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1.
Total Knee Arthroplasty Wound Complication Treatment Algorithm: Current Soft Tissue Coverage Options
Nirav H. Amin Joshua N. Speirs Matthew J. Simmons Oren Z. Lermen Fred D. Cushner Giles R. Scuderi 《The Journal of arthroplasty》2019,34(4):735-742
Background
Wound complications associated with soft tissue defects following total knee arthroplasty present challenges for the orthopedic surgeon. The scale of early complications include less morbid problems, such as quickly resolving drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft tissue coverage.Methods
This review outlines current wound management strategies and provides an algorithm to help guide treatment and clinical decision-making.Conclusion
A surgeon’s understanding of soft tissue coverage options is essential in protecting the knee prosthesis from a deep infection and to obtain an optimal functional outcome. 相似文献2.
Brian M. Godshaw Ashley E. Mehl Jeffrey G. Shaffer Mark S. Meyer Leslie C. Thomas George F. Chimento 《The Journal of arthroplasty》2019,34(4):645-649
Background
Peri-operative dexamethasone has been shown to effectively reduce post-operative nausea and vomiting and aide in analgesia after total joint arthroplasty (TJA); however, systemic glucocorticoid therapy has many adverse effects. The purpose of this study is to determine the effects of dexamethasone on prosthetic joint infection (PJI) and blood glucose levels in patients undergoing TJA.Methods
A retrospective chart review of all patients receiving primary TJA from 2011 to 2015 (n = 2317) was conducted. Patients were divided into 2 cohorts: dexamethasone (n = 1426) and no dexamethasone (n = 891); these groups were subdivided into diabetic and non-diabetic patients. The primary outcome was PJI; secondary measures included glucose levels and pre-operative hemoglobin A1c (A1c) values. Statistics were carried out using logistic and regression models.Results
Of the 2317 joints, 1.12% developed PJI; this was not affected by dexamethasone (P = .166). Diabetics were found to have higher rate of infection (P < .001); however, diabetics who received dexamethasone were not found to have a significantly higher infection rate that non-diabetics (P = .646). Blood glucose levels were found to increase post-operatively, and dexamethasone did not increase this change (P = .537). Diabetes (P < .001) and increasing hemoglobin A1c (P < .001) were also associated with increased serum glucose levels; however, this was not influenced by dexamethasone (P = .595).Conclusion
Although diabetic patients were found to have a higher infection rate overall, this was not affected by administration of intravenous dexamethasone, nor was the post-operative elevation in serum glucose levels. In this study population, peri-operative intravenous dexamethasone did not increase the rate of PJI and was safe to administer in patients undergoing TJA. 相似文献3.
Qiaojie Wang Karan Goswami Noam Shohat Arash Aalirezaie Jorge Manrique Javad Parvizi 《The Journal of arthroplasty》2019,34(5):947-953
Background
Whether prolonged operative time is an independent risk factor for subsequent surgical site infection (SSI) and periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) remains a clinically significant and underexplored issue. The aim of this study is to investigate the association between operative time and the risk of subsequent SSI and PJI in patients undergoing primary TJA.Methods
We retrospectively reviewed 17,342 primary unilateral total knee arthroplasty and total hip arthroplasty performed at a single institution between 2005 and 2016, with a minimum follow-up of 1 year. A multivariate logistic regression model was conducted to identify the association between operative time and the development of SSI within 90 days and PJI within 1 year.Results
Overall, the incidence of 90-day SSI and 1-year PJI was 1.2% and 0.8%, respectively. Patients with an operative time of >90 minutes had a significantly higher incidence of SSI and PJI (2.1% and 1.4%, respectively) compared to cases lasting between 60 and 90 minutes (1.1% and 0.7%), and those lasting ≤60 minutes (0.9% and 0.7%, P < .01). In the multivariate model, the risk for infection increased by an odds ratio of 1.346 (95% confidential interval 1.114-1.627) for 90-day SSI and 1.253 (95% confidential interval 1.060-1.481) for 1-year PJI for each 20-minute increase in operative time.Conclusion
In patients undergoing primary TJA, each 20-minute increase in operative time was associated with nearly a 25% increased risk of subsequent PJI. We advocate that surgeons pay close attention to this underappreciated risk factor while maintaining safe operative practices, which minimize unnecessary steps and wasted time in the operating room. 相似文献4.
Sreeram Penna Kerri L. Bell Feng-Chih Kuo Robert Andrew Henderson Carol Foltz Antonia F. Chen 《The Journal of arthroplasty》2019,34(5):834-838
Background
The Comprehensive Care for Joint Replacement model is the newest iteration of the bundled payment methodology introduced by the Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement model, while incentivizing providers to deliver care at a lower cost, does not incorporate any patient-level risk stratification. Our study evaluated the impact of specific medical co-morbidities on the cost of care in total joint arthroplasty (TJA) patients.Methods
A retrospective study was conducted on 1258 Medicare patients who underwent primary elective TJA between January 2015 and July 2016 at a single institution. There were 488 males, 552 hips, and the mean age was 71 years. Cost data were obtained from the Centers for Medicare and Medicaid Services. Co-morbidity information was obtained from a manual review of patient records. Fourteen co-morbidities were included in our final multiple linear regression models.Results
The regression models significantly predicted cost variation (P < .001). For index hospital costs, a history of cardiac arrhythmias (P < .001), valvular heart disease (P = .014), and anemia (P = .020) significantly increased costs. For post-acute care costs, a history of neurological conditions like Parkinson’s disease or seizures (P < .001), malignancy (P = .001), hypertension (P = .012), depression (P = .014), and hypothyroidism (P = .044) were associated with increases in cost. Similarly, for total episode cost, a history of neurological conditions (P < .001), hypertension (P = .012), malignancy (P = .023), and diabetes (P = .029) were predictors for increased costs.Conclusion
The cost of care in primary elective TJA increases with greater patient co-morbidity. Our data provide insight into the relative impact of specific medical conditions on cost of care and may be used in risk stratification in future reimbursement methodologies. 相似文献5.
Rushabh M. Vakharia Wayne B. Cohen-Levy Ajit M. Vakharia Chester J. Donnally Tsun Yee Law Martin W. Roche 《The Journal of arthroplasty》2019,34(5):959-964.e1
Background
Sleep apnea (SA) negatively affects bone mineralization, cognition, and immunity. There is paucity in the literature regarding the impact of SA on total joint arthroplasty (TJA). The purpose of this study is to compare complications in patients with and without SA undergoing either total knee (TKA) or total hip arthroplasty (THA).Methods
A retrospective review from 2005 to 2014 was conducted using the Medicare Standard Analytical Files. Patients with and without SA on the day of the primary TJA were queried using the International Classification of Diseases, ninth revision codes. Patients were matched by age, gender, Charlson Comorbidity Index), and body mass index. Patients were followed for 2 years after their surgery. Ninety-day medical complications, complications related to implant, readmission rates, length of stay, and 1-year mortality were quantified and compared. Logistic regression was used to calculate odds ratios (OR) with their respective 95% confidence interval and P values.Results
After the random matching process there were 529,240 patients (female = 271,656, male = 252,106, unknown = 5478) with (TKA = 189,968, THA = 74,652) and without (TKA = 189,968, THA = 74,652) SA who underwent primary TJA between 2005 and 2014. Patients with SA had greater odds of developing medical complications following TKA (OR 3.71) or THA (OR 2.48).Conclusion
The study illustrates an increased risk of developing postoperative complications in patients with SA following primary TJA. Surgeons should educate patients on these adverse effects and encourage the use of continuous positive airway pressure which has been shown to mitigate many postoperative complications. 相似文献6.
Tyler J. Vovos Sean P. Ryan Cierra S. Hong Claire B. Howell Thomas J. Risoli David E. Attarian Thorsten M. Seyler 《The Journal of arthroplasty》2019,34(5):824-833
Background
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, created by the Centers for Medicare and Medicaid, is directly tied to hospital reimbursement. The purpose of this study is to identify factors that are predictive HCAHPS survey responses following primary hip and knee arthroplasty.Methods
Prospectively collected HCAHPS responses from patients undergoing elective hip and knee arthroplasty between January 2013 and October 2017 at our institution were analyzed. Patient age, gender, race, marital status, body mass index, American Society of Anesthesiologists score, preoperative pain score, smoking status, alcohol use, illegal drug use, socioeconomic quartile, insurance type, procedure type, hospital type (academic vs community), distance to medical center, length of stay (LOS), and discharge disposition were obtained and correlated with HCAHPS inpatient satisfaction scores.Results
Responses from 3593 patients were obtained: 1546 total hip arthroplasties, 1899 total knee arthroplasties, and 148 unicompartmental knee arthroplasties. Mean overall HCAHPS score was 79.2. Women had lower inpatient satisfaction than men (77.6 vs 81.6, P < .001). Alcohol consumers had lower inpatient satisfaction than abstainers (77.7 vs 81.6, P < .001). Inpatient satisfaction varied by socioeconomic quartile (P < .001) with patients in the highest quartile having lower satisfaction than patients in all other quartiles (P < .001). Patients discharged to a facility had lower inpatient satisfaction than those discharged home (71.2 vs 80.2, P < .001). An inverse correlation between inpatient satisfaction and LOS (r = ?0.19, P < .001) and a direct correlation between satisfaction and distance to medical center (r = 0.06, P < .001) were seen.Conclusion
Patients more likely to report lower levels of inpatient satisfaction after total joint arthroplasty are female, affluent, and alcohol consumers, who are discharged to postacute care facilities. Inpatient satisfaction was inversely correlated with LOS and positively correlated with distance from patient home to medical center. These findings provide targets for improvements in TJA inpatient care. 相似文献7.
Kyle R. Duchman Andrew J. Pugely Christopher T. Martin Yubo Gao Nicholas A. Bedard John J. Callaghan 《The Journal of arthroplasty》2017,32(4):1285-1291
Background
Increased operative time has been associated with increased complications after total joint arthroplasty (TJA). The purpose of the present study was to investigate the effect of operative time on short-term complications after TJA while also identifying patient and operative factors associated with prolonged operative times.Methods
The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011-2013 to identify all patients who underwent primary total hip or knee arthroplasty. Patients were stratified by operative time, and 30-day morbidity and mortality data compared using univariate and multivariable analyses.Results
We identified 99,444 patients who underwent primary TJA. The overall incidence of complications after TJA was 4.9%. Overall complications were increased in patients with operative times >120 minutes (5.9%) as compared to patients with operative times <60 minutes or 60-120 minutes (4.6% and 4.8%, respectively; P < .001). Wound complications, including surgical site infection, were also increased for procedures lasting >120 minutes. In a multivariable analysis, operative time exceeding 120 minutes remained an independent predictor of any complication and wound complication, with each 30-minute increase in operative time beyond 120 minutes further increasing risk. Patient age ≤65 years, male sex, black race, body mass index ≥30 kg/m2, and an American Society of Anesthesiologists classification of 3 or 4, predicted operative times >120 minutes.Conclusion
We found that operative time >120 minutes was associated with increased short-term morbidity and mortality after primary TJA. Younger age, male sex, black race, obesity, and increased comorbidity were risk factors for operative time exceeding 120 minutes. 相似文献8.
Jared M. Newman Marcelo B.P. Siqueira Alison K. Klika Robert M. Molloy Wael K. Barsoum Carlos A. Higuera 《The Journal of arthroplasty》2019,34(3):554-559.e1
Background
Continuous wound drainage after arthroplasty can lead to the development of a periprosthetic joint infection. Closed incisional negative pressure wound therapy (ciNPWT) has been reported to help alleviate drainage and other wound complications. The purpose of this prospective randomized controlled trial is to compare the use of ciNPWT with our standard of care dressing in revision arthroplasty patients who were at high risk to develop wound complications.Methods
A total of 160 patients undergoing elective revision arthroplasty were prospectively randomized to receive either ciNPWT or a silver-impregnated occlusive dressing after surgery in a single institution. Patients were included if they had at least 1 risk factor for developing wound complication(s): wound complication, readmission, and reoperation rates were collected at 2, 4, and 12 weeks postoperatively.Results
The postoperative wound complication rate was significantly higher in the control cohort compared to the ciNPWT cohort (19 [23.8%] vs 8 [10.1%], P = .022). There was no significant difference between the control and ciNPWT cohorts in terms of readmissions (19 [23.8%] vs 16 [20.3%], P = .595). Reoperation rate was higher in controls compared to ciNPWT patients (10 [12.5%] vs 2 [2.5%], P = .017). After adjusting for the history of a prior periprosthetic joint infection and inflammatory arthritis, the ciNPWT cohort had a significantly decreased wound complication rate (odds ratio 0.28, 95% confidence interval 0.11-0.68).Conclusion
ciNPWT may decrease the rate of postoperative wound complications in patients who are at an increased risk of such wound issues after revision arthroplasty. 相似文献9.
Andrea H. Stone James H. MacDonald Maulik S. Joshi Paul J. King 《The Journal of arthroplasty》2019,34(4):656-662
Background
Racial disparities in healthcare utilization and outcomes have been reported and have wide-reaching implications for individual patient and healthcare system; as providers we bear an ethical burden to address this disparity and provide culturally competent care. This study will examine the influence of race on length of stay, discharge disposition, and complications requiring reoperation following total joint arthroplasty (TJA).Methods
Single institution retrospective analysis of a consecutive series of 7208 primary TJA procedures performed between July 2013 and June 2017 was conducted. Chi-squared and t-tests were used to quantify differences between the groups and multiple logistic regression was used to identify race as an independent risk factor.Results
In total, 6182 (84.3%) white and 1026 (14.0%) African American (AA) patients were included. AA patients were younger (63.62 vs 66.84 years, P < .001), more likely female (68.8% vs 57.0%, P < .001), had a longer length of stay (2.19 vs 2.00 days, P < .001), more likely to experience septic complications (1.3% vs 0.5%, P = .002) and manipulation under anesthesia (3.9% vs 1.8%, P < .001), and less likely to discharge home (67.1% vs 81.1%, P < .001). Multiple logistic regression showed that AA patients were more likely to discharge to a facility (adjusted odds ratio 2.63, 95% confidence interval 2.19-3.16, P < .001) and experience a manipulation under anesthesia (adjusted odds ratio 1.90, 95% confidence interval 1.26-2.85, P = .002).Conclusion
AA patients undergoing TJA were younger with longer length of stay and a higher rate of nonhome discharge; AA race was identified as an independent risk factor. Further study is required to understand the differences identified in this study. Targeted interventions should be developed to attempt to eliminate the disparity. 相似文献10.
Daniel J. Snyder Thomas R. Kroshus Aakash Keswani Evan B. Garden Karl M. Koenig Kevin J. Bozic David S. Jevsevar Jashvant Poeran Calin S. Moucha 《The Journal of arthroplasty》2019,34(4):613-618
Background
Nursing Home Compare (NHC) ratings, created and maintained by Medicare, are used by both hospitals and consumers to aid in the skilled nursing facility (SNF) selection process. To date, no studies have linked NHC ratings to actual episode-based outcomes. The purpose of this study was to evaluate whether NHC ratings are valid predictors of 90-day complications, readmission, and bundle costs for patients discharged to an SNF after primary total joint arthroplasty (TJA).Methods
All SNF-discharged primary TJA cases in 2017 at a multihospital academic health system were queried. Demographic, psychosocial, and clinical variables were manually extracted from the health record. Medicare NHC ratings were then collected for each SNF. For patients in the Medicare bundle, postacute and total bundle cost was extracted from claims.Results
Four hundred eighty-eight patients were discharged to a total of 105 unique SNFs. In multivariate analysis, overall NHC rating was not predictive of 90-day readmission/major complications, >75th percentile postacute cost, or 90-day bundle cost exceeding the target price. SNF health inspection and quality measure ratings were also not predictive of 90-day readmission/major complications or bundle performance. A higher SNF staffing rating was independently associated with a decreased odds for >75th percentile 90-day postacute spend (odds ratio, 0.58; P = .01) and a 90-day bundle cost exceeding the target price (odds ratio = 0.69; P = .02) but was similarly not predictive of 90-day readmission/complications.Conclusion
Results of our study suggest that Medicare's NHC tool is not a useful predictor of 90-day costs, complications, or readmissions for SNFs within our health system. 相似文献11.
Christopher J. Dy Derek S. Brown Hera Maryam Matthew R. Keller Margaret A. Olsen 《The Journal of arthroplasty》2019,34(4):619-625.e1
Background
Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid).Methods
Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois’ Medicaid expansion date: January 1, 2014).Results
The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012).Conclusion
Our study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures. 相似文献12.
Joshua R. Labott Cody C. Wyles Matthew T. Houdek Megha M. Tollefson David J. Driscoll William J. Shaughnessy Rafael J. Sierra 《The Journal of arthroplasty》2019,34(4):682-685
Background
Klippel-Trénaunay syndrome (KTS) is a severe vascular malformation that can lead to hypertrophic osteoarthritis. Total knee arthroplasty (TKA) performed in extremities affected with KTS is challenging given the high-risk vascular considerations and occasionally poor bone quality.Methods
We identified 12 patients with KTS who underwent TKA between 1998 and 2017. There were 7 men, mean age 42 years, and mean follow-up was 7 years. Before arthroplasty, 2 patients (17%) had preoperative sclerotherapy. Preoperative vascular studies were done for 9 patients (75%) and included magnetic resonance imaging (n = 7), magnetic resonance angiography (n = 1), and computed tomography angiography (n = 1). A preoperative blood conservation protocol was used for all operations and included the use of tranexamic acid (TXA) in later years. Posterior-stabilized TKA was used in 10 cases and cruciate-retaining TKA was used in 2 cases.Results
At final follow-up, 2 patients (17%) had undergone revision surgery: 1 for infection and 1 for tibial loosening with subsequent arthrofibrosis. Knee Society Scores (36-83, P < .0001) and functional scores (48-84, P = .0007) significantly increased between the preoperative and postoperative period. Likewise at last follow-up, the mean knee range of motion significantly increased (82°-104°, P = .04). Median blood loss for patients who received TXA was 200 mL compared to 275 mL in patients who did not receive TXA (P = .66). Likewise there was no difference (P = .5) in the proportion of patients who required a transfusion between those who received TXA (2/6, 33%) and those who did not (3/6, 50%).Conclusion
In this small series, TKA can lead to significant clinical improvement for patients with KTS. Modern blood management techniques and a careful multidisciplinary care approach render TKA a reasonable option for select patients with KTS.Level of Evidence
Level IV case series, therapeutic. 相似文献13.
Jessica L.H. Phillips Alexander J. Rondon Chris Vannello Yale A. Fillingham Matthew S. Austin P. Maxwell Courtney 《The Journal of arthroplasty》2019,34(5):819-823
Background
As alternative payment models increase in popularity for total joint arthroplasty (TJA), providers and hospitals now share the financial risk associated with unexpected readmissions. While studies have identified postacute care as a driver for costs in a bundle, the fiscal burden associated with specific causes of readmission is unclear. The purpose of this study is to quantify the additional costs associated with each of the causes of readmission following primary TJA.Methods
We reviewed a consecutive series of primary TJA patients at our institution from 2015 to 2016 using claims data from the Centers for Medicare and Medicaid Services and Medicare Advantage patients from a single private insurer. We collected demographic data, medical comorbidities, 90-day episode-of-care costs, and readmissions for all patients. Medical records for each readmission were reviewed and classified into 1 of 11 categories. We then compared the mean facility readmission costs, postacute care costs, and overall 90-day episode-of-care costs between the reasons for readmission.Results
Of the 4704 patients, there were 325 readmissions in 286 patients (6.1%), with 50% being readmitted to a different facility than their index surgery hospital. The mean additional cost was $8588 per readmission. Medical reasons accounted for the majority of readmissions (n = 257, 79.1%). However, patients readmitted for revision surgery (n = 68, 20.9%) had the highest mean readmission cost ($15,356, P < .001). Furthermore, readmissions for revision surgery had the highest mean postacute care ($37,207, P = .002) and overall episode-of-care costs ($52,162, P = .003). Risk factors for readmission included age >75 years (odds ratio [OR], 1.85; P < .001), body mass index >35 kg/m2 (OR, 1.63; P = .004), history of congestive heart failure (OR, 2.47; P = .002), diabetes mellitus (OR, 2.0; P < .001), and renal disease (OR, 2.28; P = .005).Conclusion
Providers participating in alternative payment models should be cognizant of the increased bundle costs attributed to readmissions, especially due to revision surgery. Improved communication with patients and close postoperative monitoring may help minimize the large percentage of readmissions at different facilities. 相似文献14.
Markus T. Berninger Sven Hungerer Jan Friederichs Fabian M. Stuby Christian Fulghum Rolf Schipp 《The Journal of arthroplasty》2019,34(5):920-925
Background
Developmental hip dysplasia is the most common cause of secondary hip osteoarthritis. Due to severe acetabular bone deficiency, cup positioning in total hip arthroplasty (THA) of dysplastic hips remains a surgical challenge. The aim was to analyze the functional outcome of far proximal cup positions in primary THA.Methods
Fifty patients (61 hips) with THA for severe dysplastic osteoarthritis and a far proximal cup position were included. Patients were divided according to the heights of the implanted cups with increasing vertical distance from the interteardrop line (group A: 55-65 mm, group B: 65-75 mm, group C: >75 mm). Functional outcome was assessed at latest follow-up (38 ± 16 months) by Lower Extremity Functional Score, Tegner Activity Score, and Harris Hip Score (HHS). Patients answered a Patient Satisfaction Questionnaire. Leg length discrepancy was estimated radiographically.Results
The Lower Extremity Functional Score significantly decreased in C (45.3 ± 25) compared to A (66.7 ± 15.3) and B (67.9 ± 9.9). The Tegner Activity Score significantly increased in all subgroups from preoperative to postoperative (2.2 ± 1.3 to 4.1 ± 1.4; P < .05). The mean overall HHS was 89.3 ± 14.7 (A: 89.5 ± 14.3, B: 94.3 ± 6.5, C: 78.3 ± 22.1). The HHS domains of activity of daily life and gait were significantly reduced in C (P < .05). Patients described a high satisfaction level with the surgery. No significant differences were found with regard to preoperative and postoperative leg lengthening (P = .881). Neither dislocations, impingement problems nor neurologic complications were observed.Conclusion
Primary THA without any concomitant surgical interventions with a far proximal cup position offers a safe and effective treatment option in severe dysplastic hip osteoarthritis. 相似文献15.
Artit Laoruengthana Piti Rattanaprichavej Supachok Rasamimongkol Monton Galassi Santi Weerakul Krit Pongpirul 《The Journal of arthroplasty》2019,34(5):877-881
Background
Tranexamic acid (TXA) has been widely used in total knee arthroplasty (TKA) for blood loss reduction. Given limited evidence on potential relationship between the TXA and improvement of pain control and functional outcome after TKA, this study aimed at comparing the blood loss, pain scores, morphine consumption, and knee flexion across the TXA administration routes.Methods
The 228 primary TKA were randomized into no TXA use (No-TXA), intra-articular TXA (15 mg/kg) use (IA-TXA), and intravenous TXA (10 mg/kg) use (IV-TXA). A multivariate regression analysis was used for comparing perioperative blood loss (PBL), drain output, average number of units of blood transfused (ANUBT), visual analogue scales (VAS) for pain, amount of morphine consumption, and knee flexion angle.Results
The IA-TXA and IV-TXA group had 193.26 (P < .01) and 160.30 mL (P < .01) less PBL than No-TXA, respectively. No-TXA significantly required higher ANUBT than IA-TXA and IV-TXA (P = .03). The IA-TXA group had lower VAS at 6 (P = .04), 12 (P = .03), and 24 hours (P = .02) postoperative when compared to No-TXA, while IV-TXA had no effect. The IA-TXA required 18.26 mg less total morphine at 48 hours than No-TXA (P = .02), whereas IV-TXA used insignificantly (5.31 mg; P = .31) less total morphine at 48 hours than No-TXA. Both TXA routes tended to improve knee flexion, but not statistically significant.Conclusion
Both IA-TXA and IV-TXA could significantly reduce PBL and ANUBT. The IA-TXA could significantly mitigate VAS and morphine use after TKA. Hence, IA-TXA could minimize blood loss and may be considered as an adjunct to pain control following TKA. 相似文献16.
Lewis Moss Ran Schwarzkopf Jonathan Vigdorchik Richard Iorio William J. Long 《The Journal of arthroplasty》2019,34(5):1003-1007.e3
Background
As the clinical and financial environments of total joint arthroplasty (TJA) have evolved over the last several decades so has the role of the surgeon in providing this care to patients. Our objective was to examine current practices and influential factors among fellowship-trained arthroplasty surgeons.Methods
An electronic survey was sent to all surgeons who had completed one of the three high-volume adult reconstruction fellowships from the years 2007-2016. The survey consisted of 34 questions regarding current practice characteristics, case volumes for primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA), use of advanced technologies, choice of surgical approach and implant design, factors influencing their choices, and their involvement in implant selection and contract negotiations.Results
Questionnaires were sent to 53 surgeons; 52 were completed. Sixty percent of respondents performed at least 100 TKAs and 84% performed at least 50 THAs annually. Ninety-four percent use a single company’s implant for more than 90% of primary TKA and THA. Fellowship or residency experience was the most significant influence on TKA and THA implant selection for 62% and 45% of surgeons, respectively, while contracts of their current institution were the primary influence for 17% and 12%, respectively. Fifty-five percent of surgeons used some advanced technology of which 16% said this influenced their implant choice. Eighty-six percent perform the majority of cases at centers performing at least 200 TJAs per year, and 39% participate in implant contract negotiations.Conclusion
Despite changes in the economic environment of TJA, this study demonstrates that experience with a specific implant during training, particularly fellowship, is the most influential factor for implant selection among fellowship-trained arthroplasty surgeons. 相似文献17.
Peter B. White Mrinal Sharma Ahmed Siddiqi James R. Satalich Amar S. Ranawat Chitranjan S. Ranawat 《The Journal of arthroplasty》2019,34(5):887-892
Background
Anterior knee pain (AKP) remains a complex issue affecting patient satisfaction after total knee arthroplasty. Several radiographic parameters have been shown to be causative factors with various designs. The aim of this study is to evaluate the known radiographic parameters of AKP and clinical outcomes (ie, AKP) in the setting of a modern prosthesis with an anatomic patella button.Methods
Between July 2012 and December 2013, 90 total knee arthroplasties received 3 skyline views taken at 30°, 45°, and 60°. A patient-administered questionnaire was administered at 2-year follow-up to assess the incidence of AKP, painless noise, and satisfaction. Radiographs were analyzed for patellofemoral overstuffing, patellar tilt, and patellar displacement, and evaluated the patella resection angle.Results
On the patient-administered questionnaire, 10 (11.1%) patients reported AKP of a mild-to-moderate nature. Thirty-one had the best view at 30 Merchant views, 24 had best views at 45, and 35 had best views at 60. We found that patellar resection angle correlated with AKP (odds ratio 1.21, P = .044) and painless noise (odds ratio 1.22, P = .034). Patellar displacement and patellofemoral stuffing did not correlate with AKP or painless noise. No radiographic measurements correlated with changes in Knee Society Score pain or function scores or range of motion.Conclusion
We found that a patellar resection angle correlated with the incidence of AKP and painless noise at 2-year follow-up. We failed to find any correlation with patellofemoral overstuffing, patellar displacement, or patellar tilt with clinical outcomes. We recommend the use of 3 Merchant views to fully evaluate the patellofemoral joint. 相似文献18.
Amir Khoshbin Alexandra Stavrakis Achal Sharma Pauline Woo Amit Atrey Yuo-Yu Lily Lee Amethia Joseph Douglas E. Padgett 《The Journal of arthroplasty》2019,34(5):872-876.e1
Background
The objective of the study was to compare the patient-reported outcome measures (PROM) of patients with post-traumatic arthritis (PTA) versus patients with osteoarthritis (OA) undergoing total knee arthroplasty (TKA) and compare the rates of revision among these two groups.Methods
Using a prospectively held institutional registry, we retrospectively reviewed patients ≥60 years of age who underwent unilateral TKA between May 2007 and February 2012. Patients with previous or concomitant diagnosis of inflammatory arthropathy or an initial open fracture were excluded. PTA patients were matched 1:5 with OA patients undergoing TKA. Validated PROMs were recorded at baseline before index TKA and the last follow-up. Reason and time to revision surgery was reported, and survivorship was compared using Kaplan-Meier curves.Results
Seventy-five PTA patients were matched to 375 OA patients. There was no difference between these groups with respect to age (67.7 ± 5.6 vs 67.8 ± 5.5 years; P = .876), body mass index (28.6 ± 5.4 vs 28.7 ± 5.3 kg/m2; P = .948), sex (65.3% vs 65.3% females; P = .999), Charlson Comorbidity Index (21.3% vs 21.3% Index 1-2, P = .999), and time to follow-up (93.0 ± 13.4 vs 88.2 ± 13.7 months; P = .999). No statistically significant difference was found in PROMs at baseline and the last follow-up (P > .05), the rate or time to revision surgery between the two groups (P-value = .635; log-rank test).Conclusion
Unlike previous studies, TKA for PTA does not pose lower PROMs or higher revision rates when compared to TKA for OA. These results could help provide surgeons with a frame of reference in terms of expectations for patients with PTA undergoing TKA. 相似文献19.
Frank-Christiaan B.M. Wagenaar Claudia A.M. Löwik Akos Zahar Paul C. Jutte Thorsten Gehrke Javad Parvizi 《The Journal of arthroplasty》2019,34(1):175-182
Background
Persistent wound drainage after total joint arthroplasty (TJA) is an important complication with potential substantial adverse consequences, in particular periprosthetic joint infection.Methods
This review evaluated the available literature regarding several issues in the field of persistent wound drainage after TJA and offers a classification of persistent wound drainage and an algorithmic approach to the decision-making process.Results
Available literature addressing the diagnosis and treatment of persistent wound drainage after TJA is scarce and an evidence-based clinical guideline is lacking. This is partially caused by the absence of a universally accepted definition of persistent wound drainage. In patients with persistent wound drainage, clinical signs and serological tests can be helpful in the diagnosis of a developing infection. Regarding the treatment of persistent wound drainage, nonsurgical treatment consists of absorbent dressings, pressure bandages, and temporary joint immobilization. Surgical treatment is advised when wound drainage persists for more than 5-7 days and consists of open debridement with irrigation and exchange of modular components and antimicrobial treatment.Conclusion
Based on this literature review, we proposed a classification and algorithmic approach for the management of patients with persistent wound drainage after TJA. Hopefully, this offers the orthopedic surgeon a practical clinical guideline by finding the right balance between overtreatment and undertreatment, weighing the risks and benefits. However, this classification and algorithmic approach should first be evaluated in a prospective trial. 相似文献20.
Timothy L. Tan Paul Maxwell Courtney Scot A. Brown Noam Shohat Keenan Sobol Karl E. Swanson John Abraham 《The Journal of arthroplasty》2019,34(4):626-631.e1