Comparison of Surgical Site Complications With Negative Pressure Wound Therapy vs Silver Impregnated Dressing in High-Risk Total Knee Arthroplasty Patients: A Matched Cohort Study.

BACKGROUND: Closed incision negative pressure wound therapy (ciNPWT) may reduce surgical site complications following total joint arthroplasty. Although unlikely necessary for all patients, the criteria for utilizing ciNPWT in primary total knee arthroplasty (TKA) remain poorly defined. This study's purpose was to compare the incidence of incisional wound complications, non-incisional complications (ie, dressing reactions), reoperations, and periprosthetic joint infections (PJIs) among a group of high-risk primary TKA patients treated with ciNPWT vs an occlusive silver impregnated dressing. METHODS: One hundred thirty high-risk primary TKA patients treated with ciNPWT were 1:1 propensity matched and compared to a historical control group treated with an occlusive silver impregnated dressing. High-risk criteria included the following: active tobacco use, diabetes mellitus, body mass index >35 kg/m2, autoimmune disease, chronic kidney disease, Staphylococcus aureus nasal colonization, and non-aspirin anticoagulation. RESULTS: Age, gender, and risk factor profile were comparable between cohorts. The ciNPWT cohort had significantly fewer incisional wound complications (6.9% vs 16.2%; P = .031) and significantly more non-incisional complications (16.9% vs 1.5%; P < .001). No dressing reactions required clinical intervention. There were no differences in reoperations or periprosthetic joint infections (P = 1.000). In multivariate analysis, occlusive silver impregnated dressings (odds ratio 2.9, 95% confidence interval 1.3-6.8, P = .012) and non-aspirin anticoagulation (odds ratio 2.5, 95% confidence interval 1.1-5.6, P = .028) were associated with the development of incisional wound complications. CONCLUSION: Among high-risk patients undergoing primary TKA, ciNPWT decreased incisional wound complications when compared to occlusive silver impregnated dressings, particularly among those receiving non-aspirin anticoagulation. Although an increase in dressing reactions was observed, the clinical impact was minimal.

Total joint arthroplasty cost savings with a rapid recovery protocol in a military medical center.

The reported short-term benefits of rapid recovery protocols for total joint arthroplasty primarily come from specialized centers of excellence. The feasibility of achieving similar benefits at a military health care facility has not been reported. The authors hypothesized that application of such a protocol in this setting would decrease hospital stay and costs. A retrospective study was conducted comparing 85 hip and knee replacements by one surgeon using conventional protocol to 90 cases by a second surgeon using a rapid recovery protocol in the same hospital. Outcome measures included operative time, length of hospital stay, pain at discharge, use of inpatient rehabilitation facilities, complications requiring readmission, and inpatient admission costs. The results showed decreased length of stay by 2.9 days (p < 0.001) in the rapid recovery group, resulting in average cost savings of $1,511 (p < 0.001) with shorter operative time, equivalent pain at discharge, and fewer discharges to rehabilitation facilities. This feasibility study shows promising results, but prospective randomized trials are necessary to draw firm conclusions on the superiority of a rapid recovery protocol for total hip and knee arthroplasty in a military medical system.

Do plans and execution agree in a humanitarian medical mission?

There is a significant need for orthopaedic care in developing countries. For the past 10 years, the United States Army has supported annual orthopaedic hand surgery humanitarian missions to Honduras. The goal of this article is to compare the premission planning to the realities of mission execution to provide a template for future missions. Premission planning began 1 year before the mission. Based on previous missions, supplies were brought for 50 surgical cases. The mission began with 1 preoperative clinic day followed by 8 operative days and 1 postoperative clinic day. Of the 99 prescreened patients, 65 were indicated for surgery. A total of 58 surgeries were performed using innovative methods to stretch available supplies. A multidisciplinary and multination concerted effort is required for a successful humanitarian medical mission. A premission plan is critical prior to arrival and a contingency plan must be in place for missing mission-critical items.

Magnetic resonance imaging interpretation in patients with symptomatic lumbar spine disc herniations: comparison of clinician and radiologist readings.

STUDY DESIGN: Retrospective review of imaging data from a clinical trial. OBJECTIVE: To compare the interpretation of lumbar spine magnetic resonance imaging (MRIs) by clinical spine specialists and radiologists in patients with lumbar disc herniation. SUMMARY OF BACKGROUND DATA: MRI is the imaging modality of choice for evaluation of the lumbar spine in patients with suspected lumbar disc herniation. Guidelines provide standardization of terms to more consistently describe disc herniation. The extent to which these guidelines are being followed in clinical practice is unknown. METHODS: We abstracted data from radiology reports from patients with lumbar intervertebral disc herniation enrolled in the Spine Patient Outcomes Research Trial. We evaluated the frequency with which morphology (e.g., protrusions, extrusions, or sequestrations) was reported as per guidelines and when present we compared the morphology ratings to those of clinicians who completed a structured data form as part of the trial. We assessed agreement using percent agreement and the kappa statistic. RESULTS: There were 396 patients with sufficient data to analyze. Excellent agreement was observed between clinician and radiologist on the presence and level of herniation (93.4%), with 3.3% showing disagreement regarding level, of which a third could be explained by the presence of a transitional vertebra. In 3.3% of the cases in which the clinician reported a herniation (protrusion, extrusion, or sequestration), the radiologist reported no herniation on the MRI.The radiology reports did not clearly describe morphology in 42.2% of cases. In the 214 cases with clear morphologic descriptions, agreement was fair (kappa = 0.24) and the disagreement was asymmetric (Bowker's test of symmetry P < 0.0001) with clinicians more often rating more abnormal morphologic categories. Agreement on axial location of the herniation was excellent (kappa = 0.81). There was disagreement between left or right side in only 3.3% of cases (kappa = 0.93). CONCLUSION: Radiology reports frequently fail to provide sufficient detail to describe disc herniation morphology. Agreement between MRI readings by clinical spine specialists and radiologists was excellent when comparing herniation vertebral level and location within level, but only fair comparing herniation morphology.