0.001). This is the first study that measured the release data of local antibiotics with ELISA. Compare to spacers, the exact release values of gentamicin from PMMA beads are more than 10 times higher and reached a maximum much later than spacers. This makes the use of PMMA beads more preferable to use for treatment of the infection itself.

Selecting a high-dose antibiotic-laden cement knee spacer

Prosthetic joint infection [PJI] after total knee arthroplasty (TKA) remains a common and challenging problem for joint replacement surgeons and patients. Once the diagnosis of PJI has been made, patient goals and characteristics as well as the infection timeline dictate treatment. Most commonly, this involves a two-stage procedure with the removal of all implants, debridement, and placement of a static or dynamic antibiotic spacer. Static spacers are commonly indicated for older, less healthy patients that would benefit from soft tissue rest after initial debridement. Mobile spacers are typically used in younger, healthier patients to improve quality of life and reduce soft-tissue contractures during antibiotic spacer treatment. Spacers are highly customizable with regard to antibiotic choice, cement variety, and spacer design, each with reported advantages, drawbacks, and indications that will be covered in this article. While no spacer is superior to any other, the modern arthroplasty surgeon must be familiar with the available modalities to optimize treatment for each patient. Here we propose a treatment algorithm to assist surgeons in deciding on treatment for PJI after TKA.

Risk Factors for Prolonged Hospital Stay After Femoral Neck Fracture

The purpose of this study was to investigate the association between pre-operative anemia and prolonged hospital stay among geriatric patients with operative femoral neck fractures. This retrospective cohort study was performed at a level I trauma center and included geriatric patients with femoral neck fractures (OTA/AO 31) and operative treatment with Current Procedural Terminology code 27236. Exclusion criteria were admission to the intensive care unit, evacuation of subdural hematoma, and conditions requiring exploratory laparotomy. A total of 207 individuals, with data collected between January 2015 and August 2019 and age 65 years and older, were included in the analysis. Linear regression was used to evaluate the association between anemia and length of stay adjusting for potential confounders. Anemia was defined using preoperative hematocrit. The primary outcome was prolonged length of stay, defined as 5 or more days. The group was 65% women. The mean age was 80.2 years (range, 64-98 years). The majority (61%) of patients had anemia. American Society of Anesthesiologists classification was associated with preoperative anemia (P=.02). Patients with anemia had a 16% higher risk of prolonged length of stay compared with patients without anemia (81% vs 65%, P=.009). In the linear regression model, preoperative hematocrit was associated with length of stay (P=.032) when adjusted for sex, age, preoperative tranexamic acid, preoperative hemoglobin, postoperative hemoglobin, and postoperative hematocrit. Length of stay was approximately 1 week in this study, with anemia being a statistically significant risk factor for prolonged length of stay. Health care providers and administrators can consider anemia on admission when predicting length of stay. [Orthopedics. 2023;46(4):211-217.].