Is a Higher Number of Total Hip and Knee Arthroplasty Revisions Associated With Increased Mortality?

BackgroundIt remains uncertain whether patients who undergo numerous total hip arthroplasty (THA) and/or knee arthroplasty (TKA) revisions exhibit decreased survival. Therefore, we sought to determine if the number of revisions per patient was a mortality predictor.MethodsWe retrospectively reviewed 978 consecutive THA and TKA revision patients from a single institution (from January 5, 2015-November 10, 2020). Dates of first-revision or single revision during study period and of latest follow-up or death were collected, and mortality was assessed. Number of revisions per patient and demographics corresponding to first revision or single revision were determined. Kaplan-Meier, univariate, and multivariate Cox-regressions were utilized to determine mortality predictors. The mean follow-up was 893 days (range, 3-2,658).ResultsMortality rates were 5.5% for the entire series, 5.0% among patients who only underwent TKA revision(s), 5.4% for only THA revision(s), and 17.2% for patients who underwent TKA and THA revisions (P = .019). In univariate Cox-regression, number of revisions per patient was not predictive of mortality in any of the groups analyzed. Age, body mass index (BMI), and American Society of Anesthesiologists (ASA) were significant mortality predictors in the entire series. Every 1 year of age increase significantly elevated expected death by 5.6% while per unit increase in BMI decreased the expected death by 6.7%, ASA-3 or ASA-4 patients had a 3.1 -fold increased expected death compared to ASA-1 or ASA-2 patients.ConclusionThe number of revisions a patient underwent did not significantly impact mortality. Increased age and ASA were positively associated with mortality but higher BMI was negatively associated. If health status is appropriate, patients can undergo multiple revisions without risk of decreased survival.     

Is There an Association Between Smoking Status and Prosthetic Joint Infection After Primary Total Joint Arthroplasty?

Background

Recent reports highlighted the association between smoking and higher risk of postsurgical infections. The aim was to compare the incidence of prosthetic joint infection after primary total joint arthroplasty (TJA) according to smoking status.

Is Intraoperative Dexamethasone Utilization Associated With Increased Rates of Periprosthetic Joint Infection Following Total Joint Arthroplasty?

BackgroundIntraoperative dexamethasone can reduce postoperative pain and nausea following total knee (TKA) and total hip arthroplasty (THA). To the best of our knowledge, no study to date has been adequately powered to detect the risk of periprosthetic joint infection (PJI) from early dexamethasone exposure. This study aimed to assess PJI rates and complications in patients undergoing primary elective TKA and THA who received intraoperative dexamethasone.MethodsA national database was used to identify adults undergoing primary elective TKA and THA between 2015 and 2020. Patients who received intraoperative dexamethasone and those who did not were identified. The primary endpoint was 90-day risk of infectious complications. Secondary end points included thromboembolic, pulmonary, renal, and wound complications. Multivariate analyses were performed to assess the risk of all endpoints between cohorts. Between 2015 and 2020, 1,322,025 patients underwent primary elective TJA, of which 857,496 (64.1%) underwent TKA and 474,707 (35.9%) underwent TKA.ResultsIn patients who underwent TKA, dexamethasone was associated with lower risk of PJI (adjusted odds ratio: 0.87, 95% CI: 0.82-0.93, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, and acute kidney injury. In patients who underwent THA, dexamethasone was associated with a lower risk of PJI (adjusted odds ratio: 0.80, 95% CI: 0.73-0.86, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, acute kidney injury, and pneumonia.ConclusionIntraoperative dexamethasone was not associated with increased risk of infectious complications. The data presented here provide evidence in support of intraoperative dexamethasone utilization during primary TKA or THA.     

Are Patient-Reported Drug Allergies Associated With Prosthetic Joint Infections and Functional Outcomes Following Total Hip and Knee Arthroplasty?

BackgroundThe purpose of this study is to determine if the number and types of patient-reported drug allergies are associated with prosthetic joint infection (PJI) and functional outcomes following total joint arthroplasty (TJA).MethodsThis is a retrospective review of all patients who underwent a primary, elective total hip (THA) or knee arthroplasty (TKA) over a 10-year period at a single academic institution. Demographic, clinical information, and number and type of patient-reported drug allergy was collected. Univariate and multivariate logistic regressions were performed to identify risk factors for PJI and risk of PJI based on number of allergies. Univariate analysis was also performed to identify if the number of patient-reported allergies affected functional outcome scores.ResultsOf 31,109 patients analyzed, there were 941 (3%) revisions for infection (491 knees and 450 hips). At least one allergy was reported by 16,435 (52.8%) patients, with a mean of 1.2 ± 1.9. Those who underwent revision for infection had a significantly higher number of reported allergies (1.68 ± 1.9 vs 1.23 ± 1.9, P < .0005, 95% confidence interval ?0.58 to 0.33). On univariate regression the number of allergies independently predicted revision TJA for infection (P < .0001) as did age, gender, body mass index, and smoking status. On multivariate regression for each additional patient-reported allergy, risk of PJI increased by 1.11 times (95% confidence interval 1.07-1.14, P < .0001). Number of patient-reported allergies did not predict 3-month or 1-year functional outcome scores.ConclusionPatients with a higher number of reported allergies may be at increased risk of PJI following TJA.Level of EvidencePrognostic Level II.     

Infection or Allergy in the Painful Metal-on-Metal Total Hip Arthroplasty?

Metal-on-metal articulations are increasingly used in total hip arthroplasty. Patients can be sensitive to metal ions produced by the articulation and present with pain or early loosening. Infection must be excluded. Correct diagnosis before revision surgery is crucial to implant selection and operation planning. There is no practical guide in the literature on how to differentiate between allergy and infection in a painful total hip arthroplasty. We present the history, clinical findings and hip scores, radiology, serology, hip arthroscopy and aspirate results, labeled white cell scan, revision-hip findings, histology and clinical results of a typical patient with a hypersensitivity response to a metal-on-metal hip articulation, and how results differ from patients with an infected implant. A practical scheme to investigate patients with a possible hypersensitivity response to an implant is presented.     

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.     

Preoperative Anemia in Total Joint Arthroplasty: Is It Associated with Periprosthetic Joint Infection?

Background  

Anemia is common in patients undergoing total joint arthroplasty (TJA). Numerous studies have associated anemia with increased risk of infection, length of hospital stay, and mortality in surgical populations. However, it is unclear whether and to what degree preoperative anemia in patients undergoing TJA influences postoperative periprosthetic joint infection (PJI) and mortality.     

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.     

What Happens at the Adjacent Knee Joint After Total Hip Arthroplasty of Crowe Type III and IV Dysplastic Hips?

We prospectively evaluated 30 hips of 22 patients who had normal knees with a mean age of 53.4 years (range, 38-72 years). In the early postoperative period, genu valgum deformity was observed in all knees. Of 22 patients, 17 complained of severe pain owing to strain in the medial collateral ligament and iliotibial tract. Postoperatively, the ipsilateral extremities of the patients were extended by a mean of 16.5 mm (8-25 mm). Q angles of the patients increased by a mean of 4.4° ± 2.5° (P < .001). Although the Harris hip scores were improved (40.7-87.8 points), postoperative Lysholm-Gillquist knee scores were significantly reduced (92-76 points, P < .001). Reduction of displaced hips into the anatomical hip center and lengthening the extremity despite shortening procedure may lead to strain at the knee joint iatrogenically, particularly with the mechanical effect of tensor fascia lata, which results with changes in the knee biomechanics.     

Understanding Readmission After Primary Total Hip and Knee Arthroplasty: Who’s at Risk?

Readmission has been cited as an important quality measure in the Patient Protection and Affordable Care Act. We queried an electronic database for all patients who underwent Total Hip Arthroplasty or Total Knee Arthroplasty at our institution from 2006 to 2010 and identified those readmitted within 90 days of surgery, reviewed their demographic and clinical data, and performed a multivariable logistic regression analysis to determine significant risk factors. The overall 90-day readmission rate was 7.8%. The most common readmission diagnoses were related to infection and procedure-related complications. An increased likelihood of readmission was found with coronary artery disease, diabetes, increased LOS, underweight status, obese status, age (over 80 or under 50), and Medicare. Procedure-related complications and wound complications accounted for more readmissions than any single medical complication.     

Are Bilateral Total Joint Arthroplasty Patients at a Higher Risk of Developing Pulmonary Embolism Following Total Hip and Knee Surgery?

Despite developments in prophylactic methods, venous thromboembolism (VTE) continues to be a serious complication following total joint arthroplasty. The new AAOS/ACCP guidelines on preventing pulmonary embolism (PE) after total hip/knee arthroplasty (THA/TKA) do not make specific recommendations for bilateral vs. unilateral procedures. In-patient PE rates were examined for patients undergoing unilateral or simultaneous bilateral TKA/THA at our institution in 2011. Of the 7,437 THA/TKA surgeries completed at our institution in 2011, 36 patients suffered from PE (0.48%). The rate of PE for unilateral TKA was 0.61% vs. 1.87% for bilateral (P < 0.001) and for unilateral THA was 0.17% vs. 0.52% for bilateral THA. Despite patients being screened before being cleared to undergo bilateral THA/TKA, they remain at higher risk for VTE.