Early Infection Trends for Primary Total Knee Arthroplasty: A 5-Year Review.

The aim of this study was to track the annual rates and trends of overall, deep, and superficial surgical site infections (SSIs) following total knee arthroplasty using the most recent results from a large and nationwide database. A total of 197,192 cases were performed between 2012 and 2016 from a nationwide database stratified into years and based on superficial and/or deep SSIs. Cohorts were analyzed individually and then combined to evaluate overall SSI rates. The infection incidence for each year was calculated. After a 6-year correlation and trends analysis, univariate analyses were performed to compare the most recent year, 2016, with each of the preceding 4 years. Overall, there was a downward trend in overall SSI rates over the study period (2012-2016, with the lowest rate occurring in the most recent year, 2016 [0.11%]). Additionally, there was a decreasing trend for superficial SSI, with the lowest superficial SSI incidence occurring in 2016 (0.47%) and the greatest incidence occurring in 2012 (0.53%). An overall trend of decreasing SSI rates was observed nationwide over the 5-year period evaluated. A similar decreasing trend was also noted specifically for deep SSI rates, which can be potentially more complicated to manage, and result in decreased implant survivorship. The down trending SSI rates observed give potential credence to the value for newer and developing SSI preventative therapies as well as improved medical and surgical patient management. Nevertheless, there is still room for improvement, and continued efforts are needed to further lower SSIs after total knee arthroplasty.

An Updated Review on Layered Closure Techniques for Total Hip Arthroplasty.

INTRODUCTION: One of the main concerns with total hip arthroplasty is the development of periprosthetic joint infections (PJIs). Appropriate wound closure can contribute to the prevention of PJIs with a watertight closure effectively sealing the implant from the outside. It is important to continuously investigate which materials as well as techniques are potentially the most efficacious and cost effective for wound closure. Therefore, the purpose of this review article was to critically appraise the current total hip arthroplasty wound closure materials and techniques as reported in the literature. Specifically, we evaluated: 1) fascial approximations; 2) subdermal closures; 3) subcuticular and skin closures; 4) wound dressings; as well as 5) capsular and short external rotator repairs. MATERIALS AND METHODS: A literature search was performed using the PubMed database from inception to February 2022. The query consisted of terms including "hip, arthroplasty, wound, closure, capsular closure, fascial closure, subcutaneous closure, and skin closure." References from selected texts were also reviewed for inclusion. Only manuscripts written in the English language were included for final analysis. A systematic review was performed for the five topics: 1) fascial approximations; 2) subdermal closures; 3) subcuticular and skin closures; 4) wound dressings; as well as 5) capsular and short external rotator repairs. Additionally, a meta-analysis was performed on the closing time of fascial approximations. RESULTS: The current literature supports performing a layered closure of the wound by approximating the fascial layers, which can help close any empty spaces. The techniques for closure at this layer seem to be equal regarding wound complications between running knotless barbed sutures versus interrupted throws; however, knotless sutures have the potential of a quicker closure time. A total of three out of four reports and the meta-analyses demonstrated that wound closure time can be reduced with barbed sutures, along with decreased number of sutures required as also shown by three out of four reports. The most superficial layers, subcuticular and skin, can be closed with either sutures, staples, or skin adhesives, all of which appear to have adequate outcomes. A report found that patients who had skin closure with barbed suture had faster time to a dry postoperative wound and lower rates of delayed discharge. For the overlying dressing, an occlusive and absorbent dressing can both protect the wound as well as collect any residual wound drainage. Two reports found increased dryness, decreased wound drainage, and decreased rates of delayed wound healing with use of 2-octyl cyanoacrylate topical adhesive with flexible self-adhesive polyester mesh dressings. If the capsule and short external rotators are taken down during the approach, repairing these can potentially help increase postoperative hip stability as well as decrease dislocation rates. CONCLUSION: The variety of materials and techniques available to close a THA wound allows surgeons to tailor closure to be patient specific. In general, the authors recommend performing layered closures from the capsule and short external rotators (if taken down during the approach), fascial layer closure with either a running knotless suture, subcutaneous closure either with the same knotless suture as the fascial layer brought more superficially, or with simple interrupted sutures to tack down any empty space, as well as finally subcuticular and skin sutures with a skin adhesive glue overtop. The skin adhesive can help provide an extra layer, particularly in active patients.

Psoriasis and Post-Surgical Infections in Primary Total Knee Arthroplasty: An Analysis of 10,727 Patients.

BACKGROUND: Psoriasis is a dermatologic condition characterized by erythematous plaques that may increase wound complications and deep infections following total knee arthroplasty (TKA). There is a paucity of evidence concerning the association of this disease and complications after TKA. This study aimed to determine if patients who have psoriasis vs non-psoriatic patients have differences in demographics and various comorbidities as well as post-operative infections, specifically the following: (1) wound complications; (2) cellulitic episodes; and (3) deep surgical site infections (SSIs). METHODS: We identified 10,727 patients undergoing primary TKA utilizing an institutional database between January 1, 2017 and April 1, 2019. A total of 133 patients who had psoriasis (1.2%) were identified using International Classification of Diseases, Tenth Revision codes and compared to non-psoriatic patients. The rate of wound complications, cellulitic episodes, and deep SSIs were determined. After controlling for age and various comorbidities, multivariate analyses were performed to identify the associated risks for post-operative infections. RESULTS: Psoriasis patients showed an increased associated risk of deep SSIs (3.8%) compared to non-psoriasis patients (1.2%, P = .023). Multivariate analyses demonstrated a significant associated risk of deep SSIs (odds ratio 7.04, 95% confidence interval 2.38-20.9, P < .001) and wound complications (odds ratio 4.44, 95% confidence interval 1.02-19.2, P = .047). CONCLUSION: Psoriasis is an inflammatory dermatologic condition that warrants increased pre-operative counseling, shared decision-making, and infectious precautions in the TKA population given the increased risk of wound complications and deep SSIs. Increased vigilance is required given the coexistence of certain comorbidities with this population, including depression, substance use disorder, smoking history, gastroesophageal reflux disease, and inflammatory bowel disease.

Implementation of a Geriatrics-Focused Orthopaedic and Hospitalist Fracture Program Decreases Perioperative Complications and Improves Resource Utilization.

OBJECTIVE: To evaluate whether the implementation of a geriatrics-focused orthopaedic and hospitalist comanagement program can improve perioperative outcomes and decrease resource utilization. DESIGN: A retrospective chart review study was conducted before and after the implementation of a geriatrics-focused orthopaedic and hospitalist comanagement program, based on the American Geriatrics Society (AGS) AGS CoCare:Ortho. SETTING: A large urban, academic tertiary center, located in the greater New York metropolitan area. PARTICIPANTS: Patients 65 years and older hospitalized for operative hip fracture. Those with pathologic or periprosthetic fractures and chronic substance use were excluded. MAIN OUTCOME MEASUREMENTS: Outcome measures included time to operating room (TtOR), length of stay, daily and total morphine milligram equivalents, use of preoperative transthoracic echocardiogram and blood transfusions, perioperative complications (eg, urinary tract infections), and 6-month mortality. RESULTS: Our study included 290 patients hospitalized with hip fracture, before (N = 128) and after (N = 162) implementation. When compared with the preimplementation group, the postimplementation comanagement group had a lower TtOR (36.2 vs. 30.0 hours, P = 0.026) and hospital length of stay, decreased use of indwelling bladder catheters preoperatively and postoperatively (68.0% vs. 46.9%, P < 0.001, and 83.6 vs. 58.0%, P < 0.001, respectively), reduced daily opiate use (16.0 vs. 11.1 morphine milligram equivalents, P = 0.011), and decreased 30-day complications (32.8% vs. 16.7%, P = 0.002). There was no difference in 6-month mortality between the 2 groups. CONCLUSIONS: The implementation of an AGS CoCare:Ortho-based comanagement program led to decreased perioperative complications and resource utilization. Comanagement programs are essential to improving and standardizing hip fracture care for older adults. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Time Spent in the Post-Anesthesia Care Unit Affect Hospital Lengths of Stay following Primary Total Knee Arthroplasty?

Given the current healthcare economic environment, substantial efforts have been made to help streamline the in-hospital care for total knee arthroplasty (TKA) patients. While potential cost-reducing factors have been identified in the literature, analyses specifically considering post-anesthesia care unit (PACU) lengths of stay (LOS) are lacking. Therefore, the purpose of this study was to identify factors associated with (1) longer PACU LOS as well as (2) longer Hospital LOS. Prospectively collected TKA data from seven participating hospitals within a large health system were evaluated for patient demographics, body mass indices, Charlson Comorbidity Indices (CCI), surgeon volumes/training, admission types, anesthesia types, PACU LOS, and overall hospital LOS. Complete data was available for 1,690 patients (1,082 females, mean age: 67 years). Univariate and multivariate analytical models were constructed to identify which factors were predictive of longer PACU and overall hospital LOS. Same-day admissions, higher volume surgeons (≥ 100 cases per year), fellowship-trained arthroplasty surgeons, and longer operative times were associated with longer PACU LOS (p < 0.05). Multivariate analyses found age more than or equal to 65 years (ß= 0.124) and CCI more than or equal to 3 (ß= 0.088) to be associated with longer hospital LOS (p < 0.001). Operative times, PACU LOS, and procedure times (operative time plus PACU LOS) were not associated with longer hospital LOS (p > 0.05). These data identify associative factors for PACU LOS, as well as the influence of time spent in the PACU on overall hospital LOS. Interestingly, this analysis revealed that patients of arthroplasty fellowship-trained and higher-volume surgeons had longer PACU LOS; however, this could be explained by the observation that these particular surgeons tend to perform more complex deformity cases. Also of importance, increased PACU LOS, meaning the patient spent more time in a high-monitored setting immediately after surgery, did not necessarily confer a longer overall hospital LOS. Based on these data, it may be more beneficial to identify alternate sources than time spent in the operating room or PACU to potentially help reduce overall hospital LOS. LEVEL OF EVIDENCE: II, prospective cohort.

Management of Refractory Pain After Total Joint Replacement.

PURPOSE OF REVIEW: Chronic pain after total joint replacement (TJA), specifically total knee replacement (TKA), is becoming more of a burden on patients, physicians, and the healthcare system as the number of joint replacements performed increases year after year. The management of this type of pain is critical, and therefore, understanding the various modalities physicians can use to help patients with refractory pain after TJA is essential. RECENT FINDINGS: The modalities by which chronic pain can be successfully managed include genicular nerve radioablation therapy (GN-RFA), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and peripheral subcutaneous field stimulation (PSFS). Meta-analyses and case reports have demonstrated the effectiveness of these treatment options in improving pain and functional outcomes in patients with chronic pain after TKA. The purpose of this paper is to review and synthesize the current literature investigating the different ways that refractory pain is managed after TJA, with the goal being to provide treatment recommendations for providers treating these patients.

Does Structured Postgraduate Training Affect the Learning Curve in Direct Anterior Total Hip Arthroplasty? A Single Surgeon's First 200 Cases.

BACKGROUND: The direct anterior approach (DAA) used for primary total hip arthroplasty has been shown to improve early postoperative outcomes, but prior studies have identified a marked learning curve for surgeons transitioning to this approach. However, these studies do not capture surgeons with postgraduate fellowship training in DAA. Therefore, the purpose of this study was to evaluate the learning curve by comparing perioperative outcomes for the first 100 to latter 100 cases and first 50 to final 50 cases. METHODS: The first 200 consecutive primary total hip arthroplasties performed by a single surgeon were prospectively followed up for up to 2 years postoperatively. Data on demographic and perioperative factors, 90-day readmissions, and short- and long-term complications were collected. Radiographic outcomes included acetabular cup anteversion and abduction measurements. Logistic regressions were used to calculate odds ratios and confidence intervals for surgical time greater than 2 hours. RESULTS: The first 100 and second 100 cases had significant differences in operative times (118.1 vs 110.4 minutes, P = .009), acetabular abduction (38.3 vs 35.5 degrees, P = .001) and anteversion (13.5 vs 15.1 degrees, P = .009), and incidence of neuropraxia (41 vs 9%, P < .001). Estimated blood loss, transfusions, discharge disposition, length of stay, readmission, and other complications had no statistical significance between the first and second 100 cases. The first 50 cases had higher odds of surgical time greater than 2 hours (odds ratio = 5.2, 95% confidence interval = 1.84-14.75, P = .002) than the final 50 cases. CONCLUSIONS: When compared with the existing literature, incorporation of DAA into fellowship training can lead to reduction in fractures and reoperation rates.

Annual Nationwide Infection Trends for Revision Total Knee Arthroplasty.

Several recent intraoperative and wound management techniques have been developed and implemented in the United States over the past decade; however, it is unclear what the effects of these newer modalities have on reducing surgical site infection (SSI) rates. Therefore, the purpose of this study was to track the annual rate and trends of (1) overall, (2) deep, and (3) superficial SSIs following revision total knee arthroplasty (TKA). The National Surgical Quality Improvement Program database was queried for all revision TKA cases performed between 2011 and 2016, which yielded 9,887 cases. Cases with superficial and/or deep SSIs were analyzed separately and then combined to evaluate overall SSI rates. After an overall 6-year correlation and trends analysis, univariate analysis was performed to compare the most recent year, 2016, with the preceding 5 years. Correlation coefficients and chi-square tests were used to determine correlation and statistical significance. No significant correlations between combined, deep, and/or superficial SSI rates and year were noted (p > 0.05). The lowest overall SSI incidence was in 2012 (1.16%), while the greatest incidence was in 2014 (1.76%). The deep SSI incidence over the 6 years was 0.67% (66 out of 9,887 cases). Deep SSI rate decreased by 10% in 2016 compared with 2011 (0.50 vs. 0.56%, p > 0.05). In this 6-year period, 94 cases out of 9,887 were complicated by a superficial SSI, an incidence of 0.95%. The lowest superficial SSI incidence occurred in 2015 (n = 17, 0.77%). Overall, the incidence of SSIs in revision TKA has remained fairly low with some annual variance, indicating room for improvement. These variations likely as revision surgeries can be more complex and have several associated confounding factors influencing outcomes, when compared with primary cases. Further research is needed to identify revision-specific strategies to reduce the risk of surgical site infections.

Can the Caprini score predict thromboembolism and guide pharmacologic prophylaxis after primary joint arthroplasty?

AIMS: Venous thromboembolism (VTE) has a 30-day mortality rate of between 10 and 30%. The Caprini score is a VTE risk assessment model, which assigns points to 20 past medical history and current health factors. We hypothesized that the Caprini score could predict VTE incidence and recommend prophylaxis following total joint arthroplasty. PATIENTS AND METHODS: We performed a retrospective review of prospectively collected institutional data identifying Caprini scores on 2155 primary hip (n = 840) and knee (n = 1315) arthroplasties. Surgeons were blinded to Caprini scores when prescribing VTE prophylaxis. Patients were separated into prophylaxis groups receiving Aspirin (81 mg BID or 325 mg BID) or other (Rivaroxaban, Warfarin, Enoxaparin, Apixaban, Dabigatran, Heparin). Univariate, multivariate, and Cohen's effect size analyses assessed the predictive power of the Caprini score on VTE incidence. RESULTS: The mean Caprini score was 9.49 (5-25). A majority, 83% (1792) of patients were in the Aspirin group, and 17% (363) in the other group. Other prophylaxis patients had statistically significantly higher Caprini scores (10 vs. 9, p < 0.0001). Twenty-five (1.2%) patients developed VTE. Controlling for prophylaxis, higher Caprini scores increased VTE risk, but this wasn't statistically significant (p = 0.16). Multivariate analysis showed a non-significant effect for patients with BMIs >40 or Caprini scores ≥11 to predict VTE incidence in the Aspirin or other prophylaxis groups (p = 0.52 and p = 0.15 respectively). Cohen's effect size was small, comparing Caprini scores in patients who had and had not had a VTE in both Aspirin and other prophylaxis groups (Cohen's d = 0.25 and d = 0.16 respectively). CONCLUSION: Surgeons rely on stronger pharmacologic prophylaxis for a select high risk group of their primary lower extremity total joint arthroplasty patients. When controlling for prophylaxis, the Caprini score had a small effect size and did not have the predictive power necessary to guide treatment.

Opioid Use Disorder Is Associated with an Increased Risk of Infection after Total Joint Arthroplasty: A Large Database Study.

BACKGROUND: Recent studies have shown that patients with opioid use disorder have impaired immunity. However, few studies with large patient populations have evaluated the risks of surgical site infection (SSI) and prosthetic joint infection (PJI) with opioid use disorder after total joint arthroplasty (TJA), and there is a lack of evidence for revision TJA in particular. QUESTIONS/PURPOSES: Are patients with opioid use disorder who undergo (1) primary THA, (2) primary TKA, (3) revision THA, or (4) revision TKA at a higher risk of experiencing SSIs 90 days after surgery or PJIs 2 years after surgery than those who do not have opioid use disorder? METHODS: All primary and revision TJAs performed between 2005 and 2014 were identified from the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is one of the largest nationwide databases; it comprehensively and longitudinally tracks patients based on all insurance claims rather than particular hospital visits, and has a low error rate (estimated at 1.3%). Boolean command operators were used to form a study group of patients with a history of opioid use disorder before surgery. ICD-9 diagnosis codes 304.00 to 304.02 and 305.50 to 305.52 were used to identify patients with opioid use disorder. Study group patients were matched 1:1 to control participants without opioid use disorder undergoing TJA, according to age, sex, and comorbidity burden (Elixhauser comorbidity index [ECI]). The ECI is comprised of 31 different comorbidities and can be used for large administrative databases. The query yielded a study population of 54,332 patients: 14,944 undergoing primary THA (opioid use disorder: n = 7472), 23,680 undergoing primary TKA (opioid use disorder: n = 11,840), 8116 undergoing revision THA (opioid use disorder: n = 4058), and 7592 undergoing revision TKA (opioid use disorder: n = 3796). The primary outcomes analyzed were SSI at 90 days and PJI at 2 years postoperatively, which were identified with ICD-9 codes. Logistic regression analyses were performed to calculate the risk that an infection would develop in a patient with opioid use disorder compared with the matched control patients without opioid use disorder. RESULTS: Patients with opioid use disorder undergoing primary THA had an increased risk of SSI at 90 days (OR 1.85 [95% CI 1.51 to 2.25]; p < 0.001) and PJI at 2 years (OR 1.66 [95% CI 1.42 to 1.93]; p < 0.001). Compared with matched controls, opioid use disorder patients undergoing primary TKA had an increased risk of SSI at 90 days (OR 1.72 [95% CI 1.46 to 2.02]; p < 0.001) and PJI at 2 years (OR 1.31 [95% CI 1.16 to 1.47]; p < 0.001). Similarly, for revision THAs, there was an increase in 90-day SSIs (OR 1.89 [95% CI 1.53 to 2.32]; p < 0.001) and 2-year PJIs (OR 4.24 [95% CI 3.67 to 4.89]; p < 0.001). The same held for revision TKAs for 90-day SSIs (OR 1.88 [95% CI 1.53 to 2.29]; p < 0.001) and 2-year PJIs (OR 4.94 [95% CI 4.24 to 5.76]; p < 0.001). CONCLUSIONS: After accounting for age, sex, and comorbidity burden, these results revealed that patients with opioid use disorder undergoing TJA were at increased risk of having SSIs and PJIs. Based on these findings, healthcare systems and/or administrators should recognize the increased associated PJI and SSI risks in patients with opioid use disorder and enact clinical policies that reflect these associated risks. Additionally, these findings should encourage surgeons to pursue multidisciplinary approaches to help patients reduce their opioid consumption before their arthroplasty procedure. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Are Risk Factors for Infection after Primary or Revision Total Joint Arthroplasty in Patients Older Than 80 Years?

BACKGROUND: Patients older than 80 years of age form an increasing proportion of the patient population undergoing total joint arthroplasty (TJA). With increasing life expectancy and the success of TJA, orthopaedic surgeons are more likely to operate on patients older than 80 years than ever before. Given that most other studies focus on younger populations, only evaluate primary TJA, or limit patient populations to institutional or regional data, we felt a large-database, nationwide analysis of this demographic cohort was warranted, and we wished to consider both primary and revision TJA. QUESTIONS/PURPOSES: In this study, we sought to investigate the risk factors for surgical site infections (SSIs) at 90 days and periprosthetic joint infections (PJIs) at 2 years after surgery in patients aged 80 years and older undergoing (1) primary and (2) revision lower extremity TJA. METHODS: All patients aged 80 years or older who underwent primary or revision TJA between 2005 and 2014 were identified using the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is unique in that it is one of the largest nationwide databases, and so it provides a large enough sample size of patients 80 years or older. Additionally, this database provides comprehensive and longitudinal patient data tracking, and a low error rate. Our final cohort consisted of 503,241 patients (TKA: n = 275,717; THA: n = 162,489; revision TKA: n = 28,779; revision THA: n = 36,256). Multivariate logistic regression models were constructed to evaluate the association of risk factors on the incidences of 90-day SSI and 2-year PJI. Variables such as sex, diabetes, BMI, and congestive heart failure, were included in the multivariate regression models. Several high-risk comorbidities as identified by the Charlson and Elixhauser comorbidity indices were selected to construct the models. We performed a Bonferroni-adjusted correction to account for the fact that multiple statistical comparisons were made, with a p value < 0.002 being considered statistically significant. RESULTS: For primary TKA patients, an increased risk of 90-day SSIs was associated with male sex (OR 1.28 [95% CI 1.25 to 1.52]; p < 0.001), BMI greater than 25 k/m (p < 0.001), and other comorbidities. For primary THA patients, an increased risk of 90-day SSIs was associated with patients with obesity (BMI 30-39 kg/m; OR 1.91 [95% CI 1.60 to 2.26]; p < 0.001) and those with morbid obesity (BMI 40-70 kg/m; OR 2.58 [95% CI 1.95 to 3.36]; p < 0.001). For revision TKA patients, an increased risk of SSI was associated with iron-deficiency anemia (OR 1.82 [95% CI 1.37 to 2.28]; p < 0.001). For revision THA patients, electrolyte imbalance (OR 1.48 [95% CI 1.23 to 1.79]; p < 0.001) and iron-deficiency anemia (OR 1.63 [95% CI 1.35 to 1.99]; p < 0.001) were associated with an increased risk of 90-day SSI. Similar associations were noted for PJI in each cohort. CONCLUSIONS: These findings show that in this population, male sex, obesity, hypertension, iron-deficiency anemia, among other high-risk comorbidities are associated with a higher risk of SSIs and PJIs. Based on these findings, orthopaedic surgeons should actively engage in comanagement strategies with internists and other specialists to address modifiable risk factors through practices such as weight management programs, blood pressure reduction, and electrolyte balancing. Furthermore, this data should encourage healthcare systems and policy makers to recognize that this patient demographic is at increased risks for PJI or SSI, and these risks must be considered when negotiating payment bundles. LEVEL OF EVIDENCE: Level III, therapeutic study.

Outcomes of Cementless-Backed Patellar Components.

Because of the early follow-up positive outcomes with cementless fixation, continued evaluations need to be performed to ensure longer-term efficacy. Additionally, although many studies report on the results of femoral and tibial component fixation, few studies report specifically on patellar outcomes. Therefore, the purpose of this study was to report on the: (1) implant survivorship; (2) complications; and (3) radiographic outcomes in a large cohort of patients who received cementless total knee arthroplasties (TKAs), with particular attention to the patellar component. A total of 261 patients who underwent cementless TKA by a single, high-volume academic surgeon were studied. Patients had a mean age of 66 years and were distributed between 192 women (74%) and 69 men. All patients received the same cementless tibial, femoral, and patellar components. Mean follow-up period was 4.5 years (range, 4-5 years). Primary outcomes evaluated included all postoperative complications, with particular emphasis on the patellar component. Only one patellar loosened leading to a patellar aseptic loosening rate of 0.3% (1 of 261). The one patellar loosening was the component being dislodged after a manipulation under anesthesia (MUA) at 6 weeks. This was revised to a cemented component and the patient is doing well 4 years later. A second patient experienced a patellar tendon rupture, later surgically repaired. Another patient sustained a patella fracture that was managed nonoperatively. The fracture healed by 1 year and the patient continued to have an otherwise successful outcome, now at 2 years follow-up. No progressive radiolucencies, subsidence, or changes in initial postoperative axial alignment were observed at final follow-up. The results from this study highlight a 98% success rate at mean 4.5 years follow-up in a large cohort of patients with a diverse spread of demographic details. Specific to the patella, only one patient experienced an adverse event, which was managed nonoperatively. Therefore, based on this data, patellar fixation in cementless TKA can be considered a safe technique.

The Case for Cementless Total Knee Arthroplasty.

The demographics of total knee arthroplasty (TKA) patients are changing. Individuals are more active, younger, and more obese. These changing demographics and a higher demand for longevity creates a new challenge for reliable and long-term implant fixation. Historically, cemented fixation has remained the gold standard, as cementless design and techniques from the 1980s and 1990s did not obtain long-term positive outcomes due to a failure of ingrowth onto the implants. Advances in the modern-day cementless TKA designs appear to have overcome their initial challenges, indicating the dependence of cementless TKA on implant design. However, there remains the perception that cementless total knee arthroplasty are inferior to cemented TKA. This review discusses the longer-term survivorship data for recent systems, which has shown the potential advantages of cementless fixation.

The Effect of Bladder Catheterization on Ambulation and Venous Thromboembolism Following Total Knee Arthroplasty: An Institutional Analysis.

BACKGROUND: Although intermittent catheters are immediately removed, indwelling catheterization may lead to decreased ambulation and participation in physical therapy, critical components to post-total knee arthroplasty (TKA) management. Therefore, this study aimed to compare the effect of catheterization treatments on (1) postoperative ambulation distances, (2) deep vein thromboses (DVTs), and (3) pulmonary emboli (PEs) following TKA. METHODS: A total of 9123 prospectively collected primary TKA patients were assessed based on postoperative catheter status. Patient demographics, Charlson Comorbidity Indices, body mass indices, DVT prophylaxes, first ambulation distances, DVTs, and PEs were collected at approximately mean 12 months of follow-up. Univariate and multivariate analyses were performed with independent t-tests and multiple linear regression models in order to compare catheterization techniques. RESULTS: There were 1193 patients who had urinary retention and treated with either indwelling only (62%, n = 734), both indwelling and intermittent catheterizations (13%, n = 160), or intermittent only (25%, n = 299). Multivariate analyses found that indwelling catheter-only use had an 11% decrease in ambulation distance (P < .001). Additionally, the indwelling catheterization-only group was found to be at increased risk of DVTs (odds ratio 2.605, P < .001), even after controlling for DVT prophylaxes (odds ratio 2.807, P < .001). CONCLUSION: This study showed that the use of an indwelling catheter for treatment of urinary retention significantly decreased TKA patient ambulation distance and subsequently increased the risk for DVTs. This information is important as we would recommend the treatment with intermittent catheterization rather than indwelling catheters to decrease the risk of immobilization and postoperative DVTs.

Does Intermittent Catheterization Compared to Indwelling Catheterization Decrease the Risk of Periprosthetic Joint Infection Following Total Knee Arthroplasty?

BACKGROUND: Catheterization for the prophylaxis against or treatment for urinary retention commonly occurs after total knee arthroplasty (TKA). Recent studies have questioned the use of the indwelling catheterization, especially in its potential role as a nidus for infection. We are still unsure of its downstream effects on periprosthetic joint infections (PJIs). Therefore, this study aimed to compare the risks of postoperative PJI following intermittent vs indwelling catheterization after TKA. METHODS: Between 2017 and 2019, 15 hospitals in a large health system collected data on patients undergoing TKA. Patient treatments with indwelling catheter only, intermittent straight catheter only, and both indwelling and intermittent straight catheterizations were recorded. Patient demographics, comorbidities, body mass indices, and PJIs were collected from time of surgery to time of data collection at mean 14 months of follow-up. Univariate and multivariate analyses were performed with independent t-tests and multiple linear regression models to compare catheterization treatment types. RESULTS: A total of 9123 TKAs were performed, with patients receiving indwelling catheter only (62%, n = 734), intermittent straight catheter only (25%, n = 299), or both indwelling and intermittent catheterizations (13%, n = 160). Univariate analyses showed that PJIs occurred in 1.1% of no-catheter patients and 2.3% of patients treated with bladder catheterization (P = .002). Using multivariate analyses, indwelling catheter use (odds ratio [OR] 2.647, P < .001), diabetes (OR 1.837, P = .005), and peripheral vascular disease (OR 2.372, P = .046) were found to have a statistically significant increased risk for PJIs. The use of intermittent straight catheterization (OR 1.249, P = .668) or both indwelling and intermittent (OR 1.171, P = .828) did not increase the risk for PJIs. CONCLUSION: Urinary bladder catheterization is commonly required for prophylaxis against or treatment for urinary retention following TKA. The use of a urinary catheter can provide a potential nidus for infection in these patients. This study found that indwelling catheterization, but not intermittent catheterization, was associated with an increased risk for PJI. Surgeons should therefore limit the duration of catheterization in an effort to decrease the risk for PJI.

The Cumulative Effect of Substance Abuse Disorders and Depression on Postoperative Complications After Primary Total Knee Arthroplasty.

BACKGROUND: Substance abuse disorder (SUD), alcohol abuse disorder (AUD), and depression have been identified as independent risk factors for complications after total knee arthroplasty (TKA). However, these mental health disorders are highly co-associated, and their cumulative effect on postoperative complications have not been investigated. Therefore, this study aimed to determine if patients who have more than one mental health disorder (SUD, AUD, or depression) were at an increased risk for postoperative complications following TKA. METHODS: A total of 11,403 TKA patients were identified from a prospectively collected institutional database between January 1, 2017 and April 1, 2019. Patients who had depression, SUD, and AUD were separated into 7 mental health subgroups including each of these diagnoses alone and their combined permeations. Patient demographics, body mass indices, medical comorbidities, and 15 postoperative complications were collected. Univariate analyses were performed using independent Student's t-tests. Multivariate analyses were then performed to identify odds ratios (ORs) for mental health disorders subgroups associated with complications. RESULTS: We found a total of 2073 (18%) patients diagnosed with either SUD (4%), AUD (0.6%), or depression (12%). Univariate analyses showed that depression was associated with mechanical failures (P < .001). SUD was associated with periprosthetic joint infection (PJI) (P < .001), wound complications (P = .022), and aseptic loosening (P = .007). AUD was associated with PJI (P < .001) and deep vein thromboses (P = .003). Multivariate analyses found that AUD (OR: 19.419, P < .001) and SUD (OR:3.693, P = .010) were independent risk factors for PJI. Compared with SUD alone, patients with depression plus SUD were found to have a 4-fold (OR: 13.639, P < .001) and 2-fold (OR:4.401, P = .021) increased risk for PJI and cellulitis, respectively. CONCLUSIONS: Patients who had depression, SUD, or AUD were at increased risk for postoperative complications following primary TKA. When patients have more than one mental health diagnosis, their risk for complications was amplified. The results of this study can help identify those patients who are at greater risk of postoperative complications to enable improved preoperative optimization and patient education.

The Effect of Bladder Catheterization Technique on Postoperative Urinary Tract Infections After Primary Total Hip Arthroplasty.

BACKGROUND: Urinary bladder catheters are potential sources of infection after total hip arthroplasty (THA). Therefore, the goal of this study was to determine if intermittent catheterization provides a decreased risk of postoperative urinary tract infections (UTIs) compared with indwelling catheterization in THA patients. METHODS: Patients undergoing THA at 15 hospitals within a large health system were prospectively collected between 2017 and 2019 and then stratified based on catheterization technique: no-catheter; indwelling catheter-only; intermittent catheter-only; and both intermittent and indwelling catheter. Patient demographics, medical comorbidities, anesthesia types, and postoperative UTIs were assessed. Independent Student t-tests were used to perform univariate analyses for the catheterization groups. Multiple linear regression models were used to compare the different groups while controlling for confounding variables. RESULTS: There were a total of 7306 THA patients recorded with 5513 (75%) no-catheter, 1181 (16%) indwelling catheter-only, 285 (3.9%) intermittent catheter-only, and 327 (4.5%) indwelling and intermittent catheterization patients. A total of 580 patients experienced postoperative UTI. Urinary bladder catheterization increased the risk of postoperative UTIs (P < .001) in univariate analyses. Multiple linear regression models showed that indwelling catheter-only (OR: 2.178, P < .001), intermittent catheterization (OR: 1.975, P = .003), and both indwelling and intermittent (OR: 2.372, P = .002) were more likely to experience UTIs compared with no catheters. CONCLUSION: This study found that patients treated with indwelling catheterization, with or without preceding intermittent catheterization, were significantly more likely to experience UTIs. Therefore, in an effort to decrease the risk of UTIs, THA patients experiencing postoperative urinary retention should be treated with intermittent catheterization.

The Center-Center Technique for the Direct Anterior Approach in Total Hip Arthroplasty: Precise Femoral Canal Preparation to Optimize Implant Fit and Fill.

BACKGROUND: The use of the direct anterior approach has been criticized as a significant risk factor for subsidence, perioperative fracture, and thigh pain. Therefore, the purpose of our study was to evaluate the outcome of using the center-center technique via the direct anterior approach. MATERIALS AND METHODS: Consecutive elective primary total hip arthroplasties performed using the center-center technique were retrospectively reviewed from May 2015 to February 2017. All cases were performed by a single surgeon at a high-volume, large academic center. The technique focuses on central alignment of the implant on both anteroposterior and lateral radiographs. Standardized objective radiographic measurements were taken at the first two-week follow-up visit to determine the fit and fill at the proximal and distal anatomic segments. Subsidence was measured by comparing the implant position at final follow up to the initial two-week postoperative visit. Other complications: intra- or postoperative fracture, infection, revision, and patient-reported thigh pain were further assessed. Functional postoperative outcomes were assessed using the Harris Hip Score (HHS). RESULTS: A total of 138 patients with a mean age of 65 years and average follow up of 2.8 years were assessed. The mean postoperative HHS was 90 points (59-100). Mean implant subsidence was 1mm. A total of 90% (124) of implants had acceptable radiographic fit and fill in both proximal and distal segments. A majority 74% (102) of implants subsided less than 1mm, and 91% (126) subsided less than 2mm. One implant had radiographic subsidence of 9mm, which was treated with a shoe lift. There were no intraoperative fractures. One postoperative lateral cortex fracture three weeks after surgery due to mechanical fall was treated conservatively. No patients required revision arthroplasty for any reason or reported postoperative thigh pain. CONCLUSION: The center-center technique can be used to consistently aid in proper femoral stem placement in both coronal and sagittal planes. Optimal fit and fill can be achieved safely using this technique.

Have We Actually Reduced Our 30-Day Short-Term Surgical Site Infection Rates in Primary Total Hip Arthroplasty in the United States?

BACKGROUND: The purpose of this study is to track the 30-day postoperative annual rates and trends of (1) overall, (2) deep, and (3) superficial surgical site infections (SSIs) following total hip arthroplasty (THA) using a large nationwide database. METHODS: The National Surgical Quality Improvement Program database was queried for all THA cases performed between 2012 and 2016. After an overall 5-year correlation and trends analysis, univariate analysis was performed to compare the most recent year, 2016, with the preceding 4 years. Correlation coefficients and chi-squared tests were used to determine correlation and statistical significance. RESULTS: The lowest incidence of SSIs was in the most recent year, 2016 (0.81%), while the greatest incidence was in the earliest year, 2012 (1.12%), marking a 31% decrease (P < .01). The lowest rate was in the most recent year, 2016 (0.23%), marking a 26% decrease from 2012. The lowest superficial SSI incidence occurred in the most recent year, 2016 (0.58%), while greatest incidence was in 2012 (0.83%), marking a 31% decrease over time (P < .05). There was an inverse correlation among overall, deep, and superficial SSI rates with operative year. CONCLUSION: The findings from this study suggest a decreasing trend in SSIs within 30 days following THA. Furthermore, deep SSIs, which can pose substantial threats to implant survivorship, have also decreased throughout the years. These results highlight that potentially through improved medical and surgical techniques, we are winning the fight against short-term infections, but that more can still be done.