2019 Frank Stinchfield Award: A comparison of prosthetic joint infection rates between direct anterior and non-anterior approach total hip arthroplasty

A Randomized Clinical Trial of Direct Anterior Versus Mini-Posterior Total Hip Arthroplasty: Small, Early Functional Differences Did Not Lead to Meaningful Clinical Differences at 7.5 Years

BACKGROUND

Our previously reported randomized clinical trial of direct anterior approach (DAA) versus mini-posterior approach (MPA) total hip arthroplasty showed slightly faster initial recovery for patients who had a DAA and no differences in complications or clinical or radiographic outcomes beyond 8 weeks. The aims of the current study were to determine if early advantages of DAA led to meaningful clinical differences beyond 5 years and to identify differences in midterm complications.

METHODS

Of the 101 original patients, 93 were eligible for follow-up at a mean of 7.5 years (range, 2.1 to 10). Clinical outcomes were compared with Harris Hip, 12-Item Short Form Health Survey, and Hip Disability and Osteoarthritis Outcomes Scores (HOOS) scores and subscores, complications, reoperations, and revisions.

RESULTS

Harris Hip scores were similar (95.3 ± 6.0 versus 93.5 ± 10.3 for DAA and MPA, respectively, P = .79). The 12-Item Short Form Health Survey physical and mental scores were similar (46.2 ± 9.3 versus 46.2 ± 10.6, P = .79, and 52.3 ± 7.1 versus 55.2 ± 4.5, P = .07 in the DAA and MPA groups, respectively). The HOOS scores were similar (97.4 ± 7.9 versus 96.3 ± 6.7 for DAA and MPA, respectively, P = .07). The HOOS quality of life subscores were 96.9 ± 10.8 versus 92.3 ± 16.0 for DAA and MPA, respectively (P = .046). No clinical outcome met the minimally clinically important difference. There were 4 surgical complications in the DAA group (1 femoral loosening requiring revision, 1 dislocation treated closed, and 2 wound dehiscences requiring debridement), and 6 surgical complications in the MPA group (3 dislocations, 2 treated closed, and 1 revised to dual mobility; 2 intraoperative fractures treated with a cable; and 1 wound dehiscence treated nonoperatively).

CONCLUSIONS

At a mean of 7.5 years, this randomized clinical trial demonstrated no clinically meaningful differences in outcomes, complications, reoperations, or revisions between DAA and MPA total hip arthroplasty.

LEVEL OF EVIDENCE

IV.

Incision Closure for Direct Anterior Total Hip Arthroplasty: Is There a Difference in the Rate of Superficial Wound Complications With Suture Versus Staples?

Background Direct anterior total hip arthroplasty (DA-THA) has increased in popularity over recent decades. However, DA-THA has been reported to have a higher incidence of superficial wound complications, including infection and incisional dehiscence, compared to other surgical approaches to hip arthroplasty. While this indicates a need for optimal wound closure, little research exists on the preferred method of skin closure following DA-THA. This study aimed to determine if there was any difference in rates of superficial infection, wound dehiscence, or overall wound complications with skin closure using a running subcuticular 3-0 Monocryl® suture compared to surgical staples following DA-THA.  Methods Records of patients who underwent DA-THA at our institution between July 2017 to July 2022 were retrospectively reviewed. Data were abstracted on patient demographics, comorbidities, skin closure method, and wound complications from the electronic medical record. Superficial infection and wound dehiscence were classified based on explicit diagnosis in post-operative records and incision photographs taken during follow-up visits. Overall wound complications were classified in patients who experienced either superficial infection, incisional dehiscence, or both complications following surgery. Descriptive statistics and chi-squared measures were obtained from post-operative patient data, and significance was set at p [Formula: see text] 0.05. Results A total of 365 DA-THAs were completed in 349 patients. A running subcuticular 3-0 Monocryl® suture closed 207 surgeries (56.7%), while surgical staples closed 158 surgeries (43.3%). There was no significant difference in independent rates of superficial infection (p = 0.076) or wound dehiscence (p = 0.118) between suture and staple cohorts; however, suture closure (10, 2.7%) was associated with a significantly higher rate of overall wound complications compared to staple closure (1, 0.3%) (p = 0.020). Conclusion DA-THA carries the risk of overall wound complications, including superficial infection and wound dehiscence. Our findings suggest superficial skin closure with staples may be preferred over sutures due to lower rates of overall wound complications. Further studies are needed to determine the optimal method of skin closure following DA-THA.

Femoral head size and surgical approach affect dislocation and overall revision rates in total hip arthroplasty: up to 9-year follow-up data of 269,280 procedures in the Dutch Arthroplasty Register (LROI)

BACKGROUND

Femoral head size and surgical approach might affect the revision rate for dislocation and for any other reason after total hip arthroplasty (THA). We penetrated this question based on registry data with up to 9-year follow-up.

METHODS

269,280 primary THAs documented in the Dutch Arthroplasty Registry (LROI) between 2007 and 2019 were included. Revision rates were calculated by competing risk analyses. Multivariable Cox proportional hazard regression ratios (HR) were used for comparison.

RESULTS

Revisions for dislocation were rare. They were more frequent after posterolateral (1.4% [95% CI, 1.3-1.5]), compared to straight lateral (0.6% [95% CI, 0.5-0.7]), anterolateral (0.6% [95% CI, 0.5-0.7]) and anterior (0.4% [95% CI, 0.3-0.5]) approach. Larger femoral head size decreased the dislocation revision risk: 1.4% [95% CI, 1.3-1.5) for 22-28-mm heads; 0.9% (95% CI, 0.8-1.0) for 32-mm heads; 0.6% (95% CI, 0.6-0.7) for 36-mm heads. For the anterior approach, the HR for both revision for dislocation (0.3, 95% CI, 0.3-0.4) and any other reason (0.8, 95% CI, 0.8-0.9) were lowest compared to other approaches including posterolateral (HR 1). Revision risk for any other reason was highest with anterolateral (HR 1.3 (95% CI, 1.2-1.4)) and straight lateral approach (1.1 [95% CI, 1.0-1.2]).

CONCLUSIONS

The anterior approach might reduce revision rates for both dislocation and all cause revision. Posterolateral approach is associated with a higher risk of dislocation revision but has a lower risk of any other revision. Increasing femoral head size up to 36 mm reduces revision for dislocation and improves overall revision rates for all approaches.

Patient-related risk factors of prosthetic joint infections following total hip and knee arthroplasty at King Abdulaziz Medical City, a 10-year retrospective study

BACKGROUND

Total joint arthroplasty (TJA) can be associated with the development of periprosthetic joint infection (PJI). It is necessary to determine the modifiable and non-modifiable risk factors of PJI to provide optimum healthcare to TJA candidates.

METHODS

This single-center retrospective review investigated 1198 patients who underwent TJA from 2012 to 2022. The data analysis comprised two stages. The first stage was a descriptive analysis, while the second stage was a bivariate analysis. The sociodemographic data, medical history, operative details, and presence of PJI postoperatively were evaluated.

RESULTS

The study sample consisted of 1198 patients who underwent TJA. The mean patient age was 63 years. Among the patients, only 1.3% had PJI. No comorbidity was significantly related to PJI. General anesthesia was used in almost 21% of the patients and was significantly associated with a higher risk of infection (p = 0.049). An increased operative time was also significantly related to PJI (p = 0.012). Conversely, tranexamic acid (TXA) administration was a protective factor against PJI (p = 0.017).

CONCLUSION

Although PJI is not a common complication of TJA, multiple risk factors such as general anesthesia and prolonged operative time play a significant role in its development. In contrast, TXA administration is thought to reduce the risk of PJI effectively.

No Difference in the Rate of Periprosthetic Joint Infection in Patients Undergoing the Posterolateral Compared to the Direct Anterior Approach

BACKGROUND

There remains inconsistent data about the association of surgical approach and periprosthetic joint infection (PJI). We sought to evaluate the risk of reoperation for superficial infection and PJI after primary total hip arthroplasty (THA) in a multivariate model.

METHODS

We reviewed 16,500 primary THAs, collecting data on surgical approach and all reoperations within 1 year for superficial infection (n = 36) or PJI (n = 70). Considering superficial infection and PJI separately, we used Kaplan-Meier survivorship to assess survival free from reoperation and a Cox Proportional Hazards multivariate models to assess risk factors for reoperation.

RESULTS

Between direct anterior approach (DAA) (N = 3,351) and PLA (N = 13,149) cohorts, rates of superficial infection (0.4 versus 0.2%) and PJI (0.3 versus 0.5%) were low and survivorship free from reoperation for superficial infection (99.6 versus 99.8%) and PJI (99.4 versus 99.7%) were excellent at both 1 and 2 years. The risk of developing superficial infection increased with high body mass index (BMI) (hazard ratio [HR] = 1.1 per unit increase, P = .003), DAA (HR = 2.7, P = .01), and smoking status (HR = 2.9, P = .03). The risk of developing PJI increased with the high BMI (HR = 1.04, P = .03), but not surgical approach (HR = 0.68, P = .3).

CONCLUSION

In this study of 16,500 primary THAs, DAA was independently associated with an elevated risk of superficial infection reoperation compared to the PLA, but there was no association between surgical approach and PJI. An elevated patient BMI was the strongest risk factor for superficial infection and PJI in our cohort.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Intraosseous Vancomycin in Total Hip Arthroplasty - Superior Tissue Concentrations and Improved Efficiency

BACKGROUND

Literature shows that intraosseous (IO) infusions are capable of providing increased local concentrations compared to those administered via intravenous (IV) access. Successes while using the technique for antibiotic prophylaxis administration in total knee arthroplasty (TKA) prompted consideration for use in total hip arthroplasty (THA) however; no study exists for the use of IO vancomycin in THA.

METHODS

This single-blinded randomized control trial was performed from December 2020 to May 2022. Twenty patients were randomized into one of two groups: IV vancomycin (15 mg/kg) given routinely, or IO vancomycin (500mg/100cc of NS) injected into the greater trochanter during incision. Serum vancomycin levels were collected at incision and closure. Soft tissue vancomycin levels were taken from the gluteus maximus (at start and end of case), and acetabular pulvinar tissue. Bone vancomycin levels were taken from the femoral head, acetabular reamings, and intramedullary bone. Adverse local/systemic reactions, 30-day and 90-day complications were also tracked.

RESULTS

A statistically significant reduction in serum vancomycin levels was seen when comparing IO to IV vancomycin at both the start and end of the procedure. All local tissue samples had higher concentrations of vancomycin in the IO group. Statistically significant increases were present within the acetabular bone reamings, and approached significance in intramedullary femoral bone.

CONCLUSION

This study demonstrates the utility of IO vancomycin in primary THA with increased local tissue and decreased systemic concentrations. With positive findings in an area without tourniquet use, IO may be considered for antibiotic delivery for alternative procedures.

A propensity score-matched analysis on the impact of patient and surgical factors on early periprosthetic joint infection in minimally invasive anterolateral and transgluteal total hip arthroplasty

INTRODUCTION

Increased risk of periprosthetic joint infection (PJI) in minimally invasive (MIS) total hip arthroplasty (THA) is still debated. This study aimed to identify differences in surgical and patient-related risk factors for PJI between an MIS anterolateral approach and transgluteal-modified Hardinge approach.

METHODS

A retrospective cohort of 5315 THAs performed between 2006 and 2019 at a single institution was screened. Short stem THAs performed via an MIS anterolateral approach in the supine position and standard straight stem THAs performed via a transgluteal modified Hardinge approach were included. Propensity score matching was performed to control for selection bias. After matching, 1405 (34.3%) short stem THAs implanted via MIS anterolateral approach and 2687 (65.7%) straight stem THAs implanted via a transgluteal modified Hardinge approach were included. The risk of PJI due to patient-specific and surgical factors was retrospectively analyzed using chi-square test and multivariate regression analysis.

RESULTS

PJI occurred in 1.1% in both MIS anterolateral and transgluteal approach (p = 0.823). Multivariate regression showed an increased infection risk for patients with a BMI between 35 and 39.99 kg/m² (OR 6.696; CI 1.799-24.923; p = 0.005), which could not be demonstrated for transgluteal approach (OR 0.900; CI 0.900-4.144; p = 0.93). A BMI ≥ 40 kg/m² (OR 14.150; CI 2.416-82.879; p = 0.003) was detected as a risk factor for PJI only in anterolateral approach. Increased operation time ≥ 121 min showed a significantly increased risk for PJI in the general cohort (OR 6.989; CI1.286-37.972; p = 0.024).

CONCLUSION

Minimally invasive anterolateral and transgluteal THA show a comparable rate of early PJI within the first year of index surgery. A BMI of ≥ 35 kg/m² was detected as a clear risk factor for infection in the anterolateral approach. Prolonged operation time ≥ 121 min increases the risk of PJI regardless of approach.

Penile Implants: A Lesson from the First 50 Years

This year marks the fiftieth anniversary of the first implant of an inflatable penile prosthesis (IPP). The authors of this paper want to celebrate the event with a narrative review of the current literature. The main scopes are antibiotic prophylaxis, patient satisfaction, and future developments. The implant of the first IPP in 1973, performed by Branteley Scott was a turning point in the history of penile prosthesis, revolutionizing the treatment of erectile dysfunction (ED). Since then, the idea of an inflatable device has not changed much. However, the innovations in design, materials, surgical techniques, and perioperative management led to a more natural, durable, and reliable device featuring fewer complications and greater patient satisfaction. Currently, IPP is associated with high patient satisfaction and excellent long-term outcomes, remaining the gold standard for men with refractory ED. Several strategies are under investigation to improve the technology of penile prosthesis, and we expect in the next future the introduction of new devices that are easier to activate, discreet, comfortable when deflated, and durable in time, mimicking a more physiological erection.

Comparison of periprosthetic joint infection rates in the direct anterior approach and non-anterior approaches to primary total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

Periprosthetic joint infection is a serious complication and devastating mode of failure of total hip arthroplasty. Various surgical approaches exist for total hip arthroplasty, including the increasingly popularised direct anterior approach. There is no clear consensus on which approach is least associated with periprosthetic joint infection. The objective of this meta-analysis was to compare the rate of periprosthetic joint infection between surgical approaches to primary total hip arthroplasty for osteoarthritis.

METHODS

A search of 3 electronic databases (PubMed/MEDLINE, Embase, and Cochrane Library) was conducted for relevant studies up to June 2020 with a defined list of inclusion and exclusion criteria. Randomised controlled trials and longitudinal studies reporting periprosthetic joint infection rates after primary total hip arthroplasty for osteoarthritis were included based on surgical approach. Data extraction was completed, and a meta-analysis was then performed using OpenMeta[Analyst] software.

RESULTS

A total of 24,407 hips were included for meta-analysis with an overall PJI incidence of 0.57%. The incidence rate for periprosthetic joint infection was 0.77% in the direct anterior approach group and 0.44% in the non-anterior approach group. The use of an anterior approach for a total hip arthroplasty was associated with an increased risk for periprosthetic joint infection (odds ratio = 1.404; 95% confidence interval, 0.711-2.771; p = 0.03).

CONCLUSIONS

The direct anterior approach to total hip arthroplasty may be associated with a significantly increased risk for periprosthetic joint infection compared to non-anterior approaches, even though the overall rate was still small. This should be considered by orthopedic surgeons when choosing the surgical approach.

Periprosthetic joint infection rates across primary total hip arthroplasty surgical approaches: a systematic review and meta-analysis of 653,633 procedures

INTRODUCTION

Evidence demonstrates comparable clinical outcomes across the various surgical approaches to primary total hip arthroplasty (THA). However, high-quality contemporary data regarding periprosthetic joint infection (PJI) risk between direct anterior approach (DAA) and other (THA) approaches is lacking. This systematic review and meta-analysis evaluated PJI rates reported in the literature between the DAA and other approaches.

MATERIALS AND METHODS

Five online databases were queried for all studies published from January 1st, 2000 through February 17th, 2021 that reported PJI rates between DAA and other surgical approaches. Studies reporting on primary THAs for osteoarthritis (OA) and that included PJI rates segregated by surgical approach were included. Articles reporting on revision THA, alternative THA etiologies, or minimally invasive techniques were excluded. Mantel-Haenszel (M-H) models were utilized to evaluate the pooled effect of surgical approach on infection rates. Validated risk of bias and methodological quality assessment tools were applied to each study. Multiple sensitivity analyses were conducted to evaluate the robustness of analyses.

RESULTS

28 articles reporting on 653,633 primary THAs were included. No differences were found between DAA cohorts and combined other approaches (OR: 0.95; 95% CI 0.74-1.21; p = 0.67) as well as segregated anterolateral approach cohorts (OR: 0.82, 95% CI 0.64-1.06; p = 0.13). However, DAA patients had a significantly reduced risk of infection compared to those undergoing posterior (OR: 0.66, 95% CI 0.58-0.74; p < 0.0001) and direct lateral (OR: 0.56, 95% CI 0.48-0.65; p < 0.00001) approaches.

CONCLUSION

The DAA to primary THA had comparable or lower PJI risk when compared to other contemporary approaches. The results of the most up-to-date evidence available serve to encourage adult reconstruction surgeons who have already adopted the DAA. Additionally, orthopaedic surgeons considering adoption or use of the direct anterior approach for other reasons should not be dissuaded over theoretical concern for a general increase in the risk of PJI.

LEVEL OF EVIDENCE

Level III.

Randomized Controlled Trial of Incisional Negative Pressure Following High-Risk Direct Anterior Total Hip Arthroplasty

BACKGROUND

The direct anterior (DA) approach to total hip arthroplasty (THA) is associated with higher rates of surgical site complications (SSCs) compared to other approaches, particularly among high-risk patients. Closed incision negative pressure therapy (ciNPT) is effective in reducing SSCs and surgical site infections (SSIs) in other populations. We asked whether ciNPT could decrease SSCs in high-risk patients undergoing DA THA.

METHODS

This prospective randomized controlled trial (RCT) enrolled high-risk DA THA patients at 3 centers. Patients were offered enrollment if they had previously identified risk factors for SSC: Body mass index (BMI) >30 kg/m², diabetes, active smoking, or before hip surgery. Patients were randomized after closure to either an occlusive (control) dressing or ciNPT dressing for 7 days. All 90-day SSCs were recorded. A priori power analysis demonstrated 116 patients were required to identify a 4.5x relative reduction in SSCs. Chi-square tests were used to evaluate probability of complications.

RESULTS

One hundred and twenty two patients enrolled; 120 completed data collection. SSCs occurred in 18.3% (11/60) of control patients compared to 8.3% (5/60) of ciNPT patients (χ² = 2.60, P = .107). SSCs included dehiscence to the subcutaneous level (13) and prolonged drainage (3). Nine control (15.0%) and 2 ciNPT (3.3%) patients met CDC criteria for superficial SSI (χ² = 4.90, P = .027). Fifteen of 16 SSCs resolved with local wound care. One in the ciNPT group required reoperation for acute PJI.

CONCLUSION

Among patients at risk of surgical site complications undergoing DA THA, we identified a significant reduction in superficial SSIs and a trend toward lower overall SSCs with ciNPT.

Operative Time and Risk of Surgical Site Infection and Periprosthetic Joint Infection: A Systematic Review and Meta-Analysis

BACKGROUND

The purpose of this study was to perform a systematic review and meta-analysis on the association between operative time and peri-prosthetic joint infection (PJI) after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

PubMed, Embase, and Cochrane CENTRAL databases were searched for relevant articles dating 2000-2020. Relationship of operative time and PJI rate in primary total joint arthroplasty (TJA) was evaluated by pooled odds ratios (OR) and 95% confidence intervals.

RESULTS

Six studies were identified for meta-analysis. TJA lasting greater than 120 minutes had greater odds of PJI (OR, 1.63 [1.00-2.66], p=0.048). Similarly, there were greater odds of PJI for TJA procedures lasting greater than 90 minutes (OR, 1.65 [1.27-2.14]; p<0.001). Separate analyses of TKA (OR, 2.01 [0.76-5.30]) and THA (OR, 1.06 [0.80-1.39]) demonstrated no difference in rates of PJI in cases of operative time ≥ 120 minutes versus cases < 120 minutes (p>0.05 for all). Using any surgical site infection (SSI) as an endpoint, both TJA (OR, 1.47 [1.181.83], p<0.001) and TKA (OR, 1.50 [1.08-2.08]; p=0.016) procedures lasting more versus less than 120 minutes demonstrated significantly higher odds of SSI.

CONCLUSION

Following TJA, rates of SSI and PJI are significantly greater in procedures ≥120 minutes in duration relative to those < 120 minutes. When analyzing TKA separately, higher rates of SSI were observed in procedures ≥ 120 minutes in duration relative to those <120 minutes. Rates of PJI in TKA or THA procedures alone were not significantly impacted by operative time. Level of Evidence: V.

A comparative of a single novice surgeon's direct anterior approach and posterior approach learning curves in total hip arthroplasty: a retrospective cohort study

INTRODUCTION

The purpose of the present study was to compare a novice surgeon's learning curves with the direct anterior approach and posterior approach in total hip arthroplasty.

METHODS

A consecutive series of 376 total hip arthroplasties performed from November 2014 to September 2019 in a level-one healthcare center by a single surgeon (V.B) were retrospectively studied. Demographic data, functional outcomes, and complications were collected and compared.

RESULTS

Within the ranks of the patients studied, we found differences between groups with respect to dislocation rate and length of stay; these were lower in the direct anterior approach (DAA) group. The approach was not associated with an increase in complications, but rather with a decrease in the rate of dislocations and better functional outcomes at 1-year follow-up. Operative time was initially higher with this approach, but equalized during the learning curve.

CONCLUSION

The DAA can be safe even in the early stages of a novice surgeon's learning curve. It does not present a higher complication rate than the posterior approach, either in infection rate or in periprosthetic fractures. However, the DAA may provide greater functionality, lower dislocation rate and a shorter hospital stay. It can also be concluded that after having performed a certain number of interventions, operative time for the DAA can be comparable to that of other approaches.

Direct anterior approach hip arthroplasty: How to reduce complications - A 10-years single center experience and literature review

BACKGROUND

The direct anterior approach for total hip arthroplasty (DAA-THA) is increasing in popularity due to some advantages such as less surgical trauma, minimal dissection of soft tissues, shorter rehabilitation times, faster return to daily activities, lower incidence of dislocation. On the other hand, the literature reports a high rate of intraoperative complications, with many different rates and complication types in the published papers.

AIM

To analyze our complications comparing results with the literature; to report measures that we have taken to reduce complications rate.

METHODS

All DAA-THA patients with one year minimum follow up who were operated at a single high-volume centre, between January 2010 and December 2019 were included in this retrospective study. All surgeries were performed using cementless short anatomical or straight stems and press fit cups. Patients’ follow-up was performed, at 6 wk, 3 mo, then annually post-surgery with clinical and radiological evaluation. Primary outcomes were stem revision for aseptic loosening and all-cause stem revision. Second outcome was intra-operative and post-operative complications identification.

RESULTS

A total of 394 patients underwent DDA-THA from January 2010 and December 2019, for a total of 412 hips; twelve patients lost to follow-up and one patient who died from causes not related to surgery were excluded from the study. The average age at the time of surgery was 61 years (range from 28 to 78 years). Mean follow-up time was 64.8 mo (range 12-120 mo). Seven stems were revised. One cortical perforation, one trochanteric and lateral cortical wall intraoperative fracture, one diaphyseal fracture, three clinically symptomatic early subsidence and one late aseptic loosening. We also observed 3 periprosthetic fractures B1 according to the Vancouver Classification. Other minor complications not requiring stem revision were 5 un-displaced fractures of the calcar region treated with preventive cerclage, one early infection, one case of late posterior dislocation, 18 case of asymptomatic stem subsidence, 6 cases of lateral cutaneous femoral nerve dysesthesia.

CONCLUSION

DAA is associated to good outcomes and lower incidence of dislocation. Complication rate can be reduced by mindful patient selection, thorough preoperative planning, sufficient learning curve and use of intraoperative imaging.

Inhaled Corticosteroids, Vitamin K Antagonists and Amlodipine Were Associated with an Increased Risk of Acute Periprosthetic Joint Infection in Patients with Total Hip Arthroplasty: A Retrospective Case–Cohort Study

The perioperative use of certain medication may influence the risk of developing a periprosthetic joint infection (PJI). Inhaled corticosteroids (ICSs) and cardiovascular drugs are widely used against pulmonary and cardiovascular diseases. While oral corticosteroids and anticoagulants have been shown to increase the risk of developing PJI, this is not clear for ICSs. In contrast, some cardiovascular drugs, such as amlodipine, nifedipine and statins, have been documented to show an antimicrobial effect, suggesting a synergistic effect with antibiotics in the treatment of (multi-resistant) microorganisms. We performed a case–cohort study to assess the association between the occurrence of PJI after THA and the use of inhaled corticosteroids, anticoagulants, or previously mentioned cardiovascular agents. In a cohort of 5512 primary THAs, we identified 75 patients with a PJI (1.4%), and randomly selected 302 controls. A weighted Cox proportional hazard regression model was used for the study design and to adjust for potential confounders (age, sex, smoking, and cardiovascular/pulmonary disease). We found ICS use (HR 2.6 [95% CI 1.1–5.9]), vitamin K antagonist use (HR 5.3 [95% CI 2.5–11]), and amlodipine use (HR 3.1 [95% CI 1.4–6.9]) to be associated with an increased risk of developing PJI after THA. The effect remained after correction for the mentioned possible confounders. The underlying diseases for which the medications are prescribed could also play a role in the mentioned association; we believe, however, that the usages of ICSs, vitamin K antagonists and amlodipine appear to be potential modifiable risk factors for PJI, and therefore have to be questioned during preoperative screening and consultation.

Does Surgical Approach for Total Hip Arthroplasty Impact Infection Risk in the Obese Patient? A Systematic Review

This systematic review evaluated the combined effects of obesity and surgical approach on periprosthetic joint infection (PJI) rates after total hip arthroplasty (THA). Wound complication and PJI rates were elevated among patients with body mass index (BMI) of 30 kg/m2 or greater and 35 kg/m2 or greater, respectively, with the direct anterior approach (DAA). A BMI of 30 kg/m2 or greater also increased the risk of PJI with the posterior approach. Patients with BMI of 30 kg/m2 or greater undergoing anterolateral approach THA did not have increased risk of PJI. Patients with elevated BMI (≥30 kg/m2) are at risk for PJI, regardless of approach. Patients undergoing DAA THA who have BMI of 35 kg/m2 or greater may have an increased risk of PJI compared with those undergoing THA with other approaches. [Orthopedics. 2022;45(2):e67-e72.].

Timing and duration of antibiotic prophylaxis is associated with the risk of infection after hip and knee arthroplasty

AIMS

Antibiotic prophylaxis involving timely administration of appropriately dosed antibiotic is considered effective to reduce the risk of surgical site infection (SSI) after total hip and total knee arthroplasty (THA/TKA). Cephalosporins provide effective prophylaxis, although evidence regarding the optimal timing and dosage of prophylactic antibiotics is inconclusive. The aim of this study is to examine the association between cephalosporin prophylaxis dose, timing, and duration, and the risk of SSI after THA/TKA.

METHODS

A prospective multicentre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKA/THA at one of 19 high-volume Australian public/private hospitals. Data were collected prior to and for one-year post surgery. Logistic regression was undertaken to explore associations between dose, timing, and duration of cephalosporin prophylaxis and SSI. Data were analyzed for 1,838 participants. There were 264 SSI comprising 63 deep SSI (defined as requiring intravenous antibiotics, readmission, or reoperation) and 161 superficial SSI (defined as requiring oral antibiotics) experienced by 249 (13.6%) participants within 365 days of surgery.

RESULTS

In adjusted modelling, factors associated with a significant reduction in any SSI and deep SSI included: correct weight-adjusted dose (any SSI; adjusted odds ratio (aOR) 0.68 (95% confidence interval (CI) 0.47 to 0.99); p = 0.045); commencing preoperative cephalosporin within 60 minutes (any SSI, aOR 0.56 (95% CI 0.36 to 0.89); p = 0.012; deep SSI, aOR 0.29 (95% CI 0.15 to 0.59); p < 0.001) or 60 minutes or longer prior to skin incision (aOR 0.35 (95% CI 0.17 to 0.70); p = 0.004; deep SSI, AOR 0.27 (95% CI 0.09 to 0.83); p = 0.022), compared to at or after skin incision. Other factors significantly associated with an increased risk of any SSI, but not deep SSI alone, were receiving a non-cephalosporin antibiotic preoperatively (aOR 1.35 (95% CI 1.01 to 1.81); p = 0.044) and changing cephalosporin dose (aOR 1.76 (95% CI 1.22 to 2.57); p = 0.002). There was no difference in risk of any or deep SSI between the duration of prophylaxis less than or in excess of 24 hours.

CONCLUSION

Ensuring adequate, weight-adjusted dosing and early, preoperative delivery of prophylactic antibiotics may reduce the risk of SSI in THA/TKA, whereas the duration of prophylaxis beyond 24 hours is unnecessary. Cite this article: Bone Jt Open 2022;3(3):252-260.

Differential microbiological spectrum and resistance pattern in periprosthetic hip joint infections: a matched-cohort analysis comparing direct anterior versus lateral approach

BACKGROUND

In recent years, total hip arthroplasty via the direct anterior approach (DAA) has become more common. Little is known on the influence of the surgical approach on the microbiological spectrum and resistance pattern in periprosthetic hip joint infections. The aim of the present study was to evaluate the microbiological spectrum and resistance pattern in periprosthetic hip joint infections comparing the direct anterior versus lateral approach in a matched-cohort analysis at a single institution.

METHODS

Patients who underwent revision hip arthroplasty due to PJI following primary total hip arthroplasty with culture positive microbiology were analyzed. In all study patients, both the primary surgery and the revisions surgery were performed at the same institution. Only patients in whom primary surgery was performed via a direct anterior or lateral approach were included (n = 87). A matched cohort analysis was performed to compare the microbiological spectrum and resistance pattern in PJI following direct anterior (n = 36) versus lateral (n = 36) primary THA.

RESULTS

We identified both a significantly different microbiological spectrum and resistance pattern in PJI comparing direct anterior versus lateral approach THA. Cutibacterium avidum was obtained more frequently in the anterior subgroup (22.2% vs. 2.8%, p = 0.028). In the subgroup of infections with Staphylococcus aureus (n = 12), methicillin resistance was detected in 3/5 cases in the direct anterior group versus 0/7 cases in the lateral group (p = 0.045). Overall, Staphylococcus epidermidis was the most common causative microorganism in both groups (direct anterior: 36.1%; lateral: 27.8%, p = 0.448).

CONCLUSION

The present study indicates a potential influence of the localization of the skin incision in THA on the microbiological spectrum and resistance pattern in PJI. Cutibacterium avidum seemed to be a more common causative microorganism in PJI in patients who underwent direct anterior compared to lateral approach THA.

Direct anterior approach provides better functional outcomes when compared to direct lateral approach in hip hemiarthroplasty following femoral neck fracture

PURPOSE

This study aims to compare the differences between direct anterior approach (DAA) and direct lateral approach (DLA) in hip hemiarthroplasty (HHA) after displaced femoral neck fracture (FNF) in early functional outcome, hospital length of stay, morbidity and mortality rates.

METHODS

This non-interventional retrospective study, carried out at a tertiary trauma centre within the Spanish National Health System, included all patients who underwent a bipolar HHA between 1st January 2018 and 31st December 2019 performed by 2 of our hip unit surgeons.

RESULTS

A total of 94 patients were included (40 in DAA group and 54 in DLA group). Median follow-up was 19.2 months (range 8-30.8 months). Postoperative degree of mobilisation showed statistically significant differences in favour of DAA group, where 35% of patients were able to walk with no assistance after surgery. DAA group had 1 day less of hospitalisation in contrast with DLA group overall (8 days vs 9 days, respectively, p < 0.05). Statistically significant differences were not detected in comparing postoperative complications, re-operations rates or 6-months mortality rate.

CONCLUSION

Our study highlights the benefits of DAA for HHA after displaced FNF in terms of postoperative mobilisation degree and hospitalisation length of stay when compared to DLA.

Early, Mid-Term, and Late-Term Aseptic Femoral Revisions After THA: Comparing Causes, Complications, and Resource Utilization

BACKGROUND

Registry data suggest increasing rates of early revisions after total hip arthroplasty (THA). We sought to analyze modes of failure over time after index THA to identify risk factors for early revision.

METHODS

We identified 208 aseptic femoral revision THAs performed between February 2011 and July 2019 using an institutional database. We compared demographics, diagnoses, complications, and resource utilization between aseptic femoral revision THA occurring within 90 days (early), 91 days to 2 years (mid), and greater than 2 years (late) after index arthroplasty.

RESULTS

Early revisions were 33% of revisions at our institution in the time period analyzed. Periprosthetic fractures were 81% of early, 27% of mid, and 21% of late femoral revisions (P < .01). Women were more likely to have early revisions than men (75% vs 53% of mid and 48% of late revisions; P < .01). Patients who had early revisions were older (67.97 ± 10.06) at the time of primary surgery than those who had mid and late revisions (64.41 ± 12.10 and 57.63 ± 12.52, respectively, P < .01). Index implants were uncemented in 99% of early, 96% of mid, and 64% of late revisions (P < .01). Early revisions had longer postoperative length of stay (4.4 ± 3.3) than mid and late revisions (3.0 ± 2.2 and 3.7 ± 2.1, respectively, P = .02). In addition, 58% of early revisions were discharged to an inpatient facility compared with 36% of mid and 41% of late revisions (P = .03).

CONCLUSION

Early aseptic femoral revisions largely occur in older women with uncemented primary implants and primarily due to periprosthetic fractures. Reducing the incidence of periprosthetic fractures is critical to decreasing the large health care utilization of early revisions.

Intraoperative Complications and Early Return to the Operating Room in Total Hip Arthroplasty Performed Through the Direct Anterior and Posterior Approaches. An Institutional Experience of Surgeons After Their Learning Curve

BACKGROUND

Proponents of the direct anterior approach (DAA) for total hip arthroplasty (THA) claim a faster recovery, whereas critics claim an increased risk of early femoral complications. This study analyzed intraoperative and postoperative complications requiring reoperation within one year after THA through the DAA and posterior approach (PA).

METHODS

A total of 2348 elective, unilateral DAA THAs in patients with osteoarthritis performed between 2016 and 2019 were matched 1:1 for age (±5 years), gender, body mass index (±5), and femoral fixation with 2348 patients who underwent PA THA during the same period. Mixed-effects logistic regression was used. Odds ratios were reported for the occurrence of intraoperative femoral fracture, postoperative femoral fracture, infection, dislocation, and other etiologies requiring reoperation within one year.

RESULTS

Intraoperative femoral fracture occurred in 12 DAA (0.5%) and 14 PA (0.6%) patients. Twenty-five patients (1.06%) in the DAA and 28 (1.19%) in the PA group underwent reoperation within the first year. Reoperations were due to periprosthetic fracture (40%), infection (28%), dislocation (23%), and other (9%). Regression analysis revealed no difference in intraoperative femoral fracture (odds ratio (OR): 0.86, 95% confidence interval (CI): 0.40-1.86, P = .69), postoperative femoral fracture (OR: 1.10, 95% CI: 0.47-2.60, P = .83), infection (OR: 1.50, 95% CI: 0.53-5.23, P = .44), or reoperation within one year for other reasons (OR: 1.50, 95% CI: 0.25-9.00, P = .65). DAA had fewer dislocations requiring reoperation (OR: 0.20, 95% CI: 0.04-0.91, P = .02).

CONCLUSION

This comparative study did not find differences in intraoperative or postoperative fracture or infection between DAA and PA. DAA was associated with a lower likelihood of reoperation for dislocation within one year of surgery.

Proton-pump inhibitors are associated with increased risk of prosthetic joint infection in patients with total hip arthroplasty: a case-cohort study

Background and purpose - Proton-pump inhibitors (PPI) have previously been associated with an increased risk of infections such as community-acquired pneumonia, gastrointestinal infections and central nervous system infection. Therefore, we evaluated a possible association between proton-pump inhibitor use and prosthetic joint infection (PJI) in patients with total hip arthroplasty (THA), because they can be stopped perioperatively or switched to a less harmful alternative.Patients and methods - A cohort of 5,512 primary THAs provided the base for a case-cohort design; cases were identified as patients with early-onset PJI. A weighted Cox proportional hazard regression model was used for the study design and to adjust for potential confounders.Results - There were 75 patients diagnosed with PJI of whom 32 (43%) used PPIs perioperatively compared with 75 PPI users (25%) in the control group of 302 patients. The risk of PJI was 2.4 times higher (95% CI 1.4-4.0) for patients using PPI. This effect remained after correction for possible confounders.Interpretation - The use of PPIs was associated with an increased risk of developing PJI after THA. Hence, the use of a PPI appears to be a modifiable risk factor for PJI.

Direct anterior approach for total hip arthroplasty using the "bikini incision"

OBJECTIVE

The classic skin incision for direct anterior approach (DAA) total hip arthroplasty (THA) is usually placed over the belly of the tensor fasciae latae (TFL) muscle parallel to the axis of the lower extremity. In the "bikini incision" technique however, a more horizontal skin incision is used and placed parallel to the skin creases, which largely corresponds to the skin's tension lines to prevent hypertrophic scarring and optimize cosmetic outcomes.

INDICATIONS

Primary or secondary osteoarthritis, femoral neck fracture, aseptic acetabular component loosening with sufficient bone stock and without the need for proximal extension of the approach, head and/or liner exchange.

CONTRAINDICATIONS

Complex primary or revision THA requiring extensile distal and/or acetabular exposure, revision with pre-existing longitudinal DAA incision, inguinal skin infection.

SURGICAL TECHNIQUE

The skin incision, located three fingerbreadths distal to the anterior superior iliac spine (ASIS), is orientated parallel to the groin crease. One third of the incision is medial and two thirds lateral to the ASIS. Subcutaneous dissection should only be performed in the lateral two thirds of the incision to protect the main branches of the lateral femoral cutaneous nerve (LFCN). The fascia lata is opened as far lateral over the muscle belly as possible to leave the LFCN untouched within its fascial sheet. The stepwise procedure consists of three key steps: capsular exposure, capsular release, and component insertion. The approach allows for an excellent 360° exposure of the acetabulum. The femur is aligned along the incision during femoral elevation and adduction. With this technique, DAA hip arthroplasty can be performed in a less-invasive way providing best possible functional and cosmetic outcomes.

POSTOPERATIVE MANAGEMENT

No restrictions in ambulation or range of motion. Deep vein thrombosis prophylaxis.

RESULTS

In a prospective series of 532 consecutive patients undergoing 613 primary THA with a bikini-incision in 2017, a good clinical outcome with a 2.3% incidence of wound-related problems was observed. In particular, obese patients can also benefit from the technique.

Primary total hip arthroplasty via the direct anterior approach in the lateral decubitus position : surgical technique, learning curve, complications, and early results

AIMS

The direct anterior approach (DAA) for total hip arthroplasty (THA) has potential advantages over other approaches and is most commonly performed with the patient in the supine position. We describe a technique for DAA THA with the patient in the lateral decubitus position and report the early clinical and radiological outcomes, the characteristics of the learning curve, and perioperative complications.

METHODS

All primary DAA THAs performed in the lateral position by a single surgeon over a four-year period from the surgeon's first case using the technique were identified from a prospectively collected database. Modified Harris Hip Scores (mHHS) were collected to assess clinical outcome, and routine radiological analysis was performed. Retrospective review of the medical records identified perioperative complications, the characteristics of the learning curve, and revisions.

RESULTS

A total of 257 patients were included in the study. Their mean age was 60 years (SD 9.0). A total of 164 (64%) were female. The mean mHHS improved significantly from 52.1 (SD 16.2) preoperatively to 94.4 (SD 11) at a follow-up of one year (p < 0.001), with 212 of 225 patients (94%) achieving a minimal clinically important difference (MCID) (> 8 points). Radiological evaluation showed a mean leg length discrepancy of 2.6 mm (SD 5.9) and a mean difference in femoral offset of 0.2 mm (SD 4.9). A total of 234/243 acetabular components (96.3%) were positioned within Lewinnek's safe zone. Analysis of operating time, blood loss, the position of the components, and complications did not identify a learning curve. A total of 14 patients (5.4%) had a major perioperative complication and three (1.2%) required revision THA. There were no major neurovascular complications and no dislocations.

CONCLUSION

We have described and analyzed a surgical technique for undertaking DAA THA in the familiar lateral decubitus position using a routine operating table, positioning devices, and instrumentation, and shown that it can be performed safely and effectively under these circumstances. Cite this article: Bone Joint J 2021;103-B(7 Supple B):53-58.

Dislocation rates following total hip arthroplasty via the direct anterior approach in a consecutive, non-selective cohort

AIMS

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.

METHODS

We retrospectively reviewed all patients undergoing THA via the DAA between 2011 and 2017 at our institution. Primary outcome was dislocation at minimum two-year follow-up. Patients were stratified by demographic details and risk factors for dislocation, and an in-depth analysis of dislocations was performed.

RESULTS

A total of 2,831 hips in 2,205 patients were included. Mean age was 64.9 years (24 to 96), mean BMI was 29.2 kg/m² (15.1 to 53.8), and 1,595 patients (56.3%) were female. There were 11 dislocations within one year (0.38%) and 13 total dislocations at terminal follow-up (0.46%). Five dislocations required revision. The dislocation rate for surgeons who had completed their learning curve was 0.15% compared to 1.14% in those who had not. The cumulative periprosthetic infection and fracture rates were 0.53% and 0.67%, respectively.

CONCLUSION

In a non-selective, consecutive cohort of patients undergoing THA via the DAA, the risk of dislocation is low, even among patients with risk factors for instability. Our data further suggest that the DAA can be safely used in all hip arthroplasty patients without an increased risk of wound complications, fracture, infection, or revision. The inclusion of seven surgeons increases the generalizability of these results. Cite this article: Bone Joint J 2021;103-B(7 Supple B):38-45.

Does the Organism Profile of Periprosthetic Joint Infections Change With a Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Protocol?

BACKGROUND

While vancomycin powder and dilute povidone-iodine (VIP) is associated with fewer total joint arthroplasty (TJA) periprosthetic joint infections (PJI), its effect on PJI organism profiles is unclear. This study evaluates primary TJA PJI organism profiles before and after the implementation of a VIP protocol.

METHODS

In total, 18,299 primary TJAs performed at a university-affiliated, not-for-profit orthopedic hospital from before (1/2012-12/2013) and after (1/2016-12/2019) a VIP protocol was initiated were reviewed to identify deep PJIs that occurred within 90 days of the index arthroplasty as defined by the Musculoskeletal Infection Society guidelines. Demographics, overall organism incidence (n/TJAs), and relative organism incidence (n/PJIs) from the two cohorts were compared.

RESULTS

In total, 103 TJA PJIs were identified (pre-VIP: 32/3982; VIP: 71/14,317). Following the introduction of VIP, the overall and relative incidence of coagulase-negative staphylococcal TJA PJIs significantly decreased (overall: 0.20% to 0.04%, P = .004; relative: 25.00% to 8.45%, P = .031). In response, the relative incidence of MSSA TJA PJIs significantly increased (18.75% to 40.85%, P = .042). Broken down by arthroplasty type, VIP was associated with a significantly lower overall incidence of coagulase-negative staphylococcal total knee arthroplasty (TKA) PJIs (0.27% to 0.06%, P = .015), a significantly lower overall incidence of MRSA TKA PJIs (0.18% to 0.03%, P = .031), and a nonsignificant decrease in the overall incidence of gram-negative TKA PJIs (0.18% to 0.04%, P = .059). No organism profile changes were found in total hip arthroplasty PJIs.

CONCLUSION

VIP is not associated with more difficult to treat primary TJA PJIs. While promising, these findings require a prospective randomized controlled trial for confirmation.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Direct anterior approach has short-term functional benefit and higher resource requirements compared with the posterior approach in primary total hip arthroplasty : a meta-analysis of functional outcomes and cost

AIMS

It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs.

METHODS

This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding biases in the studies which were included. The mean cost and probability were used to determine the added costs of perioperative services.

RESULTS

The DAA group had significantly longer operating times (p < 0.001), reduced length of hospital stay by a mean of 13.4 hours (95% confidence interval (CI) 9.12 to 18; p < 0.001), and greater blood loss (p = 0.030). The DAA group had significantly better functional outcome at three (p < 0.001) and six weeks (p = 0.006) postoperatively according to the Harris Hip Score (HHS). However, there was no significant difference between the groups for the HHS at six to eight weeks (p = 0.230), 12 weeks (p = 0.470), six months (p = 0.740), and one year (p = 0.610), the 12-Item Short Form Survey (SF-12) physical score at six weeks (p = 0.580) and one year (p = 0.360), SF-12 mental score at six weeks (p = 0.170) and one year (p = 0.960), and University of California and Los Angeles (UCLA) activity scale at 12 weeks (p = 0.250). The mean non-stratified and stratified difference in costs for the operating theatre time and blood transfusion were $587.57 (95% CI 263.83 to 1,010.29) to $887.04 (95% CI 574.20 to 1,298.88) and $248.38 (95% CI 1,003.40 to 1,539.90) to $1,162.41 (95% CI 645.78 to 7,441.30), respectively, more for the DAA group. However, the mean differences in costs for the time in hospital were $218.23 and $192.05, respectively, less for the DAA group.

CONCLUSION

The use of the DAA, rather than the PA, in THA has earlier benefits for function and pain. However, these are short-lasting, with no significant differences seen at later intervals. In addition the limited benefits were obtained with higher cumulative costs for DAA. Cite this article: Bone Joint J 2021;103-B(6):1078-1087.

Direct Anterior Approach to the Hip Does Not Increase the Risk for Subsequent Periprosthetic Joint Infection

BACKGROUND

Recent studies suggest an increased risk for periprosthetic joint infection (PJI) utilizing the direct anterior (DA) approach to the hip. The purpose of this study was to investigate whether such an increased risk does indeed exist on a large cohort of patients, operated by experienced surgeons and taking into account various confounders.

METHODS

This was a single institutional study, including all patients who underwent primary total hip arthroplasty during the last decade, who were operated on by four high-volume arthroplasty surgeons utilizing a single surgical approach. Three of them utilized the direct lateral (DL) approach while one of them used the DA approach throughout the entire study. Patient characteristics, demographics, and comorbidities were assessed as well as operative and perioperative factors and their association with PJI. Association between surgical approach and PJI was evaluated in a univariate followed by a multivariate regression analysis.

RESULTS

A total of 10,201 patients were included in the study. Of those, 4390 (43.0%) underwent total hip arthroplasty through the DA approach and 5811 (57.0%) through the DL approach. PJI rates were 0.9% (38/4390) in the DA group compared with 1.3% (73/5811) in the DL group (P = .068). Results from a regression analysis showed no significant association between PJI and DA approach (adjusted odds ratio 0.760, 95% confidence interval 0.428-1.348, P = .348). The risk remained nonsignificant in patients with higher body mass index. There were also no significant differences in the infecting organisms between the two groups.

CONCLUSION

The DA approach to the hip does not increase the risk for subsequent PJI.

A Single-Center Randomized Prospective Study Investigating the Efficacy of Various Wound Closure Devices in Reducing Postoperative Wound Complications

Background

Sutures and staples are the mainstay wound closure techniques in total joint arthroplasty. Newer techniques such as zipper devices and novel skin adhesives have emerged because of their potential to decrease operative time and possibly minimize complications. The aim of this study is to compare these newer techniques against conventional sutures with respect to wound complications, closure time, and costs.

Methods

A single-center randomized control trial was conducted on 160 patients (52 zipper, 55 suture, 53 mesh) who underwent primary total hip or knee arthroplasty between February 2017 and May 2018. Patients were divided into 3 closure groups: zipper device, monofilament suture plus adhesive, and monofilament plus polyester mesh with adhesive. The primary endpoint was closure time (superficial skin layer). Secondarily we collected perioperative complication rates, including infection, persistent (14-day) wound drainage, 90-day readmission, and emergency room visit rates as well as compared material costs.

Results

There were no differences in baseline characteristics between groups for age, body mass index, and American Society of Anesthesiologists classification. There was a trend toward decreased time to closure for the suture group. There were no significant differences between groups for our secondary endpoint, complications.

Conclusions

Our study shows that the suture group trended toward shorter closure time but suggests that each of the closure methods after total joint arthroplasty has equivalent complication rates. With small differences in closure time and no significant differences in complications, the decision to use one wound closure device or technique over another should be driven by institutional costs and provider familiarity.

Does performing total joint arthroplasty in the afternoon or evening increase the risk of prosthetic joint infection?

PURPOSE

Does performing total joint arthroplasty in the afternoon or evening increase the rate of early prosthetic joint infection and the likelihood of early prosthetic joint infection?

METHODS

We evaluated patients retrospectively, who underwent primary total hip (THA) or knee arthroplasty (TKA) between January 2016 and December 2019, met the inclusion criteria and had at least 90 days of follow-up. Patients were divided into two groups. Group I consisted of patients whose surgeries had been started and finished before 14:00, and group II included patients whose surgeries started after 14:01. All patients were operated after non-septic cases in specific orthopedic operating rooms. Their demographic data and comorbidities were noted. Primary outcome was to compare the risk of PJI between the groups.

RESULTS

Group I and group II included 2309 and 1881 patients. Total number of patients with the diagnosis of PJI was 58 (1.4%). It was 31 (1.3%) and 27 (1.4%), respectively (p = 0.79). Performing total joint arthroplasty after 14:01 did not increase likelihood of infection (p = 0.83, OR 1.03). Among the parameters, PJI was significantly associated with age (p < 0.01, OR 0.99), smoking status (p < 0.01, OR 0.15) and operating time (p = 0.04, OR 0.99) in TKA and with direct anterior approach (p = 0.02, OR 4.72) in THA. Age (p = 0.06, OR 1.03) was the factor affecting the risk of subsequent PJI after total joint arthroplasty.

CONCLUSION

Performing total joint arthroplasty in the afternoon or in the evening, after aseptic cases does not increase the risk of subsequent of PJI.

Preoperative Allergy Testing for Patients Reporting Penicillin and Cephalosporin Allergies is Cost-Effective in Preventing Infection after Total Knee and Hip Arthroplasty

BACKGROUND

Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin, which should reduce the risk of infection after total knee and hip arthroplasty (TKA/THA), but it remains unclear whether this practice is cost-effective. Using a break-even analysis, we calculated the cost-effectiveness of routine preoperative allergy testing for infection prevention in total joint arthroplasty patients reporting penicillin and cephalosporin allergies.

METHODS

The cost of a penicillin allergy evaluation, the cost of revision arthroplasty for prosthetic joint infection (PJI), and baseline rates of PJI in patients receiving a noncefazolin antibiotic in the perioperative period were derived from existing literature. A break-even economic model using these variables was constructed to calculate the absolute risk reduction (ARR) in infection rate needed for preoperative allergy testing to be cost-effective. The number needed to treat (NNT) was calculated from the ARR.

RESULTS

Preoperative allergy testing before TKA and THA in patients reporting penicillin and cephalosporin allergies was cost-effective if the initial infection rate decreased by an ARR of 0.810% (NNT = 123) and 0.655% (NNT = 153) for TKA and THA, respectively. Cost-effectiveness was maintained with varying allergy consultation costs, infection rates, and costs associated with PJI treatment.

CONCLUSION

Routine preoperative allergy testing and clearance are cost-effective infection prevention strategies among patients reporting penicillin and cephalosporin allergies in the setting of elective joint arthroplasty. Widespread adoption of this practice may considerably reduce the economic and societal burden associated with prosthetic infections.

Direct Anterior Approach Total Hip Arthroplasty Is Not Associated with Increased Infection Rates: A Systematic Review and Meta-Analysis

BACKGROUND

The direct anterior approach (DAA) for primary total hip arthroplasty (THA) has recently increased in popularity. Recent evidence has raised concerns about whether use of the DAA is associated with increased rates of superficial and deep infection. The aim of this study was to systematically assess the literature and comparatively evaluate the rate of superficial and deep infection following primary THA using the DAA and non-direct anterior (non-DAA) approaches.

METHODS

This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. Primary outcome measures evaluated were rates of superficial and deep infection in patients undergoing DAA and non-DAA primary THA.

RESULTS

A total of 1,872 studies were identified in the original search, of which 15 studies satisfied inclusion criteria. Our analysis evaluated 120,910 primary THAs, including 14,908 DAA and 106,002 non-DAA. The rate of superficial infection was 1.08% for DAA compared with 1.24% for non-DAA (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.79 to 1.30, p = 0.921). The rate of deep infection was 0.73% for DAA compared with 0.51% for non-DAA (OR = 1.03, 95% CI = 0.80 to 1.32, p = 0.831).

CONCLUSIONS

This study found no difference in the rate of superficial or deep infection after primary THA using the DAA versus other surgical approaches. Our results suggest that comparative infection risk need not be a primary driver in the choice of surgical approach.

LEVEL OF EVIDENCE

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

Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Reduce the Rate of Early Periprosthetic Joint Infection After Primary Total Knee Arthroplasty

BACKGROUND

Vancomycin powder and dilute povidone-iodine lavage (VIP) was introduced to reduce the incidence of periprosthetic joint infection (PJI) in high-risk total knee arthroplasty (TKA) patients. We hypothesize that VIP can reduce the incidence of early PJI in all primary TKA patients, regardless of preoperative risk.

METHODS

An infection database of primary TKAs performed before a VIP protocol was implemented (January 2012-December 2013), during a time when only high-risk TKAs received VIP (January 2014-December 2015), and when all TKAs received VIP (January 2016-September 2019) at an urban, university-affiliated, not-for-profit orthopedic hospital was retrospectively reviewed to identify patients with PJI. Criteria used for diagnosis of PJI were the National Healthcare Safety Network and Musculoskeletal Infection Society guidelines.

RESULTS

VIP reduced early primary TKA PJI incidence in both the high-risk and all-risk cohorts compared with the pre-VIP cohort by 44.6% and 56.4%, respectively (1.01% vs 0.56% vs 0.44%, P = .0088). In addition, after introducing VIP to all-risk TKA patients, compared with high-risk TKA patients, the relative risk of PJI dropped an additional 21.4%, but this finding did not reach statistical significance (0.56% vs 0.44%, P = .4212). There were no demographic differences between the 3 VIP PJI cohorts.

CONCLUSION

VIP is associated with a reduced early PJI incidence after primary TKA, regardless of preoperative risk. With the literature supporting its safety and cost-effectiveness, VIP is a value-based intervention, but given the nature of this historical cohort study, a multicenter randomized controlled trial is underway to definitively confirm its efficacy.

Surgical Approach to Total Hip Arthroplasty Affects the Organism Profile of Early Periprosthetic Joint Infections

The optimal approach for total hip arthroplasty (THA) remains hotly debated. While wound complications following the direct anterior approach are higher than with other approaches, the organism profile of periprosthetic joint infections (PJIs) by approach remains unknown. Our goal was to compare the organism profiles of PJIs following direct anterior and non-anterior THA.

METHODS

We retrospectively reviewed 12,549 primary THAs (4,515 direct anterior and 8,034 non-anterior) that had been performed between January 2012 and September 2019 at a university-affiliated single-specialty orthopaedic hospital to identify patients with an early postoperative PJI. Criteria used for the diagnosis of a PJI were the National Healthcare Safety Network, which screens for PJI that occurs within 90 days of index arthroplasty, and the Musculoskeletal Infection Society guidelines. Patient demographic information and organism characteristics were recorded for analysis.

RESULTS

We identified 84 patients (38 who underwent the direct anterior approach and 46 who underwent the non-anterior approach) with an early postoperative PJI following primary THA (0.67% total THA PJI rate, 0.84% direct anterior THA PJI rate, and 0.57% non-anterior THA PJI rate). The direct anterior THA cohort had a significantly lower body mass index and American Society of Anesthesiologists score than the non-anterior THA cohort (29.5 versus 35.2 kg/m2, p < 0.0001; 2.29 versus 2.63, p = 0.016, respectively). Regarding organism profile, patients in the direct anterior THA cohort had significantly more monomicrobial gram-negative infections than the non-anterior THA cohort (4 versus 0, p = 0.038). We did not identify any demographic risk factors other than approach for gram-negative PJI. There were no significant differences in methicillin-resistant Staphylococcus aureus, methicillin-sensitive Staphylococcus aureus, coagulase-negative Staphylococcus, obligate anaerobes, polymicrobial, or PJIs due to other organisms by approach.

CONCLUSIONS

Direct anterior THA approaches have a greater risk of monomicrobial gram-negative PJI, likely due to the unique microbiome of the inguinal region. While targeted infection prophylaxis may reduce these infections, it is not entirely effective on its own. Future studies with larger sample sizes are required to help us develop more targeted perioperative infection prophylaxis.

LEVEL OF EVIDENCE

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

Revision Arthroplasty Through the Direct Anterior Approach Using an Asymmetric Acetabular Component

Despite increasing numbers of primary hip arthroplasties performed through the direct anterior approach (DAA), there is a lack of literature on DAA revision arthroplasty. The present study was performed in order to evaluate outcomes and revision rates after revision through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation. In a retrospective cohort study, we analyzed prospectively collected data of 57 patients (61 hips, 43 female, 18 male) who underwent aseptic acetabular component revision through the DAA with the abovementioned implant system between January 2015 and December 2017. The mean follow-up was 40 months (12–56). Survival rates were estimated using the Kaplan–Meier method. All complications were documented and functional outcomes were assessed pre- and postoperatively. Kaplan–Meier analysis revealed an estimated five-year implant survival of 97% (confidence interval CI 87–99%). The estimated five-year survival with revision for any cause was 93% (CI 83–98%). The overall revision rate was 6.6% (n = 4). Two patients had to undergo revision due to periprosthetic infection (3.3%). In one patient, the acetabular component was revised due to aseptic loosening four months postoperatively. Another patient suffered from postoperative iliopsoas impingement and was treated successfully by arthroscopic iliopsoas tenotomy. Two (3.3%) of the revised hips dislocated postoperatively. The mean Harris Hip Score improved from 35 (2–66) preoperatively to 86 (38–100) postoperatively (p < 0.001). The hip joint’s anatomical center of rotation was restored at a high degree of accuracy. Our findings demonstrate that acetabular revision arthroplasty through the DAA using an asymmetric acetabular component with optional intra- and extramedullary fixation is safe and practicable, resulting in good radiographic and clinical midterm results.

Early Outcome Comparison of the Posterior Approach and the Superior Approach for Primary Total Hip Arthroplasty

Background

The superior approach for total hip arthroplasty (THA) is a minimally invasive, tissue-sparing technique that may have clinical and economic benefits. The purpose of this study was to compare early outcomes between the posterior approach and the superior approach in primary THA. Our hypothesis was that the superior approach would have a noninferior length of stay (LOS), discharge destination, and blood loss compared with the posterior approach.

Methods

All primary THAs performed by a single surgeon at one institution were retrospectively reviewed over a 2-year period (2015-2017). There were 676 patients, 40.4% of whom underwent a posterior approach and 59.6% underwent a superior approach. LOS, discharge destination, blood loss, and operating room time were analyzed. Gender, body mass index, and American Society of Anesthesiologists status were recorded and controlled.

Results

The posterior approach was independently associated with an almost threefold higher risk of prolonged LOS (>2 days, P < .001) (odds ratio: 2.90, 95% confidence interval: 1.87-4.49; P < .001). The mean LOS for the superior approach was 1.71 days vs 2.17 days for the posterior group (P < .001). Fewer patients in the superior approach cohort were discharged to a rehabilitation facility (8.9% vs 17.9%, P < .001). The mean operative time was shorter in the superior group (91.8 vs 95.8, P = .001). There was no statistically significant difference in acute postoperative blood loss. There were no dislocations or reoperations in either group.

Conclusions

The superior approach to THA was associated with a significantly shorter length of hospital stay and lower rate of discharge to rehab than the posterior approach. This approach can be used as a safe, minimally invasive, and tissue-sparing variation of a standard posterior approach for THA and has promising early outcomes.

A survey of Hip Society surgeons concerning the direct anterior approach total hip arthroplasty

Aims

To establish whether there was a consensus among the members of the Hip Society (HS) on the role of direct anterior approach (DAA) contemporary primary total hip arthroplasty (THA).

Methods

An online survey was sent to all 112 active and senior members of the HS, to which 71 members responded. The survey was constructed to determine whether they believed that evidence-based medicine proves, in modern clinical practice, that the DAA has significant benefits compared to risks when contrasted with other approaches. In addition, they were asked if they currently used the DAA.

Results

While only 16.9% (12/71) of respondents had been trained in a generic anterior approach during residency, 49.3% (35/71) had used the DAA in their clinical practice in the past or were using it at the present time. Unexpectedly, 42.9% (15/35) of respondents who had used the DAA in the past had abandoned it by the time of this survey. Only 22.5% (16/71) of all respondents believed that evidence-based medicine proves that the DAA has significant benefits compared to risks in contrast to other approaches.

Conclusion

A comprehensive literature review found only three prospective randomized clinical trials (RCT) comparing the DAA with another approach with greater than one-year follow-up. Two showed minor benefits within the early postoperative period only, and one of those showed poorer mid-term results. Most of the published comparison studies with short follow-up show longer surgical times and greater blood loss for the DAA, and many three-month comparison studies show higher complication rates for the DAA using a proprietary traction table. The complications included problems with wound healing, lateral femoral cutaneous nerve injury, femoral component loosening, and femoral fractures. Because of the lack of evidence from RCTs showing superiority of the DAA over other approaches and reports of higher complications, the opinion of a large majority (77.5%; 55/71) of HS surgeons was that the DAA lacks sufficient evidence to warrant its use. Cite this article: Bone Joint J 2020;102-B(7 Supple B):57–61.

A Comparison of Risk of Dislocation and Cause-Specific Revision Between Direct Anterior and Posterior Approach Following Elective Cementless Total Hip Arthroplasty

BACKGROUND

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased over the last decade. We sought to investigate whether (1) a difference exists in dislocation risk for DAA compared with posterior THA, (2) a difference exists in risk for specific revision reasons, and (3) the likelihood of adverse 90-day postoperative events differs.

METHODS

We conducted a cohort study using data from Kaiser Permanente's Total Joint Replacement Registry. Patients aged ≥18 years who underwent primary cementless THA for osteoarthritis with a highly cross-linked polyethylene liner were included (2009-2017). Multivariable Cox proportional hazards regression was used to evaluate dislocation and cause-specific revision risks, and multivariable logistic regression was used to evaluate 90-day emergency department visits, 90-day unplanned readmissions, and 90-day complications (including deep infection, deep vein thrombosis, and pulmonary embolism).

RESULTS

Of 38,399 primary THA, 6428 (16.7%) were DAA. All-cause revision at 2-years follow-up was 1.78% (95% confidence interval [CI] = 1.46-2.17) for DAA and 2.28% (95% CI = 2.11-2.45) for posterior. After adjusting for covariates, DAA had a lower risk of dislocation (hazard ratio [HR] = 0.39, 95% CI = 0.29-0.53), revision for instability (HR = 0.33, 95% CI = 0.18-0.58), revision for periprosthetic fracture (HR = 0.57, 95% CI = 0.34-0.96), and readmission (odds ratio = 0.82, 95% CI = 0.67-0.99) compared with posterior approach but a higher risk of revision for aseptic loosening (HR = 2.26, 95% CI = 1.35-3.79).

CONCLUSION

While the DAA associated with lower risks of dislocation and revision for instability and periprosthetic fracture, it is associated with a higher revision risk for aseptic loosening. Surgeons should discuss these risks with their patients.

Is There a Role for Preclosure Dilute Betadine Irrigation in the Prevention of Postoperative Infection Following Total Joint Arthroplasty?

BACKGROUND

Conflicting evidence exists surrounding the use of preclosure irrigation solutions in primary total joint arthroplasty (TJA). We aimed to determine the role of dilute betadine lavage in preventing early infection after primary TJA.

METHODS

We retrospectively reviewed primary TJAs between 2010 and 2018. Dilute betadine lavage was introduced to our practice in November 2014. We included 3513 total hip arthroplasties, 3932 total knee arthroplasties, and 1033 hip resurfacings (HRs). In group 1 (n = 5588), surgical wounds were irrigated with saline; group 2 used dilute betadine solution (n = 2890). Subanalyses using propensity matching based on known risk factors of infection-age, body mass index, American Society of Anesthesiologists grade, diabetes, and procedure-were completed.

RESULTS

There were 48 acute infections in group 1 (0.9%) and 23 in group 2 (0.8%) (P = .762). HR without betadine had the highest acute infection prevalence (P = .028). When groups in the whole cohort were propensity score-matched, group 1 had more acute infections than group 2 (P = .033). The effect of betadine was isolated to HR patients. After excluding HR cases, betadine continued to reduce the acute infection rate when compared with the no betadine group, but this was not statistically significant (0.4% vs 0.8%; P = .101). Likewise, we did not find a significant difference in total hip arthroplasty and total knee arthroplasty patients (P = .796).

CONCLUSION

There was a decreased infection rate in the betadine group overall when groups were propensity-matched. Because the reduction in the acute infection rate was clinically significant, we feel this practice is an effective means to prevent infections.

Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system

Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.