Outcome of cefazolin prophylaxis for total knee arthroplasty at an institution with high prevalence of methicillin-resistant Staphylococcus aureus infection.

OBJECTIVES: The aim of this study was to evaluate the outcome of cefazolin prophylaxis for total knee arthroplasty (TKA) in a hospital with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection. METHODS: Since July 1, 2006, we have applied a 'care bundle' to TKA to prevent surgical site infection (SSI) without using vancomycin as antimicrobial prophylaxis, in accordance with the 1999 Hospital Infection Control Practices Advisory Committee guidelines. All patients undergoing TKA from July 1, 2006 to September 30, 2009 were enrolled. We reviewed data on SSI collected prospectively as part of routine infection control surveillance. RESULTS: Of 1323 TKAs, an SSI developed in 14 (1.06%) cases, which is comparable to the percentage obtained in other previous reports. When stratified by the National Nosocomial Infection Surveillance risk index, SSI rates were 0.86% (8/926), 1.30% (5/384), and 7.69% (1/13) in risk categories 0, 1, and 2, respectively. Of 14 SSIs, four (29%) were classified as superficial incisional, two (14%) as deep incisional, and eight (57%) as organ-space SSI. CONCLUSIONS: Our data suggest that antimicrobial prophylaxis using only cefazolin can maintain low SSI rates if other important infection management measures are employed, even where there is a high prevalence of MRSA infection.

Subcutaneous versus intraarticular indwelling closed suction drainage after TKA: a randomized controlled trial.

BACKGROUND: TKA can involve substantial bleeding, and the issue regarding whether vacuum drainage should be used during TKA continues to be debated as both methods have disadvantages. QUESTIONS/PURPOSES: We therefore asked whether subcutaneous indwelling vacuum drainage is advantageous over intraarticular indwelling vacuum drainage in terms of blood drainage, bleeding-related complications, and functional outcomes in primary TKA. PATIENTS AND METHODS: We randomized 111 patients undergoing TKAs to have either a subcutaneous indwelling or an intraarticular indwelling catheter and compared the two groups for blood loss (hemoglobin decrease, transfusion requirements, hypotension episode), incidence of wound problems (requirements for dressing reinforcement, oozing, hematoma, hemarthrosis, ecchymosis, infection), and functional outcomes (recovery of motion arc, American Knee Society, WOMAC, and SF-36 scores) at 12 months after surgery. RESULTS: The mean vacuum drainage volume was less in the subcutaneous indwelling group than in the intraarticular indwelling group (140 mL versus 352 mL). The groups were similar in terms of decreases in hemoglobin after 2 and 5 days (3.0 versus 3.3 g/dL and 3.3 versus 3.7 g/dL, respectively), allogenic transfusion requirements (4% versus 11%), incidence of wound problems, and functional scores. CONCLUSIONS: The data suggest subcutaneous indwelling closed-suction drainage is a reasonable alternative to intraarticular indwelling closed-suction drainage and to no suction drainage. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical value of regular passive ROM exercise by a physical therapist after total knee arthroplasty.

Regular passive ROM exercise (PROME) by a physical therapist is often incorporated in rehabilitation protocols after total knee arthroplasty (TKA). This randomized, controlled trial examined whether or not the incorporation of PROME to a postoperative rehabilitation protocol would offer a better clinical outcome after TKA. Fifty consecutive patients who underwent bilateral TKAs staged 2 weeks apart received PROME for one knee and not for the other. The pain level (7D and 14D), patient's preference (before discharge, 6M), maximum flexion (7D, 14D, 3M, 6M) and American Knee Society and WOMAC scores (6M) were determined in the knees with and without PROME and compared. There were no significant differences in the maximum flexion, pain level, patient's preference, AKS scores and WOMAC scores. This study demonstrates that the incorporation of PROME does not offer additional clinical benefits to the patients after TKA. Our findings may suggest that encouraging patients to perform active ROM exercise would be a better option and that a physiotherapy session by a physical therapist can focus on more functional rehabilitation, such as preparing to return to daily activities.

Normative Temporal Values of CRP and ESR in Unilateral and Staged Bilateral TKA.

UNLABELLED: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) play helpful roles in determining the presence of infection after TKA. To provide baseline values, we documented normative temporal values of CRP and ESR in unilateral and staged bilateral TKAs for osteoarthritis. Levels of CRP and ESR were evaluated before surgery and on the first, second, fifth, seventh, fourteenth, forty-second, and ninetieth postoperative days in 320 uncomplicated primary TKAs. C-reactive protein and ESR levels were compared in three groups: unilateral (108 knees), first knee bilateral (106 knees), and second knee bilateral (106 knees) groups. All three groups exhibited similar temporal patterns. Mean CRP levels increased rapidly, reaching a peak on the second day and decreased to less than the normal reference level on the forty-second day. They returned to preoperative levels on the ninetieth day. Mean ESR levels peaked on the fifth day and returned close to the preoperative levels only on the ninetieth day. Wide variations were observed and many cases (43%) did not follow the typical patterns. C-reactive protein had greater fold changes, less frequent atypical temporal patterns, and lower correlation between preoperative and postoperative levels than ESR. Our findings should help surgeons interpret CRP and ESR to determine the presence of infection after TKA. LEVEL OF EVIDENCE: Level I, diagnostic study.

Intraobserver and interobserver reliability of the assessment of the patellar articular cartilage in osteoarthritic patients undergoing total knee arthroplasty.

This study was performed to investigate intraobserver and interobserver reliability of the intraoperative assessment of patellar cartilage status and the decision on patellar resurfacing based on the cartilage assessment in osteoarthritic patients undergoing total knee arthroplasty. Photographs of patellar cartilage were taken in 80 knees of 53 patients undergoing total knee arthroplasty. Three investigators assessed the depth and size of the cartilage lesion and made a decision on patellar resurfacing, using the photographs twice. Intraobserver and interobserver reliabilities were calculated with the kappa coefficient. Cartilage assessment had substantial intraobserver (kappa = 0.77 for depth and 0.71 for size) and moderate interobserver (kappa = 0.54 for depth and 0.45 for size) reliabilities. Decision on patellar resurfacing had almost perfect intraobserver and substantial interobserver reliabilities (kappa = 0.88 and 0.68, respectively). We found that intraoperative assessment of the patellar articular cartilage and the decision for patellar resurfacing are reliable.