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Clapp IM, Orton C, Kapron C, Blackburn B, Gililland JM, Anderson LA, Pelt CE, Peters CL, Archibeck MJ. Conversion of Tibial Plateau Fractures to Total Knee Arthroplasty is Associated with Worse Patient-Reported Outcomes, Increased Operative Time and Increased Complications. J Arthroplasty 2024:S0883-5403(24)00912-4. [PMID: 39233105 DOI: 10.1016/j.arth.2024.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Prior open reduction and internal fixation (ORIF) of tibial plateau fracture (TPF) adds complexity to subsequent total knee arthroplasty (TKA). The purpose of this study was to compare the outcomes of patients undergoing a TKA following prior ORIF of TPF to patients undergoing a primary TKA for osteoarthritis and an aseptic revision TKA. METHODS There were 52 patients who underwent primary TKA following prior ORIF of TPF between January 2009 and June 2021, who were included and matched in a 1:4 ratio by sex, body mass index, and American Society of Anesthesiologists class to 208 patients undergoing primary TKA. A second 1:1 matched comparison to 52 aseptic revision TKA patients was also included. The Knee injury and Osteoarthritis Outcome Score for Joint Replacement scores were obtained preoperatively and at 2-years postoperatively. Independent t-tests and Chi-square tests were used for statistical comparisons. RESULTS The TPF patients were significantly younger than both the primary and revision cohorts (55 ± 14.0 versus 63 ± 16.3 versus 64 ± 9.5, P < 0.001). Compared to primary TKA patients, the TPF group had worse KOOS JR scores at 2-years (46.9 ± 18.5 versus 66.2 ± 17.8, P = 0.0152), higher rates of wound complications (15.4 versus 3.9%, P = 0.0020), and increased operative times (140.2 ± 45.3 versus 95.2 ± 25.7, P < 0.0001). No significant differences in these metrics were seen between the TPF group and the revision group. Additionally, TPF patients were more likely to require a manipulation under anesthesia (MUA) than both primary and revision patients (21.2 versus 5.8 versus 5.8%, P = 0.001). CONCLUSION The TKAs following ORIF of TPF are more like revision TKAs than primary TKAs in terms of patient-reported outcomes, operative times, and wound complications. The rate of MUA was higher than in both matched groups. These findings provide valuable information that can affect preoperative patient education and postoperative management regimens for these patients. They also emphasize the need for a conversion to TKA code due to the increased complexity and complications seen in this more difficult subset of TKAs.
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Affiliation(s)
- Ian M Clapp
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah.
| | - Cody Orton
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Claire Kapron
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Brenna Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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LaValva SM, Grubel J, Ong J, Chiu YF, Lyman S, Mandl LA, Cushner FD, Gonzalez Della Valle A, Parks ML. Substantial Weight Loss May Not Improve Early Outcomes of Total Knee Arthroplasty in the Morbidly Obese. J Arthroplasty 2024; 39:2272-2279.e1. [PMID: 38670174 DOI: 10.1016/j.arth.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/03/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Body mass index (BMI) cutoffs for morbidly obese patients otherwise indicated for total knee arthroplasty (TKA) have been widely proposed and implemented, though they remain controversial. Previous studies suggested that a 5% reduction in BMI may be associated with fewer postoperative complications. Thus, the purpose of this study was to determine whether a substantial reduction in preoperative BMI in morbidly obese patients improved 90-day outcomes after TKA. METHODS There were 1,270 patients who underwent primary TKA at a single institution and had a BMI > 40 recorded during the year prior to surgery. Patients were stratified into three cohorts based on whether their BMI within 3 months to 1 year preoperatively had decreased by ≥ 5% (228 patients [18%]); increased by ≥ 5% (310 [24%]); or remained unchanged (within 5%) (732 [58%]) on the day of surgery. There were several baseline differences between the cohorts with respect to medical comorbidities. The rate of 90-day complications and six-week patient-reported outcome measures were compared via univariate and multivariable analyses. RESULTS On univariate analysis, individual and total complication rates were similar between the cohorts (P > .05). On multivariable logistic regression, the risk of complications was similar in patients who had decreased versus unchanged BMI (OR [odds ratio] 1.0; P = .898). However, there was a higher risk of complications in the increased BMI cohort compared to those patients who had an unchanged BMI (OR 1.5; P = .039). The six-week patient-reported outcome measures were similar between the cohorts. CONCLUSIONS Patients who have a BMI > 40 who achieved a meaningful reduction in BMI prior to TKA did not have a lower rate of 90-day complications than those whose BMI remained unchanged. Furthermore, considering that nearly one in four patients experienced a significant increase in BMI while awaiting surgery, postponing TKA may actually be detrimental.
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Affiliation(s)
- Scott M LaValva
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Jacqueline Grubel
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Justin Ong
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Yu-Fen Chiu
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Stephen Lyman
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Lisa A Mandl
- Division of Rheumatology, Hospital for Special Surgery, New York, New York
| | - Fred D Cushner
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | | | - Michael L Parks
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
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3
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Sadiq S, Noor R, Akram R. Risk factors of post discharge falls in patients undergoing total knee arthroplasty: An integrative review. J Back Musculoskelet Rehabil 2024:BMR230165. [PMID: 39031337 DOI: 10.3233/bmr-230165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2024]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a widely performed surgical procedure aimed at alleviating pain and restoring functionality in individuals suffering from knee osteoarthritis. Despite substantial benefits of TKA, patients are exposed to potential risks, including the occurrence of falls during their recovery period following discharge from the hospital. OBJECTIVE This integrative review endeavors to comprehensively investigate the existing body of literature to identify and assess the diverse factors that contribute to occurrence of post-discharge falls among TKA patients. Through the synthesis of available research, this study seeks to offer valuable insights that can guide clinical practices and interventions designed to mitigate the incidence of post-TKA falls, ultimately enhancing patient outcomes and quality of healthcare. METHODS An integrative review was conducted and databases were searched including Pubmed, PEDro, Cochrane, and SPORTDiscus from 2000 to 2024. A thorough search was performed to retrieve articles missed through databases as well as unpublished grey literature. Methodological quality assessment was performed using Newcastle-Ottawa Scale for Case Control and Cohort studies and AXIS tool for cross-sectional study. RESULTS Eleven articles finally met the inclusion criteria and were included in the review based on eligibility. There were 8 cohort studies (7 prospective cohorts, 1 retrospective cohort), 2 case control studies, and 1 cross-sectional study. The prospective cohort studies included in the review collected data in real-time as events occurred, making them particularly relevant for studying post-TKA falls. CONCLUSION Patients who underwent TKA are at risk of post-discharge falls. Several key risk factors have been identified, including advancing age, female gender, reduced proprioception, psychiatric disorders, living alone, and knee pain in the operated knee. It is important to recognize that the significance of these risk factors can vary depending on individual circumstances and contexts.
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Affiliation(s)
- Samreen Sadiq
- Department of Physical Therapy, Riphah College of Rehabilitation and Allied Health Sciences, Riphah International University, Gulberg III Campus, Lahore, Pakistan
| | - Rabiya Noor
- Department of Physical Therapy, Riphah College of Rehabilitation and Allied Health Sciences, Riphah International University, Gulberg III Campus, Lahore, Pakistan
| | - Rizwan Akram
- Orthopedic and Spine Department, Ghurki Trust Teaching Hospital, Lahore, Pakistan
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Lachance AD, Steika R, Lutton J, Chessa F. Total Joint Arthroplasty in Patients Who Are Obese or Morbidly Obese: An Ethical Analysis. J Bone Joint Surg Am 2024; 106:659-664. [PMID: 38377222 DOI: 10.2106/jbjs.23.00617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Andrew D Lachance
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, Pennsylvania
| | - Roman Steika
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, Pennsylvania
| | - Jeffrey Lutton
- Department of Orthopaedic Surgery, Guthrie Clinic, Sayre, Pennsylvania
| | - Frank Chessa
- Maine Medical Center, Portland, Maine
- Tufts University School of Medicine, Boston, Massachusetts
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Hoveidaei AH, Zafari H, Mirghaderi P, Ghadimi E, Mortazavi SMJ. Catastrophic skin necrosis after total knee arthroplasty: a case report and review of the literature. Ann Med Surg (Lond) 2024; 86:1641-1646. [PMID: 38463118 PMCID: PMC10923309 DOI: 10.1097/ms9.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/10/2023] [Indexed: 03/12/2024] Open
Abstract
Introduction and importance There have been few cases of post total knee arthroplasty (TKA) skin necrosis reported. Here, the authors present our patient with skin necrosis post TKA on account of its extreme rarity, considerable risk factors, and importance of its treatment. Case This is a cautionary report on the rule of including previous single longitudinal incision in surgical approach. The authors included previous medial incision in ours and performed arthroplasty through medial parapatellar incisions. After noticing skin necrosis in front of patella, reoperation including flap and skin graft was done, leading to complete recovery. Clinical discussion While skin necrosis post TKA is not common, it can be present in high-risk patients who should be considered for a decrease in their risk factors. Preoperatively, underlying diseases should be under control. Intraoperation risk factors, in particular incision selection, and considerations about lateral retinacular release are important. Conclusion A balance must be achieved between the ability to expose the knee through a prior incision and avoiding extensive undermining of the subcutaneous flaps in patients with previous knee surgery. It may be a better approach to ignore medial incisions and use the classic midline incision.
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Affiliation(s)
| | - Hamidreza Zafari
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Peyman Mirghaderi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Ghadimi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - SM Javad Mortazavi
- Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Park HJ, Koh K, Choi YJ, Suh DH, D'Lima D, Kim JG. Is Prophylactic Antibiotic Use Necessary Before Dental Procedures in Primary and Revision TKA? A Propensity Score-matched, Large-database Study. Clin Orthop Relat Res 2024; 482:411-422. [PMID: 38231150 PMCID: PMC10871784 DOI: 10.1097/corr.0000000000002966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/05/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND The question of whether dental procedures increase the risk of periprosthetic joint infection (PJI) in patients who have undergone total joint arthroplasty (TJA) remains controversial. QUESTIONS/PURPOSES (1) Are dental procedures associated with an increased incidence of PJI in the setting of either primary or revision TKA after controlling for relevant potentially confounding variables? (2) Is the administration of prophylactic antibiotics before dental procedures associated with any differences in this risk? (3) Which factors are associated with increased incidence of PJI after dental procedures? METHODS This nationwide, retrospective, comparative, large-database study evaluated 591,602 patients who underwent unilateral primary or revision TKA between 2009 and 2019 using the Health Insurance Review and Assessment Service data in South Korea, in which all people in South Korea were registered and to which all medical institutions must charge any procedures they performed. The study population was divided into 530,156 patients with dental procedures and 61,446 patients without dental procedures based on whether the patients underwent a dental procedure at least 1 year after the index surgery. After propensity score matching, patients were classified into a dental (n = 182,052) and a nondental cohort (n = 61,422). The dental cohort was then divided into two groups: 66,303 patients with prophylactic antibiotics and 115,749 patients without prophylactic antibiotics based on prophylactic antibiotic use. After propensity score matching, patients were categorized into prophylactic (n = 66,277) and nonprophylactic (n = 66,277) cohorts. Propensity score matching was used to control for covariates including posttraumatic arthritis associated with PJI risk according to the dental procedure and prophylactic antibiotic use among the cohorts. After propensity score matching, the standardized mean difference was confirmed to be less than 0.1 for all variables. Kaplan-Meier survival analyses, log-rank tests, and Cox proportional hazards regression analysis was performed. RESULTS Dental procedures were not associated with an increase in PJI risk after primary (adjusted HR 1.56 [95% CI 0.30 to 8.15]; p = 0.60) or revision TKA (adjusted HR 1.74 [95% CI 0.90 to 3.34]; p = 0.10). Additionally, use of prophylactic antibiotics was not associated with a reduced PJI risk after the index surgery, either for primary (adjusted HR 1.28 [95% CI 0.30 to 5.42]; p = 0.74) or revision TKA (adjusted HR 0.74 [95% CI 0.45 to 1.23]; p = 0.25). Although surgery type and prophylactic antibiotic use exhibited no influence on PJI occurrence after dental procedures, posttraumatic arthritis was associated with PJI. The adjusted HR for posttraumatic arthritis was 4.54 (p = 0.046). CONCLUSION Our findings suggest that dental procedures were not associated with an increased risk of PJI for up to 2 years after the dental procedure in patients who underwent either primary or revision TKA. Based on these findings, there is insufficient rationale for the use of prophylactic antibiotics before dental procedures in patients who have undergone primary or revision TKA. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Hyung Jun Park
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeongki-do, South Korea
| | - Kyeol Koh
- Department of Dentistry, Catholic University College of Medicine, Eunpyeong St. Mary's Hospital, Seoul, South Korea
- Department of Dental Science, Graduate School, Chosun University, Gwangju, South Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Ansan Hospital Ansan-si, Gyeongki-do, South Korea
| | - Dong Hun Suh
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeongki-do, South Korea
| | - Darryl D'Lima
- The Scripps Research Institute and Shiley Center for Orthopedic Research and Education, La Jolla, CA, USA
| | - Jae Gyoon Kim
- Department of Orthopedic Surgery, Korea University College of Medicine, Ansan Hospital, Ansan-si, Gyeongki-do, South Korea
- The Scripps Research Institute and Shiley Center for Orthopedic Research and Education, La Jolla, CA, USA
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Schweller E, Mueller J, Santiago Rivera OJ, Villegas SJ, Walkiewicz J. Factors Associated With Hip Fracture Length of Stay Among Older Adults in a Community Hospital Setting. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00004. [PMID: 37134192 PMCID: PMC10155900 DOI: 10.5435/jaaosglobal-d-22-00195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 02/12/2023] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Hip fractures in geriatric populations constitute a heavy burden on the healthcare system. The study goal was to identify patient, hospital, and surgical factors associated with hospital length of stay (LOS) for geriatric patients with hip fractures requiring surgical intervention in a community hospital setting. METHODS This was a cross-sectional retrospective chart review of geriatric hip fractures that underwent surgical fixation at a community hospital between 2017 and 2019. The scope of the surgeries was limited to cephalomedullary device fixation or hemiarthroplasty hip fracture surgeries. Sliding hip screw or total hip arthroplasty procedures and patients who died during the index hospitalization were excluded. Median tests were conducted to examine differences between the groups. Unadjusted and adjusted truncated negative binomial regression models were used to examine the factors associated with LOS. RESULTS Bivariate analyses revealed results that the factors associated with a longer LOS were preoperative anemia (P = 0.029), blood transfusion (P = 0.022), and the number of days between admission and surgery (P = 0.001). The adjusted regression model results suggested that older patients, patients who underwent surgery more than one day after admission, current smokers, malnourished patients, patients with sepsis, and patients with a history of a thromboembolic event had statistically significant (P < 0.05) longer LOS. However, patients who live in institutions (nursing homes or assisted living) had a shorter LOS than those who live at home alone or with family (P < 0.05). DISCUSSION Older adult patients who underwent surgery with a cephalomedullary device or hip hemiarthroplasty for a hip fracture and had preoperative anemia, postoperative blood transfusions, and increased days between admission and surgery had a longer LOS. Additional factors positively associated with a longer LOS included current smokers, malnourishment, admission with sepsis, and patients with a history of a thromboembolic event. Of interest, institutionalized patients had a shorter LOS than those living at home alone or with family.
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Affiliation(s)
- Eric Schweller
- From the Garden City Hospital, Orthopedic Surgery Residency Program, Garden City, MI (Dr. Schweller, Dr. Mueller, and Dr. Walkiewicz); the Graduate Medical Education , Garden City Hospital, Garden City, MI (Dr. Santiago Rivera); and the Michigan State University College of Osteopathic Medicine, East Lansing, MI (Dr. Santiago Rivera and Dr. Villegas)
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Carroll JD, Young JR, Mori BV, Gheewala R, Lakra A, DiCaprio MR. Total Hip and Knee Arthroplasty Surgery in the Morbidly Obese Patient: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202304000-00007. [PMID: 37098128 DOI: 10.2106/jbjs.rvw.22.00177] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
» Obesity, defined as body mass index (BMI) ≥30, is a serious public health concern associated with an increased incidence of stroke, diabetes, mental illness, and cardiovascular disease resulting in numerous preventable deaths yearly. » From 1999 through 2018, the age-adjusted prevalence of morbid obesity (BMI ≥40) in US adults aged 20 years and older has risen steadily from 4.7% to 9.2%, with other estimates showing that most of the patients undergoing hip and knee replacement by 2029 will be obese (BMI ≥30) or morbidly obese (BMI ≥40). » In patients undergoing total joint arthroplasty (TJA), morbid obesity (BMI ≥40) is associated with an increased risk of perioperative complications, including prosthetic joint infection and mechanical failure necessitating aseptic revision. » The current literature on the role that bariatric weight loss surgery before TJA has on improving surgical outcomes is split and referral to a bariatric surgeon should be a shared-decision between patient and surgeon on a case-by-case basis. » Despite the increased risk profile of TJA in the morbidly obese cohort, these patients consistently show improvement in pain and physical function postoperatively that should be considered when deciding for or against surgery.
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Affiliation(s)
- Jeremy D Carroll
- Division of Orthopaedic Surgery, Albany Medical Center, Albany, New York
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9
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Helito CP, Sobrado MF, Gobbi RG, Demange MK, Franciozi CE. Extensor mechanism injury, infection, and an extended time between trauma and surgical approach are related to the need for total knee arthroplasty removal after traumatic dehiscence. Knee 2023; 41:240-244. [PMID: 36753817 DOI: 10.1016/j.knee.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 12/07/2022] [Accepted: 01/03/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Surgical wound-related traumatic complications are rarely reported in the literature. Traumatic dehiscence is unpredictable because of the trauma magnitude and the potential of associated injuries. This study aims to report the clinical outcomes and complications of a case series due to traumatic dehiscence after total knee arthroplasty (TKA) and establish possible criteria for prognosis for maintaining the implant. METHODS Patients admitted to an emergency room due to traumatic dehiscence after TKA were retrospectively evaluated. Patient data was analyzed and patients who maintained or not the arthroplasty were compared to establish prognosis factors. RESULTS Thirty-two patients with traumatic dehiscence after TKA were evaluated. The trauma occurred on a mean of 14.3 +/- 25.0 days after the surgical procedure, and debridement in the operating room was performed on a mean of 6.2 +/- 4.9 hours after the trauma. Twenty patients maintained the arthroplasty until the end of follow-up and did not require revision. Factors related to arthroplasty removal were associated extensor mechanism injury (p = 0.026), time from trauma to surgical debridement (p = 0.035), and infection (p = 0.0001) CONCLUSION: Traumatic dehiscence after total knee arthroplasty is an event with a high rate of complications. Extensor mechanism Injury, infection, and extended time between trauma and surgical intervention were poor prognostic factors for arthroplasty maintenance.
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Affiliation(s)
- Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil; Hospital Sírio Libanês, São Paulo, Brazil
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil; Hospital Sírio Libanês, São Paulo, Brazil.
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marco Kawamura Demange
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Lyons M, Nunley RM, Ahmed Shokri A, Doneley T, Han HS, Harato K, Kuwasawa A, Lee DH, Qi X, Qian W, Ratanachai S, Wang W, Po-Han Chen B, Danker W. Goals, challenges and strategies for wound and bleeding management in total knee arthroplasty: A modified Delphi method. J Orthop Surg (Hong Kong) 2022; 30:10225536221138985. [PMID: 36374258 DOI: 10.1177/10225536221138985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Surgical techniques related to soft tissue management play critical roles in optimizing surgical outcomes and patient satisfaction in total knee arthroplasty (TKA). Despite the importance of wound closure and bleeding management approaches, no published guidelines/consensus are available. METHODS Twelve orthopedic surgeons participated in a modified Delphi panel consisting of 2 parts (each part comprising two rounds) from September-October 2018. Questionnaires were developed based on published evidence and guidelines on surgical techniques/materials. Questionnaires were administered via email (Round 1) or at a face-to-face meeting (subsequent rounds). Panelists ranked their agreement with each statement on a five-point Likert scale. Consensus was achieved if ≥70% of panelists selected 4/5, or 1/2. Statements not reaching consensus in Round 1 were discussed and repeated or modified in Round 2. Statements not reaching consensus in Round 2 were excluded from the final consensus framework. RESULTS Consensus was reached on 13 goals of wound management. Panelists agreed on 38 challenges and 71 strategies addressing surgical techniques or wound closure materials for each tissue layer, and management strategies for blood loss reduction or deep vein thrombosis prophylaxis in TKA. Statements on closure of capsular and skin layers, wound irrigation, dressings and drains required repeat voting or modification to reach consensus. CONCLUSION Consensus from Asia-Pacific TKA experts highlights the importance of wound management in optimizing TKA outcomes. The consensus framework provides a basis for future research, guidance to reduce variability in patient outcomes, and can help inform recommendations for wound management in TKA.
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Affiliation(s)
| | - Ryan M Nunley
- 12275Washington University of Medicine, St Louis, MO, USA
| | | | - Tyson Doneley
- 95053Brisbane Private Hospital, Spring Hill, QLD, Australia
| | - Hyuk-Soo Han
- 58927Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea, Republic of (South)
| | - Kengo Harato
- Keio University School of Medicine, Tokyo, Japan
| | | | - Dae-Hee Lee
- 36626Samsung Medical Center, Seoul, Korea, Republic of (South)
| | - Xin Qi
- The First Affiliated Hospital of Jilin University, Changchun City, China
| | - Wenwei Qian
- 34732Peking Union Medical College Hospital, Beijing, China
| | | | - Weijun Wang
- 66506Nanjing Drum Tower Hospital, Jiangsu Province, China
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Lazarides AL, Saltzman EB, Visgauss JD, Mithani SK, Eward WC, Brigman BE. Intraoperative angiography imaging correlates with wound complications following soft tissue sarcoma resection. J Orthop Res 2022; 40:2382-2390. [PMID: 35005805 DOI: 10.1002/jor.25270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023]
Abstract
For soft tissue sarcoma patients receiving preoperative radiation therapy, wound complications are common and potentially devastating. The purpose of this study was to assess the feasibility of intraoperative indocyanine green fluorescent angiography (ICGA) as a predictor of wound complications in these patients. A consecutive series of patients with soft tissue sarcoma of the extremities or pelvis who received neoadjuvant radiation and a subsequent radical resection received intraoperative ICGA with the SPY PHI device (Stryker Inc.) at the time of closure. Retrospective analysis of fluorescence signal along multiple points of the wound length was performed and quantified. The primary endpoint was wound complication, defined as delayed wound healing or wound dehiscence, within 3 months of surgery. Fourteen patients with preoperative irradiated soft tissue sarcoma were consecutively imaged. There were six patients with wound complications classified as "aseptic" in five cases. Using the ICGA, blinded surgeons correctly predicted wound complications in 75% of cases. During the inflow phase, a mean ratio of normal of 0.62 maximized the area under the curve (AUC = 0.90) for predicting wound complications with a sensitivity of 100% and specificity of 77.4%. During the peak phase, a mean ratio of normal of 0.55 maximized the AUC (0.95) for predicting wound complications with a sensitivity of 88.9% and a specificity of 100%. Intraoperative use of ICGA may help to predict wound complications in patients undergoing resection of preoperatively irradiated soft tissue sarcomas of the extremities and pelvis.
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Affiliation(s)
- Alexander L Lazarides
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Eliana B Saltzman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Julia D Visgauss
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Suhail K Mithani
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - William C Eward
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Brian E Brigman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Yeganeh A, Moghtadaei M, Ghaznavi A, Tavakoli N, Soleimani M, Cheraghiloohesara S, Taheri N. The distance between new and previous incisions does not affect skin necrosis in total knee arthroplasty: a parallel-randomized controlled clinical trial. BMC Surg 2022; 22:350. [PMID: 36163060 PMCID: PMC9513953 DOI: 10.1186/s12893-022-01791-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background To avoid skin necrosis, an 8 cm distance between the new and previous incision is recommended in patients undergoing total knee arthroplasty (TKA). It was hypothesized that making a new incision less than 8 cm of the prior scar does not increase the risk of skin complications, and the new incision can be made anywhere, regardless of the distance from the previous scar. This study investigated how making a new incision, irrespective of the previous scars, affects skin necrosis. Methods In this parallel, randomized clinical trial, by simple randomization method using a random number table, 50 patients with single longitudinal knee scars were randomly assigned to two groups with a 1:1 ratio and 25 participants in each group. Patients with a minimum age of 60 and a single longitudinal previous scar on the knee were included. The exclusion criteria were diabetes mellitus, hypertension, morbid obesity, smoking, vascular disorders, cardiopulmonary disorders, immune deficiencies, dementia, and taking steroids and angiogenesis inhibitors. TKA was performed through an anterior midline incision, regardless of the location of the previous scar in the intervention group. TKA was performed with a new incision at least 8 cm distant from the old incision in the control group. Skin necrosis and scar-related complications were evaluated on the first and second days and first, second, and fourth weeks after the surgery. Knee function was assessed using the Knee Society Score (KSS) six months after the surgery. Results The baseline characteristics of the groups did not differ significantly. The average distance from the previous scar was 4.1 ± 3.2 cm in the intervention group and 10.2 ± 2.1 cm in the control group. Only one patient in the control group developed skin necrosis (P-value = 0.31). Other wound-related complications were not observed in both groups. The mean KSS was 83.2 ± 10.2 and 82.9 ± 11.1 in the intervention and control groups, respectively (P-value = 0.33). Conclusions It is possible that in TKA patients, the new incision near a previous scar does not increase the risk of skin necrosis and other complications.
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Affiliation(s)
- Ali Yeganeh
- Department of Orthopedic Surgery, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mehdi Moghtadaei
- Department of Orthopedic Surgery, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Ghaznavi
- Department of Orthopedic Surgery, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nader Tavakoli
- Trauma and Injury Research Center, Hazrat-e Rasool Hospital, Iran University of Medical Sciences, Niayesh St, Satarkhan Av, Tehran, Iran
| | - Mohammad Soleimani
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Sahand Cheraghiloohesara
- Trauma and Injury Research Center, Hazrat-e Rasool Hospital, Iran University of Medical Sciences, Niayesh St, Satarkhan Av, Tehran, Iran
| | - Nima Taheri
- Trauma and Injury Research Center, Hazrat-e Rasool Hospital, Iran University of Medical Sciences, Niayesh St, Satarkhan Av, Tehran, Iran.
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Risk Factors for Wound Complications Following Conversion TKA after Tibial Plateau Fracture. Indian J Orthop 2022; 56:1751-1758. [PMID: 36187592 PMCID: PMC9485347 DOI: 10.1007/s43465-022-00709-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The purpose is to investigate the incidence of wound complications for total knee arthroplasty (TKA) following tibial plateau open reduction and internal fixation (ORIF). MATERIALS AND METHODS A prospective arthroplasty registry was queried for patients with CPT codes for primary TKA, tibial plateau ORIF, removal of hardware (ROH), and diagnosis of post-traumatic arthritis. Patients were included if they had undergone tibial plateau ORIF and subsequent TKA. Chart review was performed to obtain demographic, clinical and post-operative information. RESULTS Twenty-one patients were identified, with average age of 56.23 ± 13.2 years at time of tibial plateau ORIF and 62.91 ± 10.8 years at time of TKA. Seven (33.3%) patients had a tibial plateau fracture-related infection (FRI). Eight (38.1%) patients underwent ROH prior to TKA. Seven (33.3%) patients' TKA incision incorporated the prior plateau incisions. Eight (36.4%) patients developed wound complications following TKA and 5 (23.8%) developed an acute periprosthetic joint infection (PJI) following TKA and had the plateau incision incorporated into the TKA incision. FRI history did not increase the rate of wound complications but did increase the rate of ROH prior to TKA. CONCLUSIONS Previous FRI involving tibial plateau repair surgery doesn't correlate with PJI after conversion TKA for post traumatic OA. Surgeon-controlled factors such as staged ROH and incision placement can help reduce the rate of wound complications following TKA performed after tibial plateau ORIF. LEVEL OF EVIDENCE Prognostic Level IV. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-022-00709-1.
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Pulsed Radiofrequency Rhizotomy of the Genicular Nerves of the Knee Guided by Radioscopy and Ultrasonography: Step-By-Step Technique. Arthrosc Tech 2022; 11:e391-e396. [PMID: 35256981 PMCID: PMC8897599 DOI: 10.1016/j.eats.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023] Open
Abstract
Osteoarthritis (OA) of the knee is highly prevalent and causes pain, stiffness, and harms the quality of life of millions of patients. Scientific evidence about radiofrequency ablation or rhizotomy of genicular nerves has been presented with increasing frequency in the literature for the treatment of chronic pain related to knee OA as an alternative to total knee arthroplasty. The main indication for this procedure is symptomatic OA unresponsive to conservative treatment, regardless of the disease evolution, although more common indications are in Kellgren-Lawrence grade III or IV, in post-total knee arthroplasty residual pain without an identified cause, in patients with comorbidities and high surgical risk, and those who do not want to undergo surgery. The aim of this study is to describe the step-by-step rhizotomy technique with pulsed radiofrequency of the 3 genicular nerves, guided by radioscopy and ultrasonography.
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Ramamurti P, Fassihi SC, Stake S, Stadecker M, Whiting Z, Thakkar SC. Conversion Total Knee Arthroplasty. JBJS Rev 2021; 9:01874474-202109000-00007. [PMID: 34812774 DOI: 10.2106/jbjs.rvw.20.00198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Conversion total knee arthroplasty (TKA) represents a heterogeneous group of procedures and most commonly includes TKA performed after ligamentous reconstruction, periarticular open reduction and internal fixation (ORIF), high tibial osteotomy (HTO), and unicompartmental knee arthroplasty (UKA). » Relative to patients undergoing primary TKA, patients undergoing conversion TKA often have longer operative times and higher surgical complexity, which may translate into higher postoperative complication rates. » There is mixed evidence on implant survivorship and patient-reported outcome measures when comparing conversion TKA and primary TKA, with some studies noting no differences between the procedures and others finding decreased survivorship and outcome scores for conversion TKA. » By gaining an improved understanding of the unique challenges facing patients undergoing conversion TKA, clinicians may better set patient expectations, make intraoperative adjustments, and guide postoperative care.
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Affiliation(s)
- Pradip Ramamurti
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Seth Stake
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Monica Stadecker
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Zachariah Whiting
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Savyasachi C Thakkar
- Adult Reconstruction Division, Department of Orthopaedic Surgery, Johns Hopkins University, Columbia, Maryland
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Higuera-Rueda CA, Emara AK, Nieves-Malloure Y, Klika AK, Cooper HJ, Cross MB, Guild GN, Nam D, Nett MP, Scuderi GR, Cushner FD, Piuzzi NS, Silverman RP. The Effectiveness of Closed-Incision Negative-Pressure Therapy Versus Silver-Impregnated Dressings in Mitigating Surgical Site Complications in High-Risk Patients After Revision Knee Arthroplasty: The PROMISES Randomized Controlled Trial. J Arthroplasty 2021; 36:S295-S302.e14. [PMID: 33781638 DOI: 10.1016/j.arth.2021.02.076] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 02/12/2021] [Accepted: 02/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Revision total knee arthroplasty (rTKA) is associated with significant risk of wound-related morbidity. The present study aimed to evaluate the 1) efficacy of closed-incision negative-pressure therapy (ciNPT) vs silver-impregnated antimicrobial dressing (AMD) in mitigating postoperative surgical site complications (SSCs), 2) the effect of ciNPT vs AMD on certain postoperative health utilization parameters, and on 3) patient-reported outcomes (PROs) improvement at 90-day postoperative follow-up. METHODS This multicenter randomized controlled trial was conducted between December 2017 and August 2019. Patients ≥22 years, at high risk for SSC, and receiving rTKA with full exchange and reimplantation of new prosthetic components or open reduction and internal fixation of periprosthetic fractures were screened for inclusion. Eligible patients were randomized to receive a commercially available ciNPT system or a silver-impregnated AMD (n = 147, each) for minimum of 5-day duration. Primary outcome was the 90-day incidence of SSCs with stratification in accordance with revision type (aseptic/septic). Secondary outcomes were the 90-day health care utilization parameters (readmission, reoperation, dressing changes, and visits) and PROs. RESULTS Of 294 patients randomized (age: 64.9 ± 9.0 years, female: 59.6%), 242 (82.0%) patients completed the study (ciNPT: n = 124; AMD: n = 118). The incidence of 90-day SSCs was lower for the ciNPT cohort (ciNPT: 3.4% vs AMD: 14.3%; odds ratio (OR): 0.22, 95% confidence interval (0.08, 0.59); P = .0013). Readmission rates (3.4% vs 10.2%, OR: 0.30(0.11, 0.86); P = .0208) and mean dressing changes (1.1 ± 0.3 vs 1.3 ± 1.0; P = .0003) were lower with ciNPT. The differences in reoperation rates, number of visits, and PRO improvement between both arms were not statistically significant (P > .05). CONCLUSION ciNPT is effective in reducing the 90-day postoperative SSCs, readmission, and number of dressing changes after rTKA. Recommending routine implementation would require true-cost analyses.
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Affiliation(s)
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Herbert J Cooper
- Department of Orthopaedic Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY
| | - Michael B Cross
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - George N Guild
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | - Denis Nam
- Midwest Orthopaedics, Rush University Medical Center, Chicago, IL
| | - Michael P Nett
- Northwell Health Physician Partners Orthopaedic Institute at Babylon, Babylon, NY
| | - Giles R Scuderi
- Northwell Health Physician Partners Orthopaedic Institute at MEETH, New York, NY
| | - Fred D Cushner
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
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Cooper C, Antle O, Lowerison J, Dersch-Mills D, Kenny A. Impact of Weight-Band Dosing of Tinzaparin for Venous Thromboembolism Prophylaxis on Persistent Wound Drainage in Adult Patients Undergoing Hip and Knee Arthroplasty. Ann Pharmacother 2021; 56:290-296. [PMID: 34130496 DOI: 10.1177/10600280211024294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Persistent wound drainage and venous thromboembolism (VTE) are potential complications of total joint arthroplasty, and these risks can be challenging to balance in clinical practice. Anecdotal observation has suggested that following joint arthroplasty, persistent wound drainage occurs more frequently with higher body weight and higher doses of tinzaparin when compared with lower body weight and lower doses of tinzaparin. OBJECTIVE The overall purpose of this study was to describe the impact of a tinzaparin weight-band dosing table for VTE prophylaxis on wound healing, thrombosis, and bleeding outcomes in patients undergoing total joint arthroplasty. METHODS This retrospective chart review included patients who underwent total hip or knee arthroplasty and received tinzaparin for thromboprophylaxis per their weight-banding category. The primary outcome was the incidence of persistent wound drainage. Secondary outcomes include the occurrence of VTE and clinically important bleeding during hospital admission. RESULTS A total of 231 patients were included in the analysis. There was no significant difference in persistent wound drainage between the 3 weight categories, and there were no differences in rates of VTE or clinically important bleeding. Concurrent use of low-dose acetylsalicylic acid was associated with a 3-fold increased risk of persistent wound drainage (risk ratio = 3.35; 95% CI = 2.14-5.24; P = 0.00003). CONCLUSION AND RELEVANCE In joint arthroplasty patients, we observed no significant difference in rates of persistent wound drainage between various weight categories receiving different weight-banded doses of tinzaparin. Our results do not suggest that the current weight-band dosing table for tinzaparin needs to be adjusted to optimize patient outcomes.
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Affiliation(s)
| | - Ouida Antle
- Pharmacy Services, Alberta Health Services, Calgary, AB, Canada
| | | | | | - Ashley Kenny
- Orthopaedics and General Surgery, Foothills Medical Centre, Calgary, AB, Canada
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An X, Wang J, Shi W, Ma R, Li Z, Lei M, Liu Y, Lin F. The Effect of Passive Smoking on Early Clinical Outcomes After Total Knee Arthroplasty Among Female Patients. Risk Manag Healthc Policy 2021; 14:2407-2419. [PMID: 34113195 PMCID: PMC8187102 DOI: 10.2147/rmhp.s309893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/16/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Xiao An
- Department of Orthopedic Surgery, Hainan Hospital of Chinese PLA General Hospital, Sanya, People’s Republic of China
| | - Junliang Wang
- Department of Orthopedic Surgery, Hainan Hospital of Chinese PLA General Hospital, Sanya, People’s Republic of China
| | - Weiqing Shi
- Department of Operation Room, the Fifth Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Rui Ma
- Department of Orthopedic Surgery, Hainan Hospital of Chinese PLA General Hospital, Sanya, People’s Republic of China
| | - Zhirui Li
- Department of Orthopedic Surgery, Hainan Hospital of Chinese PLA General Hospital, Sanya, People’s Republic of China
| | - Mingxing Lei
- Department of Orthopedic Surgery, Hainan Hospital of Chinese PLA General Hospital, Sanya, People’s Republic of China
| | - Yaosheng Liu
- Department of Orthopedic Surgery, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Feng Lin
- Department of Orthopedic Surgery, Hainan Hospital of Chinese PLA General Hospital, Sanya, People’s Republic of China
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Gad BV, Langfitt MK, Robbins CE, Talmo CT, Bono OJ, Bono JV. Factors Influencing Survivorship in Vasculopathic Patients. J Knee Surg 2020; 33:1004-1009. [PMID: 31121629 DOI: 10.1055/s-0039-1688929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Total knee arthroplasty (TKA) in patients with peripheral vascular disease has sparsely been studied. This study examined patient and radiographic factors that could affect reoperation free survival in these patients. We retrospectively reviewed TKA procedures performed in patients with nonpalpable pulses on physical examination between January 1, 2004, and December 31, 2013. Ninety-two cases met inclusion criteria. Preoperative ankle-brachial index (ABI), date of surgery, sex, age, body mass index (BMI), tourniquet use, American Society of Anesthesiologists (ASA) score, presence of preoperative calcifications, and follow-up data were obtained. Failure was defined as reoperation. Patients were included if they experienced a failure or had at least 2 years of follow-up. Reoperation free survival was calculated by Kaplan-Meier's analysis. Odds ratios (ORs) were calculated for patient factors; hazard ratios (HRs) were calculated by Cox's regression analysis. Ninety-two TKAs were included in the study. Mean age was 68.8 years, mean BMI was 32.15, and mean ASA score was 2.44. Tourniquet was used in 78 patients. Mean preoperative ABI was 1.016. Nine patients had calcifications on X-ray prior to surgery. Reoperation free survival was 9.378 years. Patients with a preoperative ABI of below 0.7 had shorter reoperation free survival (ABI <0.7, 6.854 years; ABI >0.7, 9.535 years; p = 0.015). Patients with a preoperative ABI below 0.7 had greater odds of failure and were at higher risk for earlier failure (OR = 6.5, p = 0.027; HR = 1.678, p = 0.045). When corrected for age, sex, and BMI, the HR for patients with a preoperative ABI below 0.7 worsened (HR = 1.913, p = 0.035) compared with those with an ABI above 0.7. The remaining patient factors produced no statistically significant differences in survivorship, odds of failure, or HRs. No patient factors were associated with increased risk of mortality. These results suggest that patients who undergo TKA with an ABI below 0.7 are at increased risk for reoperation and have shorter reoperation free survival.
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Affiliation(s)
- Bishoy V Gad
- Sports and Orthopaedic Specialists, Adult Reconstruction Surgery, Edina, Minnesota
| | - Maxwell K Langfitt
- Department of Orthopedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Claire E Robbins
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Carl T Talmo
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Oliva Jane Bono
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - James V Bono
- Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
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20
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Helito CP, Sobrado MF, Giglio PN, Bonadio MB, Pécora JR, Demange MK, Gobbi RG. The use of negative-pressure wound therapy after total knee arthroplasty is effective for reducing complications and the need for reintervention. BMC Musculoskelet Disord 2020; 21:490. [PMID: 32711504 PMCID: PMC7382854 DOI: 10.1186/s12891-020-03510-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/15/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Wound healing complications are causal factors of prosthesis infection and poor postoperative evolution of patients after total knee arthroplasty (TKA). Negative-pressure wound therapy (NPWT) can be an option to minimize these complications. The aim of this study is to compare the complications of patients undergoing TKA who used a portable NPWT device in the immediate postoperative period with those of a control group. METHODS A total of 296 patients were evaluated. Patients were divided into two groups: those who used NPWT for seven days in the postoperative period (Group 1 - prospective evaluated) and those who used conventional dressings (Group 2 - historical control group). Epidemiological data, comorbidities, local parameters related to the surgical wound and complications were evaluated. RESULTS The groups did not differ in regard to sex, age and clinical comorbidities. Overall, 153 (51.7%) patients had at least one risk factor for wound complications. Patients who used NPWT had a lower rate of complications (28.5% vs. 45.7%, p = 0.001) and a lower rate of reintervention in the operating room (2% vs. 8.5%, p = 0.001). Patients in group 1 had a lower incidence of hyperaemia (14.7% vs. 40.2%, p = 0.01), skin necrosis (2.1% vs. 8.5%, p = 0.04) and wound dehiscence (3.1% vs 10.1%, p = 0.03). The use of NPWT was a protective factor for the presence of complications, with an odds ratio of 0.36 (95% CI 0.206-0.629). CONCLUSION The number of complications related to the wound after TKA is high; however, most of them are minor and have no impact on the treatment and clinical evolution of patients. The use of NPWT decreased the number of surgical wound complications, especially hyperaemia, dehiscence and necrosis, and reduced the need for reintervention.
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Affiliation(s)
- Camilo Partezani Helito
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP - CEP: 05403-010, Brazil.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Marcel Faraco Sobrado
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP - CEP: 05403-010, Brazil. .,Hospital Sírio Libanês, São Paulo, Brazil.
| | - Pedro Nogueira Giglio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP - CEP: 05403-010, Brazil
| | - Marcelo Batista Bonadio
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP - CEP: 05403-010, Brazil
| | - José Ricardo Pécora
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP - CEP: 05403-010, Brazil
| | - Marco Kawamura Demange
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP - CEP: 05403-010, Brazil
| | - Riccardo Gomes Gobbi
- Grupo de Joelho, Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Rua Dr. Ovídio Pires de Campos, 333, Cerqueira Cesar, São Paulo, SP - CEP: 05403-010, Brazil
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Huang K, Ren H, Ma G. One-staged surgical management of large-scale skin necrosis after total knee arthroplasty: a case report (CARE-compliant). ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:771. [PMID: 32647696 PMCID: PMC7333138 DOI: 10.21037/atm-20-4445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Total knee arthroplasty (TKA) is a common surgical procedure performed in clinical settings. However, postoperative skin necrosis surrounding the incision can be a devastating complication. A large area of black necrotic skin was observed at the incision and anterolateral side of the right knee in a 78-year-old female patient after TKA. Skin necrosis surrounding the incision site was confirmed. Deep joint infection was excluded by synovial fluid analysis. We performed extensive debridement, joint capsule was opened, the knee prosthesis was exposed and partial synovectomy was performed. Then massive soft tissue defect (about 18 cm × 10 cm) was developed with exposed implants. After irrigation, the medial and lateral gastrocnemius muscle flaps were both released and transferred to completely fill the soft tissue defect, and the muscle flaps were then covered with split-thickness skin graft. The wound defect was reconstructed by single-staged surgery. The surgical incisions were healing well with no incisional complications. No swelling, tenderness, or evidence of knee infection was noted during follow-up. The right knee maintained good function and the range of motion was 0° to 130° at 1-year follow-up after the operation. Massive skin necrosis after TKA is rare but manageable. One-stage surgical treatment is also applicable if there is no deep infection, which could shorten the treatment period and achieve early rehabilitation.
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Affiliation(s)
- Kai Huang
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Haiyong Ren
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Gouping Ma
- Department of Orthopaedics, Tongde Hospital of Zhejiang Province, Hangzhou, China
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22
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Ferry T, Batailler C, Brosset S, Kolenda C, Goutelle S, Sappey-Marinier E, Josse J, Laurent F, Lustig S. Medical innovations to maintain the function in patients with chronic PJI for whom explantation is not desirable: a pathophysiology-, multidisciplinary-, and experience-based approach. SICOT J 2020; 6:26. [PMID: 32633714 PMCID: PMC7339926 DOI: 10.1051/sicotj/2020021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION PJI is the most dramatic complication after joint arthroplasty. In patients with chronic infection, prosthesis exchange is in theory the rule. However, this surgical approach is sometimes not desirable especially in elderly patients with multiple comorbidities, as it could be associated with a dramatic loss of function, reduction of the bone stock, fracture, or peroperative death. We propose here to report different approaches that can help to maintain the function in such patients based on a pathophysiology-, multidisciplinary-, and an experience-based approach. METHODS We describe the different points that are needed to treat such patients: (i) the multidisciplinary care management; (ii) understanding the mechanism of bacterial persistence; (iii) optimization of the conservative surgical approach; (iv) use of suppressive antimicrobial therapy (SAT); (v) implementation of innovative agents that could be used locally to target the biofilm. RESULTS In France, a nation-wide network called CRIOAc has been created and funded by the French Health ministry to manage complex bone and joint infection. Based on the understanding of the complex pathophysiology of PJI, it seems to be feasible to propose conservative surgical treatment such as "debridement antibiotics and implant retention" (with or without soft-tissue coverage) followed by SAT to control the disease progression. Finally, there is a rational for the use of particular agents that have the ability to target the bacteria embedded in biofilm such as bacteriophages and phage lysins. DISCUSSION This multistep approach is probably a key determinant to propose innovative management in patients with complex PJI, to improve the outcome. CONCLUSION Conservative treatment has a high potential in patients with chronic PJI for whom explantation is not desirable. The next step will be to evaluate such practices in nation-wide clinical trials.
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Affiliation(s)
- Tristan Ferry
- Service des Maladies Infectieuses et Tropicales, Hospices Civils de Lyon, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, 69007 Lyon, France
| | - Cécile Batailler
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Chirurgie Orthopédique, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Sophie Brosset
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Chirurgie Plastique et Reconstructrice, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Camille Kolenda
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, 69007 Lyon, France - Institut des Agents Infectieux, Laboratoire de Bactériologie, Centre National de Référence des Staphylocoques, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Sylvain Goutelle
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Pharmacie, Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, 136 Rue du Commandant Charcot, 69005 Lyon, France - UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
| | - Elliot Sappey-Marinier
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Chirurgie Orthopédique, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Jérôme Josse
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, 69007 Lyon, France - Institut des Agents Infectieux, Laboratoire de Bactériologie, Centre National de Référence des Staphylocoques, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Frédéric Laurent
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - CIRI - Centre International de Recherche en Infectiologie, Inserm, U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ. Lyon, 69007 Lyon, France - Institut des Agents Infectieux, Laboratoire de Bactériologie, Centre National de Référence des Staphylocoques, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - Sébastien Lustig
- Université Claude Bernard Lyon 1, 69100 Villeurbanne, France - Centre Interrégional de Référence Pour la Prise en Charge des Infections Ostéo-Articulaires Complexes (CRIOAc Lyon), Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France - Service de Chirurgie Orthopédique, Hôpital de la Croix-Rousse, 93 Grande Rue de la Croix-Rousse, 69004 Lyon, France
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Anis HK, Mahmood BM, Klika AK, Mont MA, Barsoum WK, Molloy RM, Higuera CA. Hospital Volume and Postoperative Infections in Total Knee Arthroplasty. J Arthroplasty 2020; 35:1079-1083. [PMID: 31759799 DOI: 10.1016/j.arth.2019.10.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the associations of hospital volume with revision surgery for infection and superficial incisional infections. METHODS A review of 12,541 primary total knee arthroplasties (TKAs) at a large integrated health system from 2014 to 2017 was conducted. Sixteen hospitals were classified as low-volume, medium-volume, or high-volume hospitals according to the mean number of TKAs/year (<250, 250-500, and >500, respectively). Thresholds were guided by percentiles and the literature on volume-outcome relationships. Medical records were reviewed for revision surgery for infection and superficial incisional infections during a mean 2-year review period. Multivariate analyses, adjusted for clinical and patient characteristics, were performed to evaluate the association between hospital volume and infection. RESULTS The overall rate of revision surgery for infection was 0.7% (n = 82), and the overall rate of superficial incisional infection was 2.6% (n = 324). After accounting for potential confounders, hospital volume was not found to have a significant association with revision surgery for infection when comparing high-volume and low-volume hospitals (odds ratio, 1.615; 95% confidence interval, 0.761-3.427; P = .212) as well as when comparing high-volume and medium-volume hospitals (odds ratio, 1.464; 95% confidence interval, 0.853-2.512; P = .166). Moreover, the risk of superficial incisional infection at high-volume hospitals was similar to that at low-volume (P = .107) and medium-volume (P = .491) hospitals. CONCLUSION Infection outcomes are quality metrics that are frequently used to compare hospitals including those of varying volumes. Using contemporary thresholds, this study found that infection rates after TKA at high-volume hospitals are comparable to low-volume and medium-volume hospitals.
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Affiliation(s)
- Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Bilal M Mahmood
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
| | - Wael K Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
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Abstract
In the last few years, much has been published concerning total joint arthroplasty, and debates and discussions to new questions and points of view started many years ago. In this commentary, we report the latest evidence of best practice in the field of lower limb arthroplasty; this evidence is based on a literature search conducted by using PubMed and Scopus databases with a time limit of five years. We found novel evidence regarding cemented and not cemented implant, implant design, anticoagulant use, tourniquets, and other aspects of joints replacement surgery that we consider a common part of modern orthopedic practice. We specifically focus on lower limb joint replacement.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Diovanni di Dio e Ruggi D'Aragona, Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Diovanni di Dio e Ruggi D'Aragona, Salerno, Italy.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, London, UK.,School of Pharmacy and Bioengineering, Faculty of Medicine, Institute of Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Stoke-on-Trent, UK
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25
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Gill SK, Pearce AR, Everington T, Rossiter ND. Mechanical prophylaxis, early mobilisation and risk stratification: as effective as drugs for low risk patients undergoing primary joint replacement. Results in 13,384 patients. Surgeon 2019; 18:219-225. [PMID: 31801693 DOI: 10.1016/j.surge.2019.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/25/2019] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Current NICE Guidelines state that all patients undergoing total hip and knee arthroplasty should be given both mechanical and chemical prophylaxis. At our institution, a targeted thromboprophylaxis policy has been in place since October 1999. The aim of this study was to calculate our venous thromboembolism rates and compare these to published rates in the literature. METHODS All patients are pre-operatively assessed for their VTE risk. Patients are stratified into high or low risk: all patients received mechanical thromboprophylaxis and the higher risk patients now receive chemical and mechanical thromboprophylaxis post op. Patients are reviewed at 2, 6 and 52 weeks and with annual postal questionnaires and clinical and radiological review at 5 and 10yrs. RESULTS 13,384 primary THA and TKAs were entered into the database. The overall rate of clinically apparent DVT and overall PE rates of 0.48% and 0.42% respectively. 86.16% of our patients were low risk, of these 23.3% of patients were on Aspirin/Clopidogrel with mechanical thromboprophylaxis and 76.7% of patients had mechanical prophylaxis alone. There was no statistical difference between the DVT or PE rates in the low risk groups. CONCLUSION Our results show that use of early mobilisation and mechanical prophylaxis within an Enhanced Recovery Programme results in comparable VTE rates to chemical prophylaxis for all, which is reflected in the literature. Our results question the need for chemical thromboprophylaxis or extended use of mechanical thromboprophylaxis in "lower risk" patients if a risk stratification policy is used in the context of modern surgical approaches.
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Affiliation(s)
- Sukhdeep K Gill
- Basingstoke and North Hampshire Hospital, Aldermaston Rd, Basingstoke, Hampshire, United Kingdom.
| | - Andrea R Pearce
- Basingstoke and North Hampshire Hospital, Aldermaston Rd, Basingstoke, Hampshire, United Kingdom
| | - Tamara Everington
- Basingstoke and North Hampshire Hospital, Aldermaston Rd, Basingstoke, Hampshire, United Kingdom
| | - Nigel D Rossiter
- Basingstoke and North Hampshire Hospital, Aldermaston Rd, Basingstoke, Hampshire, United Kingdom
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26
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Large osteophyte removal from the posterior femoral condyle significantly improves extension at the time of surgery in a total knee arthroplasty. J Orthop 2019; 19:76-83. [PMID: 32021042 DOI: 10.1016/j.jor.2019.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/30/2019] [Accepted: 10/30/2019] [Indexed: 02/03/2023] Open
Abstract
Removing osteophytes from the posterior compartment of the femur eliminates the tenting effects on the joint capsule and consequently increases the extension gap in total knee arthroplasty. However, there is no clear association with the size of osteophytes removed and the potential degree of additional extension achieved at time of surgery. Aims Correlate the size of posterior osteophytes removed with the degree of extension gained intraoperatively in total knee arthroplasty and develop a radiological classification system to grade these osteophytes. Methods Patients who underwent a TKA had pre and post operative sagittal radiographs assessed and classified according to 4 different categories of a proposed classification system. Knee extension was then assessed by a computer navigated system before incision and after implant insertion. Confounding factors were controlled and considered on the analysis. The study was done retrospectively. Results 147 patients were included in the study. Ninety-three (63.2%) patients had osteophytes on the posterior aspect of the femur completely removed and fifty-four patients (36.8%) did not have radiological evidence of osteophytes on the posterior aspect of the femur. There was a positive and linear correlation (Pearson correlation 0.327, p .005) between osteophyte size and degree of extension corrected at time of surgery. On Multivariate Logistic Regression Analysis, we found that small osteophytes (Grade 1) did not seem to affect the extension, while removing Grade 2 or Grade 3 osteophytes lead to a gain in extension of 2.7 and 4.5° respectively. Conclusion Removing large osteophytes (Grade 2 and Grade 3) from the posterior femoral compartment can be used as an adjuvant strategy to ensure that intraoperative extension is optimal. However removing small osteophytes (Grade 1) should not be expected to affect extension at the time of surgery in TKA and could increase intra-operative time and morbidity.
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27
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Manista GC, Batko BD, Sexton AC, Edmiston TA, Courtney PM, Hannon CP, Levine BR. Anticoagulation in Revision Total Joint Arthroplasty: A Retrospective Review of 1917 Cases. Orthopedics 2019; 42:323-329. [PMID: 31505013 DOI: 10.3928/01477447-20190906-02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/07/2019] [Indexed: 02/03/2023]
Abstract
Although several studies now support the use of aspirin for venous thromboembolism (VTE) prophylaxis in primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), the optimal chemoprophylactic agent in revision THA and TKA is not clear. The purpose of this study was to determine if the type of chemoprophylaxis has an effect on the VTE rate in patients undergoing revision total joint arthroplasty (TJA). The second aim was to compare differences in rates of wound drainage in primary and revision TJA stratified by the postoperative chemoprophylaxis used. The authors retrospectively reviewed 1917 consecutive patients undergoing primary and revision TJA. Individual records were reviewed for patient demographics, medical comorbidities, type of chemoprophylaxis, VTE risk factors, intraoperative data, and postoperative complications. Outcomes, including VTE rate and wound complications, were compared between types of anticoagulant therapy used postoperatively. Of the 1917 patients, there were 742 (38.7%) primary TKAs, 326 (17%) revision TKAs, 608 (31.7%) primary THAs, and 241 (12.6%) revision THAs. The most common prophylactic agent used was rivaroxaban (40.6%), followed by warfarin (28.5%) and aspirin (27.6%). Type of chemoprophylaxis was not associated with postoperative VTE or wound drainage (P>.05). Although revision surgery was an independent risk factor for wound drainage (odds ratio, 3.201; 95% confidence interval, 1.594-6.426; P=.001), it was not a risk factor for VTE (odds ratio, 1.847; 95% confidence interval, 0.423-8.053; P=.414). Revision arthroplasty alone was not associated with an increased rate of VTE. Aspirin is as effective as other chemoprophylactic agents without the increased risk of bleeding in low-risk patients. [Orthopedics. 2019; 42(6):323-329.].
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28
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Soft Tissue Issues and Considerations in Total Knee Arthroplasty. Tech Orthop 2019. [DOI: 10.1097/bto.0000000000000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Anis HK, Sodhi N, Faour M, Klika AK, Mont MA, Barsoum WK, Higuera CA, Molloy RM. Effect of Antibiotic-Impregnated Bone Cement in Primary Total Knee Arthroplasty. J Arthroplasty 2019; 34:2091-2095.e1. [PMID: 31109755 DOI: 10.1016/j.arth.2019.04.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/01/2019] [Accepted: 04/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the effect of commercially available antibiotic-impregnated bone cement (AIBC) on (1) prosthetic joint infections (PJIs) and (2) surgical site infections (SSIs) after primary total knee arthroplasty (TKA). METHODS A review of primary TKAs between 2014 and 2017 from an institutional database was conducted. This identified 12,541 cases which were separated into AIBC (n = 4337) and non-AIBC (8,164) cohorts. Medical records were reviewed for PJIs and SSIs (mean 2-year postoperative period). Infection rates between the cohorts were compared with univariate analyses followed by subanalysis of high risk patients (defined as having 2 or more of the following characteristics: >65 years, body mass index >40, or Charlson Comorbidity Index score >3). To control for confounders, multivariate analyses were performed with regression models adjusted for age, gender, body mass index, comorbidities, year, operative times, and lengths of stay. RESULTS On univariate analysis, PJI rates were higher in the AIBC cohort (1.0%) compared to the non-AIBC cohort (0.5%, P < .001). Subanalysis of the high risk patients also showed that PJI rates were higher in the AIBC cohort (1.9% vs 0.6%, P < .01). After adjusting for potential confounders, no significant associations between PJIs and AIBC use were found (odds ratio 1.4, 95% confidence interval 0.9-2.3, P = .133). Similarly, no significant differences in SSI rates were observed between the AIBC (2.9%) and non-AIBC cohorts (2.4%, P = .060) and no significant associations between SSIs and AIBC were found with multivariate analysis (odds ratio 1.0, 95% confidence interval CI 0.8-1.3, P = .948). CONCLUSION This study found that there was no clinically or statistically significant decrease in infection rates with AIBC in primary TKAs.
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Affiliation(s)
- Hiba K Anis
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Mhamad Faour
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Alison K Klika
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Wael K Barsoum
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Carlos A Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
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30
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Outcomes of Superficial and Deep Irrigation and Debridement in Total Hip and Knee Arthroplasty. J Arthroplasty 2019; 34:1452-1457. [PMID: 30962091 DOI: 10.1016/j.arth.2019.03.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 03/06/2019] [Accepted: 03/11/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Following total knee arthroplasty and total hip arthroplasty, wound-related problems and deep periprosthetic joint infection may present in a similar fashion. Irrigation and debridement (I&D) has a great role in management of patients with early infection. The question that often arises is how to tell the difference between superficial and deep infection. This study evaluated the role and outcomes of both superficial and deep I&D in patients with wound-related issues and/or suspected periprosthetic joint infection. METHODS A retrospective study was conducted evaluating patients who underwent I&D within 28 days of total joint arthroplasty. A total of 176 cases with a minimum of 1-year follow-up were identified, and clinical records were reviewed in detail. Reoperations included superficial (fascia not opened) or deep (fascia opened) I&D. Failure was defined as the need for further surgical intervention within 1 year of initial I&D. RESULTS The overall success for superficial I&D was 84.28% vs 68.86% for deep I&D. The success of both deep and superficial I&D was higher if the I&D was performed closer to the index surgery. Superficial I&D in patients with a positive joint aspiration or evidence of intraoperative purulence or those in whom had no subcutaneous fluid had higher failure rates. CONCLUSION Superficial I&D is a viable option in patients with wound-related issues as long as joint aspiration is performed to rule out infection involving the prosthesis. If there are findings of no fluid or purulence, fascia may need to be opened and the deeper tissues explored.
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31
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Shahi A, Boe R, Bullock M, Hoedt C, Fayyad A, Miller L, Oliashirazi A. The risk factors and an evidence-based protocol for the management of persistent wound drainage after total hip and knee arthroplasty. Arthroplast Today 2019; 5:329-333. [PMID: 31516977 PMCID: PMC6728765 DOI: 10.1016/j.artd.2019.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 05/03/2019] [Accepted: 05/22/2019] [Indexed: 01/09/2023] Open
Abstract
Background Persistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJIs), arguably the most dreaded complication after total joint arthroplasty (TJA). The aim of this study was to identify the risk factors for PWD and provide a stepwise management protocol for it. Methods A retrospective review of 4873 TJAs was performed. After determining patients with PWD, a logistic regression model was designed to identify the risk factors using Charlson and Elixhauser comorbidity indexes. Finally, the protocol that was instituted for the management of PWD and its success rate was presented. Results The prevalence of PWD was 6.2% (302 of 4873). Of these, 196 did not require any surgical interventions, and drainage stopped with local wound care. 106 patients required surgical intervention, of which, 64 underwent superficial irrigation and debridement and 42 underwent deep irrigation and debridement with modular components exchange. Patients with PWD had significantly higher rates of PJI (odds ratio [OR]: 16.9; 95% confidence interval [CI]: 9.1-31.6). Risks factors were diabetes (OR: 21.2; 95% CI: 12.8-25.1), morbid obesity (OR: 17.3; 95% CI: 14.7-21.5), rheumatoid arthritis (OR: 14.2; 95% CI: 11.7-16.5), chronic alcohol use (OR: 4.3; 95% CI: 2.3-6.1), hypothyroidism (OR: 2.8; 95% CI: 1.3-4.2), and female gender (OR: 1.9; 95% CI: 1.1-2.2). Conclusions Several modifiable risk factors of PWD were identified. Surgeons must be cognizant of these comorbidities and optimize patients’ general health before an elective TJA. Our results demonstrated that PWD ceased in about 65% of the patients with local wound care measures alone. Patients with PWD were at substantially higher risk for PJI.
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Affiliation(s)
- Alisina Shahi
- Oliashirazi Institute at Marshall University, Huntington, WV, USA.,Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Richie Boe
- Oliashirazi Institute at Marshall University, Huntington, WV, USA
| | - Matthew Bullock
- Oliashirazi Institute at Marshall University, Huntington, WV, USA
| | - Chris Hoedt
- Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Azzam Fayyad
- Medcare Orthopedics and Spine Hospital, Dubai, UAE
| | - Lawrence Miller
- Cooper Bone and Joint Institute, Cooper University Hospital, Camden, NJ, USA
| | - Ali Oliashirazi
- Oliashirazi Institute at Marshall University, Huntington, WV, USA
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32
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Arnold WV, Bari AK, Buttaro M, Huang R, Mirez JP, Neira I, Poojary A, Purtill JJ, Quevedo MS, García Ricaurte JC, Scuderi G, Thakur H, Tozun IR. General Assembly, Prevention, Postoperative Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S169-S174. [PMID: 30348574 DOI: 10.1016/j.arth.2018.09.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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33
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Adie S, Harris I, Chuan A, Lewis P, Naylor JM. Selecting and optimising patients for total knee arthroplasty. Med J Aust 2019; 210:135-141. [DOI: 10.5694/mja2.12109] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Sam Adie
- St George and Sutherland Clinical SchoolUNSW Sydney NSW
- St George Hospital Sydney NSW
| | - Ian Harris
- South Western Sydney Clinical SchoolUNSW Sydney NSW
| | - Alwin Chuan
- South Western Sydney Clinical SchoolUNSW Sydney NSW
- Liverpool Hospital Sydney NSW
| | | | - Justine M Naylor
- South Western Sydney Clinical SchoolUNSW Sydney NSW
- South Western Sydney Local Health District Sydney NSW
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Gleason S, Mehl D, Payne W, Parry S, Stein AB. Microporous polysaccharide hemosphere efficacy and safety in primary total knee arthroplasty. J Orthop 2019; 16:19-24. [PMID: 30765929 PMCID: PMC6355655 DOI: 10.1016/j.jor.2018.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 11/28/2018] [Indexed: 11/23/2022] Open
Abstract
Absorbable hemostats such as microporous polysaccharide hemospheres (MPH) are used to manage hemostasis and prevent complications in total knee arthroplasty (TKA). We aimed to determine safety and effectiveness of MPH use in TKA. Records were reviewed for blood loss, hematomas, and infections. No differences existed regarding demographics, superficial infections (P = 0.933) or hematomas (P = 0.393). Positive correlation existed between hematoma and superficial infection (P = 0.009). Blood loss was greater in the treatment group (P = 0.014). MPH demonstrated inferior bleeding control and had no effect on complications. Our results suggest application of this agent may be unnecessary.
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Affiliation(s)
- Scott Gleason
- Midwestern University/Franciscan St. James Health, 20201 South Crawford Ave, Olympia Fields, IL, 60461, USA
| | - David Mehl
- Midwestern University/Franciscan St. James Health, 20201 South Crawford Ave, Olympia Fields, IL, 60461, USA
| | - William Payne
- Midwestern University/Franciscan St. James Health, 20201 South Crawford Ave, Olympia Fields, IL, 60461, USA
| | - Steve Parry
- Midwestern University/Franciscan St. James Health, 20201 South Crawford Ave, Olympia Fields, IL, 60461, USA
| | - Amy Buros Stein
- Midwestern University, 19555 North 59th Ave, Glendale, AZ, 85308, USA
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Avoiding Postoperative Wound Complications in Total Joint Arthroplasty. J Arthroplasty 2018; 33:3109-3112. [PMID: 29475573 DOI: 10.1016/j.arth.2018.01.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 01/18/2018] [Indexed: 02/01/2023] Open
Abstract
Avoidance of early wound complications is critical to the success of total joint arthroplasty. The magnitude of postoperative complications can be as simple as quickly resolving wound drainage, to persistent wound drainage and full-thickness soft tissue necrosis. Persistent postoperative drainage and wound complications can lead to a devastating deep periprosthetic infection. Attention to several steps in the clinical and perioperative pathway should be addressed to avoid this complication including addressing modifiable patient risk factors, implementing meticulous surgical technique, and following an algorithmic approach in response to persistent wound drainage.
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Sershon RA, Tecle N, Della Valle CJ, Levine BR, Berger RA, Nam D. The Impact of an Acute, Traumatic Wound Dehiscence on Clinical Outcomes Following Primary Knee Arthroplasty. J Arthroplasty 2018; 33:2613-2615. [PMID: 29636248 DOI: 10.1016/j.arth.2018.02.090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/21/2018] [Accepted: 02/28/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Early wound healing complications and persistent drainage are associated with an increased risk of infection following knee arthroplasty. However, the scenario in which a patient sustains an acute, traumatic wound dehiscence has not been investigated. The purpose of this study is to determine the outcomes of an acute traumatic wound dehiscence following arthroplasty treated with an urgent irrigation and debridement and primary wound closure. METHODS Using a single institution's arthroplasty registry, patients sustaining an acute, traumatic wound dehiscence within 30 days of undergoing a primary knee arthroplasty were identified. Patients experiencing chronic wound drainage without injury or a history of prior infection were excluded. Patients were followed for the occurrence of complications and clinical outcomes using the Knee Society Score. RESULTS From 2006 to 2016, 14 of 25,819 eligible patients (0.05%) were identified as having a traumatic wound dehiscence. The mean time from arthroplasty to wound dehiscence was 9.3 days. All but one patient was treated operatively within 24 hours of dehiscence. Postoperative antibiotics were administered for a mean of 21 days. At a mean of 6.5 years, 6 patients were considered failures (43%) including 2 deep infections, 3 revisions for instability, and 1 patient with a Knee Society Score <60 points. CONCLUSION Despite emergent incision and drainage and wound closure, patients experiencing an acute traumatic wound dehiscence following knee arthroplasty subsequently exhibit high rates of reoperation for instability, periprosthetic infection, and clinical failure. Further work is required to better understand the optimal modes of treatment for this complication.
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Affiliation(s)
- Robert A Sershon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Nahom Tecle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Brett R Levine
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Richard A Berger
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Denis Nam
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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DeRogatis MJ, Mahon AM, Lee P, Issack PS. Perioperative Considerations to Reduce Infection Risk in Primary Total Hip and Knee Arthroplasty. JBJS Rev 2018; 6:e8. [PMID: 29664871 DOI: 10.2106/jbjs.rvw.17.00144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Bernal-Fortich LD, Aguilar CA, Rivera-Villa AH, Galindo-Avalos J, Aguilera-Martínez P, Torres-González R, Colin-Vázquez A. A prospective randomized trial of total synovectomy versus limited synovectomy in primary total knee arthroplasty: evaluation of bleeding, postoperative pain, and quality of life with SF-12 v2. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:701-706. [PMID: 29383503 DOI: 10.1007/s00590-018-2139-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 01/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND During total knee arthroplasty (TKA), total synovectomy (TS) as a part of the surgical technique has been proposed to reduce the inflammatory tissue after the procedure, but there is a controversy about it because of the risk of major postsurgical bleeding. The aim of this study was to compare postoperative bleeding, pain, and health-related quality of life (HRQOL) after a TKA when a TS is performed and when it is not. METHODS The difference in pre and postoperative hemoglobin was measured, as well as postoperative pain using visual analogue scale (VAS) scores at 24 and 48 h post-surgical, HRQOL was measured prior to surgery and at one year using the SF-12V2 questionnaire. RESULTS We assessed a total of 148 patients (73 for TS and 75 for limited synovectomy). We have found a difference of 0.9 mg/dl of pre- and postoperative hemoglobin between both groups, with a higher bleeding amount for the TS group (P = 0.0000647); VAS scores were slightly lower for the TS group at 24 and 48 h after surgery, but not relevant. The TS group required transfusion in 13.3% and the limited synovectomy group in 6.8%. No significant differences in HRQOL were found in both groups at 1 year follow-up. CONCLUSIONS Performing a TS in TKA in patients with osteoarthrosis does not result in a relevant lower postoperative pain, or in an improvement in HRQOL, and it does increase the amount of bleeding after the procedure.
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Affiliation(s)
- Luis Dario Bernal-Fortich
- UMAE "Dr. Victorio de la Fuente Narváez" IMSS-UNAM, Av. Colector 15 s/n Esq. Av. Instituto Politécnico Nacional. Col. Magdalena de las Salinas, Delg. Gustavo A. Madero, C.P. 07760, Mexico, Mexico.
| | - Carlos Alberto Aguilar
- Joint Replacement Surgery Department, UMAE Traumatology, Orthopedics and Rehabilitation "Dr. Victorio de la Fuente Narváez" IMSS, Av. Colector 15 s/n Esq. Av. Instituto Politécnico Nacional. Col. Magdalena de las Salinas, Delg. Gustavo A. Madero, C.P. 07760, Mexico, Mexico
| | - Adrián H Rivera-Villa
- Joint Replacement Surgery Department, UMAE Traumatology, Orthopedics and Rehabilitation "Dr. Victorio de la Fuente Narváez" IMSS, Av. Colector 15 s/n Esq. Av. Instituto Politécnico Nacional. Col. Magdalena de las Salinas, Delg. Gustavo A. Madero, C.P. 07760, Mexico, Mexico
| | - Joel Galindo-Avalos
- UMAE "Dr. Victorio de la Fuente Narváez" IMSS-UNAM, Av. Colector 15 s/n Esq. Av. Instituto Politécnico Nacional. Col. Magdalena de las Salinas, Delg. Gustavo A. Madero, C.P. 07760, Mexico, Mexico
| | - Pedro Aguilera-Martínez
- Joint Replacement Surgery Department, UMAE Traumatology, Orthopedics and Rehabilitation "Dr. Victorio de la Fuente Narváez" IMSS, Av. Colector 15 s/n Esq. Av. Instituto Politécnico Nacional. Col. Magdalena de las Salinas, Delg. Gustavo A. Madero, C.P. 07760, Mexico, Mexico
| | - Rubén Torres-González
- Health Education and Research Department, UMAE Traumatology, Orthopedics and Rehabilitation "Dr. Victorio de la Fuente Narváez" IMSS, Av. Colector 15 s/n Esq. Av. Instituto Politécnico Nacional. Col. Magdalena de las Salinas, Delg. Gustavo A. Madero, C.P. 07760, Mexico, Mexico
| | - Avelino Colin-Vázquez
- UMAE "Dr. Victorio de la Fuente Narváez" IMSS-UNAM, Av. Colector 15 s/n Esq. Av. Instituto Politécnico Nacional. Col. Magdalena de las Salinas, Delg. Gustavo A. Madero, C.P. 07760, Mexico, Mexico
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Badawy M, Espehaug B, Fenstad AM, Indrekvam K, Dale H, Havelin LI, Furnes O. Patient and surgical factors affecting procedure duration and revision risk due to deep infection in primary total knee arthroplasty. BMC Musculoskelet Disord 2017; 18:544. [PMID: 29268748 PMCID: PMC5740908 DOI: 10.1186/s12891-017-1915-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 12/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to assess which patient and procedure factors affected both the risk of infection as well as procedure duration. Additionally, to assess if procedure duration affected the revision risk due to deep infection in total knee arthroplasty (TKA) patients and in a subgroup of low-risk patients. METHODS 28,262 primary TKA with 311 revisions due to deep infection were included from the Norwegian Arthroplasty Register (NAR) and analysed from primary surgery from 2005 until 31st December 2015 with a 1 and 4 year follow up. The risk of revision due to deep infection was calculated in a multivariable Cox regression model including patient and procedure related risk factors, assessing Hazard Ratio (HR) with 95% confidence interval (CI). RESULTS Multivariate analysis showed statistically significant associations with revision due to deep infection and increased procedure duration for male patients, ASA3+ (American Society of Anesthesiologists) and perioperative complications. Procedure duration ≥110 min (75 percentile) had a higher risk of deep infection compared to duration <75 min (25 percentile), in the unadjusted analysis (HR = 1.8, 95% CI 1.3-2.5, p = 0.001) and in the adjusted analysis (HR = 1.5, 95% CI 1.0-2.1, p = 0.03). For low-risk patients, procedure duration did not increase the risk of infection. CONCLUSION Male patients, ASA 3+ patients and perioperative complications were risk factors both for longer procedure duration and for deep infection revisions. Patients with a high degree of comorbidity, defined as ASA3+, are at risk of infection with longer procedure durations. The occurrence of perioperative complications potentially leading to a more complex and lengthy procedure was associated with a higher risk of infection. Long procedure duration in itself seems to have minor impact on infection since we found no association in the low-risk patient.
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Affiliation(s)
- Mona Badawy
- Coastal Hospital in Hagavik, 5217, Hagavik, Norway. .,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway.
| | - Birgitte Espehaug
- Center for Evidence-based Practice, Bergen University College, 5021, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, 5021, Bergen, Norway
| | - Kari Indrekvam
- Coastal Hospital in Hagavik, 5217, Hagavik, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway
| | - Håvard Dale
- Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway
| | - Leif I Havelin
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, 5021, Bergen, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, 5021, Bergen, Norway.,Department of Clinical Medicine, Institute of Medicine and Dentistry, University of Bergen, 5021, Bergen, Norway
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