Preoperative Vitamin D Repletion in Total Knee Arthroplasty: A Cost-Effectiveness Model

BackgroundRecent studies have identified vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/L) as a potentially modifiable risk factor for prosthetic joint infection (PJI) in arthroplasty. The purpose of this study is to determine whether implementation of preoperative 25(OH)D repletion is cost-effective for reducing PJI following total knee arthroplasty (TKA).MethodsA cost estimation predictive model was generated to determine the utility of both selective and nonselective 25(OH)D repletion in primary TKA to prevent PJI. Input data on the incidence of 25(OH)D deficiency, relative complication rates, and costs of serum 25(OH)D repletion and 2-stage revision for PJI were derived from previously published literature identified using systematic review and publicly available data from Medicare reimbursement schedules. Mean, lower, and upper bounds of 1-year cost savings were computed for nonselective and selective repletion relative to no repletion.ResultsSelective preoperative 25(OH)D screening and repletion were projected to result in $1,504,857 (range, $215,084-$4,256,388) in cost savings per 10,000 cases. Nonselective 25(OH)D repletion was projected to result in $1,906,077 (range, $616,304-$4,657,608) in cost savings per 10,000 cases. With univariate adjustment, nonselective repletion is projected to be cost-effective in scenarios where revision for PJI costs ≥$10,636, incidence of deficiency is ≥1.1%, and when repletion has a relative risk reduction ≥4.2%.ConclusionThis predictive model supports the potential role of 25(OH)D repletion as a cost-effective mechanism of reducing PJI risk in TKA. Given the low cost of 25(OH)D repletion relative to serum laboratory testing, nonselective repletion appears to be more cost-effective than selective repletion. Further prospective investigation to assess this modifiable risk factor is warranted.     

1.5-Stage Exchange Arthroplasty for Total Knee Arthroplasty Periprosthetic Joint Infections

BackgroundPeriprosthetic joint infection (PJI) in total knee arthroplasty (TKA) is a challenging problem. The purpose of this study was to outline a novel technique to treat TKA PJI. We define 1.5-stage exchange arthroplasty as placing an articulating spacer with the intent to last for a prolonged time.MethodsA retrospective review was performed from 2007 to 2019 to evaluate patients treated with 1.5-stage exchange arthroplasty for TKA PJI. Inclusion criteria included: articulating knee spacer(s) remaining in situ for 12 months and the patient deferring a second-stage reimplantation because the patient had acceptable function with the spacer (28 knees) or not being a surgical candidate (three knees). Thirty-one knees were included with a mean age of 63 years, mean BMI 34.4 kg/m², 12 were female, with a mean clinical follow-up of 2.7 years. Cobalt-chrome femoral and polyethylene tibial components were used. We evaluated progression to second-stage reimplantation, reinfection, and radiographic outcomes.ResultsAt a mean follow-up of 2.7 years, 25 initial spacers were in situ (81%). Five knees retained their spacer(s) for some time (mean 1.5 years) and then underwent a second-stage reimplantation; one of the five had progressive radiolucent lines but no evidence of component migration. Three knees (10%) had PJI reoccurrence. Four had progressive radiolucent lines, but there was no evidence of component migration in any knees.Conclusions1.5-stage exchange arthroplasty may be a reasonable method to treat TKA PJI. At a mean follow-up of 2.7 years, there was an acceptable rate of infection recurrence and implant durability.     

Preoperative Opioid Use Is Associated With Higher Revision Rates in Total Joint Arthroplasty: A Systematic Review

BackgroundAlthough preoperative opioid use has been associated with poor postoperative patient-reported outcome measures and delayed return to work in patients undergoing total joint arthroplasty, direct surgery-related complications in patients on chronic opioids are still not clear. Thus, we sought to perform a systematic review of the literature to evaluate the influence of preoperative opioid use on postoperative complications and revision following primary total joint arthroplasty.MethodsFollowing the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we queried PubMed, EMBASE, the Cochrane Library, and the ISI Web of Science for studies investigating the influence of preoperative opioid use on postoperative complications following total hip arthroplasty and total knee arthroplasty up to May 2020.ResultsAfter applying exclusion criteria, 10 studies were included in the analysis which represented 87,165 opioid users (OU) and 5,214,010 nonopioid users (NOU). The overall revision rate in the OU group was 4.79% (3846 of 80,303 patients) compared to 1.21% in the NOU group (43,719 of 3,613,211 patients). There was a higher risk of aseptic loosening (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.11-1.53, P = .002), periprosthetic fractures (OR 1.89, 95% CI 1.53-2.34, P < .00001), and dislocations (OR 1.26, 95% CI 1.14-1.39, P < .00001) in the OU group compared to the NOU group. Overall, 5 of 6 studies reporting on periprosthetic joint infection (PJI) rates showed statistically significant correlation between preoperative opioid use and higher PJI rates.ConclusionThere is strong evidence that preoperative opioid use is associated with a higher overall revision rate for aseptic loosening, periprosthetic fractures, and dislocation, and an increased risk for PJI.Level of EvidenceLevel III, systematic review.     

The Cost-Effectiveness of Silver-Impregnated Occlusive Dressings for Infection Prevention After Total Joint Arthroplasty

BackgroundProsthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty that exacts a substantial economic burden on the health-care system. This study used break-even analysis to investigate whether the use of silver-impregnated occlusive dressings is a cost-effective measure for preventing PJI after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).MethodsBaseline infection rates after TKA and THA, the cost of revision arthroplasty for PJI, and the cost of a silver-impregnated occlusive dressing were determined based on institutional data and the existing literature. A break-even analysis was then conducted to calculate the minimal absolute risk reduction needed for cost-effectiveness.ResultsThe use of silver-impregnated occlusive dressings would be economically viable at an infection rate of 1.10%, treatment costs of $25,692 for TKA PJI, and $31,753 for THA PJI and our institutional dressing price of $38.05 if it reduces infection rates after TKA by 0.15% (the number needed to treat [NNT] = 676) and THA by 0.12% (NNT = 835). The absolute risk reduction needed to maintain cost-effectiveness did not change with varying initial infection rates and remained less than 0.40% (NNT = 263) for infection treatment costs as low as $10,000 and less than 0.80% (NNT = 129) for dressing prices as high as $200.ConclusionThe use of silver-impregnated occlusive dressings is a cost-effective measure for infection prophylaxis after TKA and THA.     

The Utility of Serum d-Dimer for the Diagnosis of Periprosthetic Joint Infection in Revision Total Hip and Knee Arthroplasty

BackgroundThere is scarce and contradicting evidence supporting the use of serum d-dimer for the diagnosis of periprosthetic joint infection in revision total hip (THA) and knee (TKA) arthroplasty. Therefore, the purpose of this study is to test the accuracy of serum d-dimer against the 2013 International Consensus Meeting (ICM) criteria.MethodsA retrospective review was performed on a consecutive series of 172 revision THA/TKA surgeries performed by 3 fellowship-trained surgeons at a single institution (August 2017 to May 2019) and that had d-dimer performed during their preoperative workup. Of this cohort, 111 (42 THAs/69 TKAs) cases had complete 2013 ICM criteria tests and were included in the final analysis. Septic and aseptic revisions were categorized per 2013 ICM criteria (“gold standard”) and compared against serum d-dimer using an established threshold (850 ng/mL). Sensitivity, specificity, likelihood ratios, and positive/negative predictive values were determined. Independent t-tests, Fisher’s exact tests, chi-squared tests, and receiver operating characteristic curve analysis were performed.ResultsThere was no statistically significant difference in baseline demographics between septic and aseptic cases per 2013 ICM criteria. When compared to ICM criteria, d-dimer demonstrated high sensitivity (95.9%) and negative predictive value (90.9%) but low specificity (32.3%), positive predictive value (52.8%), and overall, poor accuracy (61%) to diagnose periprosthetic joint infection. Positive likelihood ratio was 1.42 while negative likelihood ratio was 0.13. The area under the curve (AUC) was 0.742.ConclusionSerum d-dimer has poor accuracy to discriminate between septic and aseptic cases using a described threshold in the setting of revision THA and TKA.     

The Utility of Frozen Section Histology in Diagnosing Periprosthetic Joint Infection in Revision Total Joint Arthroplasty

BackgroundSurgeons utilize a combination of preoperative tests and intraoperative findings to diagnose periprosthetic joint infection (PJI); however, there is currently no reliable diagnostic marker that can be used in isolation. The purpose of our study is to evaluate the utility of frozen section histology in diagnosis of PJI.MethodsRetrospective analysis of 614 patients undergoing revision total joint arthroplasty with frozen section histology from a single institution was performed. Discriminatory value of frozen section histology was assessed using univariate analysis and evaluation of area under the curve (AUC) of a receiver operating characteristic curve comparing frozen section histology results to the 2018 International Consensus Meeting (ICM) PJI criteria modified to exclude the histology component.ResultsThe sensitivity of the frozen section histology was 53.6% and the specificity was 95.2%. There was 99.2% concordance between the permanent section and frozen section results. The receiver operating characteristic curve for frozen section yielded an AUC of 0.744 (95% confidence interval 0.627-0.860) and the modified ICM score yielded an AUC of 0.912 (95% confidence interval 0.836-0.988) when compared to the full score. The addition of frozen section histology changed the decision to infected in 20% of “inconclusive” cases but less than 1% of total cases.ConclusionIn comparison to the modified ICM criteria, intraoperative frozen section histology has poor sensitivity, strong specificity, and acceptable overall discrimination for diagnosing PJI. This test appears to be of particular value for patients deemed “inconclusive” for infection using the remaining ICM criteria.     

Vancomycin Powder and Dilute Povidone-Iodine Lavage for Infection Prophylaxis in High-Risk Total Joint Arthroplasty

BackgroundDilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). Vancomycin powder is reported to be effective in preventing infection in spine surgery. We hypothesize that a “vanco-povidone protocol” (VIP) for TJA patients at high risk for infection is safe and will decrease the rate of PJI.MethodsHigh-risk TJA patients (body mass index >40, active smokers, American Society of Anesthesiologists ≥3, immunosuppression/diabetes, methicillin-resistant Staphylococcus aureus colonization, revision surgery) utilizing VIP were compared to a high-risk historical cohort not treated with VIP, at a single institution. VIP consisted of dilute povidone-iodine lavage followed by application of vancomycin powder prior to wound closure. Primary endpoint was PJI within 3 months postoperatively.ResultsThe historical, high-risk control cohort consisted of 3251 patients with a PJI incidence of 1.8%. A total of 1413 subjects received the VIP protocol with a PJI incidence of 1.3%. There was a 27.8% risk reduction when compared to the control group of high-risk subjects not treated with the VIP. There were no medical complications secondary to the use of VIP, no increase in vancomycin-resistant enterococcus or vancomycin-resistant Staph aureus, and no cases of acute renal impairment secondary to application of the local vancomycin.ConclusionsPJI remains a common complication of TJA, especially in high-risk populations. This study indicates that a protocol of dilute povidone-iodine lavage combined with topical vancomycin powder is safe and may reduce PJI incidence in high-risk TJA patients. Due to low, current PJI rates, a multi-institutional randomized controlled trial is necessary to assess interventions that minimize the risk of PJI.Level of EvidenceRetrospective Observational Cohort.     

A Bundle Protocol to Reduce the Incidence of Periprosthetic Joint Infections After Total Joint Arthroplasty: A Single-Center Experience

Background

Periprosthetic joint infection (PJI) represents a devastating complication of total hip arthroplasty (THA) or total knee arthroplasty (TKA). Modifiable patient risk factors as well as various intraoperative and postoperative variables have been associated with risk of PJI. In 2011, our institution formulated a “bundle” to optimize patient outcomes after THA and TKA. The purpose of this report is to describe the “bundle” protocol we implemented for primary THA and TKA patients and to analyze its impact on rates of PJI and readmission.

The Potential Value of Performing Preoperative Urinalysis Prior to Total Knee Arthroplasty

BackgroundAlthough the practice of checking a urinalysis prior to elective total knee arthroplasty (TKA) is relatively common, very little has been reported on the association between a preoperative urinary tract infection (UTI) and adverse events in primary TKA. The goal of this study is to investigate the risk of postoperative complication following TKA as it relates to preoperative UTI.MethodsPatients undergoing TKA were queried in the National Surgical Quality Improvement Program. Morbid events were classified as minor (transfusion, pneumonia, wound dehiscence, UTI, and renal insufficiency) and serious (wound infection, thromboembolic event, renal failure, myocardial infarction, prolonged ventilation, unplanned intubation, sepsis, and death). Risk factors for adverse events were analyzed in both univariate and multivariate fashion.ResultsA total of 203,851 patients undergoing TKA met inclusion criteria and 507 patients had a UTI present at time of surgery (UTI PATOS). A propensity matched analysis controlling for age, gender, body mass index, operative year, and American Society of Anesthesiologists score identified 507 patients without a UTI PATOS to serve as the control group. Following adjustment for baseline characteristics, operative year, and American Society of Anesthesiologists score, UTI PATOS was associated with increased risk for serious adverse events (odds ratio [OR] 2.746, 95% confidence interval [CI] 1.546-4.878, P = .0006), occurrence of any morbid event (OR 1.894, 95% CI 1.299-2.761, P = .0009), and reoperation (OR 4, 95% CI 2.592-6.169, P < .0001).ConclusionThis study suggests that a UTI present at time of TKA increases the risk of multiple postoperative complications and reoperation.     

Low-Dose Aspirin for Venous Thromboembolism Prophylaxis is Associated With Lower Rates of Periprosthetic Joint Infection After Total Joint Arthroplasty

BackgroundAspirin as a venous thromboembolism (VTE) prophylactic agent has been shown to have antistaphylococcal and antibiofilm roles. Optimal acetylsalicylic acid (ASA) dosage would facilitate antimicrobial effects while avoiding over-aggressive inhibition of platelet antimicrobial function. Our purpose was to determine the periprosthetic joint infection (PJI) rate after total joint arthroplasty in patients receiving low-dose ASA (81 mg twice a day), in comparison to high-dose ASA (325 mg twice a day).MethodsWe conducted a retrospective cohort study between 2008 and 2020. Eligible patients were older than 18 years, underwent primary total joint arthroplasty, both total knee arthroplasty and total hip arthroplasty, had a minimum 30-day follow-up, and received a full course ASA as VTE prophylaxis. Patients’ records were reviewed for PJI, according to Musculoskeletal Infection Society criteria. Patients were excluded if they underwent revision arthroplasty, had a history of coagulopathy, or had an ASA regimen that was not completed. In total 15,825 patients were identified, 8,761 patients received low-dose ASA and 7,064 received high-dose ASA.ResultsThe high-dose cohort had a higher PJI rate (0.35 versus 0.10%, P = .001). This relationship was maintained when comparing subgroups comprising total knee arthroplasty (0.32 versus 0.06%, P = .019) or total hip arthroplasty (0.38 versus 0.14%, P = .035) and accounting for potentially confounding demographic and surgical variables (odds ratio = 2.59, 95% CI = 1.15-6.40, P = .028).ConclusionComparing low-dose to high-dose ASA as a VTE prophylactic agent, low-dose ASA had a lower PJI rate. This may be attributable to a balance of anti-infective properties of ASA and antiplatelet effects.     

High Mortality After Total Knee Arthroplasty Periprosthetic Joint Infection is Related to Preoperative Morbidity and the Disease Process but Not Treatment

BackgroundPeriprosthetic joint infection (PJI) mortality rate is approximately 20%. The etiology for high mortality remains unknown. The objective of this study was to determine whether mortality was associated with preoperative morbidity (frailty), sequalae of treatment, or the PJI disease process itself.MethodsA multicenter observational study was completed comparing 184 patients treated with septic revision total knee arthroplasty (TKA) to a control group of 38 patients treated with aseptic revision TKA. Primary outcomes included time and the cause of death. Secondary outcomes included preoperative comorbidities and Charlson Comorbidity Index (CCMI) measured preoperatively and at various postoperative timepoints.ResultsThe septic revision TKA cohort experienced earlier mortality compared to the aseptic cohort, with a higher mortality rate at 90 days, 1, 2, and 3 years after index revision surgery (P = .01). There was no significant difference for any single cause of death (P > .05 for each). The mean preoperative CCMI was higher (P = .005) in the septic revision TKA cohort. Both septic and aseptic cohorts experienced a significant increase in CCMI from the preoperative to 3 years postoperative (P < .0001 and P = .002) and time of death (P < .0001 both) timepoints. The septic revision TKA cohort had a higher CCMI 3 years postoperatively (P = .001) and at time of death (P = .046), but not one year postoperatively (P = .119).ConclusionCompared to mortality from aseptic revision surgery, septic revision TKA is associated with earlier mortality, but there is no single specific etiology. As quantified by changes in CCMI, PJI mortality was associated with both frailty and the PJI disease process, but not treatment.     

Preoperative Risk Factor Screening Protocols in Total Joint Arthroplasty: A Systematic Review

BackgroundPreoperative optimization protocols targeting potentially modifiable risk factors could prove beneficial in reducing the rate of complications in lower extremity total joint arthroplasty (LE-TJA). We aimed to summarize the evidence on preoperative screening protocols targeting modifiable risk factors to assess their effect on postoperative outcomes following primary LE-TJA.MethodsA literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in August 2019. The bibliographies of relevant publications were searched for further applicable studies. Included studies were required to report at least one outcome including prosthetic joint infection/surgical site infection (PJI/SSI), hospital length of stay (LOS), disposition, 90-day emergency department visits, or hospital readmissions after implementation of an evidence-based preoperative optimization protocol targeting modifiable risk factors. Methodological quality of included studies was assessed using the methodological index for non-randomized studies (MINORS) criteria.ResultsA total of 8 retrospective cohort studies including 9915 patients were reviewed. Implementation of preoperative optimization protocols were associated with reductions in SSI (0.56% vs. 2.60%; RR 0.21 [95% CI 0.12 to 0.37]; P < .00001), hospital LOS, mean cost of care, and hospital readmission rates. The mean MINORS score for comparative studies was 16.285.ConclusionsImplementation and compliance with evidence-based preoperative protocols for optimization of modifiable risk factors is associated with overall improved outcomes following LE-TJA. SSI, hospital LOS, average total cost of care, and hospital readmission rates were favorable in those cohorts subjected to a preoperative intervention protocol. Future prospective studies are necessary for further refinement of preoperative optimization protocols and referral algorithms, without compromising patients’ access to surgery.Level of EvidenceIII, Systematic Review;     

Risk Factors for Failure and Optimal Treatment of Total Joint Arthroplasty for Septic Arthritis

BackgroundPatients with native joint septic arthritis are one of the highest risk groups for developing complications following total joint arthroplasty (TJA), especially periprosthetic joint infection(PJI). There is a paucity of information on the risk factors for developing PJI and the optimal treatment modality of the native septic joint that can mitigate that risk. This multicenter study aimed to determine these risk factors, including prior treatment.MethodsA retrospective study of 233 TJAs performed, following prior septic arthritis at five institutions, was conducted. Comorbidities, organism profile, prior surgery, etiology of septic arthritis, and other relevant variables were reviewed. The primary outcome was the development of PJI, defined by Musculoskeletal Infection Society criteria. Bivariate and multivariate analyses were performed to identify risk factors for PJI.ResultsOverall, the PJI rate was 12.4% in patients who underwent TJA after native septic arthritis. Predisposing risk factors for PJI included antibiotic-resistant organisms, male gender, diabetes, and a postsurgical cause of septic arthritis eg open reduction internal fixation. When controlling for potential confounders, multivariate analysis revealed that male gender, diabetes, and a postoperative etiology were predictors of PJI. The definitive treatment modality for the septic joint did not affect the rate of PJI for both arthroscopy vs irrigation and debridement (I&D), and two-stage exchange vs single-stage procedure.DiscussionThis study has identified several risk factors for developing PJI in patients with prior septic joint arthritis, some of which are modifiable. The initial treatment modality of the native septic joint has no bearing on the development of PJI after TJA.     

Risk Factors for Periprosthetic Joint Infection Following Primary Total Hip Arthroplasty: A Case Control Study

The purpose of this study was to identify the specific comorbidities and demographic factors that are independently associated with an increased risk of periprosthetic joint infection (PJI) in total hip arthroplasty (THA) patients. A case–control study design was used to compare 88 patients who underwent unilateral primary THA and developed PJI with 499 unilateral primary THA patients who did not develop PJI. The impact of 18 comorbid conditions and other demographic factors on PJI was examined. Depression, obesity, cardiac arrhythmia, and male gender were found to be independently associated with an increased risk of PJI in THA patients. This information is important to consider when counseling patients on the risks associated with elective THA, and for risk-adjusting publicly reported THA outcomes.     

Outcomes of Total Hip Arthroplasty in Human Immunodeficiency Virus-Positive Patients

Today, patients with human immunodeficiency virus (HIV) live long enough to develop chronic degenerative and HIV-associated joint disease. There is a growing population of patients infected with HIV who are candidates for total hip arthroplasty (THA). A total of 31 HIV-positive, non-hemophilic patients undergoing 41 THAs at our institution between 2000 and 2012 were identified. In-hospital medical complications were reported in 5 of 41 hips, all of which resolved prior to discharge. Deep infection developed in 1 of 41 hips and revision was required in 3 of 41 hips. These results suggest that low rates of complications and revision can be achieved in the HIV-positive, non-hemophilic population. We believe that with careful patient selection, THA may improve the quality of life in the HIV-positive population.     

Patellar Resurfacing in Total Knee Arthroplasty: A Cost-Effectiveness Analysis

Background

This study estimates the cost-effectiveness of patellar resurfacing in total knee arthroplasty (TKA).

Aseptic Reoperations Within 1 Year of Primary Total Knee Arthroplasty Markedly Increase the Risk of Later Periprosthetic Joint Infection

BackgroundDespite the high rate of success of primary total knee arthroplasty (TKA), some patients are candidates for early aseptic reoperation. The goal of this study is to evaluate the risk of subsequent periprosthetic joint infection (PJI) in patients treated with an aseptic reoperation within 1 year of primary TKA.MethodsA retrospective review of our total joint registry compared 249 primary TKAs requiring an aseptic reoperation within 1 year following index arthroplasty to a control group of 17,867 TKAs not requiring reoperation within 1 year. Patients were divided into groups based on time from index TKA: (1) 90 days or less (114 TKAs) and (2) 91 to 365 days (135 TKAs). Mean age was 68 years with 57% female. Mean follow-up was 7 years.ResultsAt 2 years postoperatively, patients undergoing an aseptic reoperation within 90 days subsequently had a 9% PJI rate, while patients undergoing an aseptic reoperation between 91 and 365 days subsequently had a 3% PJI rate. The control group had a 0.4% PJI rate. Compared to the control group, patients undergoing an aseptic reoperation within 90 days had an elevated risk of PJI (hazard ratio, 9; P < .0001), as did patients who had a reoperation between 91 and 365 days (hazard ratio, 4; P < .0001).ConclusionAseptic reoperation within 1 year of primary TKA was associated with a notably increased risk of subsequent PJI.