Cefazolin Prophylaxis for Total Joint Arthroplasty: Obese Patients Are Frequently Underdosed and at Increased Risk of Periprosthetic Joint Infection

Background One of the most effective prophylactic strategies against periprosthetic joint infection (PJI) is administration of perioperative antibiotics. Many orthopedic surgeons are unaware of the weight-based dosing protocol for cefazolin. This study aimed at elucidating what proportion of patients receiving cefazolin prophylaxis are underdosed and whether this increases the risk of PJI. Methods A retrospective study of 17,393 primary total joint arthroplasties receiving cefazolin as perioperative prophylaxis from 2005 to 2017 was performed. Patients were stratified into 2 groups (underdosed and adequately dosed) based on patient weight and antibiotic dosage. Patients who developed PJI within 1 year following index procedure were identified. A bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify risk factors for PJI. Results The majority of patients weighing greater than 120 kg (95.9%, 944/984) were underdosed. Underdosed patients had a higher rate of PJI at 1 year compared with adequately dosed patients (1.51% vs 0.86%, P = .002). Patients weighing greater than 120 kg had higher 1-year PJI rate than patients weighing less than 120 kg (3.25% vs 0.83%, P < .001). Patients who were underdosed (odds ratio, 1.665; P = .006) with greater comorbidities (odds ratio, 1.259; P < .001) were more likely to develop PJI at 1 year. Conclusion Cefazolin underdosing is common, especially for patients weighing more than 120 kg. Our study reports that underdosed patients were more likely to develop PJI. Orthopedic surgeons should pay attention to the weight-based dosing of antibiotics in the perioperative period to avoid increasing risk of PJI

Irreparable Massive Rotator Cuff Tears: Subacromial Balloon Surgical Technique

Massive irreparable rotator cuff tears pose a significant challenge for both the treating orthopedic surgeon and patient. Surgical treatment options for massive rotator cuff tears include arthroscopic debridement, biceps tenotomy or tenodesis, arthroscopic rotator cuff repair, partial rotator cuff repair, cuff augmentation, tendon transfers, superior capsular reconstruction, subacromial balloon spacer, and ultimately reverse shoulder arthroplasty. The present study will provide a brief overview of these treatment options along with a description of the surgical technique for subacromial balloon spacer placement

Risk Factors and Effect of Acute Kidney Injury on Outcomes Following Total Hip and Knee Arthroplasty

Introduction: Development of acute kidney injury (AKI) following primary total joint arthroplasty (TJA) is a potentially avoidable complication associated with negative outcomes including increased length of stay and mortality. The purpose of this study was to determine the effect of AKI on short-term outcomes and identify risk factors for developing AKI following either total hip or total knee arthroplasty. It was hypothesized that AKI has significant adverse effects on short-term outcomes metrics. Methods: Patients undergoing primary TJA at a single hospital from 2005 to 2017 were identified and patient demographics, comorbidities, short-term outcomes, and perioperative laboratory results were recorded. AKI was defined as an increase in creatinine levels by 50% or 0.3 points. Demographics, comorbidities, and outcomes were compared between patients who developed AKI and those who did not. Multivariate regressions identified the independent effect of AKI on outcomes. Results: In total, 814 (3.9%) of 20,800 patients developed AKI. AKI independently increased length of stay by 0.26 days (P \u3c .001), in-hospital complication risk (odds ratio = 1.73,P \u3c .001), and discharge to facility risk (odds ratio = 1.26, P = .012). Potentially modifiable variables including body mass index, perioperative hemoglobin levels, surgery duration, and operative fluids administered were predicative of AKI. Discussion: AKI following TJA has significant adverse effects on outcomes including length of stay, discharge, and complications. Although many identified risk factors are nonmodifiable, maintaining adequate renal perfusion through optimizing preoperative hemoglobin, sufficient fluid resuscitation, and reducing blood loss may aid in mitigating the risk of developing AKI

Comprehensive Analysis of Opioid Use After Common Elective Outpatient Orthopaedic Surgeries

Background: Prescription opioid abuse remains an ongoing public health crisis, especially in orthopaedic surgery. The purpose of the present study is to analyze opioid-prescribing patterns and investigate risk factors for prolonged opioid use after common outpatient orthopaedic surgical procedures. Methods: After institutional review board approval, a review of 1,384 patients undergoing common elective outpatient orthopaedic procedures from January 2018 to June 2019 was conducted. Data on controlled substance prescriptions were obtained from the prescription drug monitoring program website. Statistical analysis was done to identify predictors for a second opioid prescription and prolonged opioid use (\u3e6 months). Results: Over 10% (150/1,384) of patients were still using opioids beyond 6 months. Of the opioid exposed patients, 60.4% (174/288) filled at least 1 additional opioid prescription postoperatively, and 29.2% (84/288) filled prescriptions beyond 6 months, compared with 26.4% (289/1,096) and 6.0% (66/1,096) of opioid-naive patients, respectively. Following multivariate analysis, significant predictors for filling a second opioid prescription included preoperative opioid use, current smoker status, benzodiazepine use, psychiatric disorder, and advanced age. Conclusion: This study revealed risk factors for prolonged opioid use after orthopaedic surgery. Surgeons should be mindful of these risk factors and counsel patients regarding postoperative pain management

Assessing Potato Psyllid Haplotypes in Potato Crops in the Pacific Northwestern United States

The potato psyllid, Bactericera cockerelli (Šulc), is a vector of the bacterium ‘Candidatus Liberibacter solanacearum’ (Lso) that has been linked to the economically devastating zebra chip disease of potato. To date, four haplotypes of the potato psyllid have been identified and include Central, Western, Northwestern, and Southwestern haplotypes. Zebra chip was reported in potato crops in the Pacific Northwestern United States for the first time in 2011, and the Lso-infected psyllids collected from zebra chip-affected fields were identified as the Western haplotype. Additional studies have reported a mix of the Western and Northwestern psyllid haplotypes in the Pacific Northwest. The present study further examined psyllid population dynamics over the duration of the 2012 potato season in the Pacific Northwest by haplotype analysis of 864 potato psyllids collected from potato fields in Washington, Oregon, and Idaho. In the Yakima Valley of Washington and the lower Columbia Basin of Washington and Oregon, the Northwestern haplotype was predominant (78%), and was detected earlier in the season than the Western haplotype. Interestingly, in south-central Idaho, all four psyllid haplotypes were identified, but the predominant haplotype was the Western haplotype (77%). Here, Northwestern psyllids were detected early in the season from June to mid-August, whereas Central psyllidswere detected in late July and thereafter. These results suggest that haplotype composition of psyllid populations in potato fields throughout the 2012 growing season in south-central Idaho differed greatly from those in Washington and Oregon. Additionally, all psyllids were analyzed for the presence of Lso, and no Lso-positive psyllids were found in Washington and Oregon, whereas Lso-positive psyllids were found in south-central Idaho. These Lso-positive psyllids consisted of the Western, Northwestern, and Central haplotypes

Prevalence and Factors Associated with Leishmania infantum Infection of Dogs from an Urban Area of Brazil as Identified by Molecular Methods

Visceral leishmaniasis (VL) is a disease caused by the parasite Leishmania infantum, and dogs are the most important domestic reservoirs of the agent. During recent decades, VL has expanded to large Brazilian urban centers. In the present work, we have demonstrated by using molecular techniques that the rate of canine infection as detected by serology has been considerably underestimated. Two groups of seronegative dogs (infected and non-infected according to molecular methods) were further evaluated from data obtained through interviews with owners of the animals. The factors associated with Leishmania infection in dogs were a family income of less than two minimum salaries, the knowledge of the owner regarding the vector, the dog spending most of its time in the backyard and the dog never having had a previous serological examination. Awareness regarding the factors associated with canine infection will improve health services and the understanding of the disease's expansion in urban areas

Melatonin Does Not Improve Sleep Quality in a Randomized Placebo-controlled Trial After Primary Total Joint Arthroplasty.

INTRODUCTION: Sleep disturbance is a common concern among patients who have undergone total joint arthroplasty (TJA). Poor sleep during the postoperative period affect quality of life directly and may influence pain recovery after TJA. The purpose of this prospective study was to investigate whether the daily use of exogenous melatonin for 6 weeks after TJA can mitigate the effects of TJA on sleep. METHODS: A cohort of 118 patients undergoing primary total hip arthroplasty or total knee arthroplasty from 2018 to 2020 were randomized to melatonin (6 mg) or placebo for 42 days after surgery. Inclusion criterion was patients undergoing unilateral primary TJA. Patients who underwent bilateral TJA and revision TJA, with a history of sleep disturbance, and on opioid medication or sleep aids preoperatively were excluded. Sleep quality was assessed at baseline and at 2 and 6 weeks postoperatively using the validated self-administered questionnaire, Pittsburgh Sleep Quality Index (PSQI). Continuous and categorical variables were analyzed using Student t-test and chi-square analysis, respectively. Multivariate linear regression analysis was also conducted. RESULTS: Patients in both groups exhibited higher PSQI scores, representing lower sleep quality, at both 2 and 6 weeks postoperatively compared with that at baseline. Overall, global PSQI scores were 6.8, 9.8, and 8.8 at baseline, week 2, and week 6, respectively. No significant differences were noted between melatonin and placebo groups at baseline (6.8 versus 6.8, P = 0.988), week 2 (10.2 versus 9.3, P = 0.309), or week 6 (8.8 versus 8.7, P = 0.928). In multivariable regression, the only significant predictors of increased PSQI scores were an elevated baseline PSQI score (at both time points), a decreased length of stay (at week 2 only), and patients undergoing total hip arthroplasty versus total knee arthroplasty (at week 6 only). CONCLUSION: Patients undergoing TJA had poor sleep quality both preoperatively and postoperatively. The use of exogenous melatonin did not demonstrate any notable effect on sleep quality

Failure after two-stage exchange arthroplasty for treatment of periprosthetic joint infection: the role of antibiotics in the cement spacer

Introduction: Failure after a two-stage exchange surgery for periprosthetic joint infections (PJI) is high. Previous studies demonstrated that positive cultures at reimplantation are associated with failure afterwards. The aim of this multicenter study was to define the role of antibiotics in the cement spacer in relation to reimplantation cultures and subsequent failure. Methods: We retrospectively evaluated two-stage exchange procedures between 2000 and 2015. Culture-negative PJIs, cases in whom no cultures were obtained during reimplantation and cases without data on cement spacers were excluded. Results: 344 cases were included. The rate of positive cultures during reimplantation was 9.5% for cement spacers containing a glycopeptide (27/284) (with or without an aminoglycoside) versus 21.7% for those containing monotherapy with an aminoglycoside (13/60) (p 0.008), and was mostly attributed by a reduction in coagulase-negative staphylococci (CoNS) (17% versus 2%, p < 0.001). Failure rate was more than two-folds higher at 40.0% (16/40) in cases with positive cultures at reimplantation compared to 15.8% (48/304) for those with negative cultures (p < 0.001). Overall, a glycopeptide in the cement spacer was not associated with a lower failure rate (18% versus 23%, p 0.3), but was associated with lower failure due to CoNS (2.5% versus 13.3%, p < 0.001). Conclusion: In a two-stage exchange procedure for PJI, adding a glycopeptide to the cement spacer reduces the rate of positive cultures during reimplantation and is associated with a lower failure rate due to CoNS afterwards