Definition of Periprosthetic Joint Infection

Diagnosis of periprosthetic joint infection (PJI) remains challenging as no “gold standard” for diagnosis exists [3]. The challenge is then what test(s) or criterion (ia) can be used to define PJI. In an effort to standardize the definition of PJI, Musculoskeletal Infection Society (MSIS) convened a workgroup in 2011 to issue diagnostic criteria for PJI [1]. The MSIS definition of PJI consists of two major criteria, when the presence of either criterion would indicate PJI, and six minor criteria, when the presence of four or more would indicate PJI

The Use of Cementless Components Does Not Significantly Increase Procedural Costs in Total Knee Arthroplasty

Introduction: Modern cementless total knee arthroplasty (TKA) designs have shown promising early clinical success; however, concerns exist regarding the higher cost of the cementless implants. The purpose of this study is to evaluate the total facility cost of cementless vs traditional cemented TKA along with the effect of cementless fixation on short-term outcomes. Methods: We reviewed a consecutive series of patients between 2015 and 2017 who underwent either cementless or cemented primary TKA. Itemized facility costs were calculated for every procedure using a time-driven activity-based costing algorithm. Controlling for demographic variables and medical comorbidities, we performed a multivariate analysis to identify independent risk factors for facility costs following TKA. Short-term outcome metrics including complications, readmissions, and patient-reported outcomes were compared between groups. Results: Among the 2426 primary TKA patients in this study, 119 (4.91%) were performed using cementless implants. When compared to cemented TKA, cementless TKA patients had higher implant costs, but lower supply costs and lower operating room personnel costs. When controlling for confounding variables, cementless fixation did not have a significant effect on total facility cost or outcomes. Discussion: The use of cementless TKA implants did not significantly increase total procedural costs when compared to traditional cemented TKA components at our institution. Our data suggest that the increased cost of a cementless implant is recouped through savings in cost of cement and supplies, as well as shorter operative times. The authors encourage investigators at other institutions to use the authors\u27 methodology to evaluate (preferably in a prospective manner) whether the findings from this study can be corroborated

Selective Serotonin Reuptake Inhibitors Are Associated with Increased Bleeding Related Complications Following Primary Total Hip and Total Knee Arthroplasty

Introduction: Approximately 10-22% of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) are diagnosed with depression. Pre-operative depression is associated with poorer patient reported outcomes, costs and increased complications. Selective serotonin-reuptake inhibitors (SSRIs) are first-line treatment for depression due to their efficacy and low side effect profile. There are conflicting studies regarding SSRI-related bleeding complications. This study compares the rate of bleeding-related complications in THA and TKA patients taking SSRI’s to a control group of non-SSRI users. Methods: A retrospective single institution study of 16,407 primary THA and TKA’s from 2008 to 2018 was performed. Patients with THA for fracture, conversion arthroplasty with existing hardware, revision TJA, and uni-compartmental knee arthroplasty. Patients taking SSRIs (2,588) were compared to non-SSRI users (13,819). Patient demographics were reviewed and matched at a 3:1 ratio. Multivariate logistic regression analysis was performed and adjusted to control for potential confounders. Results: Patients on SSRI had a significant increase in transfusion, post-operative anemia, irrigation and debridement (I&D) and superficial infection. There was a trend towards increased hematoma and revision. There was a significantly higher rate of pulmonary embolism for SSRI users compared to non-SSRI. Rates of 1-year PJI, hematoma removal or calculated blood loss did not differ. Discussion: The rate of bleeding related complications is significantly greater in SSRI users undergoing TKA and THA. Poorer outcomes in depression may be due to the intrinsic nature of the disease; however, increased pain due to swelling and wound complications may be due to increased rates of bleeding in SSRI users

Red Cell Distribution Width: an Unacknowledged Predictor of Mortality and Length of Stay following Revision Arthroplasty

Introduction Red blood cell distribution width (RDW), a measure of variability in size of circulating erythrocytes, is routinely reported in complete blood cell analysis, and together with mean cell volume (MCV) has conventionally been used to distinguish the cause of anemia. It is calculated by (Standard deviation of MCV÷ mean MCV) x 100, with normal range being 11.5%-14.5%. Several recent publications have described RDW as an independent predictor of adverse outcome and mortality in patients with different underlying medical conditions such as acute and chronic heart failure, peripheral artery disease, chronic pulmonary disease and acute kidney injury1. The purposes of this study were 1) to investigate possible relationship between RDW levels and length of stay (LOS) and mortality following revision total joint arthroplasty (TJA), and if that correlation existed, 2) to develop predictive models for LOS and mortality based on preoperative patient-related factors including RDW values

Aspirin May Be Adequate for Venous Thromboembolic Event Prophylaxis after Revision Hip and Knee Arthroplasty

Introduction: The optimal prophylaxis for prevention of venous thromboembolic events (VTE) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) remains unknown.(1) Current studies focus on primary arthroplasty and there are little to no data on the ideal prophylaxis for VTE following revision arthroplasty.(2) Revision surgery, due to its complexity, longer operative time, higher risk of bleeding and infection diff­ers from primary arthroplasty.(3) The objective of this study was to evaluate whether aspirin, known to be e­ffective for prevention of VTE after primary arthroplasty, is also e­ffective against such events following revision THA and TKA

Postoperative Urinary Retention (POUR): What Are The Risk Factors?

Introduction Total hip arthroplasty (THA) is a successful procedure alleviating pain in patients with debilitating arthritis. Postoperative urinary retention (POUR) is a common complication following surgery and is managed with intermittent or continued urinary catheterization. POUR has been estimated in retrospective literature to be on the order of 5% – 70% of surgical cases with early catheter removal or without a catheter. At our institution, and based on a Level 1 study here, urinary catheter is not used routinely in patients undergoing THA under regional anesthesia. The purpose of this study was to evaluate the incidence of POUR and risk factors leading to urinary retention in patients undergoing THA using regional anesthesia who did not receive urinary catheterization

A Clinical Decision Support Tool to Predict the Risk of Failure in Patients with Femoroacetabular Impingement Undergoing Hip Preservation Surgery

In modern orthopaedics, risk prediction scores can help discriminate between ideal and poor candidates for a specifi­c therapeutic intervention. We consider these tools useful during the process of shared medical decision-making1. To our knowledge, such a strategy has never been explored in the ­field of hip preservation surgery. The aim of our study is to generate a clinical decision support tool to predict risk of failure after hip preservation surgery among patients with femoroacetabular impingement (FAI)

Spinal anesthesia: should everyone receive a urinary catheter?: a randomized, prospective study of patients undergoing total hip arthroplasty.

BACKGROUND: The objective of this randomized prospective study was to determine whether a urinary catheter is necessary for all patients undergoing total hip arthroplasty under spinal anesthesia. METHODS: Consecutive patients undergoing total hip arthroplasty under spinal anesthesia were randomized to treatment with or without insertion of an indwelling urinary catheter. All patients received spinal anesthesia with 15 to 30 mg of 0.5% bupivacaine. The catheter group was subjected to a standard postoperative protocol, with removal of the indwelling catheter within forty-eight hours postoperatively. The experimental group was monitored for urinary retention and, if necessary, had straight catheterization up to two times prior to the placement of an indwelling catheter. RESULTS: Two hundred patients were included in the study. There was no significant difference between the two groups in terms of the prevalence of urinary retention, the prevalence of urinary tract infection, or the length of stay. Nine patients in the no-catheter group and three patients in the catheter group (following removal of the catheter) required straight catheterization because of urinary retention. Three patients in the catheter group and no patient in the no-catheter group had development of urinary tract infection. CONCLUSIONS: Patients undergoing total hip arthroplasty under spinal anesthesia appear to be at low risk for urinary retention. Thus, a routine indwelling catheter is not required for such patients

Low Dose Aspirin: An Effective Chemoprophylaxis for Preventing Venous Thromboembolic Events

The available guidelines, endorsed by Surgical Care Improvement Project (SCIP), have advocated that aspirin (ASA) is a safe and eff­ective strategy for venous thromboembolic events (VTE) prophylaxis following total joint arthroplasty (TJA). The optimal dose of aspirin for this purpose is not known. The first guidelines for prevention of VTE that were issued by the American Academy of Orthopedic Surgeons recommended 325 mg Bis in die (twice a day) (bid) for this purpose with the recommendation having a 1C grade (little evidence to support the recommendation). It is known that platelet aggregation inhibition occurs at lower doses. Traditionally, ASA 81mg has been used as a cardioprotective medication. Additionally, all available randomized studies, including the sentinel study on Pulmonary Embolism Prevention (PEP) trial1-4 have used lower doses of ASA. It was our hypothesis that lower dose aspirin is likely to be as eff­ective as higher dose aspirin while reducing the gastrointestinal side e­ffects associated with the higher dose aspirin

Reactive scoliosis: a challenging phenomenon in adolescent patients with hip arthritis

Functional limb length discrepancy (LLD) in adolescents can result from soft tissue contracture following long-standing hip disease. We present a case of a 13-year-old girl with difficulty in ambulation due to right hip pain and LLD. Radiographs revealed severe arthritis of right hip with signs of avascular necrosis of the femoral head. The patient had developed reactive scoliosis of lumbar spine along with pelvic obliquity. After failing conservative management, total hip arthroplasty (THA) without attempting to equalize LLD was performed. At 6-month follow-up, patient was pain free with full range of motion and her functional LLD was completely resolved. In such adolescent patients, reactive scoliosis of spine is reversible, and with no evidence of true LLD, THA without correcting LLD should be the right choice