In-hospital surgical site infections after primary hip and knee arthroplasty--incidence and risk factors

Improved outcomes with perioperative dietitian-led interventions in patients undergoing total joint arthroplasty: A systematic review

Background

Nutritional assessment is important for optimization of patients undergoing elective total joint arthroplasty (TJA). Preoperative nutritional intervention is a potentially modifiable optimization target, but the outcomes of such intervention are not well-studied. The purpose of this study is to assess the impact of nutritional interventions on elective TJA outcomes.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to perform a systematic review of the Ovid Medline, Embase, and Cochrane Library systems. Included studies were comprised of patients greater than 18 years of age undergoing a primary unilateral TJA who received a perioperative dietitian-led intervention. Data analyzed included nutritional intervention protocol, patient demographics, length of stay (LOS), postoperative labs and complications, among others.

Results

Our initial search identified a total of 1766 articles. Four studies representing 5006 patients met inclusion criteria. The studies utilized a protein-dominant diet, with or without a carbohydrate solution accompanied by dietitian assessment or education. The 4 studies found that the intervention group had significantly decreased LOS, fewer albumin infusions, less wound drainage, lower rates of hypocalcemia and hypokalemia, reduced C-reactive protein (CRP) values, improved time out of bed, and decreased overall costs.

Conclusion

The findings support the potential benefits of perioperative dietitian-led intervention on key outcomes for patients undergoing primary TJA. Surgeons should consider nutritional intervention in their preoperative optimization protocols. Future studies could help elucidate the optimum nutritional regimens and monitoring for idealized intervention and surgical timing.

Prospero registration number

CRD4202338494.

The influence of operating room temperature and humidity on surgical site infection: A multisite ACS-NSQIP analysis

BACKGROUND

Literature evaluating intraoperative temperature/humidity and risk of surgical site infection (SSI) is lacking.

METHODS

All operations at three centers reported to the ACS-NSQIP were reviewed (2016-2020); ambient intraoperative temperature (⁰F) and relative humidity (RH) were recorded in 15-min intervals. The primary endpoint was superficial SSI, which was evaluated with multi-level logistic regression.

RESULTS

14,519 operations were analyzed with 179 SSIs (1.2%). The lower/upper 10th percentiles for temperature and RH were 64.4/71.4 °F and 33.5/55.5% respectively. Low or high temperature carried no significant increased risk for SSI (Low ⁰F OR = 0.95, 95% CI 0.51-1.77, P = 0.86; High ⁰F OR = 1.13, 95% CI = 0.69-1.86, P = 0.63). This was also true for low and high RH (Low RH OR = 0.96, 95% CI 0.58-1.61, p = 0.88; High RH OR = 0.61, 95% CI = 0.33-1.14, P = 0.12). Analysis of combined temperature/humidity showed no increased risk for SSI.

CONCLUSION

Significant deviations in intraoperative temperature/humidity are not associated with increased risk of SSI.

The Effect of Prosthetic Joint Infection on Work Status and Quality of Life: A Multicenter, International Study

BACKGROUND

Periprosthetic joint infection (PJI) and subsequent revision surgeries may affect patients' social and physical health, ability to complete daily activities, and disability status. This study sought to determine how PJI affects patients' quality of life through patient-reported outcome measures with minimum 1-year follow-up.

METHODS

Patients who suffered PJI following primary total joint arthroplasty (TJA) from 2012 to 2021 were retrospectively reviewed. Patients met Musculoskeletal Infection Society criteria for acute or chronic PJI, underwent revision TJA surgery, and had at least 1 year of follow-up. Patients were surveyed regarding how PJI affected their work and disability status, as well as their mental and physical health. Outcome measures were compared between acute and chronic PJIs. In total, 318 patients (48.4% total knee arthroplasty and 51.6% total hip arthroplasty) met inclusion criteria.

RESULTS

Following surgical treatment for knee and hip PJI, a substantial proportion of patients reported that they were unable to negotiate stairs (20.5%), had worse physical health (39.6%), and suffered worse mental health (25.2%). A high proportion of patients reported worse quality of life (38.5%) and social satisfaction (35.3%) following PJI. Worse reported patient-reported outcome measures including patients' ability to complete daily physical activities were found among patients undergoing treatment for chronic PJI, and also, 23% of patients regretted their initial decision to pursue primary TJA.

CONCLUSIONS

A PJI negatively affects patients' ability to carry out everyday activities. This patient population is prone to report challenges overcoming disability and returning to work. Patients should be adequately educated regarding the risk of PJI to decrease later potential regrets.

LEVEL OF EVIDENCE

Case series (IV).

Are There Racial Differences in the Rate of Surgical Site Infection Based on Surgical Subspecialty?

Background: Surgical site infection (SSI) is a common, morbid post-operative complication. We hypothesized the presence of racial differences in SSI rates, comparing black/African American (BAA) to white non-Hispanic (WNH) patients. Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), BAA and WNH surgery patients across 10 surgical specialties were identified: general surgery (GS), vascular surgery (VS), cardiac surgery (CS), thoracic surgery (TS), orthopedics (OS), neurosurgery (NS), urology (US), otolaryngology (ENT), plastic surgery (PS), and gynecology (GYN). The primary outcome was SSI rate (superficial, deep incisional, or organ/space). The secondary outcome was rate of non-surgical infection. Pearson χ2 and Fisher exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, or Mann-Whitney U test, with statistical significance set at a value of p < 0.05. Multivariable logistic regression models were conducted to analyze the association between race/ethnicity and the infection outcomes. Results: A total of 740,144 patients were included: 99,425 (13.4%) BAA and 640,749 (86.6%) WNH, distributed as follows; 32,2976 GS, 17,6175 OS, 44,383 VS, 2,227 CS, 9,645 TS, 42,298 NS, 42,726 US, 18,518 ENT, 20,709 PS, and 60,517 GYN cases. Surgical site infection rates were higher among WNH in GS (4.4% vs. 4.1%; p = 0.003) and TS (3.1% vs. 1.7%; p = 0.015); lower in VS (3.2% vs. 4.4%; p < 0.001), OS (1.2% vs.1.6%; p < 0.001), and GYN (2.4% vs. 3%; p < 0.001); and similar between WNH and BAA in ENT (1.8% vs 1.8%; p = 0.76), and US (1.9% vs. 1.9%; p = 0.90). Non-surgical infection was higher in BAA in NS (3.2% vs. 2.5%; p = 0.003), and higher in WNH in GYN (2.6% vs. 2%; p < 0.001), OS (1.7% vs. 1.1%; p < 0.001), US (4.4% vs. 3.6%; p = 0.014), and VS (3.4% vs. 2.6%; p < 0.001). Conclusions: Variation exists in SSI rates between WNH and BAA patients among surgical subspecialties. Further research is required to understand these differences and address racial disparities in outcomes.

Patient and Surgical Risk Factors for Surgical Site Infection in Lower-Extremity Oncological Endoprosthetic Reconstruction: A Secondary Analysis of the PARITY Trial Data

BACKGROUND

The specific risk factors for surgical site infection (SSI) in orthopaedic oncology patients undergoing endoprosthetic reconstruction have not previously been evaluated in a large prospective cohort. In the current study, we aimed to define patient- and procedure-specific risk factors for SSI in patients who underwent surgical excision and endoprosthetic reconstruction for lower-extremity bone or soft-tissue tumors using the prospectively collected data of the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial.

METHODS

PARITY was a multicenter, blinded, randomized controlled trial with a parallel 2-arm design that aimed to determine the effect of a long duration (5 days) versus short duration (24 hours) of postoperative prophylactic antibiotics on the rate of SSI in patients undergoing surgical excision and endoprosthetic reconstruction of the femur or tibia. In this secondary analysis of the PARITY data, a multivariate Cox proportional hazards regression model was constructed to explore predictors of SSI within 1 year postoperatively.

RESULTS

A total of 96 (15.9%) of the 604 patients experienced an SSI. Of the 23 variables analyzed in the univariate analysis, 4 variables achieved significance: preoperative diagnosis, operative time, volume of muscle excised, and hospital length of stay (LOS). However, only hospital LOS was found to be independently predictive of SSI in the multivariate regression analysis (hazard ratio per day = 1.03; 95% confidence interval = 1.01 to 1.05; p < 0.001). An omnibus test of model coefficients demonstrated that the model showed significant improvement over the null model (χ2 = 78.04; p < 0.001). No multicollinearity was found.

CONCLUSIONS

This secondary analysis of the PARITY study data found that the only independent risk factor for SSI on multivariate analysis was hospital LOS. It may therefore be reasonable for clinicians to consider streamlined discharge plans for orthopaedic oncology patients to potentially reduce the risk of SSI.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Intra-articular Hip Injections Prior to Total Hip Arthroplasty: Infection and Cost-Related Associations

Intra-articular injections prior to total hip arthroplasty (THA) have been associated with postoperative infections. The purpose of this study was to determine whether a temporal relationship exists between hip injections prior to THA and infection. Specifically, we asked (1) Do patients who receive hip injections within 3 months of THA have a higher incidence of prosthetic joint infections (PJIs) or surgical site infections (SSIs)? and (2) Do these patients incur higher 90-day costs? Patients with hip injections prior to THA were identified using a national database from 2010 to 2019. Three laterality-specific groups (injection 0 to 3 months, 3 to 6 months, and 6 to 12 months prior to THA)were compared with a matched cohort without prior injection (n=277,841). Primary outcomes included PJIs, SSIs, and costs. Patients who had injections within 3 months of THA had a higher incidence of PJIs at 90 days (5.1% vs 1.6%, P<.01) and 1 year (6.8% vs 2.1%, P<.01), when compared with the matched cohort. They also had a higher incidence of SSIs at 90 days (2.8% vs 1.2%, P<.01) and 1 year (3.7% vs 1.7%, P<.01). Mean costs were 13.7% higher in this injection cohort. Patients who had injections between 3 and 6 months prior to THA had higher incidence and odds of postoperative PJIs at 90 days (2.6% vs 1.6%, P<.04), whereas those with injections beyond 6 months had no differences in PJIs (P≥.46). Patients who receive hip injections within 3 months of undergoing primary THA are at increased risk for postoperative PJIs, SSIs, and higher costs. This study reaffirms guidelines for when to perform THAs in these populations. [Orthopedics. 2023;46(1):19-26.].

[Periprosthetic infection after total hip replacement : Risk factors for an early infection after primary implantation]

BACKGROUND

Periprosthetic infection is one of the most serious complications in primary arthroplasty. The infection rates reported in the current literature range from 0.36 to 2.23%.

OBJECTIVES

The aim of this retrospective case-control study was to determine preoperative risk factors for the occurrence of early periprosthetic infection after primary hip arthroplasty.

MATERIALS AND METHODS

The influence of patient age, gender, body mass index (BMI), C‑reactive protein, preoperative leukocyte count and morbidity level (American Society of Anaesthesiologists score) on the occurrence of periprosthetic early infection of the hip joint was examined, and their correlation was investigated.

RESULTS

Of the 1383 patients followed up, 25 were diagnosed with early infection. With an increase in BMI of 1 kg/m², the risk of periprosthetic early infection increased by 12.1% (p < 0.001). In addition, using the receiver operating characteristic (ROC) curve, a BMI ≥ 29 kg/m² is identified as a significant cut-off for the increased likelihood of periprosthetic hip infection. Using the ROC curve, a preoperative CrP value > 5 mg/l can be validated as a cut-off value for an increased risk of early infection. Using binary logistic regression, no influence of CrP > 5 mg/l on the development of early infection was statistically proven (p = 0.065).

CONCLUSIONS

Patients with a BMI ≥ 29 kg/m² should be informed about the increased risk of periprosthetic early infection after hip prosthesis implantation and a risk assessment should be performed. Furthermore, the determination of the preoperative CrP value should be considered standard.

The role of antibiotic calcium sulfate beads in acute periprosthetic knee infection: a retrospective cohort study

Background

The study aimed to compare debridement, antibiotics, and implant retention (DAIR) vs. debridement antibiotic bead and retention of the implant (DABRI) in terms of infection-free success rate and treatment cost for acute periprosthetic joint infections after total knee arthroplasty (TKA).

Method

Between 2017 and 2020, 32 patients with acute periprosthetic joint infection who were treated by total knee arthroplasty were retrospectively reviewed. The patients were divided into a DAIR group (n=15) and a DABRI group (n=17). During the DABRI, additional calcium ulphate antibiotic beads were used. Patient age, the Musculoskeletal Infection Society score, microorganisms involved, and success rate were assessed.

Results

The mean age of DAIR group (n=15) was 69 years, with 7 being male, and 8 female. The mean follow-up period lasted 30 months. The success rate was 80% (12/15). The mean age of DABRI group (n=17) was 64 years, with 10 patients being male and 7 female. The mean follow-up period was 16 months. The success rate was 88% (15/17). There were no significant differences in patient age (P>0.05), the Musculoskeletal Infection Society score (P>0.05), and success rate (P>0.05). A significant difference was found in the follow-up period between the two groups (P<0.05).

Conclusion

Both DAIR and DABRI could be used to treat acute periprosthetic joint infections and the outcomes and treatment costs of the two procedures were comparable. Additional use of calcium sulfate beads was safe, but might not improve the treatment result. Randomized controlled studies are warranted for the routine use.

Risk Factors for Infection Following Operative Treatment of Traumatic Upper Extremity Amputation Injury

Background: Identification of the risk factors for surgical site infection (SSI) can be a straightforward and cost-effective measure to reduce or prevent the occurrence of SSI. However, there are no studies that revealed risk factors for SSI for traumatic upper extremity amputation. The aim of this study is to investigate the risk factors that promote SSI after surgery for traumatic upper extremity amputation using a large nationwide database.

Methods: We used data from the Japan Trauma Data Bank. Diagnoses were defined using the Abbreviated Injury Scale code. We applied multivariate logistic regression to evaluate the infection risk factor. We chose age, sex, vital signs, cause and type of trauma, concomitant injury, diabetes, amputation level, Glasgow coma scale, Injury Severity Score (ISS) and blood transfusion within 24 hours following hospital arrival as confounders. Receiver operating characteristic (ROC) curve analysis was adopted to identify thresholds for change in infection risk. We also applied propensity score (PS) matching to adjust for confounding factors that may affect the outcome.

Results: A total of 1,150 patients (967 males, 183 females) had traumatic upper extremity amputation. The mean patient age was 46.5 years. A total of 21 patients (1.8%) suffered from SSI. ISS, blood transfusion, systolic blood pressure (BP) and the upper extremity amputation except for finger were identified as the independent significant risk factors for SSI occurrence by the multivariate analysis (p < 0.05, p < 0.005, p < 0.05 and p < 0.005, respectively). ROC modelling revealed that patients with ISS of over 9 or systolic BP of over 160 had a risk for SSI. After PS matching, the patients with blood transfusion or systolic BP of over 160 had a significantly higher risk of infection (OR 9.0; p = 0.01 and OR 7.0; p = 0.03, respectively).

Conclusions: In treating patients with these risk factors, we must be especially careful in performing thorough debridement and wound care.

Level of Evidence: Level II (Therapeutic)

Rifampicin resistance and risk factors associated with significantly lower recovery rates after two stage revision in patients with prosthetic joint infection

PURPOSE

Rifampicin plays a key role in the management of prosthetic joint infections (PJIs), however, the emergence of rifampicin resistance is associated with less favorable clinical outcomes. The purpose of this study was to investigate the impact of rifampicin resistance and other patient-related factors on recovery rates among patients with PJI undergoing two-stage revision.

METHODS

We reviewed medical records and microbiology reports of 73 patients (41 males and 32 females) undergoing two-stage revision due to PJI between 2017 and 2019. Patient-specific data, co-morbidities and the antibiotic resistance of microbiological isolates were registered. 48 patients had hip, 22 had knee, 2 had shoulder and 1 had elbow joint infection. Obtained data were statistically analyzed with a logistic regression model.

RESULTS

Rifampicin-sensitive organism was isolated in 53 cases (72.6%). Recovery rate was 92.5% in the sensitive and 60.0% in the resistant group. We observed that rifampicin resistance significantly reduced the probability of recovery. Furthermore, in the rifampicin-sensitive group, the probability of recovery decreased with advancing age with a significant drop above the age of 60 years. The effect of age is negligible in the rifampicin-resistant group. We also found that type 2 diabetes mellitus has a negative effect on recovery. Coagulase-negative Staphylococci were predominant in the rifampicin-sensitive (50% of the isolates) and Gram-negative rods in the resistant group (40%).

CONCLUSIONS

Rifampicin resistance was associated with lower recovery rates among patients undergoing two-stage revision due to PJI. Higher age and type 2 diabetes mellitus had negative impact on clinical outcome.

Risk factors associated with surgical site infections following joint replacement surgery: a narrative review

Background

Surgical site infection following joint replacement surgery is still a significant complication, resulting in repeated surgery, prolonged antibiotic therapy, extended postoperative hospital stay, periprosthetic joint infection, and increased morbidity and mortality. This review discusses the risk factors associated with surgical site infection.

Related risk factors

The patient-related factors include sex, age, body mass index (BMI), obesity, nutritional status, comorbidities, primary diagnosis, living habits, and scores of the American Society of Anesthesiologists physical status classification system, etc. Surgery-related factors involve preoperative skin preparation, prolonged duration of surgery, one-stage bilateral joint replacement surgery, blood loss, glove changes, anti-microbial prophylaxis, topical anti-bacterial preparations, wound management, postoperative hematoma, etc. Those risk factors are detailed in the review.

Conclusion

Preventive measures must be taken from multiple perspectives to reduce the incidence of surgical site infection after joint replacement surgery.

Prediction of Early Periprosthetic Joint Infection After Total Hip Arthroplasty

Purpose

To develop a parsimonious risk prediction model for periprosthetic joint infection (PJI) within 90 days after total hip arthroplasty (THA).

Patients and Methods

We used logistic LASSO regression with bootstrap ranking to develop a risk prediction model for PJI within 90 days based on a Swedish cohort of 88,830 patients with elective THA 2008–2015. The model was externally validated on a Danish cohort with 18,854 patients.

Results

Incidence of PJI was 2.45% in Sweden and 2.17% in Denmark. A model with the underlying diagnosis for THA, body mass index (BMI), American Society for Anesthesiologists (ASA) class, sex, age, and the presence of five defined comorbidities had an area under the curve (AUC) of 0.68 (95% CI: 0.66 to 0.69) in Sweden and 0.66 (95% CI: 0.64 to 0.69) in Denmark. This was superior to traditional models based on ASA class, Charlson, Elixhauser, or the Rx Risk V comorbidity indices. Internal calibration was good for predicted probabilities up to 10%.

Conclusion

A new PJI prediction model based on easily accessible data available before THA was developed and externally validated. The model had superior discriminatory ability compared to ASA class alone or more complex comorbidity indices and had good calibration. We provide a web-based calculator (https://erikbulow.shinyapps.io/thamortpred/) to facilitate shared decision making by patients and surgeons.

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Evaluation of the costing methodology of published studies estimating costs of surgical site infections: A systematic review

OBJECTIVES

Surgical site infections (SSIs) are associated with increased length of hospitalization and costs. Epidemiologists and infection control practitioners, who are in charge of implementing infection control measures, have to assess the quality and relevance of the published SSI cost estimates before using them to support their decisions. In this review, we aimed to determine the distribution and trend of analytical methodologies used to estimate cost of SSIs, to evaluate the quality of costing methods and the transparency of cost estimates, and to assess whether researchers were more inclined to use transferable studies.

METHODS

We searched MEDLINE to identify published studies that estimated costs of SSIs from 2007 to March 2021, determined the analytical methodologies, and evaluated transferability of studies based on 2 evaluation axes. We compared the number of citations by transferability axes.

RESULTS

We included 70 studies in our review. Matching and regression analysis represented 83% of analytical methodologies used without change over time. Most studies adopted a hospital perspective, included inpatient costs, and excluded postdischarge costs (borne by patients, caregivers, and community health services). Few studies had high transferability. Studies with high transferability levels were more likely to be cited.

CONCLUSIONS

Most of the studies used methodologies that control for confounding factors to minimize bias. After the article by Fukuda et al, there was no significant improvement in the transferability of published studies; however, transferable studies became more likely to be cited, indicating increased awareness about fundamentals in costing methodologies.

The Socioeconomic Impact of Surgical Site Infections

Précis: Surgical site infections are an ever-increasing phenomenon worldwide due to different factors. This brief report aimeds to highlight at a glance, for both physicians and political and institutional leaders, the economic burden of surgical site infections.

Objectives: This brief report aimed to highlight the economic burden of surgical site infections (SSIs).

Methods: A narrative review focusing on this subject has been carried out.

Results: Surgical site infections are responsible for generating important costs. In 2017, a French cohort highlighted a mean cost of each SSI treatment to be around €1,814; the same year, the Centers for Disease Control and Prevention guidelines evaluated the mean cost caused by SSI treatment to be from $10,443 to $25,546 per SSI. This cost depends on many factors including the patient himself and the type of surgery.

Conclusions: Prevention of the risk of infection is, therefore, a profitable concept for surgery that must be integrated within all healthcare managements worldwide.

Hospital-Acquired Conditions: A Review of Classical and Novel Risk Factors Following Total Hip and Knee Arthroplasties

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In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $41,000 per patient per HAC.

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In the settings of total hip arthroplasty (THA) and total knee arthroplasty (TKA), increased age, a body mass index of >35 kg/m2, male sex, diabetes mellitus, electrolyte disturbances, and a history of anemia increase the likelihood of surgical site infections.

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Institution-specific (surgical) risk factors such as increased tourniquet time, an operative time of >130 minutes, bilateral procedures, a femoral nerve block, and general anesthesia increase the risk of HACs in the settings of THA and TKA.

Risk Factors for Deep Surgical Site Infection in Patients With Operatively Treated Tibial Plateau Fractures: A Retrospective Multicenter Study

OBJECTIVES

To identify the potential controllable risk factors for surgical site infection (SSI).

DESIGN

A retrospective cohort study.

SETTING

Seven Level-I trauma centers.

PATIENTS/PARTICIPANTS

Patients with OTA/AO 41 B or C tibial plateau fractures (n = 2106).

INTERVENTION

Various surgical treatments for tibial plateau fractures.

MAIN OUTCOME MEASUREMENTS

The primary outcome was SSI after the index operation. The secondary outcomes were the risk factors for SSI, identified using backward stepwise generalized multiple regression analysis.

RESULTS

Of the 2106 enrolled patients, 94 had deep SSIs. The average SSI rate was 4.5%. Fracture morphology revealed type B injuries in 57.5% and type C in 42.5% of the patients. Univariate regression analysis revealed that several factors, namely, number of comorbidities [>6 vs. none; odds ratio (OR) 8.01, 95% confidence interval (CI) 2.8-22.8, P < 0.001], diabetes mellitus (OR 3.5, 95% CI 2.0-6.3, P < 0.001), high body mass index (OR 1.3, 95% CI 1.1-1.6, P = 0.001), OTA/AO fracture type C (OR 5.6, 95% CI 3.3-9.5, P < 0.001), compartment syndrome (OR 9.1, 95% CI 5.7-14.8, P < 0.001), and open fracture (OR 6.6, 95% CI 3.7-11.7, P < 0.001), were associated with a significantly higher SSI risk. Analysis of microbial sensitivity tests revealed that 55.1% of the pathogens were resistant to perioperative antibiotic prophylaxis.

CONCLUSIONS

Most of the identified risk factors cannot be controlled or are subject to other factors that are difficult to control. However, our data suggest that the choice of perioperative antibiotic prophylaxis may influence the rate of SSI. This possibility should be investigated in a prospective randomized controlled trial.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Incidence and Risk Factors of In-Hospital Prosthesis-Related Complications Following Total Knee Arthroplasty: A Retrospective Nationwide Inpatient Sample Database Study

Objective

To examine the incidence and risk factors of in‐hospital prosthesis‐related complications (PRCs) following total knee arthroplasty (TKA) using a large‐scale national database.

Methods

A retrospective database analysis was performed based on Nationwide Inpatient Sample (NIS) from 2005–2014. Patients who underwent TKA were included. The recruited cases were divided into two groups according to the occurrence of PRCs. Patient demographics (age, sex, and race), hospital characteristics (type of admission and payer, and bedsize, teaching status, location, and region of hospital), length of stay (LOS), total charges during hospitalization, in‐hospital mortality, comorbidities, and perioperative complications were analyzed.

Results

A total of 1,227,244 TKAs were captured from the NIS database. There were 8484 cases of in‐hospital PRCs after TKA and the overall incidence was 0.69%, with a slight downward trend annually. Periprosthetic joint infection (PJI) was the main category among PRCs (0.20%), followed by mechanical loosening (0.04%), dislocation (0.02%), and periprosthetic fracture (PPF) (0.01%). Patients suffered from in‐hospital PRCs were 3 years younger (64 years vs 67 years) and 6.51% more likely to be male (43.60% vs 37.09%) compared to the nonaffected population (P < 0.0001). Additionally, patients experiencing in‐hospital PRCs after TKA were 2.11% less likely through elective admission (92.07% vs 94.18%) while 2.34% more likely in teaching hospital (45.53% vs 43.19%) than those without these complications (P < 0.0001). Furthermore, the occurrence of in‐hospital PRCs was associated with longer LOS (4 days vs 3 days; P < 0.0001), more total charges ($53,418 vs $41,204, P < 0.0001), and higher in‐hospital mortality (0.30% vs 0.07%; P < 0.0001). Multivariate logistic regression was performed to identify independent risk factors of in‐hospital PRCs after TKA which included younger age, male, non‐elective admission, teaching hospital, deficiency and chronic blood loss anemia, coagulopathy, congestive heart failure, depression, diabetes with chronic complications, fluid and electrolyte disorders, pulmonary circulation disorders, metastatic cancer, and weight loss. Besides, in‐hospital PRCs after TKA were associated with secondary osteoarthritis, inflammatory arthritis, prior knee arthroscopy, acute renal failure, acute myocardial infarction, deep vein thrombosis, sepsis, transfusion, and wound dehiscence.

Conclusion

It is beneficial to study the risk factors of in‐hospital PRCs after TKA to ensure the appropriate management and optimize consequences although a relatively low incidence was identified.

The Effect of Passive Smoking on Early Clinical Outcomes After Total Knee Arthroplasty Among Female Patients

PURPOSE

The aim of this study was to assess whether passive smoking affects clinical outcomes among female patients with knee osteoarthritis after being treated with total knee arthroplasty (TKA).

METHODS

The study prospectively enrolled 216 female patients who did not smoke and those patients were classified into three groups in terms of the severity of exposure to environmental tobacco smoke. A three-month follow-up was conducted to assess the physical and mental outcomes between the three groups. The physical outcomes were evaluated by the visual analogue score (VAS), range of motion (ROM), hospital for special surgery (HSS) knee score, and postoperative complications. The mental outcomes were assessed by the anxiety and depression scale (HADS) and medical outcome study short form 36 (SF-36). Subgroup analysis of patients with and without surgical site infection (SSI) was also calculated.

RESULTS

Baseline characteristics were similarly distributed between the three groups (P>0.05). Patients in the heavy passive smoking group had a higher VAS and a lower ROM score as compared with patients in the no and mild passive smoking group at discharge (P<0.01), 1 month (P<0.01), and 3 months (P<0.01) after surgery. Patients in the heavy passive smoking group also had a higher rate of HADS more than 8 at postoperative 1 month (P=0.01) and 3 months (P=0.03) and lower SF-36 summary (P<0.01) and HSS score (P<0.01) at postoperative 3 months. Forty-five postoperative complication events were observed during follow-up. Patients in the heavy passive smoking group (8.51%) had the highest SSI rate, followed by patients in the mild (1.82%) and no passive smoking group (0.88%) at discharge (P=0.02) and postoperative 1 month (P=0.03).

CONCLUSION

Passive smoking negatively affects TKA among female patients. It may trigger poor pain and functional outcomes, aggravate depression and anxiety, and deteriorate quality of life after discharge from hospital. Avoiding exposure to smoking environment may be beneficial among TKA female patients before and after surgery.

Determinants of orthopedic physicians' self-reported compliance with surgical site infection prevention: results of the WACH-trial's pilot survey on COM-B factors in a German university hospital

BACKGROUND

Prevention of surgical site infections (SSIs), which due to their long-term consequences are especially critical in orthopedic surgery, entails compliance with over 20 individual measures. However, little is known about the psychosocial determinants of such compliance among orthopedic physicians, which impedes efforts to tailor implementation interventions to improve compliance. Thus, for this professional group, this pilot survey examined psychosocial determinants of self-reported compliance, which have been theoretically derived from the COM-B (Capability, Opportunity, Motivation and Behavior) model.

METHODS

In 2019, a cross-sectional survey was conducted in a tertiary care university orthopedic clinic in Hannover, Germany, as a pilot for the WACH-trial ("Wundinfektionen und Antibiotikaverbrauch in der Chirurgie" [Wound Infections and Antibiotics Consumption in Surgery]). Fifty-two physicians participated (38 surgeons, 14 anesthesiologists; response rate: 73.2%). The questionnaire assessed self-reported compliance with 26 SSI preventive measures, and its psychosocial determinants (COM-B). Statistical analyses included descriptive, correlational, and linear multiple regression modeling.

RESULTS

Self-reported compliance rates for individual measures varied from 53.8 to 100%, with overall compliance (defined for every participant as the mean of his or her self-reported rates for each individual measure) averaging at 88.9% (surgeons: 90%, anesthesiologists: 85.9%; p = 0.097). Of the components identified in factor analyses of the COM-B items, planning, i.e., self-formulated conditional plans to comply, was the least pronounced (mean = 4.3 on the 7-point Likert scale), while motivation was reported to be the strongest (mean = 6.3). Bi-variately, the overall compliance index co-varied with all four COM-B-components, i.e., capabilities (r = 0.512, p < 0.001), opportunities (r = 0.421, p = 0.002), planning (r = 0.378, p = 0.007), and motivation (r = 0.272, p = 0.051). After mutual adjustment and adjustment for type of physician and the number of measures respondents felt responsible for, the final backward regression model included capabilities (β = 0.35, p = 0.015) and planning (β = 0.29, p = 0.041) as COM-B-correlates.

CONCLUSION

Though based on a small sample of orthopedic physicians in a single hospital (albeit in conjunction with a high survey response rate), this study found initial evidence for positive correlations between capabilities and planning skills with self-reported SSI preventive compliance in German orthopedic physicians. Analyses of the WACH-trial will further address the role of these factors in promoting SSI preventive compliance in orthopedic surgery.

TRIAL REGISTRATION

This survey was conducted as part of the research project WACH ("Wundinfektionen und Antibiotikaverbrauch in der Chirurgie" [Wound Infections and Antibiotic Consumption in Surgery]), which has been registered in the German Clinical Trial Registry ( https://www.drks.de/ ; ID: DRKS00015502).

Compensated Cirrhosis Is Associated With Increased Risk of Complications Following Total Hip Arthroplasty in a Large Medicare Database

BACKGROUND

The aim of this study is to evaluate medical and surgical complications of liver cirrhosis patients following total hip arthroplasty (THA), with attention to different etiologies of cirrhosis and their financial burden following THA.

METHODS

In total, 18,321 cirrhotics and 722,757 non-cirrhotics who underwent primary elective THA between 2006 and 2013 were identified from a retrospective database review. This cohort was further subdivided into 2 major etiologies of cirrhosis (viral and alcoholic cirrhosis) and other cirrhotic etiology. Cirrhotics were compared to non-cirrhotics for hospital length of stay, 90-day mean total charges and reimbursement, hospital readmission, and major medical and arthroplasty-specific complications.

RESULTS

Cirrhosis was associated with increased rates of major medical complications (4.3% vs 2.4%; odds ratio [OR] 1.20, P < .001), minor medical complications, transfusion (3.4% vs 2.1%; OR 1.16, P = .001), encephalopathy, disseminated intravascular coagulation, and readmission (13.5% vs 8.6%; OR 1.18, P < .001) within 90 days. Cirrhosis was associated with increased rates of revision, periprosthetic joint infection, hardware failure, and dislocation within 1 year postoperatively (3.1% vs 1.6%; OR 1.37, P < .001). Cirrhosis independently increased hospital length of stay by 0.14 days (P < .001), and it independently increased 90-day charges and reimbursements by $13,791 (P < .001) and $1707 (P < .001), respectively. Viral and alcoholic cirrhotics had higher rates of 90-day and 1-year complications compared to controls-other causes only had higher rates of 90-day medical complications, encephalopathy, readmission, and 1-year revision, hardware failure, and dislocation compared to controls.

CONCLUSION

Cirrhosis, especially viral and alcoholic etiologies, is associated with higher risk of early postoperative complications and healthcare utilization following elective THA.

Operative Duration and Short-Term Postoperative Complications after Unicompartmental Knee Arthroplasty

BACKGROUND

Prolonged operative duration is an independent risk factor for postoperative complications in many orthopedic procedures ranging from shoulder arthroscopy to total hip and knee arthroplasties. It has not been well studied in unicompartmental knee arthroplasty (UKA). The purpose of this study is to assess the effect of operative duration on complications after UKA.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified all primary unilateral UKAs from 2005 to 18. Patients were divided into three cohorts based on the operative duration: < 90 minutes, between 90 and 120 minutes, and >120 minutes. Baseline patient and operative demographics (age, gender, etc.) and thirty-day complications were compared using bivariate analysis. Multivariate analysis was used to assess the independent effect of operative duration on postoperative outcomes after adjusting for differences in baseline characteristics.

RESULTS

We identified 11,806 patients who underwent primary UKA from 2005 to 18. There was no difference in the "any complication" rate between cohorts. However, operative duration >120 minutes was associated with a significantly higher likelihood of reoperation (odds ratio [OR] 2.02, 95% confidence interval [CI]: 1.15-3.57, P = .015), non-home discharge (OR: 2.14, CI: 1.65-2.77, P < .001), surgical site infection (OR: 1.76, CI: 1.03-3.01, P = .038), and blood transfusions (OR: 3.23, CI: 1.44-7.22, P = .004) when compared with operative duration <90 minutes. There was no difference in mortality rates.

CONCLUSION

Increased operative duration greater than 2 hours in primary UKA is associated with an increased risk of non-home discharge, surgical site infection, reoperation, and blood transfusion.

Hair of the Dog? Periprosthetic Joint Infection with Streptococcus can is

A 61-year-old man underwent elective primary total hip arthroplasty at an academic center and presented to the emergency department 2 weeks later with a periprosthetic infection. Intraoperative cultures were positive for Streptococcus canis. He was successfully treated with one-stage revision and 6 weeks of intravenous cefazolin. It was later determined that the patient has a pet dog who frequently licks his legs. We hypothesize that patients with pets are more likely to carry this pathogen as part of their skin microbiome, and further research is required to establish whether S. canis poses an infectious risk beyond that of normal group B Streptococcus skin flora and if preoperative decolonization strategies are warranted.

The Impact of Hepatitis C and Liver Disease on Risk of Complications After Total Hip and Knee Arthroplasty: Analysis of Administrative Data From Louisiana and Texas

Background

Millions of Americans have hepatitis C and other liver diseases, many of whom have end-stage osteoarthritis requiring total joint arthroplasty (TJA). This study aimed to determine the extent to which hepatitis C and other liver diseases are independent risk factors for complications, including readmission and reoperation, in patients undergoing TJA.

Methods

Retrospective study of a REACHnet data set containing demographics, International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and clinical and laboratory data for patients who underwent primary total knee or hip replacement from 2013 to 2017 at 3 hospital systems in Louisiana and Texas. Multivariable logistic regression analyses examined predictors of complications. Any complication was defined as a 90-day medical complication or readmission or reoperation within 1 year.

Results

Among 13,673 patients who met inclusion criteria, 14.9% (2044/13,673) had any complication, 11.7% (1600/13,673) were readmitted within 90 days, and 3.6% (497/13,673) had a reoperation within 1 year. Liver disease increased the odds for any complication (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.18), 90-day medical complication (OR, 1.13; 95% CI, 1.04-1.22), and 90-day readmission (OR, 1.11; 95% CI, 1.06-1.17). Hepatitis C was not, by itself, associated with an increase in any type of complication but was usually associated with liver disease. Comorbidity severity was the strongest predictor of all types of complications after TJA.

Conclusion

Patients in Louisiana and Texas with liver disease were at increased risk for complications after TJA, corroborating findings of previous studies. Hepatitis C was not an independent predictor of complications because of its high association with liver disease.

The Association of Calcium and Vitamin D Use With Implant Survival of Total Knee Arthroplasty: A Nationwide Population-Based Cohort Study

BACKGROUND

Calcium and vitamin D have been regarded as beneficial nutrients for bone metabolism that may affect survival of arthroplasties. However, the relationship between their use and revision rate of knee arthroplasty has not been evaluated. Thus, we investigated an association between calcium and vitamin D use and the revision rate after primary total knee arthroplasty.

METHODS

A nationwide population-based cohort study was conducted using the Korean National Health Insurance database. We included patients diagnosed with knee osteoarthritis and underwent primary total knee arthroplasty between 2009 and 2018. Risk for arthroplasty revision was estimated using a Cox proportional hazards model with time-dependent covariates. Log-rank test was used to assess survival of knee arthroplasty.

RESULTS

Out of 142,147 subjects, 28,403 were calcium and vitamin D users and 113,744 were never users. Calcium and vitamin D significantly reduced the revision risk with a 6-month drug use lag period (adjusted hazard ratio [aHR] 0.56, 95% confidence interval [CI] 0.45-0.70). Calcium and vitamin D combination use for more than 1 year was associated with reduced revision risks in both patients with periprosthetic joint infection (aHR 0.63, 95% CI 0.42-0.95) and patients without infection (aHR 0.70, 95% CI 0.54-0.91). Implant survival was significantly improved in calcium and vitamin D combination users for more than 1 year compared with never users (log-rank P < .001).

CONCLUSION

Combination use of calcium and vitamin D with a dose of 800 IU or greater for more than 1 year was associated with the greatest reduction in the risks for revision surgery after total knee arthroplasty.

Prevalence of surgical site infection after orthopaedic surgery with two types of drainage at three public hospitals in Iran

INTRODUCTION

Orthopaedic surgical site infections (SSIs) are among the most important and prevalent because implanted devices are used in such surgeries which increase the risk of infection. This study aimed to examine the incidence of infection in orthopaedic surgeries and related factors in a group of public hospitals in Iran.

METHODS

This analytical cross-sectional study was condcuted in 2018. Data were collected about the incidence of infection and related factors including use/non-use of drains and well as types of drain . The presence of SSIs were determined using a researcher-devised Wound Infection Checklist (WIC) and microbial cultures.

RESULTS

Of 110 included patients undergoing orthopaedic surgeries, 18.2% had an infection. The highest rate of infection was associated with lower extremity surgeries following tibia and fibula fractures. The incidence of infection among individuals under the age of 35 years was also higher. Emergency procedures demonstrated a higher incidence of infection. No significant relationship was observed between use of wound drains and development of SSIs.

CONCLUSION

Reducing the incidence of orthopaedic infection can be achieved by focusing more attention on open fractures occurring in the lower extremity. Use of surgical drains for the sole purpose of reducing the rate of infection is not effective. Accordingly, infection provention protocols should be implemented in orthopaedic surgery units to control and reduce rates of infection.

Trends in surgical volume and in-hospital mortality among United States cirrhosis hospitalizations

Background

In the aging population of patients with cirrhosis in the United States, there is a potentially increased need for surgical procedures. However, individuals with cirrhosis have increased perioperative risk relative to patients without cirrhosis. We sought to quantify temporal trends in cirrhosis surgical procedures and in-hospital mortality in relation to surgical procedure type, elective admission status and compensated vs. decompensated status.

Methods

We performed a retrospective cohort study of cirrhosis hospitalizations between 2005 and 2014 using the National Inpatient Sample. Surgical procedures of interest included cholecystectomy, hernia repair, and major abdominal, orthopedic and cardiovascular surgery. We plotted trends in volume and in-hospital mortality by procedure type, and used linear regression to test the significance of trends.

Results

While the number of cirrhosis hospitalizations increased over time, the number of surgeries per 1000 admissions decreased (b=-1.454, P<0.001). When stratified by elective admission status, elective major orthopedic surgeries significantly increased over time (b=177.9; P<0.001). In-hospital mortality rates for most surgeries were significantly higher in the non-elective vs. elective setting (each P<0.001). In patients with compensated cirrhosis, there was a significant increase in the number of orthopedic (b=272.4; P<0.001) and hernia repair surgeries over time (b=191.1; P<0.001). Overall, there was significantly greater in-hospital mortality among patients with decompensated cirrhosis (each P<0.05). Q. Please mention the exact P-value unless <0.001

Conclusions

Despite an increasing number of cirrhosis hospitalizations, the decreasing relative number of cirrhosis surgeries may indicate progressive surgical risk aversion. Future cirrhosis surgical risk scores should consider surgical procedure type, elective/non-elective status, and decompensation status.

Association of Medicare Mandatory Bundled Payment System for Hip and Knee Joint Replacement With Racial/Ethnic Difference in Joint Replacement Care

Importance

There are marked racial/ethnic differences in hip and knee joint replacement care as well as concerns that value-based payments may exacerbate existing racial/ethnic disparities in care.

Objective

To examine changes in joint replacement care associated with Medicare's Comprehensive Care for Joint Replacement (CJR) model among White, Black, and Hispanic patients.

Design, Setting, and Participants

Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic patients undergoing joint replacement in 67 treatment (selected for CJR participation) and 103 control metropolitan statistical areas.

Exposures

The CJR model holds hospitals accountable for spending and quality of joint replacement care during care episodes (index hospitalization through 90 days after discharge).

Main Outcomes and Measures

The primary outcomes were spending, discharge to institutional postacute care, and readmission during care episodes.

Results

Among 688 346 patients, 442 163 (64.2%) were women, and 87 286 (12.7%) were 85 years or older. Under CJR, spending decreased by $439 for White patients (95% CI, -$718 to -$161; from pre-CJR spending in treatment metropolitan statistical areas of $25 264) but did not change for Black patients and Hispanic patients. Discharges to institutional postacute care decreased for all groups (-2.5 percentage points; 95% CI, -4.7 to -0.4, from pre-CJR risk of 46.2% for White patients; -6.0 percentage points; 95% CI, -9.8 to -2.2, from pre-CJR risk of 59.5% for Black patients; and -4.3 percentage points; 95% CI, -7.6 to -1.0, from pre-CJR risk of 54.3% for Hispanic patients). Readmission risk decreased for Black patients by 3.1 percentage points (95% CI, -5.9 to -0.4, from pre-CJR risk of 21.8%) and did not change for White patients and Hispanic patients. Under CJR, Black-White differences in discharges to institutional postacute care decreased by 3.4 percentage points (95% CI, -6.4 to -0.5, from the pre-CJR Black-White difference of 13.3 percentage points). No evidence was found demonstrating that Black-White differences changed for other outcomes or that Hispanic-White differences changed for any outcomes under CJR.

Conclusions and Relevance

In this cohort study of patients receiving joint replacements, CJR was associated with decreased readmissions for Black patients. Furthermore, Black patients experienced a greater decrease in discharges to institutional postacute care relative to White patients, representing relative improvements despite concerns that value-based payment models may exacerbate existing disparities. Nonetheless, differences between White and Black patients in joint replacement care still persisted even after these changes.

What Are Risk Factors for Infection after Primary or Revision Total Joint Arthroplasty in Patients Older Than 80 Years?

BACKGROUND

Patients older than 80 years of age form an increasing proportion of the patient population undergoing total joint arthroplasty (TJA). With increasing life expectancy and the success of TJA, orthopaedic surgeons are more likely to operate on patients older than 80 years than ever before. Given that most other studies focus on younger populations, only evaluate primary TJA, or limit patient populations to institutional or regional data, we felt a large-database, nationwide analysis of this demographic cohort was warranted, and we wished to consider both primary and revision TJA.

QUESTIONS/PURPOSES

In this study, we sought to investigate the risk factors for surgical site infections (SSIs) at 90 days and periprosthetic joint infections (PJIs) at 2 years after surgery in patients aged 80 years and older undergoing (1) primary and (2) revision lower extremity TJA.

METHODS

All patients aged 80 years or older who underwent primary or revision TJA between 2005 and 2014 were identified using the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is unique in that it is one of the largest nationwide databases, and so it provides a large enough sample size of patients 80 years or older. Additionally, this database provides comprehensive and longitudinal patient data tracking, and a low error rate. Our final cohort consisted of 503,241 patients (TKA: n = 275,717; THA: n = 162,489; revision TKA: n = 28,779; revision THA: n = 36,256). Multivariate logistic regression models were constructed to evaluate the association of risk factors on the incidences of 90-day SSI and 2-year PJI. Variables such as sex, diabetes, BMI, and congestive heart failure, were included in the multivariate regression models. Several high-risk comorbidities as identified by the Charlson and Elixhauser comorbidity indices were selected to construct the models. We performed a Bonferroni-adjusted correction to account for the fact that multiple statistical comparisons were made, with a p value < 0.002 being considered statistically significant.

RESULTS

For primary TKA patients, an increased risk of 90-day SSIs was associated with male sex (OR 1.28 [95% CI 1.25 to 1.52]; p < 0.001), BMI greater than 25 k/m (p < 0.001), and other comorbidities. For primary THA patients, an increased risk of 90-day SSIs was associated with patients with obesity (BMI 30-39 kg/m; OR 1.91 [95% CI 1.60 to 2.26]; p < 0.001) and those with morbid obesity (BMI 40-70 kg/m; OR 2.58 [95% CI 1.95 to 3.36]; p < 0.001). For revision TKA patients, an increased risk of SSI was associated with iron-deficiency anemia (OR 1.82 [95% CI 1.37 to 2.28]; p < 0.001). For revision THA patients, electrolyte imbalance (OR 1.48 [95% CI 1.23 to 1.79]; p < 0.001) and iron-deficiency anemia (OR 1.63 [95% CI 1.35 to 1.99]; p < 0.001) were associated with an increased risk of 90-day SSI. Similar associations were noted for PJI in each cohort.

CONCLUSIONS

These findings show that in this population, male sex, obesity, hypertension, iron-deficiency anemia, among other high-risk comorbidities are associated with a higher risk of SSIs and PJIs. Based on these findings, orthopaedic surgeons should actively engage in comanagement strategies with internists and other specialists to address modifiable risk factors through practices such as weight management programs, blood pressure reduction, and electrolyte balancing. Furthermore, this data should encourage healthcare systems and policy makers to recognize that this patient demographic is at increased risks for PJI or SSI, and these risks must be considered when negotiating payment bundles.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Are high-risk patient and revision arthroplasty effective indications for closed-incisional negative-pressure wound therapy after total hip or knee arthroplasty? A systematic review and meta-analysis

To determine the effective indications of closed-incisional negative-pressure wound therapy (ciNPWT) following total hip or knee arthroplasty, this systematic review and meta-analysis was conducted. The systematic search was performed on MEDLINE, Embase, and Cochrane Library, and 11 studies were included. The studies comparing between ciNPWT and conventional dressings were categorised into following subgroups based on patient risk and revision procedures: routine vs high-risk patient; primary vs revision arthroplasty. Pooled estimates were calculated for wound complication and surgical site infection (SSI) rates in the subgroup analyses using Review Manager. In high-risk patients, the overall rates of wound complication (odds ratio [OR] = 0.38; 95% confidence interval [CI] 0.15-0.93; P = .030) and SSI (OR = 0.24; 95% CI = 0.09-0.64; P = .005) were significantly lower in the ciNPWT; however, there were no differences in routine patients. In cases involving revision arthroplasties, the overall rates of wound complication (OR = 0.33; 95% CI = 0.18-0.62; P < .001) and SSI (OR = 0.26; 95% CI = 0.11-0.66; P = .004) were significantly lower in the ciNPWT; however, there were no differences in cases involving primary arthroplasties. In summary, ciNPWT showed a positive effect in decreasing the rates of wound complication and SSI in high-risk patients and in revision arthroplasties.

Variability of patient and surgical risk factors for infection in a single, urban, academic total joint replacement center

Background

We describe surgeon-specific patient and procedure variability in a single center to determine how much variability exists between surgeons.

Methods

Data was analyzed from 2009 to 2013 at a single center. The total number of primary and revision hip and knee arthroplasty surgeries were quantified for each surgeon.

Results

Surgeon caseload varied significantly, with the largest differences observed in primary TKA caseload. The largest patient differences were in regards to percentage of patients with diabetes mellitus amongst primary TKA patients.

Conclusion

Significant differences in patient characteristics that could significantly impact outcomes after total joint arthroplasty were found amongst surgeons.

Risk factors for periprosthetic joint infection after total knee arthroplasty

INTRODUCTION

Periprosthetic joint infection (PJI) is the most serious and feared complication in total knee arthroplasty (TKA) and can have catastrophic consequences. The number of total knee arthroplasties is increasing, so infections could also be greater in the future. The aim of this study is to identify the most relevant risk factors associated with infection after a total knee arthroplasty.

METHODS

This is a case-control study of patients who underwent total knee arthroplasty at the University Hospital of Salamanca. We included 66 TKA PJI patients and 66 control TKA patients. Demographic and clinical variables were collected. A descriptive and inferential analysis was performed by logistic regression and attributable risk fraction assessed.

RESULTS

Prolonged operative time (> 90') and tourniquet time (> 60') were the most relevant risk factors described (OR 40.77, AFE 0.97, p > 0.001 and OR 37.14, AFE 0.97, p < 0.001, respectively). The use of non-antibiotic-laded cement (OR 3.62), obesity (BMI > 30, OR 8.86), diabetes (OR 2.33), high ASA grade (III-IV, OR 15.30), and blood transfusion requirement (OR 4.60) were also statistically significant risk factors for TKA PJI.

CONCLUSIONS

Our study provides evidence concerning that operative time, tourniquet time, cement type, diabetes, obesity, ASA grade, and blood transfusion requirement as independently associated risk factors for TKA PJI. Modifiable risk factors were specifically relevant, so we should be able to reduce the infection rate.

Biodistribution, biocompatibility and targeted accumulation of magnetic nanoporous silica nanoparticles as drug carrier in orthopedics

BACKGROUND

In orthopedics, the treatment of implant-associated infections represents a high challenge. Especially, potent antibacterial effects at implant surfaces can only be achieved by the use of high doses of antibiotics, and still often fail. Drug-loaded magnetic nanoparticles are very promising for local selective therapy, enabling lower systemic antibiotic doses and reducing adverse side effects. The idea of the following study was the local accumulation of such nanoparticles by an externally applied magnetic field combined with a magnetizable implant. The examination of the biodistribution of the nanoparticles, their effective accumulation at the implant and possible adverse side effects were the focus. In a BALB/c mouse model (n = 50) ferritic steel 1.4521 and Ti90Al6V4 (control) implants were inserted subcutaneously at the hindlimbs. Afterwards, magnetic nanoporous silica nanoparticles (MNPSNPs), modified with rhodamine B isothiocyanate and polyethylene glycol-silane (PEG), were administered intravenously. Directly/1/7/21/42 day(s) after subsequent application of a magnetic field gradient produced by an electromagnet, the nanoparticle biodistribution was evaluated by smear samples, histology and multiphoton microscopy of organs. Additionally, a pathohistological examination was performed. Accumulation on and around implants was evaluated by droplet samples and histology.

RESULTS

Clinical and histological examinations showed no MNPSNP-associated changes in mice at all investigated time points. Although PEGylated, MNPSNPs were mainly trapped in lung, liver, and spleen. Over time, they showed two distributional patterns: early significant drops in blood, lung, and kidney and slow decreases in liver and spleen. The accumulation of MNPSNPs on the magnetizable implant and in its area was very low with no significant differences towards the control.

CONCLUSION

Despite massive nanoparticle capture by the mononuclear phagocyte system, no significant pathomorphological alterations were found in affected organs. This shows good biocompatibility of MNPSNPs after intravenous administration. The organ uptake led to insufficient availability of MNPSNPs in the implant region. For that reason, among others, the nanoparticles did not achieve targeted accumulation in the desired way, manifesting future research need. However, with different conditions and dimensions in humans and further modifications of the nanoparticles, this principle should enable reaching magnetizable implant surfaces at any time in any body region for a therapeutic reason.

Comparison of Functional Outcomes and Associated Complications in Patients Who Underwent Total Hip Arthroplasty for Femoral Neck Fracture in Relation to Their Underlying Medical Comorbidities

Purpose

In patients with independent mobility, full hip range of motion and sufficient muscle strength for daily life without cognitive impairment, treatment of a femoral neck fracture with total hip arthroplasty (THA) may be a better option compared to bipolar hip hemiarthroplasty. Here, functional outcomes and complications in patients who underwent THA for femoral neck fracture based on their comorbidity status were analyzed.

Materials and Methods

Between January 2013 and December 2018, 110 patients were treated with THA for femoral neck fractures at our institution. These patients were retrospectively analyzed for clinical outcomes at final follow-up (mean=24.4 months, range: 6-81 months) using the Harris hip score (HHS) and the presence or absence of two potential comorbidities: i) diabetes mellitus (DM; 35 with and 75 without) and ii) hypertension (HTN; 50 with and 60 without).

Results

The incidence of superficial infections at the surgical site in patients with DM was significantly higher compared with patients without DM (P=0.024). There were no significant differences in other potential complications based on DM status. HHS at final follow-up between patients with and without DM and with and without HTN were not significantly different (83.3 vs. 81.0, P=0.39 and 81.6 vs. 82.4, P=0.75, respectively).

Conclusion

Superficial infections occurred more frequently in patients with DM compared with patients without DM. DM and HTN status are not correlated with HHS.

Incidence and predictors of early complications following primary and revision total ankle arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) offers an effective option for end-stage osteoarthritis. The incidence and preoperative risk factors for early adverse events (AEs) following primary and revision TAA may be useful information for providers.

METHODS

A large database was queried from 2010 to 2016 to identify 905 patients of whom 818 underwent primary TAA (90.4%) and 87 underwent revision TAA (9.6%). Data on patient demographics, comorbidities, and hospital length of stay were analyzed as risk factors for reported 30-day AEs.

RESULTS

The overall AE rate was 5.5% (50/905) for the entire cohort. AEs occurred more frequently for revision TAA (9/87) than primary TAA (41/818) cases (OR 2.43, p=0.022). Age (OR 1.03, p=0.045), BMI (OR 1.04, p=0.046), and revision TAA (OR 2.56, p=0.002) were independent risk factors for 30-day AEs in multivariate analysis.

CONCLUSIONS

Older age, higher BMI, and revision cases are associated with a higher risk of AEs.

Total hip arthroplasty in patients with chronic liver disease: A systematic review

INTRODUCTION

Chronic liver disease (CLD) is a significant and increasingly prevalent co-morbidity in patients undergoing total hip arthroplasty (THA). These patients may develop metabolic bone disease (MBD) and systemic dysfunction, which pose challenges to THA surgery. This systematic review of literature aims to examine clinical outcomes and complications in patients with CLD undergoing THA and provide evidence-based approaches as to the optimization of their perioperative care.

METHODS

A Pubmed search was performed, identifying eight studies on 28 514 THAs for inclusion. Two additional studies reported on 44 patients undergoing THA post liver transplant. These were reviewed separately.

RESULTS

Increased early perioperative complications are reported recurrently. Review of long-term complications demonstrates an increased postoperative infection rate of 0.5% (p < 0.001) and perioperative mortality of 4.1% (p < 0.001). The need for revision surgery is more frequent at 4% (p < 0.001). Aetiology of need for revision surgery included; periprosthestic infection (70%), aseptic loosening (13%), instability (13%), periprosthetic fracture (2%) and liner wear (2%). THA in patients with liver transplants seems to offer functional improvement; however, no studies have formally assessed functional outcomes in the patient with active CLD.

DISCUSSION

A multidisciplinary perioperative approach is suggested in order to minimize increased complication risks. Specific measures include optimizing haemoglobin and taking measures to reduce infection. This review also highlights gaps in available literature and guides future research to appraise functional outcomes, further detail long-term failure reasons and study any differences in outcomes and complications based on the range of operative approaches and available implant choices.

Comparison of the Efficacy Between Closed Incisional Negative-Pressure Wound Therapy and Conventional Wound Management After Total Hip and Knee Arthroplasties: A Systematic Review and Meta-Analysis

BACKGROUND

Wound-related problems after total hip arthroplasty (THA) and total knee arthroplasty (TKA) can cause periprosthetic joint infections. We sought to evaluate the effect of closed incisional negative-pressure wound therapy (ciNPWT) on wound complications, skin blisters, surgical site infections (SSIs), reoperations, and length of hospitalization (LOH).

METHODS

Studies comparing ciNPWT with conventional dressings following THA and TKA were systematically searched on MEDLINE, Embase, and the Cochrane Library. Two reviewers performed the study selection, risk of bias assessment, and data extraction. Funnel plots were employed to evaluate publication bias and forest plots to analyze pooled data.

RESULTS

Twelve studies were included herein. The odds ratios (ORs) for wound complications and SSIs indicated a lack of publication bias. ciNPWT showed significantly lower risks of wound complication (OR, 0.44; 95% confidence interval [CI], 0.22-0.9; P = .027) and SSI (OR, 0.39; 95% CI, 0.23-0.68; P < .001) than did conventional dressings. ciNPWT also yielded a significantly lower reoperation rate (OR, 0.38; 95% CI, 0.21-0.69; P = .001) and shorter LOH (mean difference, 0.41 days; 95% CI, -0.51 to -0.32; P < .001). However, the rate of skin blisters was higher in ciNPWT (OR, 4.44; 95% CI, 2.24-8.79; P < .001).

CONCLUSION

Although skin blisters were more likely to develop in ciNPWT, the risks of wound complication, SSI, reoperation, and longer LOH decreased in ciNPWT compared with those in conventional dressings. This finding could alleviate the potential concerns regarding wound-related problems after THA and TKA.

Infection after operative fixation of tibia plateau fractures. A risk factor analysis

INTRODUCTION

Surgical fixation of tibial plateau fractures has been shown to improve long-term functional outcomes, but a major complication is that of postoperative infection which can be deleterious to long-term outcomes. This study aims to assess the impact of common comorbidities on the risk of postoperative infection.

METHOD

A retrospective study of 210 consecutive operatively treated patients, treated at two Level 1 Trauma Centres over a 27-month period was performed. Records were analysed to assess the presence of the study factors; smoking, alcohol intake >13 units/week, diabetes, and BMI > 30. The impact of these factors on infection was assessed with univariate and multivariate analyses.

RESULTS

175 patients were included in the study, 56.6% male with a mean age of 46.9 years (± 18.2 years). Excessive alcohol consumption of >13 units/week was the only significant risk factor for postoperative infection (p = 0.05) on multivariate analysis.

CONCLUSION

This study has identified excessive alcohol consumption as the only independent risk factor for postoperative infection in patients with all types of tibial plateau fracture treated with operative fixation. No relationship between smoking, diabetes nor obesity was found for postoperative infection.

Impact of patient comorbidities on surgical site infection within 90 days of primary and revision joint (hip and knee) replacement

BACKGROUND

The frequency of primary and revision total knee and hip replacements (pTKRs, rTKRs, pTHRs, and rTHRs, respectively) is increasing in the United States due to demographic changes. This study evaluated the impact of preoperative patient and clinical factors on the risk of surgical site infection (SSI) within the 90-day period after primary and revision total joint replacements (TJR).

METHODS

A retrospective observational cohort study was designed using the IBM MarketScan and Medicare databases, 2009-2015. Thirty-four comorbidities were assessed for all patients, and multivariable logistic regression models were used to evaluate factors associated with higher odds of SSI after adjusting for other patient and clinical preoperative conditions.

RESULTS

The study included a total of 335,134 TKRs and 163,547 THRs. SSI rates were 15.6% and 8.6% after rTKR and rTHR, respectively, compared with 2.1% and 2.1% for pTKR and pTHR, respectively. Comorbidities with the greatest adjusted effect on SSI across all TJRs were acquired immunodeficiency syndrome (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.06-2.34; P = .0232), paralysis (OR, 1.56; 95% CI, 1.26-1.94; P < .0001), coagulopathy (OR, 1.48; 95% CI, 1.36-1.62; P < .0001), metastatic cancer (1.48; 95% CI, 1.24-1.76; P < .0001), and congestive heart failure (OR, 1.39; 95% CI, 1.30-1.49; P < .0001).

CONCLUSIONS

SSI occurred most commonly among patients after revision TJR and were related to many patient comorbidities, including diabetes, congestive heart failure, and coagulopathy, which were significantly associated with a higher risk of SSI after TJR.

Incidence and risk factors of surgical site infection after total knee arthroplasty: Results of a retrospective cohort study

Knee arthroplasty is commonly performed in the case of advanced osteoarthritis, and deep joint infections represent a severe complication following surgery. A 4-year retrospective cohort study was conducted to determine the incidence and risk factors for such surgical site infections. Of the 2439 patients included in the study, 84 of them (3.4%) developed infections. Postoperative bleeding, Ahlbäck's disease, obesity, smoking, and male gender were independent risk factors that should be considered when caring for those patients.

Systemic sclerosis is associated with knee arthroplasty outcomes: a National US study

OBJECTIVE

To assess whether systemic sclerosis (SSc) is associated with total knee arthroplasty (TKA) outcomes.

METHODS

We used the 1998-2014 US National Inpatient Sample. We conducted multivariable-adjusted logistic regression analyses to examine the association of a diagnosis of SSc with post-TKA in-hospital complications (implant infection, revision, transfusion, mortality) and healthcare utilization (hospital charges, hospital stay, non-home vs. home discharge). Odds ratios (OR) and 95 % confidence intervals (CI) were calculated.

RESULTS

Our cohort included 8,123,388 people without SSc and 3894 people with SSc. In multivariable-adjusted analyses, compared to people without SSc, people with SSc had higher odds of transfusion, hospital stay > 3 days and non-home discharge with higher OR of 1.42 (95 % CI, 1.20, 1.69), 1.29 (95 % CI, 1.11, 1.49), and 1.29 (95 % CI, 1.11, 1.49), respectively. No differences were seen in revision, 0.68 (95 % CI, 0.10, 4.69) or hospital charges above the median, 1.01 (95 % CI, 0.70, 1.46). Differences in implant infection or mortality were not estimable, since none of the patients with SSc had implant infection or died. Sensitivity analyses that adjusted the main analysis additionally for hospital-level variables confirmed study findings with minimal or no attenuation of OR.

CONCLUSION

SSc was associated with higher risk of transfusion and increased healthcare utilization after TKA. Future studies should examine if interventions can address modifiable factors to further optimize these outcomes.Key Points• Systemic sclerosis was independently associated with higher healthcare utilization after TKA.• The adjusted odds of transfusion was higher in people with systemic sclerosis compared to those without systemic sclerosis who underwent TKA.

Economic burden of surgical site infections within the episode of care following joint replacement

Background

Recent policy initiatives, including Bundled Payments for Care Improvement (BPCI) Initiative by the Centers for Medicare and Medicaid Health Services (CMS), encourage healthcare providers to manage the total episode of care, rather than just the surgical episode. Surgical site infections (SSI) following total joint replacement result in preventable morbidity and suffering for patients and excess healthcare utilization for healthcare providers. This study sought to estimate the additional resources associated with SSIs within the 90-day episode of care following hip and knee joint replacement.

Methods

Using the 2013 Nationwide Readmissions Database (NRD), healthcare resource utilization was compared between propensity score matched patient groups with and without SSI-related readmissions within the 90-day episode of care following total joint replacement.

Results

Surgical site infections were associated with significantly longer hospital length of stay and increased costs following hip and knee joint replacement procedures. Generalized estimating equation regression results confirmed that additional costs associated with SSIs following both cohorts were significant, with additional hospital length of stay and costs following total hip and knee replacement procedures ranging from 4.9 to 5.2 days and $12,689 to $12,890, respectively.

Conclusion

Surgical site infections following total joint replacement account for significant additional healthcare resource use within the 90-day episode of care.

Risk factors associated with revision for prosthetic joint infection following knee replacement: an observational cohort study from England and Wales

Background

Prosthetic joint infection is a devastating complication of knee replacement. The risk of developing a prosthetic joint infection is affected by patient, surgical, and health-care system factors. Existing evidence is limited by heterogeneity in populations studied, short follow-up, inadequate power, and does not differentiate early prosthetic joint infection, most likely related to the intervention, from late infection, more likely to occur due to haematogenous bacterial spread. We aimed to assess the overall and time-specific associations of these factors with the risk of revision due to prosthetic joint infection following primary knee replacement.

Methods

In this cohort study, we analysed primary knee replacements done between 2003 and 2013 in England and Wales and the procedures subsequently revised for prosthetic joint infection between 2003 and 2014. Data were obtained from the National Joint Registry linked to the Hospital Episode Statistics data in England and the Patient Episode Database for Wales. Each primary replacement was followed for a minimum of 12 months until the end of the observation period (Dec 31, 2014) or until the date of revision for prosthetic joint infection, revision for another indication, or death (whichever occurred first). We analysed the data using Poisson and piecewise exponential multilevel models to assess the associations between patient, surgical, and health-care system factors and risk of revision for prosthetic joint infection.

Findings

Of 679 010 primary knee replacements done between 2003 and 2013 in England and Wales, 3659 were subsequently revised for an indication of prosthetic joint infection between 2003 and 2014, after a median follow-up of 4·6 years (IQR 2·6–6·9). Male sex (rate ratio [RR] for male vs female patients 1·8 [95% CI 1·7–2·0]), younger age (RR for age ≥80 years vs <60 years 0·5 [0·4–0·6]), higher American Society of Anaesthesiologists [ASA] grade (RR for ASA grade 3–5 vs 1, 1·8 [1·6–2·1]), elevated body-mass index (BMI; RR for BMI ≥30 kg/m²vs <25 kg/m² 1·5 [1·3–1·6]), chronic pulmonary disease (RR 1·2 [1·1–1·3]), diabetes (RR 1·4 [1·2–1·5]), liver disease (RR 2·2 [1·6–2·9]), connective tissue and rheumatic diseases (RR 1·5 [1·3–1·7]), peripheral vascular disease (RR 1·4 [1·1–1·7]), surgery for trauma (RR 1·9 [1·4–2·6]), previous septic arthritis (RR 4·9 [2·7–7·6]) or inflammatory arthropathy (RR 1·4 [1·2–1·7]), operation under general anaesthesia (RR 1·1 [1·0–1·2]), requirement for tibial bone graft (RR 2·0 [1·3–2·7]), use of posterior stabilised fixed bearing prostheses (RR for posterior stabilised fixed bearing prostheses vs unconstrained fixed bearing prostheses 1·4 [1·3–1·5]) or constrained condylar prostheses (3·5 [2·5–4·7]) were associated with a higher risk of revision for prosthetic joint infection. However, uncemented total, patellofemoral, or unicondylar knee replacement (RR for uncemented vs cemented total knee replacement 0·7 [95% CI 0·6–0·8], RR for patellofemoral vs cemented total knee replacement 0·3 [0·2–0·5], and RR for unicondylar vs cemented total knee replacement 0·5 [0·5–0·6]) were associated with lower risk of revision for prosthetic joint infection. Most of these factors had time-specific effects, depending on the time period post-surgery.

Interpretation

We have identified several risk factors for revision for prosthetic joint infection following knee replacement. Some of these factors are modifiable, and the use of targeted interventions or strategies could lead to a reduced risk of revision for prosthetic joint infection. Non-modifiable factors and the time-specific nature of the effects we have observed will allow clinicians to appropriately counsel patients preoperatively and tailor follow-up regimens.

Funding

National Institute for Health Research.

Use of Closed Incisional Negative Pressure Wound Therapy After Revision Total Hip and Knee Arthroplasty in Patients at High Risk for Infection: A Prospective, Randomized Clinical Trial

BACKGROUND

Continuous wound drainage after arthroplasty can lead to the development of a periprosthetic joint infection. Closed incisional negative pressure wound therapy (ciNPWT) has been reported to help alleviate drainage and other wound complications. The purpose of this prospective randomized controlled trial is to compare the use of ciNPWT with our standard of care dressing in revision arthroplasty patients who were at high risk to develop wound complications.

METHODS

A total of 160 patients undergoing elective revision arthroplasty were prospectively randomized to receive either ciNPWT or a silver-impregnated occlusive dressing after surgery in a single institution. Patients were included if they had at least 1 risk factor for developing wound complication(s): wound complication, readmission, and reoperation rates were collected at 2, 4, and 12 weeks postoperatively.

RESULTS

The postoperative wound complication rate was significantly higher in the control cohort compared to the ciNPWT cohort (19 [23.8%] vs 8 [10.1%], P = .022). There was no significant difference between the control and ciNPWT cohorts in terms of readmissions (19 [23.8%] vs 16 [20.3%], P = .595). Reoperation rate was higher in controls compared to ciNPWT patients (10 [12.5%] vs 2 [2.5%], P = .017). After adjusting for the history of a prior periprosthetic joint infection and inflammatory arthritis, the ciNPWT cohort had a significantly decreased wound complication rate (odds ratio 0.28, 95% confidence interval 0.11-0.68).

CONCLUSION

ciNPWT may decrease the rate of postoperative wound complications in patients who are at an increased risk of such wound issues after revision arthroplasty.

Major Aseptic Revision Following Total Knee Replacement: A Study of 478,081 Total Knee Replacements from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

Major revision is associated with less satisfactory outcomes, substantial complications, and added cost. Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were analyzed to identify factors associated with major aseptic revision (MAR) of primary total knee replacement (TKR).

METHODS

The cumulative percent major aseptic revision rate following all primary TKRs performed in Australia from September 1, 1999, to December 31, 2015, was assessed. Kaplan-Meier estimates of survivorship were utilized to describe the time to first revision. Hazard ratios (HRs) from Cox proportional hazard models, adjusted for age and sex, were utilized to compare revision rates.

RESULTS

There were 5,973 MARs recorded from the total cohort of 478,081 primary TKRs. The cumulative percent MAR at 15 years was 3.0% (95% confidence interval [CI], 2.8% to 3.2%). Fixed bearings had a significantly lower rate of MAR at 15 years: 2.7% (95% CI, 2.4% to 2.9%) compared with 4.1% (95% CI, 3.8% to 4.5%) for mobile bearings (HR, 1.77 [95% CI, 1.68 to 1.86]; p < 0.001). Age had a significant effect on MAR rates, with a cumulative percent revision at 15 years for patients <55 years old of 7.8% (95% CI, 6.5% to 9.2%) compared with 1.0% for those ≥75 years old (95% CI, 0.8% to 1.1%; p < 0.001). Minimally stabilized TKR had a lower rate of MAR compared with posterior-stabilized TKR after 2 years (HR, 0.83 [95% CI, 0.77 to 0.90]; p < 0.001). Cementless fixation had a higher rate of revision than cemented or hybrid fixation. There was a higher rate of MAR with non-navigated compared with computer navigated TKR (HR, 1.32 [95% CI, 1.21 to 1.44], p < 0.001). The tibial component was revised more commonly than the femoral component.

CONCLUSIONS

Younger age, posterior stabilization, cementless fixation, a mobile bearing, and non-navigation were risk factors for higher rates of MAR following TKR.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does the Use of Antibiotic-Loaded Bone Cement Have an Effect on Deep Infection in Primary Total Knee Arthroplasty Practice?

BACKGROUND

Total knee arthroplasty (TKA) is performed to improve the quality of life by reducing knee arthralgia. One of the most destructive and expensive complications of TKA is deep infection. The primary purpose of this study was to evaluate the effect of using antibiotic-loaded bone cement (ALBC) on the incidence of deep infection after primary TKA.

PATIENTS AND METHODS

A total of 506 patients who underwent primary knee arthroplasty at the Antalya Training and Research Hospital between February 2009 and January 2016 were investigated retrospectively.

RESULTS

The ALBC was used for 85 patients (16.7%), who constituted group 1. Plain bone cement was used for 421 patients (83.2%), who constituted group 2. Deep infection was observed in one patient (1.1%) in group 1 and in six patients (1.4%) in group 2, a difference that is not statistically significant. On average, the deep infection occurred six months after the surgery at the earliest and 19 months at the latest.

CONCLUSION

Use of ALBC did not decrease the incidence of deep infection in TKA. Therefore, we prefer bone cement without any antibiotic.