Does Aspirin Have a Role in Venous Thromboembolism Prophylaxis in Total Knee Arthroplasty Patients?

The objectives of this study were to compare the risk of venous thromboembolism (VTE), bleeding, surgical site infection, and mortality in patients receiving aspirin or guideline-approved VTE prophylactic therapies (warfarin, low-molecular-weight heparins, synthetic pentasaccharides) in total knee arthroplasty (TKA). We analyzed clinical and administrative data from 93?840 patients who underwent primary TKA at 307 US hospitals over a 24-month period. Fifty-one thousand nine hundred twenty-three (55%) patients received warfarin, 37?198 (40%) received injectable agents, and 4719 (5%) received aspirin. After adjustment for patient and hospital factors, patients who received aspirin VTE prophylaxis (VTEP) had lower odds for thromboembolism compared to warfarin patients but with similar odds compared with injectable VTEP; there were no differences in risk of bleeding, infection, or mortality after adjustment. Our results suggest that aspirin, when used in conjunction with other clinical care protocols, may be effective VTEP for certain TKA patients.     

Is There a Role for Extended Postoperative Oral Antibiotics in Primary Total Joint Arthroplasty High-Risk Individuals After Surgery for Periprosthetic Joint Infection?

With moderate level of evidence, 76% of delegates (super majority/strong consensus) of the most recent (2018) International Consensus Meeting on orthopedic infections agreed that extended oral antibiotics directed toward initial organisms after reimplantation for 3 months probably reduce the risk of failure due to periprosthetic joint infection. Nevertheless, the use of oral antibiotics becomes increasingly problematic with extended or long-term utilization. The development of antibiotic resistance and side effects are of particular concern, the most common being Clostridium difficile–associated diarrhea. Antibiotic stewardship is important when preventing and treating periprosthetic joint infection to hopefully prevent increase of bacterial antibiotic resistance. Two recent studies showed a significant difference in the incidence of surgical site infections after arthroplasty procedures in high-risk patients during short- and long-term follow-up without significant increase of adverse effects. However, another study showed no significant benefit of this practice. This summary discussed the details of those studies suggesting that the use of extended oral antibiotic prophylaxis in high-risk primary and revision hip and knee arthroplasty may reduce infection rates; nonetheless, additional higher level of evidence (level 1) is still needed to validate this practice as its potential adverse effects are not clear.     

Does Aseptic Revision Risk Differ for Primary Total Knee Arthroplasty Patients Who Have and Do not Have a Prior Primary or Revision Arthroplasty?

BackgroundWe sought to evaluate the risk of aseptic revision in total knee arthroplasty (TKA) patients who have and do not have a history of primary or revision arthroplasty of a different major joint.MethodsWe conducted a matched cohort study using data from Kaiser Permanente’s arthroplasty registries. Patients who underwent primary unilateral TKA (index knee) were identified (2009-2018). Two matches based on exposure history were performed: (1) 33,714 TKAs with a history of primary arthroplasty of a different joint (contralateral knee, either hip, and/or either shoulder) were matched to 67,121 TKAs without an arthroplasty history and (2) 597 TKAs with a history of aseptic revision in a different joint were matched to 1,190 TKAs with a history of a prior arthroplasty in a different joint, but without any revision. After the matches were performed, Cox regressions were used to evaluate aseptic revision risk of the index knee using the no history groups as the reference in regression models.ResultsNo difference in aseptic revision risk for the index knee was observed when comparing patients who had a prior primary arthroplasty in a different joint to those who did not have an arthroplasty history (hazard ratio = 0.95, 95% CI = 0.86-1.06). Those patients who did not have any prior aseptic revision history in a different joint had higher risk of aseptic revision in the index knee (hazard ratio = 2.06, 95% CI = 1.17-3.63).ConclusionPatients who had a prior revision history had over a 2-fold higher risk of aseptic revision in the index knee, warranting close surveillance of these patients.Level of EvidenceLevel III.     

Does Race Affect Outcomes in Total Joint Arthroplasty?

Background

Several studies suggest worse surgical outcomes among racial/ethnic minorities. There is a paucity of research on preoperative and postoperative pain, general health, and disease-specific measures in which race is the main subject of investigation; furthermore, the results are not conclusive.

Questions/purposes

(1) Do black patients have more severe or more frequent preoperative pain, well-being, general health, and disease-specific scores when compared with white patients? (2) Are there differences between black patients and white patients after hip or knee arthroplasty on those same measures?

Methods

In this retrospective study, we used an institutional arthroplasty registry to analyze data on 2010 primary arthroplasties (1446 knees and 564 hips) performed by one surgeon at a single institution. Cases from patients self-identifying as black (n = 105) and white (n = 1905) were compared (controlling for confounders, including age and ethnicity) on the following preoperative and postoperative patient-oriented outcomes: pain intensity/frequency as measured by a visual analog scale (VAS), Quality of Well-Being (QWB-7), SF-36, and WOMAC scores. T-tests, chi square, and multivariate analysis of covariance were used. Alpha was set at 0.05. Postoperative analysis was performed only on those cases that had a minimum followup of 1 year (mean, 3.5 years; range, 1–9 years). Of the 2010 arthroplasties, 37% (39 of 105) of those cases performed in black patients and 64% (1219 of 1905) of those performed in white patients were included in the final postoperative model (multivariate analysis of covariance).

Results

Black patients had more severe preoperative pain intensity (VAS: 8 ± 1.8 versus 8 ± 2.0, mean difference = 0.76 [95% confidence interval {CI}, 0.34–1.1], p < 0.001). Black patients also had worse well-being scores (QWB-7: 0.527 ± 0.04 versus 0.532 ± 0.05, mean difference = −0.01 [CI, −0.02 to 0.00], p = 0.037). Postoperatively, pain intensity (VAS: 1 ± 3.1 versus 1 ± 1.8, mean difference= 0.8 [CI, 0.19–1.4], p= 0.010) and (QWB-7: 0.579 ± 0.09 versus 0.607 ± 0.11, mean difference= −0.049 [CI, −0.08 to −0.01], p = 0.008) were different but without clinical significance.

Conclusions

Black patients underwent surgery earlier in life and with different preoperative diagnoses when compared with white patients. Black patients had worse preoperative baseline pain, well-being, general health, and disease-specific scores as well as worse postoperative scores. However, these differences were very narrow and without clinical significance. Notwithstanding, the relations of race with outcomes remain complex. Further investigations to recognize disparities and minimize or address them are warranted.

Level of Evidence

Level III, prognostic study.     

Does Discharge Disposition After Primary Total Joint Arthroplasty Affect Readmission Rates?

We reviewed 90-day readmission rates for 9150 patients with a primary total hip or knee arthroplasty performed between April 2001 and December 2004. Patients with an American Society of Anesthesiologists score of 3 or greater or with perioperative complications were excluded. We correlated the readmission rate with discharge disposition to either skilled nursing facilities (SNFs) or Home. Of the 9150 patients identified, 1447 were discharged to an SNF. After statistically adjusting for sex, age and American Society of Anesthesiologists scores, total hip arthroplasty and total knee arthroplasty patients discharged to SNFs had higher odds of hospital readmission within 90 days of surgery than those discharged home (total hip arthroplasty: odds ratio = 1.9; 95% confidence interval, 1.2-3.2; P = .008; total knee arthroplasty: odds ratio = 1.6; 95% confidence interval, 1.1-2.4; P = .01). Healthy patients discharged to SNFs after primary total joint arthroplasty need to be followed closely for complications.     

Does Total Ankle Arthroplasty Belong in the Comprehensive Care for Joint Replacement?

The Comprehensive Care for Joint Replacement (CJR) model seeks to lower costs and improve quality for primary lower extremity joint replacements. This includes total ankle arthroplasty (TAA), which is performed far less frequently than total hip (THA) and knee (TKA) arthroplasty. We used the SPARCS database to identify 537 TAA and 239,053 elective primary THA or TKA procedures from 2009 to 2014, excluding hip fractures. Compared with THA and TKA, TAA had a shorter mean length of stay (2.2 versus 3.2 days), greater mean cost ($20,817 versus $17,613), lower rate of disposition to nursing and rehabilitation facilities (17% versus 52%), and lower rate of 90-day readmission (4.9% versus 5.8%). In multivariable-adjusted regression models of TAA versus THA and TKA, length of stay was 30% shorter (p?<?.001), costs were 14% greater (p?<?.001), and risk of disposition to nursing and rehabilitation facilities was 86% lower (p?<?.001), with no significant difference in 90-day readmission (p?=?.957). Patients undergoing TAA had different patterns of short-term resource usage compared with patients undergoing THA and TKA, most notably higher short-term costs. The economic viability of TAA is threatened by alternative payment models that reimburse hospitals for TAA at the same rate as THA and TKA.     

General vs Spinal Anesthesia for Revision Total Knee Arthroplasty: Do Complication Rates Differ?

BackgroundThe incidence of both primary total knee arthroplasty (TKA) and revision TKA is increasing. Data from primary arthroplasty patients suggest a risk reduction with the use of spinal anesthesia when compared with general anesthesia. However, the same relationship has not been examined in the revision knee arthroplasty patient.MethodsThis is a retrospective cohort study using the American College of Surgeons-National Surgical Quality Improvement database. Patients undergoing revision TKA with either spinal or general anesthesia were identified from the database. Baseline characteristics were compared, and ultimately patients were matched using coarsened exact matching. Multivariate analysis was then performed on matched cohorts controlling for baseline patient and operative characteristics. This model was used to look for any differences in rates of complications, operative time, length of stay, and readmission.ResultsPatients undergoing revision TKA with general anesthesia had increased risk of several postoperative complications, even after controlling for baseline patient characteristics. Specifically, there were significantly increased rates of the following: unplanned readmission (OR = 1.43, 95% confidence interval [CI] = 1.18-1.72, P < .001), nonhome discharge (OR = 1.60, 95% CI = 1.46-1.76, P < .001), transfusion (OR = 1.63, 95% CI = 1.41-1.88, P < .001), deep surgical site infection (OR = 1.43, 95% CI = 1.01-2.03, P = .043), and extended length of stay (OR = 1.22, 95% CI = 1.11-1.34, P < .001). General anesthesia was additionally associated with increased operative time.ConclusionGeneral anesthesia is associated with increased risk of numerous postoperative complications in patients undergoing revision TKA. This study is retrospective in nature, and while causality cannot be definitively determined, the results suggest that spinal anesthesia is preferential to general anesthesia in the revision TKA patient.     

Editorial Commentary: Does the Scope Have a Role in Painful Shoulder Arthroplasty?

Arthroscopy is a powerful tool in the management of the painful total shoulder arthroplasty and should be considered when evaluating cases in which a clear cause of pain is not present. Patients may present with a painful shoulder arthroplasty due to a number of causes—occult infection, instability, component loosening, malposition, or rotator cuff pathology. In certain cases, advanced imaging may not be diagnostic, given the presence of metal artifact. It is our routine clinical practice to evaluate arthroscopically such cases in which the diagnosis is not readily evident. The most common indication for shoulder arthroscopy is pain with no clear cause or loss of motion (39%), followed by biopsy to rule out occult infection (25%), and finally rotator cuff assessment (19%).     

Total Joint Arthroplasty: Should Patients Have Preoperative Dental Clearance?

Obtaining dental clearance prior to elective total joint arthroplasty is a common practice; however, little published data exist to justify this requirement. Dental clearance data for 365 elective total knee and total hip arthroplasty patients were gathered prospectively. Of these patients, 358 (average age of 62.4 years; 157 men and 201 women; 152 primary total knee arthroplasties (TKAs), 16 revision TKA arthroplasties, one conversion TKA, 168 primary total hip (THAs) arthroplasties and 21 revision THA arthroplasties) proceeded to surgery and follow-up data were available for 355. A comparison group of 218 hip fracture patients (average age of 78.7 years; 52 men and 109 women; 137 THA and 81 hemiarthroplasties) with no preoperative dental clearance who were treated with hip arthroplasty was extracted retrospectively from an institutional database. Follow-up data were available for 161 of these patients. The incidence of dental pathology in the elective arthroplasty group was 8.8%. Early postoperative infection requiring surgical treatment occurred in six patients (1.7%) in the dental clearance elective arthroplasty group and in four patients (2.5%) in the hip fracture arthroplasty group. No statistical difference was found between the two groups. This suggests that the perceived need for routine preoperative dental screening for all hip and knee arthroplasty patients should be reassessed.     

Does Symptomatic Benign Prostatic Hyperplasia Increase the Risk of Periprosthetic Joint Infection After Primary Total Joint Arthroplasty?

BackgroundPeriprosthetic joint infection (PJI) is among the leading causes of failure in total joint arthroplasty. A recently proposed risk factor for PJI is symptomatic benign prostatic hyperplasia (sBPH). This study aims to determine if sBPH is associated with PJI following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsUsing the Mariner all-payer claims database, 1745 patients with sBPH undergoing primary THA were propensity-matched with 3490 controls, and 3053 patients with sBPH undergoing primary TKA were propensity-matched with 6106 controls. Additionally, the same 1745 patients with sBPH undergoing THA were compared to 317,360 prematched controls, and the same 3053 patients with sBPH undergoing TKA were compared to 557,730 prematched controls. Univariate analysis was conducted using chi-squared or ANOVA where appropriate.ResultsAt two years postoperatively, patients with sBPH were not at significantly increased risk for PJI following primary THA (1.54% vs 1.43%; P = .745) and TKA (1.99% vs 2.14%; P = .642) relative to postmatch controls. Compared to matched controls, THA patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), and urinary tract infection (UTI; P < .001). Total knee arthroplasty patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), cellulitis (P = .023), renal failure (P = .030), heart failure (P = .029), and UTI (P < .001) relative to matched controls.ConclusionIn primary THA and TKA, sBPH does not appear to be an independent risk factor for PJI within two years postoperatively. However, clinicians should be cognizant of the significantly increased risk for postoperative UTI in this patient population.     

Does Prednisone Dose Affect Rates of Periprosthetic Joint Infection Following Primary Total Hip and Total Knee Arthroplasty?

BackgroundPrednisone use is associated with higher rates of periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). However, the relationship between prednisone dosage and infection risk is ill-defined. Therefore, this study aimed to assess the relationship between prednisone dosage and rates of PJI following TJA.MethodsA national database was queried for all elective total hip (THA) and total knee arthroplasty (TKA) patients between 2015 and 2020. Patients who received oral prednisone following TJA were matched in a 1:2 ratio based on age and sex to patients who did not. Univariate and multivariate regression analyses were performed to assess the 90-day risk of infectious complications based on prednisone dosage as follows: 0 to 5, 6 to 10, 11 to 20, 21 to 30, and >30 milligrams. Overall, 1,322,043 patients underwent elective TJA (35.9% THA, 64.1% TKA). Of these, 14,585 (1.1%) received prednisone and were matched to 29,170 patients who did not.ResultsAfter controlling for confounders, TKA patients taking prednisone were at increased risk for sepsis (adjusted odds ratio [aOR] 2.76, P < .001), PJI (aOR 2.67, P < .001), and surgical site infection (aOR: 2.56, P = .035). THA patients taking prednisone were at increased risk for sepsis (aOR: 3.21, P < .001) and PJI (aOR: 1.73, P = .001). No dose-dependent relationship between prednisone and infectious complications was identified when TJA was assessed in aggregate.ConclusionPatients receiving prednisone following TJA were at increased risk of PJI and sepsis. A dose-dependent relationship between prednisone and infectious complications was not identified. Arthroplasty surgeons should be aware of these risks and counsel TJA patients who receive prednisone therapy.     

Is There a Role for Preoperative Iron Supplementation in Patients Preparing for a Total Hip or Total Knee Arthroplasty?

Background

Several treatment modalities exist for the treatment of perioperative anemia. We determined the effect of oral iron supplementation on preoperative anemia, and the use of blood-conserving interventions before total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Time Required for Planned and Unplanned Episodes of Care in Primary Total Joint Arthroplasty: Has Anything Changed With a Growth in Outpatient Arthroplasty?

BackgroundThis study sought to determine the total amount of time committed to planned and unplanned episodes of care related to primary, unilateral total joint arthroplasty (TJA), relative to a growth in outpatient TJA.MethodsAll primary, unilateral TJA procedures performed over a 7-year period by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. All telephone inquiries and readmissions involving the surgeon’s direct input, over the episode of care, constituted time dedicated to unplanned work.ResultsBetween 2012 and 2018, as the proportion of outpatient TJAs increased, the average planned episode-of-care time per patient decreased from 412 minutes to 361 minutes. Despite a 108% increase in the total number of outpatient TJAs between 2017 and 2018 (51/432 (11.8%) to 106/555 (19.1%); P = .002), neither the average number of unplanned telephone inquiries (4.6 ± 3.8 vs 4.2 ± 3.7; P = .124), nor the mean time per patient required to respond to calls (23.1 ± 19.4 vs 21.2 ± 18 minutes, P = .135) differed. Between 2017 and 2018, the average total episode-of-care time per patient decreased from 403 minutes (376 planned + 27 unplanned) to 387 minutes (361 planned + 26 unplanned).ConclusionDespite an increase in outpatient TJA, the average time required for planned and unplanned patient care remained relatively constant. The growth of outpatient TJA nationally should not trigger a change in Centers for Medicare and Medicaid Services benchmarks.     

Is There a Role for Preclosure Dilute Betadine Irrigation in the Prevention of Postoperative Infection Following Total Joint Arthroplasty?

BackgroundConflicting evidence exists surrounding the use of preclosure irrigation solutions in primary total joint arthroplasty (TJA). We aimed to determine the role of dilute betadine lavage in preventing early infection after primary TJA.MethodsWe retrospectively reviewed primary TJAs between 2010 and 2018. Dilute betadine lavage was introduced to our practice in November 2014. We included 3513 total hip arthroplasties, 3932 total knee arthroplasties, and 1033 hip resurfacings (HRs). In group 1 (n = 5588), surgical wounds were irrigated with saline; group 2 used dilute betadine solution (n = 2890). Subanalyses using propensity matching based on known risk factors of infection—age, body mass index, American Society of Anesthesiologists grade, diabetes, and procedure—were completed.ResultsThere were 48 acute infections in group 1 (0.9%) and 23 in group 2 (0.8%) (P = .762). HR without betadine had the highest acute infection prevalence (P = .028). When groups in the whole cohort were propensity score–matched, group 1 had more acute infections than group 2 (P = .033). The effect of betadine was isolated to HR patients. After excluding HR cases, betadine continued to reduce the acute infection rate when compared with the no betadine group, but this was not statistically significant (0.4% vs 0.8%; P = .101). Likewise, we did not find a significant difference in total hip arthroplasty and total knee arthroplasty patients (P = .796).ConclusionThere was a decreased infection rate in the betadine group overall when groups were propensity-matched. Because the reduction in the acute infection rate was clinically significant, we feel this practice is an effective means to prevent infections.