When to lavage in the absence of a sonographically visible joint effusion in painful total knee arthroplasty: a retrospective longitudinal study.

OBJECTIVE: To determine if knee arthroplasty without sonographically visible effusion needs to undergo lavage to rule out infection. METHODS: Patients were accrued by a retrospective search of a longitudinally maintained radiology database looking for patients referred for ultrasound guided aspiration of suspected TKA infection. Clinical presentations, laboratory tests, intraoperative findings, and follow-up were reviewed. RESULTS: Four hundred sixty-nine patients were included (mean age of 67 years (range, 36-91)) including 251 females. Four hundred three patients had effusions, of which 57 were infected based on ultrasound-guided and surgical aspirates. Sixty-four patients lacked effusions, of which 47 underwent lavage at the clinicians' request, with 6/47 infected. Nineteen patients without effusion were not lavaged at the clinicians' request due to low suspicion, and none were infected. Patients with positive lavage cultures all had clinical risk factors. Infection rates were significantly higher in patients with joint effusion and clinical suspicion for infection compared to absent joint effusion and absent clinical suspicion. A significantly higher proportion of patients with hyperemia or moderate-severe synovial thickening on ultrasound were symptomatic and had joint effusion and positive joint cultures. Aspiration of native fluid had 85% sensitivity and 100% specificity while lavage had a sensitivity of 57% and specificity of 100%. Negative predictive value for native aspirates was 94% compared to 86% for lavage. CONCLUSION: A TKA with low clinical suspicion of infection does not need to undergo lavage in the absence of a sonographically visible effusion.

Skin Reactions Following Primary Total Knee Arthroplasty With an Adhesive Superficial Closure System: A Case Series.

BACKGROUND: We investigated a skin adhesive closure device consisting of a self-adhesive polyester mesh placed over the surgical incision, followed by a liquid adhesive that is spread over the mesh and surrounding the skin. It is intended to reduce wound closure times, scarring, and skin complications associated with traditional closure with sutures or staples. The aim of this study was to report on skin reactions in patients who underwent primary total knee arthroplasty (TKA) using the skin adhesive closure system. METHODS: A retrospective review of patients who underwent TKA using adhesive closure between 2016 to 2021 at a single institute was performed. A total of 1,719 cases were analyzed. Patient demographics were collected. The primary outcome was any postoperative skin reaction. Skin reactions were classified as allergic dermatitis, cellulitis, or other. Treatment(s), duration of symptoms, and surgical infections were also collected. RESULTS: A total of 5.0% (86) of patients were found to have any type of skin reaction following their TKA. Of these 86, 39 (2.3%) had symptoms of allergic dermatitis (AD), 23 (1.3%) had symptoms of cellulitis, and 24 (1.4%) had other symptoms. A total of 27 (69%) allergic dermatitis patients were treated with a topical corticosteroid cream only; their symptoms resolved within an average of 25 days. There was only 1 case of superficial infection (<0.001%). No prosthetic joint infections were observed. CONCLUSION: Despite skin reactions appearing in 5.0% of cases, the rate of infection was low. A patient-specific preoperative workup and effective treatment strategies can minimize complications associated with adhesive closure system and increase patient satisfaction following TKA.

Beyond Recidivism: Hospital-Based Violence Intervention and Early Health and Social Outcomes.

BACKGROUND: Hospital-based violence intervention programs (HVIPs) are aimed at decreasing recurrent injury and improving the social determinants of health. We hypothesized that the HVIP intervention should be evaluated by how well it can address the immediate health and social needs of patients after injury. Our study sought to describe the experience of our nascent HVIP. STUDY DESIGN: Case management records of patients treated by the HVIP of a level 1 trauma center from July 1, 2017 to October 1, 2020 were reviewed. Inclusion criteria were as follows: age between 18 and 60 with injury mechanisms that resulted from intentional violence. Patient-stated goals and social worker designation of patient services provided were analyzed. A subset of HVIP patients who completed the three planned study visit surveys at discharge and 1 and 3 months were compared with a cohort of violently injured patients to whom HVIP services were not available. Participants in both groups were asked to complete a battery of validated surveys to assess social outcomes and post-traumatic stress disorder (PTSD). Repeated-measures ANOVA was used to compare the two groups. RESULTS: Two hundred and ninety-five patients met the inclusion criteria. One hundred and forty-six patients (49%) achieved their stated goals within 6 months of hospital discharge. Sixteen patients who achieved their stated goals disengaged from the program. Engagement in the HVIP resulted in significantly less PTSD at the time of hospital discharge. HVIP patients also experienced higher positive affect at hospital discharge, as described in the Positive and Negative Affect Schedule. HVIP participants were significantly more likely to achieve early positive health outcomes, such as completion of victim of crime compensation and return to school. CONCLUSIONS: Our HVIP successfully achieved patient-stated short-term health and social goals in nearly half of all enrollees, indicating that HVIP patients are more likely to improve their social determinants of health than non-HVIP patients. Short-term health and social outcomes were improved in HVIP patients compared with non-HVIP patients, indicating increased engagement with the healthcare system. We suggest that these outcomes should replace recidivism as a metric for the efficacy of HVIP programs.

Unpacking the Causes of Post-Traumatic Stress Disorder in Violently Injured Patients.

BACKGROUND: Violence is a public health problem that disproportionately affects urban communities. The root causes of PTSD and effects on quality of life, substance abuse, and mental health are unclear. The purpose of this study was to evaluate the prevalence of PTSD and its root causes to direct services to be provided in a hospital-based violence intervention program. METHODS: Victims of Violence (VOVs) at University Hospital were approached from December 2017 to June 2019. They completed several validated patient-reported outcome surveys, including the Traumatic Life Events Questionnaire, the Peritraumatic Dissociative Experiences Questionnaire, Peritraumatic Dissociative Inventory, Positive and Negative Affect Scale, and the Alcohol Use Disorders Identification Test and the Drug Abuse Screening Test. Responses were recorded in Research Electronic Data Capture and were analyzed using Microsoft Excel. RESULTS: Fifty-four individuals completed the surveys; 94% were men, 88% black, and 100% victims of interpersonal violence. 85% screened positive for PTSD. VOVs experienced many traumatic events throughout their life. Reported alcohol and drug abuse were low, with 91% at low risk for alcohol use disorders and 92% at low risk for drug abuse disorders (Figure 1). Positive affect remained high, indicating the possibility of resiliency in this population. CONCLUSIONS: PTSD is high in VOVs in urban trauma centers. Understanding the root causes of PTSD can help direct interventions to support individuals with services that meet their individual needs. Simple screening tools can help hospital-based violence intervention programs and trauma social workers identify individual needs and assess risk for mental health and substance abuse disorders.

Identifying participants for inclusion in hospital-based violence intervention: An analysis of 18 years of urban firearm recidivism.

BACKGROUND: Identifying individuals at highest risk maximizes efficacy of prevention programs in decreasing recidivist gunshot wound (GSW) injury. Characteristics of GSW recidivists may identify this population. Hospital-based violence intervention programs (HVIPs) are one effective strategy; however, programs are expensive, therefore, when possible, epidemiologic data should guide inclusion criteria. METHODS: Seventeen years of all GSW patients presenting to an urban Level I trauma center were reviewed. Countywide murders were reviewed from the same timeframe. Recidivists were any patient presenting twice, either to the hospital or once to the hospital and subsequently dying by firearm. Demographics and characteristics of future recidivists were compared with nonfuture recidivists. RESULTS: There were 9,699 unique intentional, GSW cases reviewed and 1,426 died, leaving 8,273 at risk of recidivism. Five hundred fourteen (6.2%) became recidivists. Most recidivists were African-American men and were younger at first GSW. Median time between incidents was 2.5 years, with a range of 0 days to 16 years. Nearly half were treated and released from the emergency department at their first episode of GSW. For recidivists who died, 128 died at the second incident, 29 at later incidents. Mortality from a second incident of firearm injury is 10% higher than first injuries, second hospitalizations are US $5,000 more expensive, and loss of life has a societal cost of US $167 billion in this community alone. CONCLUSION: The most appropriate population for inclusion in HVIPs at our hospital are young black men. The HVIP services are needed in the emergency department to address those treated and released at first GSW. Recidivists have higher mortality, and hospitalizations are significantly more expensive at the second injury. The investment in prevention is justified and may lead to a decrease in recidivism. LEVEL OF EVIDENCE: Therapeutic/Care Management level III.