C-reactive protein levels after 4 types of arthroplasty

Background and purpose Postoperative C-reactive protein (CRP) levels in serum appear to reflect surgical trauma. We examined CRP levels after 4 types of arthroplasty.

Material and methods We investigated 102 patients who had total knee arthroplasty (TKA), computer navigation-assisted total knee arthroplasty (NAV-TKA), hip resurfacing arthroplasty (metal on metal, MMSA) and total hip arthroplasty (THA), respectively. CRP levels were estimated before surgery and postoperatively at 2 and 7 days.

Results Postoperatively, the peak CRP levels were highest on the second day after surgery in each of the groups. The peak CPR levels after hip resurfacing were lower than those after conventional primary THA. The peak CRP levels after computer navigation-assisted TKA were lower than those after conventional primary TKA.

Interpretation The extent of bone and bone marrow injury rather than the region of surgery or the amount of soft tissue damage appears to determine the extent of the postoperative CRP response.     

对全髋与全膝关节置换术后LMWH应用时机的初步研究

目的 探讨全髋与全膝关节置换术后应用低分子肝素(LMWH)预防深静脉血栓(DVT)的时机.方法 158例全髋与全膝关节置换者中髋关节置换(THA)81例、全膝关节置换(TKA)77例.观察术后不同时机使用LMWH对术后引流量、DVT发生率的影响.结果 THA术后开始使用LMWH组引流量与术后72 h组差异具有统计学意义(P=0.000),而TKA术后组与术后72 h组差异无统计学意义(P=0.552).在THA和TKA中,术后组与术后72 h组DVT发生率差异均有统计学意义(P=0.000).结论 THA术后LMWH的最佳应用时机是术后72 h,但术后即应用LMWH则是TKA术后预防DVT的最佳时机.     

Total hip and total knee arthroplasty in juvenile rheumatoid arthritis

Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is indicated for patients with juvenile rheumatoid arthritis (JRA) when marked joint destruction is present and pain or deformity compromises function despite optimal medical therapy. Relief of pain, reduction of the deformity, and dramatic improvement in functional status and quality of life can be achieved in most patients. Functional impairment and deformity rather than pain are usually the primary indications for THA or TKA. When there is both hip and knee involvement, hip arthroplasty should probably be done first. Regional anesthetic appears to be the anesthetic of choice. Careful preoperative planning and the availability of custom and minisized components are essential. Small bone size, osteoporosis, and severe soft tissue disease make the surgery technically demanding. Skeletal immaturity may not contraindicate surgery if the patient is otherwise bedridden with progressive deformity. In the hip trochanteric osteotomy is often necessary for adequate exposure, with the possible exception being a patient with juvenile ankylosing spondylitis who is subject to heterotopic bone formation. Although complete capsulectomy and psoas tenotomy may be necessary to relieve a hip flexion contracture, a soft tissue release that produces leg lengthening may lead to nerve palsy. In the hip component loosening has been less common in patients with JRA than in other young patients who have undergone THA, but it is still the most frequent cause of failure. In the knee preoperative and postoperative serial casts can aid in the correction of severe flexion contracture. Secondary patellar pain has been the most common cause of late failure. Patellar resurfacing should probably be performed at the time of the original knee arthroplasty in all patients with JRA.     

Perioperative changes of blood coagulability evaluated by thromboelastography (TEG) in patients undergoing total knee and total hip arthroplasty

BACKGROUND : A large number of studies have examined the incidence of thromboembolic complications after orthopedic surgery of the lower extremity. We investigated the perioperative changes of coagulability following total knee arthroplasty (TKA) or total hip arthroplasty (THA) using thromboelastography (TEG), which could comprehensively assess the coagulation and fibrinolytic system. METHODS : Thirty patients scheduled for TKA (n= 10), THA (n= 10) and other lower extremity orthopedic surgery (control, n= 10) were studied. TEG was analyzed with K-value, MA-value and coagulation index (CI) before induction of anesthesia and 24 hours after surgery. RESULTS : K-values decreased significantly after TKA and THA compared with the values before the induction of anesthesia. MA-values and CI increased significantly after TKA and THA compared with the values before the induction. There were no significant changes in K-value, MA-value and CI in the control group during the perioperative period. CONCLUSIONS : The results suggest that TKA and THA lead blood coagulation to hypercoagulable state at the early postoperative stage.     

Rivaroxaban, an oral, direct factor Xa inhibitor: a new option for thromboprophylaxis

Patients undergoing major orthopedic surgery, including total hip arthroplasty (THA) and total knee arthroplasty (TKA), are at high risk for developing venous thromboembolism (VTE). Although largely a preventable complication, VTE develops in a significant proportion of patients, highlighting the need for improved methods of VTE prevention. Current thromboprophylactic options are limited by unpredictable pharmacokinetics and pharmacodynamics (vitamin K antagonists), parenteral/subcutaneous administration (heparin and low-molecular-weight heparins), complicated dosing, and increased risk of bleeding.Rivaroxaban is an oral, direct Factor Xa inhibitor that has recently received marketing authorization in the United States for prophylaxis of deep vein thrombosis in patients undergoing hip or knee replacement surgery. The clinical pharmacology of rivaroxaban supports a convenient, oral, once-daily dosing regimen without the need for routine coagulation monitoring after THA or TKA. A comprehensive phase II and III study program supports its safety and efficacy for VTE prevention after THA or TKA. Phase III results have demonstrated the superior efficacy of rivaroxaban regimens compared with enoxaparin regimens, with similar rates of major bleeding. This article provides an overview of the phase II and III results that support the use of this agent for the prevention of VTE after elective total hip or knee replacement.     

Autotransfusion in major orthopaedic surgery: experience with 1785 patients

Using a prospective audit, we have evaluated the efficacy of an integrated autotransfusion regimen which comprised predepositing and intra- and postoperative blood salvage in major orthopaedic surgery. We examined prospectively the records of 1785 patients (1198 females, 5867 males, mean age 62 (range 16-90) yr, preoperative haemoglobin concentration 13.4 (SD 1.4) g dl-1) undergoing total hip arthroplasty (THA, 1229 patients), THA after removal of internal fixation devices (RFD + THA, 18 patients), total knee arthroplasty (TKA, 263 patients), revision surgery of the hip (HR cup + stem revision, 197 patients; cup revision, 53 patients; stem revision, 16 patients) and total knee revision (TKR, nine patients). We estimated that the number of predonations (MSBOS = maximum surgery blood order schedule) was 2 u. for THA, TKA and TKR, and 3 u. for partial or total hip revision and total hip arthroplasty with fixation removal. We found that it was possible to obtain the MSBOS in 1597 patients (89.5%). Homologous red blood cell (HRBC) transfusions were carried out in 131 patients (7.3%). We found that the need to use HRBC was significantly associated with failure to meet the number of MSBOS, female sex, lower preoperative haemoglobin concentration, use of calcium heparin for antithrombosis prophylaxis, more extensive surgery, higher ASA rating and co-existing diseases such as coronary artery disease.      

Use of a trabecular metal patella for marked patella bone loss during revision total knee arthroplasty

This study evaluates the short-term results following patellar resurfacing with a trabecular metal patella shell in the setting of marked patellar bone loss at the time of revision total knee arthroplasty (TKA). Twenty consecutive patients undergoing revision TKA with the use of a trabecular metal patella were evaluated at a mean 23-month follow-up. All patients had marked patellar bone loss at surgery precluding resurfacing with a standard cemented patellar button. Results were good or excellent in 17 of 20 patients. There were no displacements of any trabecular metal patella shells, and the fixation appeared excellent despite the poor quality of bone remaining. Complications included 3 patients with polar patella fractures postoperatively. Qualitatively, these results compare favorably with patellar resection arthroplasty in this setting.     

Comparison of weight changes after total hip or knee arthroplasty

A prospective study of the effect on weight in 192 patients after total hip arthroplasty (THA) (124 hips) or total knee arthroplasty (TKA) (68 knees) was performed. Patients' weights at 1 year after THA or TKA were compared with their preoperative weights. There was little or no effect on a patient's weight after TKA. Women undergoing THA gained on average 3.1 kg (6.8 lb), whereas men gained on average 2.5 kg (5.5 lb). This information may be of benefit to a surgeon whose patient needs encouragement to lose weight before undergoing a THA.     

Heterotopic ossification after hip and knee arthroplasty: risk factors,prevention, and treatment

Symptomatic heterotopic ossification (HO) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is relatively rare. Patients at high risk for developing HO after THA include men with bilateral hypertrophic osteoarthritis, patients with a history of HO in either hip, and patients with posttraumatic arthritis characterized by hypertrophic osteophytosis. Patients at moderate risk are those with ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, Paget's disease, or unilateral hypertrophic osteoarthritis. Patients at high risk for developing HO after TKA include those with limited postoperative knee flexion, increased lumbar bone mineral density, hypertrophic arthrosis, excessive periosteal trauma and/or notching of the anterior femur, and those who require forced manipulation after TKA. Preoperative radiation is effective for preventing HO after THA, as are post-operative prophylactic drug regimens and single-dose radiation treatments. Recurrence of HO after surgical excision should be expected unless prophylaxis is administered. Prophylactic measures against HO after THA and TKA should be administered before the fifth postoperative day, optimally within 24 to 48 hours.     

Gait symmetry: a comparison of hip resurfacing and jumbo head total hip arthroplasty patients

Proponents of large femoral head total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) have touted the potential for restoration of more normal hip kinematics. This study examined 20 patients (10 THA and 10 HRA patients) approximately 18 months after surgery. Subjects were evaluated at a self-selected pace, while bilateral spatial-temporal gait variables, hip flexion/extension kinematics, and ground reaction forces were collected. For both groups, swing time was increased on the surgical side, whereas peak hip flexion, peak extension, and flexion at heel strike were decreased. Peak hip extension and peak vertical ground reaction forces were decreased in THA subjects compared with HRA subjects. After a large-diameter THA or HRA, subjects do not display symmetric gait approximately 18 months postoperatively. Total hip arthroplasty subjects demonstrated restricted hip extension and reduced limb loading when compared with HRA subjects.     

Predictors of Allogeneic Blood Transfusion in Total Hip and Knee Arthroplasty in the United States, 2000–2009

We examined the predictors of allogeneic blood transfusion (ALBT) in primary unilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA), analyzing the Nationwide Inpatient Sample between 2000 and 2009. Multivariate logistic regression analysis was performed. Significant predictors of ALBT in both THA and TKA included older age, female gender, race, weight loss, anemia, Elixhauser Comorbidity Score, hospital caseload, hospital region, and insurance status. No autologous-related blood transfusion was a significant predictor of ALBT in THA, however, not in TKA. We believe that the utilization of ALBT in THA and TKA can decrease by taking these factors into consideration for patient blood management before surgery.     

Primary and revision arthroplasty surgery caseloads in the United States from 1990 to 2004

We analyzed the temporal changes in the caseload of primary and revision hip and knee arthroplasty surgeons in the United States between 1990 and 2004. The Nationwide Inpatient Sample was used to identify arthroplasty procedures and the surgeons who performed them. Annual caseloads were analyzed for each procedure; 47% +/- 2% and 39% +/- 2% of hip and knee surgeons performed revisions nationwide. Average revision caseloads increased slightly over time at a rate of 1.2 and 1.4 cases per surgeon per decade for total hip arthroplasty (THA) and total knee arthroplasty (TKA), respectively. The caseload of primary THA and TKA increased by 1.4 and 1.7 cases per surgeon per decade. The caseload for the top 5% of primary THA and TKA surgeons increased from 25 to 45 and 33 to 86, respectively, during this period compared with the median caseload, which increased from 4 to 5 (hip) and 5 to 10 (knee). The revision caseload of surgeons has increased over time, particularly for surgeons with the highest caseloads.     

How Often are Patient and Surgeon Recovery Expectations for Total Joint Arthroplasty Aligned? Results of a Pilot Study

Background  

Surgeons strive to set patient expectations for recovery following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, some patients report dissatisfaction after surgery due to unmet expectations.     

Sodium Abnormalities Are an Independent Predictor of Complications in Total Joint Arthroplasty: A Cautionary Tale!

BackgroundElectrolyte levels are commonly obtained as part of the preoperative workup for total joint arthroplasty, but limited information exists on the interplay between electrolyte abnormalities and outcomes.MethodsThe National Surgical Quality Improvement Program was queried for primary, elective total hip arthroplasty and total knee arthroplasty (THA, TKA) performed between 2011 and 2017. Three patient groups were compared: normal (control), hypernatremia, and hyponatremia. The primary outcomes were length of stay (LOS) and 30-day adverse events: complications, readmissions, reoperations, and mortality.ResultsA total of 244,538 TKAs and 145,134 THAs were analyzed. The prevalence of hyponatremia and hypernatremia was 6.9% and 1.0%, respectively. After controlling for any baseline differences, hypernatremia was an independent predictor of ventilation >48 hours (THA, odds ratio [OR] 3.53), unplanned intubation (THA, OR 3.14), cardiac arrest (THA, OR 2.42), pneumonia (THA, OR 2.16), Clostridium difficile infection (OR 4.66 and 3.25 for THA and TKA, respectively), LOS >2 days (THA, OR 1.16), and mortality (THA, OR 4.69). Similarly, hyponatremia was an independent predictor of LOS >2 days (TKA, OR 1.21), readmission (TKA, OR 1.40), reoperation (OR 1.32 and 1.47 for THA and TKA, respectively), surgical site infections (OR 1.39 and 1.54 for THA and TKA, respectively), and transfusion (OR 1.13 and 1.20 for THA and TKA, respectively).ConclusionAs the focus of total joint arthroplasty continues to shift toward value-based payment models and outpatient surgery, caution should be exercised in patients with abnormal preoperative sodium levels, particularly hypernatremia, because of significantly increased risk of prolonged LOS and 30-day adverse events.     

低分子肝素预防髋、膝关节手术后下肢深静脉血栓形成的多中心研究

目的 探讨国人髋、膝关节手术后下肢深静脉血栓（deepvenous thrombosis,DVT）的发生率及应用低分子肝素预防DVT的有效性和安全性。方法 根据入选标准选择120例髋、膝关节手术患者,分别在北京、上海、广州三个中心参加该项研究,观察组和对照组分别为68例和52例。观察组中男30例,其中全髋关节置换术19例,全膝关节置换术2例,动力髋螺钉（DHS）9例;女38例,其中全髋关节置换术17例,全膝关节置换术17例,DHS4例。对照组中男21例,其中全髋关节置换术19例,全膝关节置换术1例,DHS1例;女31例,其中全髋关节置换术15例,全膝关节置换术15例,DHS1例。结果 除观察组与对照组女性全髋关节置换术患者术中、术后失血量差异有统计学意义（P〈0．05）外,其余出血量差异均无统计学意义（P〉0．05）。手术前后血红蛋白、血小板、凝血酶原时间及活动度与活化部分凝血活酶时间变化差异均无统计学意义（P〉0．05）。两组患者术后下肢DVT发生率差异有统计学意义（P〈0．05）。观察组总的不良反应发生率为8．8％（6.68）。结论 低分子肝素可以有效预防髋、膝关节置换术后DVT的发生,同时对于已发生的DVT有良好的治疗效果,不良反应发生率低。     

Mark-Up Trends in Contemporary Medicare Primary and Revision Total Joint Arthroplasty

BackgroundUnderstanding mark-up ratios (MRs), the ratio between a healthcare institution’s submitted charge and the Medicare payment received, for high-volume orthopaedic procedures is imperative to inform policy about price transparency and reducing surprise billing. This analysis examined the MRs for primary and revision total hip and knee arthroplasty (THA and TKA) services to Medicare beneficiaries between 2013 and 2019 across healthcare settings and geographic regions.MethodsA large dataset was queried for all THA and TKA procedures performed by orthopaedic surgeons between 2013 and 2019, using Healthcare Common Procedure Coding System (HCPCS) codes for the most frequently used services. Yearly MRs, service counts, average submitted charges, average allowed payments, and average Medicare payments were analyzed. Trends in MRs were assessed. We evaluated 9 THA HCPCS codes, averaging 159,297 procedures a year provided by a mean of 5,330 surgeons. We evaluated 6 TKA HCPCS codes, averaging 290,244 procedures a year provided by a mean of 7,308 surgeons.ResultsFor knee arthroplasty procedures, a decrease was noted for HCPCS code 27438 (patellar arthroplasty with prosthesis) over the study period (8.30 to 6.62; P = .016) and HCPCS code 27447 (TKA) had the highest median (interquartile range [IQR]) MR (4.73 [3.64 to 6.30]). For revision knee procedures, the highest median (IQR) MR was for HCPCS code 27488 (removal of knee prosthesis; 6.12 [3.83-8.22]). While no trends were noted for both primary and revision hip arthroplasty, median (IQR) MRs in 2019 for primary hip procedures ranged from 3.83 (hemiarthroplasty) to 5.06 (conversion of previous hip surgery to THA) and HCPCS code 27130 (total hip arthroplasty) had a median (IQR) MR of 4.66 (3.58-6.44). For revision hip procedures, MRs ranged from 3.79 (open treatment of femoral fracture or prosthetic arthroplasty) to 6.10 (revision of THA femoral component). Wisconsin had the highest median MR by state (>9) for primary knee, revision knee, and primary hip procedures.ConclusionThe MRs for primary and revision THA and TKA procedures were strikingly high, as compared to nonorthopaedic procedures. These findings represent high levels of excess charges billed, which may pose serious financial burdens to patients and must be taken into consideration in future policy discussions to avoid price inflation.     

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.     

Knee arthrodesis in failed total knee arthroplasty with severe osteolysis and ipsilateral long-stem total hip arthroplasty

We report a case of knee fusion after a failed total knee arthroplasty (TKA) with severe osteolysis including the epicondyle and ipsilateral total hip arthroplasty (THA) with long Wagner revision stem (Sulzer Orthopedics, Baar, Switzerland). The conventional devices for arthrodesis were unavailable in this case because of the long Wagner revision stem and poor bone stock. A connector was made between the long Wagner revision stem and an intramedullary nail (IM nail; Solco, Seoul, Korea). The custom-made connector was coupled with a femoral stem by cylindrical taper fit with additional cement augmentation and an intramedullary nail by screws. Osseous fusion was achieved without pain or instability.     

Deep venous thrombosis after total hip or knee arthroplasty in a "low-risk" Chinese population

Scarcely any information has been published on deep vein thrombosis (DVT) in Chinese patients after total hip arthroplasty (THA) or total knee arthroplasty (TKA). However, generally, no prophylaxis is given to patients who do not have conventional high-risk factors because they are believed to be at "low risk." We performed a prospective study on 80 such "low risk" patients undergoing THA or TKA (58 TKA and 22 THA) without prophylaxis and performed duplex ultrasonography on both lower limbs 6 to 8 days after surgery. A total of 22 patients (27.5%) showed ultrasonographic evidence of DVT. Eighteen (31%) TKAs and 4 (18.1%) THAs were complicated by DVT. Three patients showed bilateral involvement, all of whom underwent TKA. Two patients had symptomatic pulmonary embolism. The sensitivity and positive predictive value of the clinical examination was 27.2% and 31.6%, respectively. This study showed that patients who are labeled "low risk" for DVT actually had a significant risk and suggests that the current practice of providing prophylaxis to only patients deemed at "high risk" should be revised.