Recovery of Lung Function After 149 Days on Extracorporeal Membrane Oxygenation for COVID-19.

This report highlights survival and the patient's perspective after prolonged venovenous extracorporeal membrane oxygenation (ECMO) for COVID-19-related respiratory failure. A 36-year-old man with COVID-19 presented with fever, anosmia, and hypoxia. After respiratory deterioration necessitating intubation and lung-protective ventilation, he was referred for ECMO. After 3 days of conventional venovenous ECMO, he required multiple creative cannulation configurations. Adequate sedation and recurrent bradycardia were persistent challenges. After 149 consecutive days of ECMO, he recovered native lung function and was weaned from mechanical ventilation. This represents the longest-duration ECMO support in a survivor of COVID-19 yet reported. Necessary strategies included unconventional cannulation and flexible anticoagulation.

Neer Award 2015: Analysis of cytokine profiles in the diagnosis of periprosthetic joint infections of the shoulder.

BACKGROUND: Periprosthetic joint infection (PJI) after shoulder arthroplasty can present a diagnostic and therapeutic challenge. This study evaluated the diagnostic utility of broader synovial fluid cytokine analysis for identifying PJI in patients undergoing revision shoulder arthroplasty. METHODS: Synovial fluid levels of 9 cytokines (interleukin [IL] 6, granulocyte-macrophage colony-stimulating factor, IL-1ß, IL-12, IL-2, IL-8, interferon-γ, IL-10, and tumor necrosis factor-α) were measured in 75 cases of revision shoulder arthroplasty with a multiplex immunoassay. Cases were classified into infection categories and groups based on objective perioperative findings. Differences in cytokine levels among infection groups were evaluated. Receiver operating characteristic curves were used to assess the diagnostic utility of the individual synovial fluid cytokines and combinations of cytokines in determining infection status. RESULTS: Synovial IL-6, granulocyte-macrophage colony-stimulating factor, interferon-γ, IL-1ß, IL-2, IL-8, and IL-10 were significantly elevated in cases of revision shoulder arthroplasty classified as infected. Individually, IL-6, IL-1ß, IL-8, and IL-10 showed the best combination of sensitivity and specificity for predicting infection, and a combined cytokine model consisting of IL-6, tumor necrosis factor-α, and IL-2 showed better diagnostic test characteristics than any cytokine alone, with sensitivity of 0.80, specificity of 0.93,, positive and negative predictive values of 0.87 and 0.89, and positive and negative likelihood ratios of 12.0 and 0.21. CONCLUSIONS: Individual and combined synovial fluid cytokine analysis were both more effective than routine perioperative testing, such as serum erythrocyte sedimentation rate and C-reactive protein, in the diagnosis of PJI of the shoulder. Once validated, combined synovial fluid cytokine analysis could be used as a predictive tool to determine the probability of PJI in patients undergoing revision shoulder arthroplasty and better guide treatment.

Infection Is Not a Risk Factor for Perioperative and Postoperative Blood Loss and Transfusion in Revision Total Hip Arthroplasty.

BACKGROUND: Septic hip revisions are associated with greater complications and higher costs than aseptic revisions. It is unclear whether blood loss and transfusion requirements are different in septic and aseptic revisions. We hypothesized that the blood loss and transfusion are dependent on the complexity of the revision surgery and patient's general health rather than the presence of infection. METHODS: We retrospectively reviewed 626 revision total hip arthroplasties in 547 patients between 2009 and 2013. All the procedures were classified as septic (n = 120) or aseptic (n = 506) based on the Musculoskeletal Infection Society criteria for periprosthetic joint infection. Independent risk factors for transfusion and blood loss were analyzed using a multiple regression analysis. RESULTS: The transfusion rate was higher in septic revisions (septic = 108/120 [90%], aseptic = 370/506 [73%]; P < .001), so was the average amount of blood loss (septic = 2533 ± 161 mL, aseptic = 1974 ± 68 mL; P < .001). After adjusting for potential confounders, infection was not an independent risk factor for transfusion (P = .176) or blood loss (P = .437). Increasing age (P = .004), higher American Society of Anesthesiologists score (P = .047), lower preoperative hemoglobin (P < .001), cell saver use (P < .001), and complex revision surgery (P < .001) were independently associated with greater risk of transfusion. CONCLUSIONS: Although blood loss and transfusion rates were higher in septic revisions, the presence of infection alone did not increase the risk of transfusion or blood loss. Blood management strategies in revision total hip arthroplasties should be guided by the type of surgery planned and patient's preoperative health rather than the presence of infection.

α-Defensin Accuracy to Diagnose Periprosthetic Joint Infection-Best Available Test?

BACKGROUND: The purpose of this study was to test the accuracy of a single synovial fluid biomarker, α-defensin, in diagnosing periprosthetic joint infection in revision total hip and revision total knee arthroplasty. METHODS: A total of 102 patients comprising 116 revision total hip arthroplasty and revision total knee arthroplasty procedures performed between May 2013 and March 2014 were prospectively evaluated. Cases were categorized as infected or notinfected using Musculoskeletal Infection Society criteria. Synovial fluid was obtained and tested for α-defensin using a commercially available kit (Synovasure [CD Diagnostics, Baltimore, Maryland]). RESULTS: For first-stage and single-stage revisions, the α-defensin test had a sensitivity of 100% (95% confidence interval [CI], 86%-100%) and a specificity of 98% (95% CI, 90%-100%) with a positive predictive value of 96% (95% CI, 80%-99%) and negative predictive value of 100% (95% CI, 93%-100%). CONCLUSION: A positive α-defensin test result was significantly more sensitive and specific for predicting infection than current diagnostic testing and should be considered when managing periprosthetic joint infection. LEVEL OF EVIDENCE: Level III, Study of Diagnostic Test.

Effect of price capitation on implant selection for primary total hip and knee arthroplasty.

While price capitation strategies may help to control total hip (THA) and knee arthroplasty (TKA) implant costs, its effect on premium implant selection is unclear. Primary THA and TKA cases 6 months before and after capitated pricing implementation were retrospectively identified. After exclusions, 716 THA and 981 TKA from a large academic hospital and 2 midsize private practice community hospitals were reviewed. Academic hospital surgeons increased premium THA implant usage (66.5% to 70.6%; P = 0.28), while community surgeons selected fewer premium implants (36.4%) compared to academic surgeons, with no practice change (P = 0.95). Conversely, premium TKA implant usage significantly increased (73.4% to 89.4%; P < 0.001) for academic surgeons. Community surgeons used premium TKA implants at greater rates in both periods, with all cases having ≥1 premium criterion.