10-Year Cumulative Incidence and Indications for Revision Total Knee Arthroplasty Among Patients Who Have Sickle Cell Disease

BackgroundLiterature regarding total knee arthroplasty (TKA) outcomes in sickle cell disease (SCD) is limited. Moreover, 10-year survivorship of SCD implants is unknown. This study aimed to observe 10-year cumulative incidence and indications for revision TKA in patients who did and did not have SCD.MethodsPatients who underwent primary TKA were identified using a large national database. The SCD patients were matched by age, sex, and a comorbidity index to a control cohort in a 1:4 ratio. The 10-year cumulative incidence rates were determined using Kaplan–Meier survival analyses. Multivariable analyses were conducted using Cox proportional hazard modeling. Chi-squared analyses were conducted to compare indications for revision between cohorts. In total, 1,010 SCD patients were identified, 100,000 patients included in the unmatched control, and 4,020 patients included in the matched control.ResultsCompared to the unmatched control cohort, SCD patients exhibited higher 10-year all-cause revision (HR: 1.86; P < .001) with higher proportions of revisions for periprosthetic joint infection (PJI) (P < .001), aseptic loosening (P < .001), and hematoma (P < .001). Compared to the matched control, SCD patients had higher 10-year all-cause revision (Hazard Ratio (HR): 1.39; P = .034) with a higher proportion of revisions for PJI (P = .044), aseptic loosening (P = .003), and hematoma (P = .019).ConclusionIndependent of other comorbidities, SCD patients are more likely to undergo revisions for PJI, aseptic loosening, and hematoma compared to patients who do not have SCD. Due to the high-risk of these complications, perioperative and postoperative surgical optimization should be enforced in SCD patients.     

Mortality Following Revision Total Knee Arthroplasty: A Matched Cohort Study of Septic versus Aseptic Revisions

We report the medium-term mortality after septic versus aseptic revision total knee arthroplasty (TKA) and factors that can contribute to mortality in revision TKA. Mortality rates of 88 patients undergoing septic revision (septic group) were compared with age- and year of surgery-matched 88 patients of aseptic revision (aseptic group). The overall mortality after revision TKA was 10.7% at a median of 4 years of follow-up (range, 2–7 years). However, the mortality after septic revision (18%, 16/88) was six times higher than that of aseptic revision (3%, 3/88) (P = 0.003). Infections with Staphylococcus aureus and/or methicillin resistance was not associated with higher mortality rates. Multivariate analysis indicated that increased age (P < 0.001), higher ASA class (P = 0.002), and septic revision (P < 0.001) were identified as independent predictors of increased mortality after revision TKA.     

Single-Stage Revision of the Infected Total Knee Arthroplasty Is Associated With Improved Functional Outcomes: A Propensity Score–Matched Cohort Study

BackgroundSingle-stage revision is an alternative to the standard 2-stage revision, potentially minimizing morbidities and improving functional outcomes. This study aimed at comparing single-stage and 2-stage revision total knee arthroplasty (TKA) for chronic periprosthetic joint infection (PJI) with regard to patient-reported outcome measures (PROMs) and complication rates.Methods:A total of 185 consecutive revision TKA patients for chronic PJI with complete preoperative and postoperative PROMs were investigated. A total of 44 patients with single-stage revision TKA were matched to 88 patients following 2-stage revision TKA using propensity score matching, yielding a total of 132 propensity score–matched patients for analysis. Patient demographics and clinical information including reinfection and readmission rates were evaluated.Results:There was no significant difference in preoperative PROMs between propensity score–matched single-stage and 2-stage revision TKA cohorts. Postoperatively, significantly higher PROMs for single-stage revision TKA were observed for Knee disability and Osteoarthritis Outcome Score physical function (62.2 vs 51.9, P < .01), physical function short form 10A (42.8 vs 38.1, P < .01), PROMIS SF Physical (44.8 vs 41.0, P = .01), and PROMIS SF Mental (50.5 vs 47.1, P = .02). There was no difference between propensity score–matched single-stage and 2-stage revision TKA cohorts for clinical outcomes including reinfection rates (25.0% vs 27.2%, P = .78) and 90-day readmission rates (22.7% vs 25.0%, P = .77).ConclusionThis study illustrated that single-stage revision TKA for chronic PJI may be associated with superior patient-reported outcomes compared to 2-stage revision for the infected TKA using a variety of PROMs. Improved PROMs were not accompanied by differences in complication rates between both cohorts, suggesting that single-stage revision TKA may provide an effective alternative to 2-stage revision in patients with chronic TKA PJI.     

Weight Gain After Primary Total Knee Arthroplasty Is Associated With Accelerated Time to Revision for Aseptic Loosening

BackgroundObesity is a major health problem worldwide and is associated with complications after total knee arthroplasty (TKA). It remains unknown whether a change in body mass index (BMI) after primary TKA affects the reasons for revision TKA or the time to revision TKA.MethodsA total of 160 primary TKAs referred to an academic tertiary center for revision TKA were retrospectively stratified according to change in BMI from the time of their primary TKA to revision TKA. The association between change in BMI and time to revision was also analyzed according to indication for revision of TKA using Pearson's chi-square test.ResultsThe mean change in BMI from primary to revision TKA was 0.82 ± 3.5 kg/m². Maintaining a stable weight after primary TKA was protective against late revision TKA for any reason (P = .004). Patients who failed to reduce their BMI were revised for aseptic loosening earlier, at less than 5 years (P = .020), whereas those who reduced their BMI were revised later, at over 10 years (P = .004).ConclusionMaintaining weight after primary TKA is protective against later revision TKA for any reason but failure to reduce weight after primary TKA is a risk factor for early revision TKA for aseptic loosening and osteolysis. Orthopedic surgeons should recommend against weight gain after primary TKA to reduce the risk of an earlier revision TKA in the event that a revision TKA is indicated.     

The Effect of Polyethylene Liner Thickness on Patient Outcomes and Failure After Primary Total Knee Arthroplasty

BackgroundThe effect of using thicker liners in primary total knee arthroplasty (TKA) on functional outcomes and aseptic failure rates remains largely unknown. As such, we devised a multicenter study to assess both the clinical outcomes and survivorship of thick vs thin liners after primary TKA.MethodsA search of our institutional databases was performed for patients having undergone bilateral (simultaneous or staged) primary TKA with similar preoperative and surgical characteristics between both sides. Two cohorts were created: thick liners and thin liners. Outcomes collected were as follows: change in Knee Society Score (ΔKSS), change in range of motion, and aseptic revision. Ad hoc power analysis was performed for ΔKSS (⍺ = 0.05; power = 80%). Differences between cohorts were assessed.ResultsAbout 195 TKAs were identified for each cohort. ΔKSS and change in range of motion in the thin vs thick cohorts were similar: 51.4 vs 51.6 (P = .86) and 11.1° vs 10.0° (P = .66), respectively. No difference in aseptic revision rates were observed between thin and thick cohorts: all cause (4.1%, 3.1%; P = .59), aseptic loosening (0.5%, 0.5%; P = 1.0), instability (0.5%, 0.5%; P = 1.0), all-cause revision for stiffness (3.1%, 2.1%; P = .52), manipulation under anesthesia (2.1%, 2.1%; P = 1.0), and liner exchange (0.5%, 0%; P = .32).ConclusionThe results of this study suggest that both rates of revision surgery and clinical outcomes are similar for TKAs performed with thick and thin liners. Preoperative factors are likely to play an important role in liner thickness selection, and emphasis should be placed on ensuring sound surgical technique.     

Prior Knee Arthroscopy Is Associated With Increased Risk of Revision After Total Knee Arthroplasty

BackgroundKnee arthroscopy (KA) is frequently performed to provide improved joint function and pain relief. However, outcomes following total knee arthroplasty (TKA) after prior KA are not fully understood. The purpose of this study is to determine the relationship between prior KA within 2 years of TKA on revision rates after TKA.MethodsData were collected from the Humana insurance database using the PearlDiver Patient Records Database from 2006 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes to identify primary TKA. Patients were stratified into 2 groups based upon a history of prior KA. Univariate and multivariate analyses were conducted to determine association between KA and outcomes at 2-year postoperative period.ResultsIn total, 138,019 patients were included in this study, with 3357 (2.4%) patients receiving a KA before TKA and 134,662 (97.6%) patients who did not. The most common reason for KA was osteoarthritis (40.0%), followed by medial tear of the meniscus (26.0%) and chondromalacia (21%.0). After adjustment, prior KA was associated with increased revision rate (odds ratio [OR], 1.392; P = .003), postoperative stiffness (OR, 1.251; P = .012), periprosthetic joint infection (OR, 1.326; P < .001), and aseptic loosening (OR, 1.401; P = .048).ConclusionPrior KA is significantly associated with increased 2-year TKA revision rate. The most common etiology for arthroscopy was osteoarthritis. The results of the study, showing that arthroscopy before TKA substantially increases the rates of revision, PJI, aseptic loosening, and stiffness, lend further credence to the idea that patients may be better served by nonsurgical management of their degenerative pathology until they become candidates for TKA. Subjecting this population to arthroscopy appears to offer limited benefit at the cost of poorer outcomes when they require arthroplasty in the future.Level of EvidenceLevel III therapeutic study.     

Surgical Helmet Systems Are Associated With a Lower Rate of Prosthetic Joint Infection After Total Knee Arthroplasty: Combined Results From the New Zealand Joint Registry and Surgical Site Infection Improvement Programme

BackgroundThis study aimed to identify the risk factors, in particular the use of surgical helmet systems (SHSs), for prosthetic joint infection (PJI) after total knee arthroplasty (TKA). Data recorded by the New Zealand Surgical Site Infection Improvement Programme (SSIIP) and the New Zealand Joint Registry (NZJR) were combined and analyzed.MethodsPrimary TKA procedures performed between July 2013 and June 2018 that were recorded by both the SSIIP and NZJR were analyzed. Two primary outcomes were measured: (1) PJI within 90 days as recorded by the SSIIP and (2) revision TKA for deep infection within 6 months as recorded by the NZJR. Univariate and multivariate analyses were performed to identify risk factors for both outcomes with results considered significant at P < .05.ResultsA total of 19,322 primary TKAs were recorded by both databases in which 97 patients had a PJI within 90 days as recorded by the SSIIP (0.50%), and 90 patients had a revision TKA for deep infection within 6 months (0.47%) as recorded by the NZJR. An SHS was associated with a lower rate of PJI (adjusted odds ratio [OR] = 0.50, P = .008) and revision for deep infection (adjusted OR = 0.55, P = .022) than conventional gowning. Male sex (adjusted OR = 2.6, P < .001) and an American Society of Anesthesiologists score >2 were patient risk factors for infection (OR = 2.63, P < .001 for PJI and OR = 1.75, P = .017 for revision for deep infection).ConclusionUsing contemporary data from the SSIIP and NZJR, the use of the SHS was associated with a lower rate of PJI after primary TKA than conventional surgical gowning. Male sex and a higher American Society of Anesthesiologists score continue to be risk factors for infection.     

Higher 2-Year Cumulative Incidence of Mental Health Disorders Following Antibiotic Spacer Placement for Chronic Periprosthetic Joint Infection following Total Joint Arthroplasty

BackgroundThe relationship of chronic periprosthetic joint infection (PJI) treatment on the development and relapse of mood disorders remains largely unreported. This study aims to compare the incidence of different mental health disorders following antibiotic spacer placement for chronic PJI when compared to aseptic revisions and primary procedures.MethodsPatients who underwent antibiotic spacer for septic total hip and knee arthroplasty (PJI THA/TKA) were identified in the PearlDiver Database using Current Procedure Terminology (CPT) codes for hip and knee antibiotic spacers. Patients who underwent aseptic revision and primary-THA/TKA were also identified using CPT codes. The incidences of depressive, anxiety, bipolar, psychotic, and stress disorders were identified within 2 years following the index procedures via Kaplan–Meier Analysis.ResultsThe risk of depressive (hazard ratio (HR): 1.5; P < .001) and stress (HR: 1.5; P < .001) disorders were significantly higher in those who underwent PJI-THA when compared to aseptic revision, with the added risk of bipolar when compared to primary THA. The risk of depressive (HR: 1.6; P < .001), stress (HR: 1.4; P < .001), bipolar (HR: 1.3; P < .001), and psychotic disorders (HR: 1.5; P = .003) were significantly higher in those who underwent PJI-TKA when compared to aseptic revision, with the added risk of anxiety when compared to primary TKA.ConclusionPatients who undergo spacer placement for septic-THA/TKA have a disproportionately higher incidence of mental health disorders within 2 years following surgery when compared those undergoing aseptic revisions and primary procedures. Due to this higher risk, physicians should strongly consider collaborative care with psychiatrists or mental health professionals.Level of EvidenceIII.     

Comparison of Modular Conventional and High-Flexion Posterior-Stabilized Total Knee Arthroplasties in the Same Patients at a Mean Follow-Up of 15 Years

BackgroundAs previous studies are limited to short-term clinical data on conventional and high-flexion total knee arthroplasties (TKAs), long-term clinical data on these TKAs remain unclear. Therefore, we evaluated long-term functional outcome, range of knee motion, revision rate, implant survival, and the prevalence of osteolysis after conventional and high-flexion TKAs in the same patients.MethodsThe authors evaluated a cohort of 1206 patients with a mean age of 65.3 ± 7 years (range: 22-70) who underwent bilateral simultaneous sequential TKAs. One knee received a conventional TKA and the other received a high-flexion TKA. The mean duration of follow-up was 15.6 years (range: 14-17).ResultsNo significant differences were found between the 2 groups at the latest follow-up with respect to Knee Society score (93 vs 92 points, P = .765), pain score (45 vs 44 points, P = .641), range of knee motion (125° vs 126°, P = .712), and radiographic and computed tomography scan results. Furthermore, no significant revision rate differences were found between the 2 groups (1.3% for conventional TKA vs 1.6% for high-flexion TKA; P = .137). There was no osteolysis recorded in either group. The rate of survivorship free of implant revision or aseptic loosening was 98.7% (95% CI = 91-100) for conventional TKA and 98.4% (95% CI = 91-100) for high-flexion TKA at 17 years.ConclusionAt the latest follow-up, we were not able to demonstrate any significant difference between conventional and high-flexion TKAs with respect to functional outcome scores, range of knee motion, revision rate, implant survival, and prevalence of osteolysis.     

Risk of Prosthetic Joint Infection Increases Following Early Aseptic Revision Surgery of Total Hip and Knee Arthroplasty

BackgroundIt is important to identify risk factors for periprosthetic joint infection (PJI) following total joint arthroplasty in order to mitigate the substantial social and economic burden. The objective of this study is to evaluate early aseptic revision surgery as a potential risk factor for PJI following total hip (THA) and total knee arthroplasty (TKA).MethodsPatients who underwent primary THA or TKA with early aseptic revision were identified in 2 national insurance databases. Control groups of patients who did not undergo revision were identified and matched 10:1 to study patients. Rates of PJI at 1 and 2 years postoperatively following revision surgery were calculated and compared to controls using a logistic regression analysis.ResultsIn total, 328 Medicare and 222 Humana patients undergoing aseptic revision THA within 1 year of index THA were found to have significantly increased risk of PJI at 1 year (5.49% vs 0.91%, odds ratio [OR] 5.61, P < .001 for Medicare; 7.21% vs 0.68%, OR 11.34, P < .001 for Humana) and 2 years (5.79% vs 1.10%, OR 4.79, P < .001 for Medicare; 8.11% vs 1.04%, OR 9.05, P < .001 for Humana). Similarly for TKA, 190 Medicare and 226 Humana patients who underwent aseptic revision TKA within 1 year were found to have significantly higher rates of PJI at 1 year (6.48% vs 1.16%, OR 7.69, P < .001 for Medicare; 6.19% vs 1.28%, OR 4.89, P < .001 for Humana) and 2 years (8.42% vs 1.58%, OR 6.57, P < .001 for Medicare; 7.08% vs 1.50%, OR 4.50, P < .001 for Humana).ConclusionEarly aseptic revision surgery following THA and TKA is associated with significantly increased risks of subsequent PJI within 2 years.     

Prior Septic Arthritis Within One Year of Knee Arthroplasty is Associated With a High Risk for Infection

BackgroundA prior history of a septic knee may predispose patients to a periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). We performed multivariate analyses of known risk factors that portend a periprosthetic infection for patients who have a history of septic arthritis (SA). The focus of the study was an assessment of the incidence of TKA PJIs at various time intervals after the onset of a septic knee (0 to 3 months, 3 to 6 months, 6 to 9 months, and 9 months to 1-year).MethodsWe queried a national database to identify patients who underwent a primary TKA between 2010 and 2021 (n = 1.9 million). Patients who had a prior septic knee ipsilateral to the primary TKA were characterized (n = 4,251) and were put into four specific cohorts based on the interval between the SA diagnosis and TKA: less than 3 months; 3 to 6 months; 6 to 9 months; and 9 to 12 months. A cohort of patients who did not have history of septic knee were used for comparison (n = 5,000). The incidence of PJIs from 90 days to 1 year was identified and compared using multivariate analyses.ResultsAll time cohorts were more likely to require revisions due to PJI, as compared to the comparison group. Significant differences were demonstrated among all time cohorts who had prior SA compared to patients who did not have a history of SA (odds ratio [OR] range, 90.0 to 113.0, P < .001).ConclusionThis study has shown an increased PJI risk in the first year after SA (P < .05). The surgeon should be aware of the increased PJI risk after SA within the first year after TKA.     

Heterotopic Ossification Negatively Influences Range of Motion After Revision Total Knee Arthroplasty

BackgroundThe incidence of heterotopic ossification (HO) after total knee arthroplasty (TKA) varies and is of unclear clinical significance. This study aimed to identify the incidence of HO in patients undergoing revision TKA for either stiffness or aseptic loosening/instability and determine if the presence of HO is associated with inferior absolute range of motion (ROM) and ROM gains.MethodsEighty-seven patients were prospectively enrolled and separated into 2 cohorts to evaluate ROM after revision TKA (2017-2019). Group 1 (N = 40) patients were revised for stiffness, while group 2 (N = 47) patients were revised for either aseptic loosening or instability. Goniometer-measured ROM values were obtained preoperatively and at 6 weeks, 6 months, and 1 year postoperatively. Statistical analysis included a Fisher’s exact test to assess for an association between preoperative HO and final ROM at 1 year after revision TKA.ResultsHO was identified on preoperative radiographs in 17 patients (20%). There was a significantly higher rate of preoperative HO in patients revised for stiffness compared to patients revised for instability or loosening (30% vs 11%; P = .03). Five cases of HO qualitatively identified as most clinically severe were associated with lower ROM at each time point compared to the remainder of HO cases in this study cohort (P < .02).ConclusionThe presence of HO is greater in patients undergoing revision TKA for stiffness. Additionally, HO severity appears to have a major effect on preoperative and postoperative ROM trajectory. This information should help guide patient expectations and highlight the need for a comprehensive, standardized classification system for HO.     

Patient-Reported Outcomes and Satisfaction 1 to 3 Years After Revisions of Total Knee Arthroplasties for Unexplained Pain Versus Aseptic Loosening

BackgroundIt is unknown if patients are relieved of pain after knee arthroplasty revision for unexplained pain. The aim of this cross-sectional case-control study was to compare patient-reported outcome measures (PROMs) and satisfaction 1 to 3 years after revision of total knee arthroplasties (TKAs) for the indications of unexplained pain versus aseptic loosening.MethodsWe included 384 patients undergoing TKA revision for the indications of unexplained pain and aseptic loosening from January 1, 2018 to December 31, 2020 from the Danish Knee Arthroplasty Register. A total of 81 patients were revised for unexplained pain and 303 for aseptic loosening. Questionnaires including PROMs (Oxford Knee Score, EQ-5D-5L, and Forgotten Joint Score) and satisfaction with the surgery on a 0-100 scale (100 = not satisfied; 0 = very satisfied) were sent to digitally secured mailboxes. Time from revision to data collection was a median 3.1 years (range, 1.4-4.4 years).ResultsMedian Oxford Knee Score was 25 (interquartile range [IQR] 15) versus 31 (IQR 18) 1-3 years after revisions for unexplained pain versus aseptic loosening, P = .009. Median EQ-5D-5L was 0.6 (IQR 0.4) versus 0.8 (IQR 0.3) for unexplained pain versus aseptic loosening, P = .009. Median Forgotten Joint Score was 50 (IQR 7) versus 50 (IQR 16) for unexplained pain versus aseptic loosening, P = .905. Satisfaction was 75 (IQR 38) for unexplained pain and 50 (IQR 73) for aseptic loosening, P < .001.ConclusionPatients undergoing TKA revision for the indication of unexplained pain had worse results on PROMs than those revised for aseptic loosening. Likewise, patients revised for unexplained pain were less satisfied compared to patients revised for aseptic loosening. This information is valuable to both surgeons and patients when candidates for revision surgery are selected, to obtain the best possible outcomes.     

Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Reduce the Rate of Early Periprosthetic Joint Infection After Primary Total Knee Arthroplasty

BackgroundVancomycin powder and dilute povidone-iodine lavage (VIP) was introduced to reduce the incidence of periprosthetic joint infection (PJI) in high-risk total knee arthroplasty (TKA) patients. We hypothesize that VIP can reduce the incidence of early PJI in all primary TKA patients, regardless of preoperative risk.MethodsAn infection database of primary TKAs performed before a VIP protocol was implemented (January 2012-December 2013), during a time when only high-risk TKAs received VIP (January 2014-December 2015), and when all TKAs received VIP (January 2016-September 2019) at an urban, university-affiliated, not-for-profit orthopedic hospital was retrospectively reviewed to identify patients with PJI. Criteria used for diagnosis of PJI were the National Healthcare Safety Network and Musculoskeletal Infection Society guidelines.ResultsVIP reduced early primary TKA PJI incidence in both the high-risk and all-risk cohorts compared with the pre-VIP cohort by 44.6% and 56.4%, respectively (1.01% vs 0.56% vs 0.44%, P = .0088). In addition, after introducing VIP to all-risk TKA patients, compared with high-risk TKA patients, the relative risk of PJI dropped an additional 21.4%, but this finding did not reach statistical significance (0.56% vs 0.44%, P = .4212). There were no demographic differences between the 3 VIP PJI cohorts.ConclusionVIP is associated with a reduced early PJI incidence after primary TKA, regardless of preoperative risk. With the literature supporting its safety and cost-effectiveness, VIP is a value-based intervention, but given the nature of this historical cohort study, a multicenter randomized controlled trial is underway to definitively confirm its efficacy.     

Dilute Betadine Lavage Reduces the Risk of Acute Postoperative Periprosthetic Joint Infection in Aseptic Revision Total Knee and Hip Arthroplasty: A Randomized Controlled Trial

BackgroundThe purpose of this randomized, controlled trial is to determine whether dilute betadine lavage compared to normal saline lavage reduces the rate of acute postoperative periprosthetic joint infection (PJI) in aseptic revision total knee (TKA) and hip arthroplasty (THA).MethodsA total of 478 patients undergoing aseptic revision TKA and THA were randomized to receive a 3-minute dilute betadine lavage (0.35%) or normal saline lavage before surgical wound closure. Fifteen patients were excluded following randomization (3.1%) and six were lost to follow-up (1.3%), leaving 457 patients available for study. Of them, 234 patients (153 knees, 81 hips) received normal saline lavage and 223 (144 knees, 79 hips) received dilute betadine lavage. The primary outcome was PJI within 90 days of surgery with a secondary assessment of 90-day wound complications. A priori power analysis determined that 285 patients per group were needed to detect a reduction in the rate of PJI from 5% to 1% with 80% power and alpha of 0.05.ResultsThere were eight infections in the saline group and 1 in the betadine group (3.4% vs 0.4%, P = .038). There was no difference in wound complications between groups (1.3% vs 0%, P = .248). There were no differences in any baseline demographics or type of revision procedure between groups, suggesting appropriate randomization.ConclusionDilute betadine lavage before surgical wound closure in aseptic revision TKA and THA appears to be a simple, safe, and effective measure to reduce the risk of acute postoperative PJI.Level of EvidenceLevel I.     

The Impact of Exchanging Cerclage Fixation after Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty for Periprosthetic Joint Infection

BackgroundAn extended trochanteric osteotomy (ETO) is a powerful tool for femoral component revision. There is limited evidence that directly supports its use in the setting of a periprosthetic joint infection (PJI). Cerclage fixation raises the theoretical concern for persistent infection.MethodsOur institutional database included 76 ETOs for revision hip arthroplasty between January 1, 2008 and December 31, 2019. The cohort was divided based on indication for femoral component revision: PJI versus aseptic revision. The PJI group was subdivided based on second-stage exchange versus retention of initial cerclage fixation. Operative time, estimated blood loss, complications, and rate of repeat revision surgery were evaluated.ResultsForty-nine patients (64%) underwent revision for PJI and 27 patients (36%) underwent aseptic revision. There was no significant difference in operative times (P = .082), postoperative complications (P = .258), or rate of repeat revision surgery (P = .322) between groups. Of the 49 patients in the PJI group, 40 (82%) retained cerclage fixation while 9 (18%) had cerclage exchange. Cerclage exchange did not significantly impact operative time (P = .758), blood loss (P = .498), rate of repeat revision surgery (P = .302), or postoperative complications (P = .253) including infection (P = .639).ConclusionAn ETO remains a powerful tool for femoral component removal, even in the presence of a PJI. A multi-institutional investigation would be required to validate observed trends toward better infection control with cerclage exchange. Cerclage exchange did not appear to increase operative time, blood loss, or postoperative complication rates.     

Utilization of Debridement,Antibiotics, and Implant Retention for Infection After Total Joint Arthroplasty Over a Decade in the United States

BackgroundReported clinical outcomes have varied for debridement, antibiotics, and implant retention (DAIR) and little is known regarding trends in utilization. We sought to evaluate the rate of DAIR utilization for total knee arthroplasty (TKA) and total hip arthroplasty (THA) periprosthetic joint infection (PJI) over a decade and clinical factors associated with these trends.MethodsA retrospective study of primary TKAs and THAs was performed using Medicare data from 2005 to 2014 using the PearlDiver database platform. Current Procedural Technology and International Classification of Diseases Ninth Edition codes identified patients who underwent a surgical revision for PJI, whether revision was a DAIR, as well as associated clinical factors including timing from index arthroplasty.ResultsThe proportion of revision TKAs and THAs performed using DAIR was 27% and 12% across all years, respectively. This proportion varied by year for TKAs and THAs with a linear trend toward increasing relative use of DAIR estimated at 1.4% and 0.9% per year (P < .001; P < .001). DAIR for TKA and THA performed within 90 days increased at a faster rate, 3.4% and 2.1% per year (P < .001; P < .001). Trends over time in TKA DAIRs showed an association with Elixhauser Comorbidity Index (ECI), 0-5 group increasing at 2.0% per year (P = .03) and patients >85 years (P = .04).ConclusionThe proportion of revision arthroplasty cases for PJI managed with DAIR has been increasing over time in the United States, with the most substantial increase seen <90 days from index arthroplasty. Age, gender, and ECI had a minimal association with this trend, except in the TKA population >85 years and in those with a very low ECI score.     

Changes in Patient Satisfaction Following Total Joint Arthroplasty

BackgroundThe primary aim is to identify the degree to which patient satisfaction with the outcome of total hip arthroplasty (THA) or total knee arthroplasty (TKA) changes between 1 and 3 years from the procedure. The secondary aim is to identify variables associated with satisfaction.MethodsData were sourced from 2 prospective international, multicenter studies (919 THA and 450 TKA patients). Satisfaction was assessed by a 10-point numerical rating scale, at 1- and 3-year follow-up. Linear mixed-effects models were used to assess factors associated with satisfaction.ResultsFor the THA cohort, higher preoperative joint space width (odds ratio [OR] = 0.28; P = .004), pain from other joints (OR = 0.26; P = .033), and lower preoperative health state (OR = −0.02; P < .001) were associated with consistently lower levels of satisfaction. The model also showed that patients with preoperative anxiety/depression improved in satisfaction between 1 and 3 years (OR = −0.26; P = .031).For the TKA cohort, anterior (vs neutral or posterior) tibial component slope (OR = 0.90; P = .008), greater femoral component valgus angle (OR = 0.05; P = .012), less severe osteoarthritis (OR = −0.10; P < .001), and lower preoperative health state (OR = −0.02; P = .003) were associated with lower levels of satisfaction across the study period. In addition, patients with anterior tibial component slope improved in satisfaction level over time (OR = −0.33; P = .022).ConclusionChanges in satisfaction following THA and TKA are rare between 1- and 3-year follow-up. The findings of this study can be used to guide patient counseling preoperatively and to determine intervals of routine follow-up postoperatively.     

Isolated Versus Full Component Revision in Total Knee Arthroplasty for Aseptic Loosening

BackgroundRevision of both femoral and tibial components of a total knee arthroplasty (TKA) for aseptic loosening has favorable outcomes. Revision of only one loose component with retention of others has shorter operative time and lower cost; however, implant survivorship and clinical outcomes of these different operations are unclear.MethodsBetween January 2009 and December 2019, a consecutive cohort of revision TKA was reviewed. Univariate and multivariable analyses were used to study correlations among factors and surgical related complications, time to prosthesis failure, and functional outcomes (University of California Los Angeles, Knee Society functional, knee osteoarthritis and outcome score for joint replacement, Veterans RAND 12 (VR-12) physical, and VR-12 mental).ResultsA total of 238 patients underwent revision TKA for aseptic loosening. The mean follow-up time was 61 months (range 25 to 152). Ten of the 105 patients (9.5%) who underwent full revision (both femoral and tibial components) and 18 of the 133 (13.5%) who underwent isolated revision had subsequent prosthesis failure [Hazard ratio (HR) 0.67, P = .343]. The factor analysis of type of revision (full or isolated revision) did not demonstrate a significant difference between groups in terms of complications, implant failures, and times to failure. Metallosis was related to early time to failure [Hazard ratio 10.11, P < .001] and iliotibial band release was associated with more complications (Odds ratio 9.87, P = .027). Preoperative symptoms of instability were associated with the worst improvement in University of California Los Angeles score. Higher American Society of Anesthesiologists status and higher Charlson Comorbidity Index were related with worse VR-12 physical (?30.5, P = .008) and knee osteoarthritis and outcome score for joint replacement (?4.2, P = .050) scores, respectively.ConclusionIsolated and full component revision TKA for aseptic loosening does not differ with respect to prosthesis failures, complications, and clinical results at 5 years. Poor American Society of Anesthesiologists status, increased comorbidities, instability, and a severe bone defect are related to worse functional improvement.Level of evidenceIII, cohort with control.     

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

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