A dedicated anticoagulation clinic does not improve postoperative management of warfarin after total joint arthroplasty

Background: Periprosthetic joint infections (PJIs) are devastating complications. Excessive anticoagulation with warfarin is an independent risk factor for PJIs. The use of a dedicated anticoagulation clinic to improve warfarin management has not been proven. Methods: Between 2006 and 2014, we identified 92 patients who were placed on postoperative warfarin, and later developed PJI. These patients were compared to 313 patients who underwent total joint arthroplasty placed on warfarin without developing PJI. Patients were included if they had no history of a venous thromboembolic event, were warfarin naive, and enrolled in the anticoagulation clinic. A univariate analysis compared independent variables, and statistical analysis was performed using Student's t-test and Pearson chi-square test for continuous and categorical variables. Results: Thirty-six PJI patients and 297 control patients met the inclusion criteria. The venous thromboembolism rate was 2.1%. At discharge, 82% of all patients were subtherapeutic. Patients were within their target international normalized ratio (INR) range 26.7% of the time. The mean INR in the initial postoperative period for the PJI group was 1.46 and 1.29 in the control group (P < .001). In the acute postoperative period, 13.3% of the knee PJI group were therapeutic or supratherapeutic compared with 3.5% in the knee control group (P = .002). Conclusions: Despite utilization of a dedicated anticoagulation clinic, patients were only within their target INR range 27% of the time. Total knee arthroplasty patients who developed a PJI were more likely to be therapeutic or supratherapeutic in the initial postoperative period. Consequently, the risks associated with warfarin as a venous thromboembolism prophylaxis may outweigh the potential benefits. Keywords: Total joint arthroplasty (TJA), Periprosthetic joint infection (PJI), International normalized ratio (INR), Warfarin, Venous thromboembolism (VTE), Pulmonary emboli (PE

Preoperative radiographic valgus alignment predicts the extent of lateral soft tissue release and need for constraint in valgus total knee arthroplasty

Background: In total knee arthroplasty (TKA) for valgus knees, the decision to use a constrained implant is often made intraoperatively depending on the extent of soft tissue releases performed and residual soft tissue imbalance. The purpose of this study is to determine if preoperative radiographic criteria of valgus knees can predict the extent of soft tissue releases required and the level of constraint needed to balance the knee during TKA. Methods: A single surgeon's 807 consecutive TKA standing hip-knee-ankle radiographs from 2007-2012 were analyzed. One hundred eighty-seven valgus knees were identified and annotated. Statistical univariate and multivariate analyses were performed for both outcomes, lateral release and articulation, to assess the association with risk factors of gender, age, and preoperative radiographic markers of valgus deformity. A P-value .05). A preoperative anatomic tibiofemoral valgus angle of >16.8° was associated with the use of a constrained articulation during surgery. Conclusions: Our data demonstrate that preoperative radiographic characteristics of the valgus knee can be utilized to predict the extent of lateral soft tissue release and whether a constrained articulation will be required in TKA. This will provide surgeons with useful information to offer accurate preoperative counseling to patients and to ensure that the appropriate prosthetic parts are available during surgery. Keywords: Total knee arthroplasty, Valgus, Constrained, Stabilized, Releas

A Contemporary Classification System of Femoral Bone Loss in Revision Total Hip Arthroplasty

Background: Current femoral bone loss classification systems in revision total hip arthroplasty were created at a time when the predominant reconstructive methods used cylindrical porous-coated cobalt-chrome stems. As these stems have largely been replaced by fluted-tapered titanium stems, the ability of these classification systems to help guide implant selection is limited. The purpose of this study was to describe a novel classification system based on contemporary reconstructive techniques. Methods: We reviewed the charts of all patients who underwent femoral component revision at our institution from 2007 through 2019. Preoperative images were reviewed, and FBL was rated according to the Paprosky classification and compared to ratings using our institution’s NCS. Rates of reoperation at the time of most recent follow-up were determined and compared. Results: Four-hundred and forty-two femoral revisions in 330 patients with a mean follow-up duration of 2.7 years were identified. Femoral type according to Paprosky and NCS were Paprosky I (36, 8.1%), II (61, 13.8%), IIIA (180, 40.7%), IIIB (116, 26.2%), and IV (49 11.1%) and NCS 1 (35, 7.9%), 2 (364, 82.4%), 3 (8, 1.8%), 4 (27, 6.1%), and 5 (8, 1.8%). Of the 353 nonstaged rTHAs, there were 42 cases requiring unplanned reoperation (11.9%), including infection (18, 5.1%), instability (10, 2.8%), femoral loosening (5, 1.4%), and various other causes (9, 2.5%). The NCS was more predictive of reoperation than the Paprosky classification (Fisher’s exact test, P = .008 vs P = ns, respectively). Conclusion: We present a novel femoral classification system that can help guide contemporary implant selection

Changes Over a Decade in Patient-Reported Outcome Measures and Minimal Clinically Important Difference Reporting in Total Joint Arthroplasty

Background: When used appropriately, the minimal clinically important difference (MCID) provides a powerful tool for identifying meaningful improvements brought about by a given treatment, offering more clinically relevant information than frequentist statistical analysis. However, recent studies have shown inconsistent derivation methods and use of MCIDs. The goal of this study was to report the rate of patient-reported outcome measures (PROMs) and MCIDs use in the literature and assess how this rate has changed over time. Methods: All articles published in 2010 and 2020 reporting on total hip arthroplasty or total knee arthroplasty in The Journal of Clinical Orthopaedics and Related Research, The Journal of Bone and Joint Surgery, and The Journal of Arthroplasty were reviewed. In each reviewed article, every reported PROM and, if present, its corresponding MCID was recorded. These data were used to calculate the rate of reporting of each PROM and MCID. Results: While the total number of articles on total hip arthroplasty and total knee arthroplasty reporting PROMs increased over time, the proportion of articles reporting PROMs decreased from 49.8% (131/263) in 2010 to 35.5% (194/546) in 2020 (P = .011). Of these articles that report PROMs, the proportion of articles reporting any MCID increased from 2.3% (3/131) in 2010 to 16.5% (32/194) in 2020 (P = .002). Conclusions: The rate of reporting of MCIDs among articles relating to total hip arthroplasty and total knee arthroplasty that report PROMs has increased significantly between 2010 and 2020 but remains low. Continued emphasis on appropriate inclusion and value of MCIDs when PROMS are reported in clinical outcomes studies is needed