Relationship Between Perioperative Urinary Tract Infection and Deep Infection After Joint Arthroplasty

Abstract Surgical wound infection is a serious and potentially catastrophic complication after joint arthroplasty. Urinary tract infection is a common infection that creates a potential reservoir of resistant pathogens and increases patient morbidity. We asked whether treated preoperative and postoperative urinary tract infections are risk factors for deep joint infection. We examined the medical records of 19,735 patients. The minimum had joint infections develop. Of these, three had preoperative and four had postoperative urinary tract infections. The majority of bacteria were not enteric. The bacteria in the two types of infections were not identical. Control subjects were randomly selected from a list of patients matched with patients having infections. Of these, eight had preoperative and one had postoperative urinary tract infections. We found no association between the preoperative urinary tract infection (odds ratio, 0.341; 95% confidence interval, 0.086-1.357) or postoperative urinary tract infection (odds ratio, 4.222; 95% confidence interval, 0.457-38.9) and wound infection. Only one of the 58 patients with wound infections had a urinary tract infection with the same bacteria in both infections. Given the infection rate was very low (0.29%), the power of the study was only 25%. Although limited, the data suggest patients with urinary tract infections had no more likelihood of postoperative infection. We believe treated urinary tract infection should not be a reason to delay or postpone surgery. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence

Predicting the Outcome of Limb Revascularization in Patients With Lower-extremity Arterial Trauma: Development and External Validation of a Supervised Machine-learning Algorithm to Support Surgical Decisions.

Objectives: Estimating the likely success of limb revascularization in patients with lower-extremity arterial trauma is central to decisions between attempting limb salvage and amputation. However, the projected outcome is often unclear at the time these decisions need to be made, making them difficult and threatening sound judgement. The objective of this study was to develop and validate a prediction model that can quantify an individual patient's risk of failed revascularization. Methods: A BN prognostic model was developed using domain knowledge and data from the US joint trauma system. Performance (discrimination, calibration, and accuracy) was tested using ten-fold cross validation and externally validated on data from the UK Joint Theatre Trauma Registry. BN performance was compared to the mangled extremity severity score. Results: Rates of amputation performed because of nonviable limb tissue were 12.2% and 19.6% in the US joint trauma system (n = 508) and UK Joint Theatre Trauma Registry (n = 51) populations respectively. A 10-predictor BN accurately predicted failed revascularization: area under the receiver operating characteristic curve (AUROC) 0.95, calibration slope 1.96, Brier score (BS) 0.05, and Brier skill score 0.50. The model maintained excellent performance in an external validation population: AUROC 0.97, calibration slope 1.72, Brier score 0.08, Brier skill score 0.58, and had significantly better performance than mangled extremity severity score at predicting the need for amputation [AUROC 0.95 (0.92–0.98) vs 0.74 (0.67–0.80); P < 0.0001]. Conclusions: A BN (https://www.traumamodels.com) can accurately predict the outcome of limb revascularization at the time of initial wound evaluation. This information may complement clinical judgement, support rational and shared treatment decisions, and establish sensible treatment expectations

Potent Anticoagulants are Associated with a Higher All-Cause Mortality Rate After Hip and Knee Arthroplasty

Anticoagulation for thromboprophylaxis after THA and TKA has not been confirmed to diminish all-cause mortality. We determined whether the incidence of all-cause mortality and pulmonary embolism in patients undergoing total joint arthroplasty differs with currently used thromboprophylaxis protocols. We reviewed articles published from 1998 to 2007 that included 6-week or 3-month incidence of all-cause mortality and symptomatic, nonfatal pulmonary embolism. Twenty studies included reported 15,839 patients receiving low-molecular-weight heparin, ximelagatran, fondaparinux, or rivaroxaban (Group A); 7193 receiving regional anesthesia, pneumatic compression, and aspirin (Group B); and 5006 receiving warfarin (Group C). All-cause mortality was higher in Group A than in Group B (0.41% versus 0.19%) and the incidence of clinical nonfatal pulmonary embolus was higher in Group A than in Group B (0.60% versus 0.35%). The incidences of all-cause mortality and nonfatal pulmonary embolism in Group C were similar to those in Group A (0.4 and 0.52, respectively). Clinical pulmonary embolus occurs despite the use of anticoagulants. Group A anticoagulants were associated with the highest all-cause mortality of the three modalities studied

Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis

BACKGROUND: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER: PROSPERO CRD42018099935