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1.
Brett T. Venker Beejal R. Ganti Hannah Lin Elizabeth D. Lee Ryan M. Nunley Brian F. Gage 《The Journal of arthroplasty》2017,32(2):645-652
Background
Venous thromboembolism (VTE) is a common and potentially fatal complication of arthroplasty.Methods
We reviewed randomized trials to determine which anticoagulant has the best safety and efficacy in hip and knee arthroplasty patients. We searched PubMed, MEDLINE, and EMBASE through January 2016.Results
Compared to enoxaparin (most commonly dosed 40 mg once daily), the relative risk (RR) of VTE was lowest for edoxaban 30 mg once daily (0.49; 95% confidence interval [CI], 0.32-0.75), fondaparinux 2.5 mg once daily (0.53; 95% CI, 0.45-0.63), and rivaroxaban 10 mg once daily (0.55; 95% CI, 0.46-0.66), and highest for dabigatran 150 mg once daily (1.19; 95% CI; 0.98-1.44). The RR of major/clinically relevant bleeding was lowest for apixaban 2.5 mg twice daily (0.84; 95% CI; 0.70-0.99) and highest for rivaroxaban (1.27; 95% CI, 1.01-1.59) and fondaparinux (1.64; 95% CI, 0.24-11.35). Fondaparinux was the only agent that was more effective than enoxaparin 30 mg twice daily (VTE RR = 0.58; 95% CI, 0.43-0.76).Conclusion
With the possible exception of apixaban, newer anticoagulants that lower the risk of postoperative VTE increase bleeding. 相似文献2.
Guy Cafri Elizabeth W. Paxton Yuexin Chen Craig T. Cheetham Michael K. Gould Janet Sluggett Stefano A. Bini Monti Khatod 《The Journal of arthroplasty》2017,32(11):3524-3528.e1
Background
Rates of venous thromboembolism in contemporary studies of primary total knee arthroplasty (TKA) have been reported to be as high as 3.5%. Although drug prophylaxis is effective, the best option among these regimens is not well established. The purpose of this study was to evaluate the comparative effectiveness and safety of aspirin, low-molecular-weight heparin, synthetic pentasaccharide factor Xa inhibitors, and vitamin K antagonist.Methods
Data were from a US total joint replacement registry, with 30,499 patients receiving unilateral TKA from May 16, 2006, to December 31, 2013. Patients received either aspirin (324-325 mg daily), enoxaparin (40-60 mg daily), fondaparinux (2.5 mg daily), or warfarin (all doses) and were followed up 90 days postoperatively on several outcomes: deep vein thrombosis, pulmonary embolism, major bleeding, wound complications, infection, and death.Results
There was no evidence that fondaparinux, enoxaparin, or warfarin were superior to aspirin in the prevention of pulmonary embolism, deep vein thrombosis, or venous thromboembolism or that aspirin was safer than these alternatives. However, enoxaparin was found to be as safe as aspirin with respect to bleeding, and fondaparinux was as safe as aspirin for risk of wound complications.Conclusion
Among TKA patients, we did not find evidence for decreased effectiveness or increased safety with use of aspirin, but enoxaparin had comparable safety to aspirin for bleeding and fondaparinux had comparable safety to aspirin for wound complications. 相似文献3.
Matthew J. Brown John R. Matthews Mary T. Bayers-Thering Matthew J. Phillips Kenneth A. Krackow 《The Journal of arthroplasty》2017,32(7):2120-2126
Background
A number of postoperative complications of navigated total knee arthroplasty (TKA) have been discussed in the literature, including tracker pin site infection and fracture. In this article, we discuss the low postoperative complication rate in a series of 3100 navigated TKAs and the overall complication rate in a systematic analysis of the literature.Methods
Three thousand one hundred consecutive patients with navigated TKAs from 2001-2016 were retrospectively evaluated for complications specific to navigation. We discuss the 2 cases of postoperative fracture through tracker pin sites that we experienced and compare this systematically with the literature.Results
Postoperatively, our 3100 patient cohort experienced a total of 2 fractures through pin sites for an incidence of 0.065%. One was a distal femoral fracture which was treated surgically, and the other was a proximal tibial fracture treated nonoperatively. Because of our incorporation of the tracker sites within our operative incision, there were no identifiable pin site infections, which others have noted at an incidence of 0.47%. Our 0.065% fracture rate compares favorably with the 0.16% rate of fracture published in the literature.Conclusion
There is an extremely low risk of perioperative complications because of the instrumentation used in navigated TKA when using the Stryker Navigation System and 4.0 mm anchoring pins placed within the surgical incision. 相似文献4.
Background
Since the initial design of surgical theatres, the thermal environment of the operating suite itself has been an area of concern and robust discussion. In the 1950s, correspondence in the British Medical Journal discussed the most suitable design for a surgeon's cap to prevent sweat from dripping onto the surgical field. These deliberations stimulated questions about the effects of sweat-provoking environments on the efficiency of the surgical team, not to mention the effects on the patient. Although these benefits translate to implant-based orthopedic surgery, they remain poorly understood and, at times, ignored.Methods
A review and synthesis of the body of literature on the topic of maintenance of normothermia was performed.Results
Maintenance of normothermia in orthopedic surgery has been proven to have broad implications from bench top to bedside. Normothermia has been shown to impact everything from nitrogen loss and catabolism after hip fracture surgery to infection rates after elective arthroplasty.Conclusion
Given both the physiologic impact this has on patients, as well as a change in the medicolegal environment around this topic, a general understanding of these concepts should be invaluable to all surgeons. 相似文献5.
Background
The global rise in infectious disease has led the Center for Disease Control and Prevention and the World Health Organization to release new guidelines for the prevention of surgical site infection.Methods
In this article, we summarize current recommendations based on level of evidence, review unresolved and unaddressed issues, and supplement them with new literature.Results
Although the guidelines discuss major issues in reducing surgical site infection, many questions remain unanswered.Conclusion
These guidelines will hopefully help in setting a standard of care based on best evidence available and focus investigators on areas where evidence is lacking. 相似文献6.
David Gomez Helen Razmjou Andrea Donovan Vikas B. Bansal Jeffrey D. Gollish John J. Murnaghan 《The Journal of arthroplasty》2017,32(3):958-964
Background
Multiple randomized controlled trials have documented the effectiveness of rivaroxaban in the prevention of venous thromboembolism up to 1-month following total joint arthroplasty. However, the effectiveness and safety of rivaroxaban in the real-world setting, outside of the strict protocols used by randomized clinical trials, are unknown.Methods
This was a prospective, observational, noninterventional, phase IV study of 3914 consecutive patients who underwent total joint arthroplasty from June 2010 to December 2012. Patients were treated with rivaroxaban 10 mg by mouth daily starting postoperative day 1 and continued for 15 days. Participants were followed up in clinic at 6 weeks and contacted by telephone at 12 weeks. The primary outcome of interest was symptomatic venous thromboembolism; secondary outcomes included bleeding events, transfusion requirements, and death.Results
The incidence of symptomatic deep venous thrombosis at 3 months was 0.5% (n = 18). Only 1 deep venous thrombosis event occurred within 7 days of surgery. The incidence of symptomatic pulmonary embolism (PE) at 3 months was 0.7% (n = 28). Thirteen PEs (46%) occurred within 7 days of surgery. The rate of major bleeding while on prophylaxis was 0.1%. Only 5% of patients received a blood transfusion. No deaths were attributed to thromboembolic events.Conclusion
This prospective, observational, phase IV study demonstrates that rivaroxaban appears to protect patients against symptomatic PE and is not associated with major bleeding events when used in a real-world setting as described. 相似文献7.
Tarang Tandon Baha J. Tadros Harold Akehurst Adhish Avasthi Richard Hill Madhu Rao 《The Journal of arthroplasty》2017,32(12):3711-3717
Background
Methicillin-resistant Staphylococcus aureus (MRSA) is globally endemic and is a leading cause of surgical site infection (SSI). The purpose of this study was to evaluate the incidence of SSI in MRSA carriers undergoing elective hip or knee arthroplasty, who had confirmed eradication and to compare it with incidence of SSI in non-MRSA carriers.Methods
This is a retrospective analysis of 6613 patients who underwent elective total hip arthroplasty (THA; n = 3347) and total knee arthroplasty (TKA; n = 3266) at our institution. A cohort of patients who were preoperatively colonized with MRSA was identified. We compared the infection rates with non-MRSA carriers.Results
We had a colonization rate of 1.3% (83 patients). A total of 79 patients had confirmed eradication of carrier status before surgical intervention. Of these, 38 were THAs and 41 were TKAs. Five of 79 patients (6.32%; 95% confidence interval [CI]: 2.35%-14.79%) had “deep SSI” within 1 year of surgery. There were 2 MRSA infections in THAs (relative risk 4.46; 95% CI: 1.12-17.82). There were 2 MRSA and 1 methicillin-sensitive Staphylococcus aureus infections in TKAs (relative risk 5.61; 95% CI: 1.81-17.38). A significant statistical difference in infection rates from MRSA negative control group was noted, which had a deep sepsis rate of 1.17% in THAs and 1.3% in TKAs over the same period.Conclusion
In spite of a selective treatment program for carriers and confirmed eradication, there is still a significantly increased risk of SSI in MRSA-colonized patients undergoing hip or knee arthroplasties. 相似文献8.
Background
The increasing cost of our country's healthcare is not sustainable. To address this crisis, the federal government is transiting healthcare reimbursement from the traditional volume-based system to a value-based system. As such, increasing healthcare value has become an essential point of discussion for all healthcare stakeholders.Methods
The purpose of this study is to discuss the importance of healthcare value as a means to achieve this goal of value-based medicine and 3 methods to create value in total joint arthroplasty.Results
These methods are to: (1) improve outcomes greater than the increased costs to achieve this improvement, (2) decrease costs without affecting outcomes, and (3) decrease costs while simultaneously improving outcomes.Conclusion
Following these guidelines will help practitioners thrive in a bundled care environment. 相似文献9.
Jun-Wen Wang Bradley Chen Po-Chun Lin Shih-Hsiang Yen Chung-Cheng Huang Feng-Chih Kuo 《The Journal of arthroplasty》2017,32(3):801-806
Background
Tranexamic acid (TXA) was reportedly to decrease postoperative blood loss after standard total knee arthroplasty (TKA). However, the blood-conservation effect of TXA in minimally invasive TKA, in particular, receiving a direct oral anticoagulant was unclear. The aim of the study was to investigate the efficacy of combined use of TXA and rivaroxaban on postoperative blood loss in primary minimally invasive TKA.Methods
In a prospective, randomized, controlled trial, 198 patients were assigned to placebo (98 patients, normal saline injection) and study group (100 patients, 1g TXA intraoperative injection) during primary unilateral minimally invasive TKA. All patients received rivaroxaban 10 mg each day for 14 doses postoperatively. Total blood loss was calculated from the maximum hemoglobin drop after surgery plus amount of transfusion. The transfusion rate and wound complications were recorded in all patients. Deep-vein thrombosis was detected by ascending venography of the leg 15 days postoperatively.Results
The mean total blood loss was lower in the study group (1020 mL [95% confidence interval, 960-1080 mL]) compared with placebo (1202 mL [95% confidence interval, 1137-1268 mL]) (P < .001). The transfusion rate was lower in the study group compared with placebo (1% vs 8.2%, P = .018). Postoperative wound hematoma and ecchymosis were higher in placebo than the study group (P = .003). There was no symptomatic deep-vein thrombosis or pulmonary embolism in either group.Conclusion
Systemic administration of TXA can effectively reduce the postoperative blood loss which results in lower rate of transfusion requirement and wound hematoma in minimally invasive TKA patients when rivaroxaban is used for thromboprophylaxis. Rivaroxaban has a high rate of bleeding complications when used alone in TKA patients. 相似文献10.
Jonathan Robinson John I. Shin James E. Dowdell Calin S. Moucha Darwin D. Chen 《The Journal of arthroplasty》2017,32(8):2370-2374
Background
Impact of gender on 30-day complications has been investigated in other surgical procedures but has not yet been studied in total hip arthroplasty (THA) or total knee arthroplasty (TKA).Methods
Patients who received THA or TKA from 2012 to 2014 were identified in the National Surgical Quality Improvement Program database. Patients were divided into 2 groups based on gender. Bivariate and multivariate analyses were performed to assess associations between gender and patient factors and complications after THA or TKA and to assess whether gender was an independent risk factor.Results
THA patients consisted of 45.1% male and 54.9% female. In a multivariate analysis, female gender was found to be a protective factor for mortality, sepsis, cardiovascular complications, unplanned reintubation, and renal complications and as an independent risk factor for urinary tract infection, blood transfusion, and nonhome discharge after THA. TKA patients consisted of 36.7% male and 62.3% female. Multivariate analysis revealed female gender as a protective factor for sepsis, cardiovascular complications, and renal complications and as an independent risk factor for urinary tract infection, blood transfusion, and nonhome discharge after TKA.Conclusion
There are discrepancies in the THA or TKA complications based on gender, and the multivariate analyses confirmed gender as an independent risk factor for certain complications. Physicians should be mindful of patient's gender for better risk stratification and informed consent. 相似文献11.
Alisina Shahi Timothy L. Tan Antonia F. Chen Mitchell G. Maltenfort Javad Parvizi 《The Journal of arthroplasty》2017,32(3):948-952.e1
Background
While periprosthetic joint infection (PJI) has a huge impact on patient function and health, only a few studies have investigated its impact on mortality. The purpose of this large-scale study was to (1) determine the rate and trends of in-hospital mortality for PJI and (2) compare the in-hospital mortality rate of patients with PJI and those undergoing revision arthroplasty for aseptic failure and patients undergoing other nonorthopedic major surgical procedures.Methods
Data from the Nationwide Inpatient Sample from 2002 to 2010 were analyzed to determine the risk of in-hospital mortality for PJI patients compared with aseptic revision arthroplasty. The Elixhauser comorbidity index was used to obtain patient comorbidities. Multiple logistic regression analyses were used to examine whether PJI and other patient-related factors were associated with mortality.Results
PJI was associated with an increased risk (odds ratio, 2.05; P < .0001) of in-hospital mortality (0.77%) compared with aseptic revisions (0.38%). The in-hospital mortality rate of revision total hip arthroplasties with PJI was higher than those for interventional coronary procedures (1.22%; 95% confidence interval [CI], 1.20-1.24), cholecystectomy (1.13%; 95% CI, 1.11-1.15), kidney transplant (0.70%; 95% CI, 0.61-0.79), and carotid surgery (0.89%; 95% CI, 0.86-0.93).Conclusion
Patients undergoing treatment for PJI have a 2-fold increase in in-hospital mortality for each surgical admission compared to aseptic revisions. Considering that PJI cases often have multiple admissions and that this analysis is by surgical admission, the risk of mortality will accumulate for every additional surgery. Surgeons should be cognizant of the potentially fatal outcome of PJI and the importance of infection control to reduce the risk of mortality. 相似文献12.
13.
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14.
Background
The Bundled Payments for Care Improvement (BPCI) initiative and the Arkansas Payment Improvement (API) initiative seek to incentivize reduced costs and improved outcomes compared with the previous fee-for-service model. Before participation, our practice initiated a standardized clinical pathway (CP) to reduce length of stay (LOS), readmissions, and discharge to postacute care facilities.Methods
This practice implemented a standardized CP focused on patient education, managing patient expectations, and maximizing cost outcomes. We retrospectively reviewed all primary total joint arthroplasty patients during the initial 2-year “at risk” period for both BPCI and API and determined discharge disposition, LOS, and readmission rate.Results
During the “at risk” period, the average LOS decreased in our total joint arthroplasty patients and our patients discharged home >94%. Patients within the BPCI group had a decreased discharge to home and decreased readmission rates after total hip arthroplasty, but also tended to be older than both API and nonbundled payment patients.Conclusion
While participating in the BPCI and API, continued use of a standardized CP in a high-performing, high-volume total joint practice resulted in maintenance of a low-average LOS. In addition, BPCI patients had similar outcomes after total knee arthroplasty, but had decreased rates of discharge to home and readmission after total hip arthroplasty. 相似文献15.
Rajitha Gunaratne Dylan N. Pratt Joseph Banda Daniel P. Fick Riaz J.K. Khan Brett W. Robertson 《The Journal of arthroplasty》2017,32(12):3854-3860
Background
Dissatisfaction following total knee arthroplasty (TKA) is common. Approximately 20% of patients report dissatisfaction following primary TKA. This systematic literature review explores key factors affecting patient dissatisfaction following TKA.Methods
Six literature databases published between 2005 and 1 January 2016 were searched using 3 key search phrases. Papers were included if the study investigated patient dissatisfaction in primary unilateral or bilateral TKA. Information from each article was categorized to the domains of socioeconomic, preoperative, intraoperative, and postoperative factors affecting patient dissatisfaction.Results
This review found that patient dissatisfaction pertains to several key factors. Patient expectations prior to surgery, the degree of improvement in knee function, and pain relief following surgery were commonly cited in the literature. Fewer associations were found in the socioeconomic and surgical domains.Conclusion
Identifying who may be dissatisfied after their TKA is mystifying; however, we note several strategies that target factors whereby an association exists. Further research is needed to better quantify dissatisfaction, so that the causal links underpinning dissatisfaction can be more fully appreciated and strategies employed to target them. 相似文献16.
Richard J. Hanly Salman K. Marvi Sarah L. Whitehouse Ross W. Crawford 《The Journal of arthroplasty》2017,32(9):2712-2716
Background
It is increasingly apparent that the effect of obesity in arthroplasty is joint-specific. This study evaluates the effects of morbid obesity on primary total knee arthroplasty by comparing short-term outcomes between a morbidly obese (body mass index ≥40 kg/m2) and a normal weight (body mass index 18.5-<25 kg/m2) cohort at our institution between January 2003 and December 2010.Methods
One hundred seventeen morbidly obese patients were compared with 94 normal weight patients. Operative time, length of stay, complications, 30-day readmission, and readmission length were compared.Results
Morbid obesity conveyed no significant increase in 30-day readmission. Operative time was increased at 100 minutes in the morbidly obese group, compared with 90.5 minutes (P = .026).Conclusion
Morbid obesity conveyed no increased risk of length of stay or readmission in this cohort. 相似文献17.
Jeong Lae Kim Jong-Hoon Park Seung-Beom Han Il Youp Cho Ki-Mo Jang 《The Journal of arthroplasty》2017,32(1):320-325
Background
Blood loss occurs significantly more frequently during total hip and knee arthroplasty than among any other type of orthopedic operation, which can sometimes lead to requiring a blood transfusion. Although allogeneic blood transfusion has been identified as a risk factor for postoperative surgical-site infection following arthroplasty, results are inconclusive. The purpose of this study was to conduct a systematic meta-analysis to investigate whether having an allogeneic blood transfusion significantly increases the risk for surgical-site infection, particularly after total hip and knee arthroplasty.Methods
We performed a systematic review and meta-analysis using random-effect models. Using an electronic database search, we selected 6 studies that included data on 21,770 patients and among these studies compared the postoperative infection rate between an allogeneic blood-transfusion exposure group and a nonexposure group. We calculated the pooled odds ratios and 95% confidence intervals for the groups.Results
The prevalences of surgical-site infections in our pooled analyses were 2.88% and 1.74% for the transfusion and nontransfusion groups, respectively. The allogeneic blood transfusion group had a significantly higher frequency of surgical-site infections based on pooled analysis using a random-effect model (pooled odds ratio = 1.71, 95% confidence interval: 1.23-2.40, P = .002).Conclusion
Allogeneic blood transfusion is a significant risk factor for increasing the surgical-site infection rate after total hip and knee arthroplasty. 相似文献18.
William K. Oelsner Stephen M. Engstrom Michael A. Benvenuti Thomas J. An Richard A. Jacobson Gregory G. Polkowski Jonathan G. Schoenecker 《The Journal of arthroplasty》2017,32(1):309-314
Background
During surgery, trauma to musculoskeletal tissue induces a systemic reaction known as the acute phase response (APR). When excessive or prolonged, the APR has been implicated as an underlying cause of surgical complications. The purpose of this study was to determine the typical APR following total joint arthroplasty in a healthy population defined by the Charlson Comorbidity Index (CCI).Methods
This retrospective study identified 180 healthy patients (CCI < 2) who underwent total joint arthroplasty by a single surgeon for primary osteoarthritis from 2013 to 2015. Serial measurements of C-reactive protein (CRP) and fibrinogen were obtained preoperative, perioperative, and at 2 and 6 weeks postoperative.Results
Postoperative CRP peaked during the inpatient period and returned to baseline by 2 weeks. Fibrinogen peaked after CRP and returned to baseline by 6 weeks. Elevated preoperative CRP correlated with a more robust postoperative APR for both total hip arthroplasty and total knee arthroplasty, suggesting that a patient's preoperative inflammatory state correlates with the magnitude of the postoperative APR.Conclusion
Measurement of preoperative acute phase reactants may provide an objective means to predict a patient's risk of postoperative dysregulation of the APR and complications. 相似文献19.
Background
Potential advantages combined with lower cost have prompted a renewed interest in modern all-polyethylene tibial designs.Methods
A total of 317 Natural Knee total knee arthroplasties with an all-polyethylene tibial component that was performed since 1993 were retrospectively reviewed to confirm that cost savings were not associated with inferior clinical results. They were primarily used in elderly, low-demand patients. The average age at the time of surgery was 80.8 years.Results
227 knees with a minimum of 2-year follow-up were identified. The average follow-up was 5.6 years (range, 2-20 years). Clinical and radiographic outcomes were evaluated. At the latest follow-up, the average Knee Society and functional score was 94.2 and 57.2. The average postoperative range of motion was 1.6°-115.4°. No patient required a revision for aseptic or septic loosening, wear, or instability. Only 5 knees had a partial nonprogressive cement/bone radiolucency. There was an approximate 33% cost savings for the implants when the all-polyethylene component was used.Conclusion
An all-polyethylene tibial component of this design provides excellent results in the elderly population along with a significant cost savings. 相似文献20.
Hongyi Shao Chi-Lung Chen Mitchell G. Maltenfort Camilo Restrepo Richard H. Rothman Antonia F. Chen 《The Journal of arthroplasty》2017,32(2):689-695