Risk of Obtaining Routine Cultures During Presumed Aseptic Orthopaedic Procedures

Treating patients with antibiotics that are selected based on routine cultures obtained from presumed aseptic orthopaedic procedures may lead to an increased risk of antibiotic-related complications without reducing the rate of late deep infection. Routine cultures obtained from 60 of 169 procedures resulted in 23 (38.3%) positive and 37 (61.7%) negative results. Twenty-two patients (13.5%) developed late infections. Seven of 14 patients with positive cultures, who were treated with antibiotics, developed a late infection, while two of nine patients with routine cultures, who received no antibiotic treatment, developed a late infection. Six of 37 patients with negative cultures and seven of 109 patients with no cultures developed a late infection. In patients who developed late deep infection, the microorganism isolated on routine culture only corresponded to the microorganism causing late infection 55.5% of the time. Of all patients treated with antibiotics, seven (29%) experienced an antibiotic-related complication (p = .01). (Journal of Surgical Orthopaedic Advances 26(4):239-245, 2017).

Modified Frailty Index Is an Effective Risk Assessment Tool in Primary Total Hip Arthroplasty

BACKGROUND

Frailty is described as decreased physiological reserve and typically increasing with age. Hospitals are being penalized for reoperations and readmissions, which can affect reimbursement. The purpose of this study was to determine if the modified frailty index (MFI) could be used as a risk assessment tool for preoperative counseling and to make an objective decision on whether to perform total hip arthroplasty (THA) on a frail patient.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried by Current Procedural Terminology code for primary THA (27130) from 2005 to 2014. MFI was calculated using 11 variables extracted from the medical record. Bivariate analysis was performed for outcomes and complications, and the multiple logistic regression model was used to compare MFI with other predictors of readmission, any complication, and reoperation.

RESULTS

A total of 51,582 patients underwent primary THA during the study period. MFI was a significant and stronger predictor than the American Society of Anesthesiologists class and age for readmission (odds ratio [OR], 14.72; 95% confidence interval [CI], 6.95-31.18; P < .001), any complication (OR, 3.63; 95% CI, 1.64-8.05; P = .002), and reoperation (OR, 8.78; 95% CI, 3.67-20.98; P < .001). As MFI increased, adverse discharge, any complication, readmission, reoperation, and mortality significantly increased (P < .001). Rates of systemic complications and length of stay significantly increased with increasing MFI.

CONCLUSION

MFI is a simple and effective risk assessment tool to preoperatively counsel and make an objective decision on whether to perform THA on a frail patient.

Modified Frailty Index Is an Effective Risk Assessment Tool in Primary Total Knee Arthroplasty

BACKGROUND

"Frailty" is a marker of physiological decline of multiple organ systems, and the frailty index identifies patients who are more susceptible to postoperative complications. The purpose of this study is to validate the modified frailty index (MFI) as a predictor of postoperative complications, reoperations, and readmissions in patients who underwent primary total knee arthroplasty (TKA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2014 was queried by the Current Procedural Terminology code for primary TKA (27447). A previously described MFI was used to summate 11 variables in 5 organ systems. Bivariate analysis was performed for postoperative complications. A multiple logistic regression model was used to determine the relationship between MFI, American Society of Anesthesiologists score, and 30-day reoperation, controlling for age, gender, and body mass index.

RESULTS

A total of 90,260 patients underwent primary TKA during the study period. As MFI score increased, 30-day mortality significantly increased (P < .001). In addition, significantly higher rates of postoperative complications (all P < .001) were observed with increasing MFI: infection, wound, cardiac, pulmonary, and renal complications; and any occurrence. More frail patients also had increasing odds of adverse hospital discharge disposition, reoperation, and readmission (all P < .001). Length of hospital stay increased from 3.10 to 5.16 days (P < .001), while length of intensive care unit stay increased from 3.47 to 5.07 days (P < .001) between MFI score 0 and ≥0.36. MFI predicts 30-day reoperation with an adjusted odds ratio of 3.32 (95% confidence interval, 1.36-8.11; P < .001). Comparatively, MFI was a stronger predictor of reoperation compared with American Society of Anesthesiologists score and age with adjustment for gender and body mass index.

CONCLUSION

Utilization of the MFI is a valid method in predicting postoperative complications, reoperations, and readmissions in patients undergoing primary TKA and can provide an effective and robust risk assessment tool to appropriately counsel patients and aid in preoperative optimization.

Gross Trunnion Failure of a Cobalt-Chromium Femoral Head on a Titanium Stem at Midterm Follow-up: A Report of 3 Cases

CASE

Three patients underwent uncomplicated primary total hip arthroplasty with cobalt-chromium femoral heads (36+5 mm) on titanium V40 tapers. At 6 to 9 years of follow-up, severe effects of corrosion at the trunnion were noted in all 3 patients, along with elevated levels of serum cobalt ions and normal levels of serum chromium ions. Gross trunnion failure, apparently caused by corrosion, required femoral stem revision in all of the patients.

CONCLUSION

Decreased neck diameter, longer trunnion length, and large-sized cobalt-chromium heads are possible contributors to early failure after primary total hip arthroplasty due to trunnionosis. Surgeons should be mindful of trunnionosis as a cause of pain and a mechanism of failure following total hip arthroplasty, and serum metal ions should be monitored in these patients.

Economic Impact of Ketorolac vs Corticosteroid Intra-Articular Knee Injections for Osteoarthritis: A Randomized, Double-Blind, Prospective Study

BACKGROUND

Knee osteoarthritis is a disabling disease that costs billions of dollars to treat. Corticosteroid gives varying pain relief and costs $12 per injection, whereas ketorolac costs $2 per injection, per institutional costs. The aim of this study was to compare ketorolac with corticosteroid based on pain relief using patient outcome measures and cost data.

METHODS

A total of 35 patients were randomized to ketorolac or corticosteroid intra-articular knee injection in a double-blind, prospective study. Follow-up was 24 weeks. Osteoarthritis was evaluated using Kellgren-Lawrence grading. Visual analog scale (VAS) was the primary outcome measure. A query of the institutional database was performed for International Classification of Diseases, Ninth Revision codes 715.16 and 719.46, and procedure code 20610 over a 3-year period. Two-way, repeated measures analysis of variance and Spearman rank correlation were used for statistical analysis.

RESULTS

Mean VAS for ketorolac and corticosteroid decreased significantly from baseline at 2 weeks, 6.3-4.6 and 5.2-3.6, respectively and remained decreased for 24 weeks. There was no correlation between VAS and demographics within treatments. There were 220, 602, and 405 injections performed on patients with the International Classification of Diseases, Ninth Revision codes 715.16 and 719.46 during 2013, 2014, and 2015, respectively. The cost savings per year using ketorolac instead of corticosteroid would be $2259.40, $6182.54, and $4159.35 for 2013, 2014, and 2015, respectively, with a total savings of $12,601.29 over this period.

CONCLUSION

Pain relief was similar between ketorolac and corticosteroid injections. Ketorolac knee injection is safe and effective with a cost savings percentage difference of 143% when compared with corticosteroid.

Does a longer delay in fixation of talus fractures cause osteonecrosis?

This retrospective study investigated active duty soldiers with delayed definitive fixation of combat-related talus fractures. The authors predicted a longer delay to internal fixation and a correlation between the timing of fixation and development of osteonecrosis and posttraumatic arthritis. The Joint Theater Trauma Registry was queried by ICD-9 codes for talus fractures. Soldiers, ages 18 to 40, with talus fracture between 2001 and 2008 were included. Radiographs identified the injury type, Hawkins sign, osteonecrosis, and posttraumatic arthritis. Mean time to fixation was 12.9 days. Hawkins sign was observed in 59% of fractures at a mean of 7 weeks. No correlation was found between osteonecrosis or posttraumatic arthritis and open fractures, comminuted fractures, or timing of fixation. Average follow-up was 16 months. This case series has the longest mean time to fixation by more than threefold. There was no correlation of delayed timing of fixation and development of osteonecrosis or posttraumatic arthritis.

Salivary levels of CGRP and VIP in rhinosinusitis and migraine patients

BACKGROUND

Secretion of calcitonin gene-related peptide (CGRP) from trigeminal nerves and vasoactive intestinal peptide (VIP) from parasympathetic nerves is involved in the pathophysiology of migraine and rhinosinusitis. Analysis of these neuropeptides in human saliva samples can be used as markers of trigeminal and parasympathetic nerve activity in patients between and during attacks as well as in response to specific treatments.

OBJECTIVE

To compare the amount of trigeminal sensory and parasympathetic nerve activation by measuring CGRP and VIP levels in the saliva of subjects experiencing noninfectious allergic rhinosinusitis, migraine with sinus symptoms, and no symptoms.

METHODS

Subjects were enrolled in three groups. Group A: subjects without a history of migraine, "sinus" headache, or allergic rhinosinusitis within the previous 6 months. Group B: subjects with chronic recurrent noninfectious rhinosinusitis and no history of migraine or "sinus" headache. Group C: subjects with self-described "sinus" headaches whose symptoms met International Headache Society diagnostic criteria (1.1 or 1.2) for migraine. The total amount of CGRP and VIP present in saliva collected under normal, pathological, and therapeutic conditions was determined by radioimmunoassay. Neuropeptide levels were normalized to total volume and amount of protein, and levels were correlated to onset and change in clinical symptoms.

RESULTS

Total volume, total protein, and CGRP and VIP levels did not significantly change in saliva collected on consecutive days in the clinic and at the subject's home, respectively. No appreciable change in baseline salivary levels of CGRP and VIP was detected in control subjects. However, baseline salivary levels of CGRP and VIP were significantly elevated between attacks in allergic rhinosinusitis and migraine subjects compared to control values. For rhinosinusitis subjects, the amount of CGRP and VIP during attacks returned to baseline values following treatment with pseudoephedrine and relief of symptoms. Similarly, CGRP and VIP levels during a migraine headache were significantly reduced within 2 hours after sumatriptan treatment and reported symptom relief.

CONCLUSION

Correlation of CGRP and VIP saliva levels observed in our study supports physiologically coordinated regulation of trigeminal and parasympathetic nerve activation in allergic rhinosinusitis and migraine patients between and during attacks as well as following treatment. Furthermore, our findings demonstrate that analysis of human saliva neuropeptides may provide a semiquantitative index of pathological and therapeutic states and, therefore, function as a clinical model for studying neuronal mechanisms involved in migraine and rhinosinusitis.