AAHKS Surgical Techniques & Technologies Award: Inferior Screw Fixation Decreases Acetabular Component Failure Following Revision Total Hip Arthroplasty.

BACKGROUND: Adjunctive screw fixation has been shown to be reliable in achieving acetabular component stability in revision total hip arthroplasty (THA). The purpose of this study was to assess the effect of inferior screw placement on acetabular component failure following revision THA. We hypothesized that inferior screw fixation would decrease acetabular failure rates. METHODS: We reviewed 250 patients who had Paprosky Type II or III defects who underwent acetabular revision between 2001 and 2021 across three institutions. Demographic factors, the number of screws, location of screw placement (superior versus inferior), use of augments and/or cup-cage constructs, Paprosky classification, and presence of discontinuity were documented. Multivariate regression was performed to identify the independent effect of inferior screw fixation on the primary outcome of aseptic rerevision of the acetabular component. RESULTS: At a mean follow-up of 53.4 months (range, 12 to 261), 16 patients (6.4%) required re-revision for acetabular loosening. There were 140 patients (56.0%) who had inferior screw fixation, all of whom did not have neurovascular complications during screw placement. Patients who had inferior screws had a lower rate of acetabular rerevision than those who only had superior screw fixation (2.1 versus 11.8%, P = .0030). Multivariate regression demonstrates that inferior screw fixation decreased the likelihood of rerevision for acetabular loosening when compared to superior screw fixation alone (odds ratio: 0.1, confidence interval: 0.03 to 0.5; P = .0071). No other risk factors were identified. CONCLUSIONS: Inferior screw fixation is a safe and reliable technique to reduce acetabular component failure following revision THA in cases of severe acetabular bone loss.

Diagnostic Test Performances for Identifying Periprosthetic Joint Infection in Hip Hemiarthroplasty.

INTRODUCTION: Periprosthetic joint infection (PJI) is a devastating complication of hip hemiarthroplasty (HHA) that is not well-represented in the literature. Therefore, this study aimed to evaluate diagnostic markers for identifying PJI in patients after HHA and compare them with the most recent 2018 International Consensus Meeting on Musculoskeletal Infection criteria. METHODS: A total of 98 patients (64 PJIs, 65.3%) were analyzed. Patients were identified by relevant Current Procedural Terminology and International Classification of Diseases-9/10 codes from 2000 to 2021 across a single healthcare system. Preoperative or intraoperative synovial fluid nucleated cell (NC) count, synovial polymorphonuclear (PMN) percentage, serum erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), and serum white blood cell count were compared with Student t -test between aseptic and septic cohorts. Diagnostic utility and laboratory cutoff values were determined using receiver-operating characteristic curves and Youden index, respectively. RESULTS: Mean values were significantly higher in the septic cohort for synovial NC count (120,992.2 versus 1,498.0 cells/µL, P < 0.001), synovial PMN percentage (91.3% versus 56.2%, P < 0.001), serum ESR (75.6 versus 36.3 mm/hr, P < 0.001), serum CRP (20.2 versus 125.8 mg/L, P < 0.001), and serum white blood cell count (8.5 versus 11.5 cells/µL, P < 0.001). Synovial NC count, synovial PMN percentage, and serum CRP had excellent PJI discriminatory ability with an area under the curve of 0.99, 0.90, and 0.93, respectively. Optimal cutoffs were 2,700 cells/µL for synovial NC count (100% sensitivity and 94% specificity), 81.0% for synovial PMN percentage (96% sensitivity and 89% specificity), 52.0 mm/hr for serum ESR (75% sensitivity and 80% specificity), and 40.0 mg/L for serum CRP (85% sensitivity and 92% specificity). CONCLUSION: Our findings support the continued use of routine serum and synovial fluid tests for diagnosing PJI in HHA patients. Optimal cutoff values for both synovial fluid biomarkers were very close in alignment with the 2018 International Consensus Meeting criteria. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Does the Primary Surgical Approach Matter When Choosing the Approach for Revision Total Hip Arthroplasty?

BACKGROUND: Multiple surgical approaches are used for primary total hip arthroplasty (pTHA) and revision total hip arthroplasty (rTHA). This study sought to investigate prevalence of discordance of pTHA and rTHA surgical approaches and to evaluate how approach concordance impacts postoperative outcomes. METHODS: A retrospective review of patients who underwent rTHA from 2000 to 2021 was conducted at 3 large urban academic centers. Patients who had minimum 1-year follow-up post-rTHA were included and grouped based on whether they received pTHA via a posterior (PA), direct anterior (DA), or laterally based (DL) approach, and by concordance of index rTHA approach with their pTHA approach. Of the 917 patients studied, 839 (91.5%) were included in the concordant cohort and 78 (8.5%) in the discordant cohort. Patient demographics, operative characteristics, and postoperative outcomes were compared. RESULTS: Discordance was most prevalent in the DA-pTHA subset (29.5%), compared to the DL-pTHA subset (14.7%) or PA-pTHA subset (3.7%). Discordance varied significantly between primary approaches among all revisions, with DA-pTHA patients having the highest discordance rate for patients revised for aseptic loosening (46.3%, P < .001), fracture (22.2%, P < .001), and dislocation (33.3%, P < .001). There were no differences between groups in dislocation rate, re-revision for infection, or re-revision for fracture. CONCLUSION: The results of this multicenter study showed patients who received pTHA via the DA were more likely to receive rTHA via a discordant approach compared to other primary approaches. Since approach concordance did not impact dislocation, infection, or fracture rates after rTHA, surgeons can feel reassured using a separate approach for rTHA. LEVEL III EVIDENCE: Retrospective Cohort Study.

The Dome Technique for Managing Massive Anterosuperior Medial Acetabular Bone Loss in Revision Total Hip Arthroplasty: Short-Term Outcomes.

Purpose: The dome technique is a technique used in performance of revision total hip arthroplasty (THA) involving intraoperative joining of two porous metal acetabular augments to fill a massive anterosuperior medial acetabular bone defect. While excellent outcomes were achieved using this surgical technique in a series of three cases, short-term results have not been reported. We hypothesized that excellent short-term clinical and patient reported outcomes could be achieved with use of the dome technique. Materials and Methods: A multicenter case series was conducted for evaluation of patients who underwent revision THA using the dome technique for management of Paprosky 3B anterosuperior medial acetabular bone loss from 2013-2019 with a minimum clinical follow-up period of two years. Twelve cases in 12 patients were identified. Baseline demographics, intraoperative variables, surgical outcomes, and patient reported outcomes were acquired. Results: The implant survivorship was 91% with component failure requiring re-revision in only one patient at a mean follow-up period of 36.2 months (range, 24-72 months). Three patients (25.0%) experienced complications, including re-revision for component failure, inter-prosthetic dual-mobility dissociation, and periprosthetic joint infection. Of seven patients who completed the HOOS, JR (hip disability and osteoarthritis outcome score, joint replacement) survey, five patients showed improvement. Conclusion: Excellent outcomes can be achieved using the dome technique for management of massive anterosuperior medial acetabular defects in revision THA with survivorship of 91% at a mean follow-up period of three years. Conduct of future studies will be required in order to evaluate mid- to long-term outcomes for this technique.

Visceral Fat as a Risk Factor for Periprosthetic Joint Infection After Total Hip and Knee Arthroplasty.

BACKGROUND: Visceral obesity, a strong indicator of chronic inflammation and impaired metabolic health, has been shown to be associated with poor postoperative outcomes and complications. This study aimed to evaluate the relationship between visceral fat area (VFA) and periprosthetic joint infection (PJI) in total joint arthroplasty (TJA) patients. METHODS: A retrospective study of 484 patients who had undergone a total hip or knee arthroplasty was performed. All patients had a computed tomography scan of the abdomen/pelvis within two years of their TJA. Body composition data (ie, VFA, subcutaneous fat area, and skeletal muscle area) were calculated at the Lumbar-3 vertebral level via two fully automated and externally validated machine learning algorithms. A multivariable logistic model was created to determine the relationship between VFA and PJI, while accounting for other PJI risk factors. Of the 484 patients, 31 (6.4%) had a PJI complication. RESULTS: The rate of PJI among patients with VFA in the top quartile (> 264.1 cm2) versus bottom quartile (< 82.6 cm2) was 5.6% versus 10.6% and 18.8% versus 2.7% in the total hip arthroplasty and total knee arthroplasty cohorts, respectively. In the multivariate model, total knee arthroplasty patients with a VFA in the top quartile had a 30.5 times greater risk of PJI than those in the bottom quartile of VFA (P = .0154). CONCLUSION: VFA may have a strong association with PJI in TJA patients. Using a standardized imaging modality like computed tomography scans to calculate VFA can be a valuable tool for surgeons when assessing risk of PJI.

A Matched Comparison of the Rates of Achieving the Minimal Clinically Important Difference Following Conversion and Primary Total Hip Arthroplasty.

BACKGROUND: Patient-reported outcome measures (PROMs) are often lower following conversion total hip arthroplasty (cTHA) compared to matched primary total hip arthroplasty (THA) controls. However, the minimal clinically important differences (MCIDs) for any PROMs are yet to be analyzed for cTHA. This study aimed to (1) determine if patients undergoing cTHA achieve primary THA-specific 1-year PROM MCIDs at comparable rates to matched controls undergoing primary THA and (2) establish 1-year MCID values for specific PROMs following cTHA. METHODS: A retrospective case-control study was conducted using 148 cases of cTHA which were matched 1:2 to 296 primary THA patients. Previously defined anchor values for 2 PROM measures in primary THA were used to compare cTHA to primary THA, while novel cTHA-specific MCID values for 2 PROMs were calculated through a distribution method. Predictors of achieving the MCID of PROMs were analyzed through multivariate logistic regressions. RESULTS: Conversion THA was associated with decreased odds of achieving the primary THA-specific 1-year Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement PROM (Odds Ratio: 0.319, 95% Confidence Interval: 0.182-0.560, P < .001) and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a PROM (Odds Ratio: 0.531, 95% Confidence Interval: 0.313-0.900, P = .019) MCIDs in reference to matched primary THA patients. Less than 60% of cTHA patients achieved an MCID. The 1-year MCID of the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a specific to cTHA were +10.71 and +4.68, respectively. CONCLUSION: While cTHA is within the same diagnosis-related group as primary THA, patients undergoing cTHA have decreased odds of achieving 1-year MCIDs of primary THA-specific PROMs. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Sarcopenia is an independent risk factor for failure to achieve the 1-year MCID of the KOOS, JR and PROMIS PF-SF10a after TKA.

BACKGROUND: Sarcopenia, which is a progressive and multifactorial condition of decreased muscle strength, has been identified as an independent predictor for falls, revision, infection, and readmissions following total knee arthroplasty (TKA), but its association to patient reported outcomes (PROMs) is less studied. The aim of this study is to determine if sarcopenia and other measures of body composition are correlated with ability to achieve the 1-year minimal clinically important difference (MCID) of the KOOS JR and PROMIS-PF-SF10a following primary TKA. METHODS: A multicenter retrospective case-control study was performed. Inclusion criteria consisted of patients over the age of 18 undergoing primary TKA, body composition metrics determined by computed tomography (CT), and available pre- and post-operative PROM scores. Predictors of achievement of the 1-year MCID of the KOOS JR and PROMIS PF-SF-10a were determined through a multivariate linear regression. RESULTS: 140 primary TKAs met inclusion criteria. 74 (52.85%) patients achieved the 1-year KOOS, JR MCID and 108 (77.41%) patients achieved the 1-year MCID for the PROMIS PF-SF10a. Sarcopenia was independently associated with decreased odds of achieving the MCID of both the KOOS, JR (OR 0.31, 95%CI 0.10-0.97, p = 0.04) and the PROMIS-PF-SF10a (OR 0.32, 95%CI 0.12-0.85, p = 0.02) CONCLUSIONS: In our study, sarcopenia was independently associated with increased odds of failure to achieve the 1-year MCID of the KOOS, JR and PROMIS PF-SF10a after TKA. Early identification of sarcopenic patients may be beneficial for arthroplasty surgeons so that targeted nutritional counseling and exercises can be recommended prior to TKA.

Which Factors Are Considered by Patients When Considering Total Joint Arthroplasty? A Discrete-choice Experiment.

BACKGROUND: TKA and THA are major surgical procedures, and they are associated with the potential for serious, even life-threatening complications. Patients must weigh the risks of these complications against the benefits of surgery. However, little is known about the relative importance patients place on the potential complications of surgery compared with any potential benefit the procedures may achieve. Furthermore, patient preferences may often be discordant with surgeon preferences regarding the treatment decision-making process. A discrete-choice experiment (DCE) is a quantitative survey technique designed to elicit patient preferences by presenting patients with two or more hypothetical scenarios. Each scenario is composed of several attributes or factors, and the relative extent to which respondents prioritize these attributes can be quantified to assess preferences when making a decision, such as whether to pursue lower extremity arthroplasty. QUESTIONS/PURPOSES: In this DCE, we asked: (1) Which patient-related factors (such as pain and functional level) and surgery-related factors (such as the risk of infection, revision, or death) are influential in patients' decisions about whether to undergo lower extremity arthroplasty? (2) Which of these factors do patients emphasize the most when making this decision? METHODS: A DCE was designed with the following attributes: pain; physical function; return to work; and infection risks, reoperation, implant failure leading to premature revision, deep vein thrombosis, and mortality. From October 2021 to March 2022, we recruited all new patients to two arthroplasty surgeons' clinics who were older than 18 years and scheduled for a consultation for knee- or hip-related complaints who had no previous history of a primary TKA or THA. A total of 56% (292 of 517) of new patients met the inclusion criteria and were approached with the opportunity to complete the DCE. Among the cohort, 51% (150 of 292) of patients completed the DCE. Patients were administered the DCE, which consisted of 10 hypothetical scenarios that had the patient decide between a surgical and nonsurgical outcome, each consisting of varying levels of eight attributes (such as infection, reoperation, and ability to return to work). A subsequent demographic questionnaire followed this assessment. To answer our first research question about the patient-related and surgery-related factors that most influence patients' decisions to undergo lower extremity arthroplasty, we used a conditional logit regression to control for potentially confounding attributes from within the DCE and determine which variables shifted a patient's determination to pursue surgery. To answer our second question, about which of these factors received the greatest priority by patients, we compared the relevant importance of each factor, as determined by each factor's beta coefficient, against each other influential factor. A larger absolute value of beta coefficient reflects a relatively higher degree of importance placed on a variable compared with other variables within our study. Of the respondents, 57% (85 of 150) were women, and the mean age at the time of participation was 64 ± 10 years. Most respondents (95% [143 of 150]) were White. Regarding surgery, 38% (57 of 150) were considering THA, 59% (88 of 150) were considering TKA, and 3% (5 of 150) were considering both. Among the cohort, 49% (74 of 150) of patients reported their average pain level as severe, or 7 to 10 on a scale from 0 to 10, and 47% (71 of 150) reported having 50% of full physical function. RESULTS: Variables that were influential to respondents when deciding on lower extremity total joint arthroplasty were improvement from severe pain to minimal pain (ß coefficient: -0.59 [95% CI -0.72 to -0.46]; p < 0.01), improvement in physical function level from 50% to 100% (ß: -0.80 [95% CI -0.9 to -0.7]; p < 0.01), ability to return to work versus inability to return (ß: -0.38 [95% CI -0.48 to -0.28]; p < 0.01), and the surgery-related factor of risk of infection (ß: -0.22 [95% CI -0.30 to -0.14]; p < 0.01). Improvement in physical function from 50% to 100% was the most important for patients making this decision because it had the largest absolute coefficient value of -0.80. To improve physical function from 50% to 100% and reduce pain from severe to minimal because of total joint arthroplasty, patients were willing to accept a hypothetical absolute (and not merely an incrementally increased) 37% and 27% risk of infection, respectively. When we stratified our analysis by respondents' preoperative pain levels, we identified that only patients with severe pain at the time of their appointment found the risk of infection influential in their decision-making process (ß: -0.27 [95% CI -0.37 to -0.17]; p = 0.01) and were willing to accept a 24% risk of infection to improve their physical functioning from 50% to 100%. CONCLUSION: Our study revealed that patients consider pain alleviation, physical function improvement, and infection risk to be the most important attributes when considering total joint arthroplasty. Patients with severe baseline pain demonstrated a willingness to take on a hypothetically high infection risk as a tradeoff for improved physical function or pain relief. Because patients seemed to prioritize postoperative physical function so highly in our study, it is especially important that surgeons customize their presentations about the likelihood an individual patient will achieve a substantial functional improvement as part of any office visit where arthroplasty is discussed. Future studies should focus on quantitatively assessing patients' understanding of surgical risks after a surgical consultation, especially in patients who may be the most risk tolerant. CLINICAL RELEVANCE: Surgeons should be aware that patients with the most limited physical function and the highest baseline pain levels are more willing to accept the more potentially life-threatening and devastating risks that accompany total joint arthroplasty, specifically infection. The degree to which patients seemed to undervalue the harms of infection (based on our knowledge and perception of those harms) suggests that surgeons need to take particular care in explaining the degree to which a prosthetic joint infection can harm or kill patients who develop one.

Rates and Outcomes of Periprosthetic Joint Infection in Persons Who Inject Drugs.

BACKGROUND: The risk of periprosthetic joint infection (PJI) is higher in persons who inject drugs (PWID) after total joint arthroplasty (TJA), though reported rates vary widely. This study was designed to assess outcomes of TJA in PWID and to describe factors associated with improved PJI outcomes among PWID. METHODS: A retrospective matched cohort study was performed using a 1:4 match among those with and those without a history of injection drug use (IDU) undergoing TJA. Demographic, surgical, and outcome variables were compared in multivariate logistic regressions to determine PJI predictors. Kaplan-Meier analyses were constructed to characterize the difference in survival of patients who did not have PJI or undergo joint explantation between PWID and the matching cohort. RESULTS: PWID had a 9-fold increased risk of PJI compared to the matched cohort (odds ratio 9.605, 95% CI 2.781-33.175, P < .001). Ten of 17 PWID whose last use was within 6 months (active use) of primary TJA had a PJI, while 7 of 41 PWID who did not have active use developed a PJI. Of PWID with PJI, treatment failure was seen in 15 of 17, while in patients who did not have an IDU history, 5 of 8 with PJI had treatment failure. CONCLUSION: IDU is a significant risk factor for PJI following TJA. Future work investigating the effect of a multidisciplinary support team to assist in cessation of IDU and to provide social support may improve outcomes and reduce morbidity in this vulnerable population.

Dislocation After Debridement, Antibiotics, and Implant Retention for Periprosthetic Joint Infections of the Hip.

BACKGROUND: Debridement, antibiotics, and implant retention (DAIR) is a common treatment option for hip periprosthetic joint infection (PJI). However, noninfectious outcomes of DAIR such as instability are not well reported. The purpose of this study was to evaluate risk factors for hip dislocation post-DAIR for PJI of both primary and revision total hip arthroplasty (THA). METHODS: A retrospective chart review identified all patients who underwent DAIR of a primary or revision THA over a 20-year period with a minimum 1-year follow-up. A total of 151 patients met inclusion criteria, 19.9% of whom had a post-DAIR dislocation. Demographic and intraoperative variables were obtained. Patients who had modular components exchanged during DAIR to those with increased offset, increased "jump distance", or a more stable acetabular liner were defined as patients who had "components exchanged to increase stability." Predictors of hip dislocation post-DAIR were inserted into a multivariate linear regression. RESULTS: Post-DAIR dislocation rates were 16.3% in primary THAs and 25.4% in revision THAs. In patients who had "components exchanged to increase stability" during hip DAIR, there was at least an 11-fold reduction (1/odds ratio (OR), 0.09) in dislocation risk compared to patients who had no components altered during modular component exchange during hip DAIR (OR, 0.09; 95% confidence interval, 0.02-0.44; P < .001), while a 13-fold increased dislocation risk was seen in patients with a history of neuromuscular disease (OR, 13.45; 95% confidence interval, 1.73-104.09; P = .01). CONCLUSIONS: During DAIR of hip PJI, surgeons should consider prophylactically exchanging components to increase stability even if components appear stable intraoperatively.

Peri-Prosthetic Joint Infection in Patients Prescribed Suppressive Antibiotic Therapy Undergoing Primary Total Joint Arthroplasty: A 1:4 Case Control Matched Study.

Background: Oral suppressive antibiotic therapy (SAT) has emerged as a potential means to increase rates of infection-free survival in many complex peri-prosthetic joint infection (PJI) cases after total joint arthroplasty (TJA). The purpose of the present study is to evaluate the risk of PJI of a new primary TJA in patients on oral SAT. Patients and Methods: A retrospective matched cohort study from five hospitals in a 20-year period within a large hospital network was performed. Inclusion criteria consisted of patients over age 18 undergoing primary TJA, with any order for oral long-term (>6 months duration) SAT, and minimum of one-year clinical follow-up. Patients were matched 1:4 on age, gender, body mass index (BMI), hip or knee surgery, diabetes mellitus, smoking status, and indication for primary TJA. Student t-test, Fisher exact, and χ2 tests were utilized for group comparisons. Our study was powered to detect a 10.5% increase in PJI incidence compared with a 1% baseline rate of PJI. Results: We identified 45 TJA in 33 patients receiving SAT, which were matched to 180 control cases. There was no difference in the rate of development of PJI at any time point within follow-up between the SAT cohort and control group (2.22% vs. 1.11%; p = 0.561). Conclusions: We found a 2.22% rate of PJI in a cohort of patients receiving SAT identified over a 20-year period. As the clinical scenario of primary TJA while on SAT is rare but likely to become more prevalent, future large-scale studies can be performed to better clarify rates and risk of PJI in this population.

Increased Regular Season Soft Tissue Injury Rates in National Football League (NFL) Players May Be Associated With the Canceled 2020 NFL Preseason Due to COVID-19.

Introduction The purpose of this study is to evaluate the rates of regular season soft tissue injuries in National Football League (NFL) players during the 2020 season, which had a canceled preseason due to the COVID-19 pandemic. Methods This study retrospectively reviewed the injury rates of the 2020-2021 NFL regular season in comparison to the 2018-2019 NFL regular season using publicly available injury data. The focus of our analysis was comparing the following soft tissue injuries: hamstring, groin, calf, quadriceps, thigh, knee - anterior cruciate ligament (ACL), pectoral, and Achilles. The week of injury occurrence, duration of injury in weeks, position of the injured player, and age of the NFL player at injury were obtained. Injury rates were calculated per 1000 athletic exposures with 95% confidence intervals (CIs). A chi-square test and Student's t-test were utilized as appropriate. Results There were 1370 total injuries in the 2018-2019 regular NFL season and 2086 total injuries reported in the 2020-2021 regular NFL season. The total number of injuries per 1000 athletic exposures was significantly higher in the 2020-2021 NFL season compared to the 2018-2019 NFL season (88.57 versus 58.17, p < 0.001). The rates of injuries per 1000 athletic exposures for hamstring (9.98 versus 5.31, p = 0.043), groin (5.56 versus 2.46, p = 0.007), calf (4.08 versus 1.61, p = 0.006), quadriceps (2.00 versus 0.72, p = 0.030), and thigh (1.23 versus 0.30, p = 0.012) injuries were significantly higher in the 2020-2021 regular NFL season compared to the 2018-2019 NFL regular season. Conclusions The 2020-2021 NFL season had a significantly higher incidence of soft tissue injuries compared to the 2018-2019 regular NFL season, which may have been associated with the absent preseason due to the COVID-19 pandemic and an abrupt increase in the athletic workload of players.

Effect of the COVID-19 Pandemic on Rates of Ninety-Day Peri-Prosthetic Joint and Surgical Site Infections after Primary Total Joint Arthroplasty: A Multicenter, Retrospective Study.

Background: The impact of the coronavirus 2019 (COVID-19) pandemic on the rate of primary total joint arthroplasty (TJA) peri-prosthetic joint infection (PJI) and superficial surgical site infections (SSI) is currently unknown. The purpose of this multicenter study was to evaluate any changes in the rates of 90-day PJI or 30-day SSI, including trends in microbiology of the infections, during the COVID-19 pandemic compared to the three years prior. Patients and Methods: An Institutional Review Board-approved, multicenter, retrospective study was conducted with five participating academic institutions across two healthcare systems in the northeastern United States. Primary TJA patients from the years 2017-2019 were grouped as a pre-COVID-19 pandemic cohort and patients from the year 2020 were grouped as a COVID-19 pandemic cohort. Differences in patient demographics, PJI, SSI, and microbiology between the two cohorts were assessed. Results: A total of 14,844 TJAs in the pre-COVID-19 pandemic cohort and 5,453 TJAs in the COVID-19 pandemic cohort were evaluated. There were no substantial differences of the combined 90-day PJI and 30-day superficial SSI rates between the pre-COVID-19 pandemic cohort (0.35%) compared with the COVID-19 pandemic cohort (0.26%; p = 0.303). Conclusions: This study did not find any change in the rates of 90-day PJI or 30-day superficial SSI in patients undergoing primary TJA between a pre-COVID-19 pandemic and COVID-19 pandemic cohort. Larger national database studies may identify small but substantial differences in 90-day PJI and 30-day superficial SSI rates between these two time periods. Our data may support continued efforts to maintain high compliance with hand hygiene, use of personal protective equipment, and limited hospital visitation whenever possible.

Outcomes of Concurrent Endocarditis and Periprosthetic Joint Infection: A Retrospective Case Series of 16 Patients.

Introduction Concurrent diagnosis of periprosthetic joint infection (PJI) of total hip arthroplasty (THA) or total knee arthroplasty (TKA) with infectious endocarditis is a devastating clinical scenario infrequently documented in the literature. To date, no studies have fully described the orthopedic and infectious outcomes of patients with these concurrent diagnoses. The purpose of this study was to conduct a case series of patients with these diagnoses and document the orthopedic and infectious outcomes so that surgeons may effectively counsel patients regarding the gravity of the condition and the expected course of treatment. Methods This study is a retrospective case series using patient data from five hospitals within an academic healthcare system in the northeastern United States. Cases of concurrent endocarditis and THA or TKA PJI with a minimum of one-year follow-up were identified from January 2000 to January 2021. Basic statistics such as means, standard deviations, and percentages were used to identify trends within our series. Kaplan-Meier survivorship curves with log-rank tests were performed to determine if there were any differences in two-year mortality and joint survival (defined as needing explant) between patients who had cardiac surgery prior to surgical management for their PJI and those who had surgical management for PJI prior to cardiac surgery. Results A total of 18 joints in 16 patients with endocarditis and concurrent TKA or THA PJI were identified. All PJIs were managed surgically, with 14/18 (77.77%) of joint infections initially being managed by debridement, antibiotics, and implant retention (DAIR) and 4/18 (22.22%) of joint infections initially being managed by explant. Within the first six months of PJI diagnosis, 25% (4/16) of patients died of complications related to their infection, and one additional patient died of bacteremia just over a year after the initial PJI diagnosis. Of the 18 PJIs, 72.23% (13/18) had treatment failure, defined as any outcome equal to or worse than requiring chronic suppressive antibiotics for the infection. Due to low statistical power, we were not able to identify any differences in two-year mortality from PJI diagnosis (p=0.311) or joint survival (in terms of requiring explant) (p=0.420) depending on whether cardiac surgery or DAIR was performed first. Conclusions Concurrent infectious endocarditis and prosthetic joint infection is associated with high morbidity and mortality. Patients with these concurrent infections should be counseled that not only the associated mortality rate is high, but also the surgical treatment of their PJI has a high rate of treatment failure, including an explant following an initial DAIR, an explant with retained spacer, or a requirement of lifelong antibiotic suppression.

Morbidly Obese Patients Undergoing Primary Total Joint Arthroplasty May Experience Higher Rates of Venous Thromboembolism When Prescribed Direct Oral Anticoagulants vs Aspirin.

BACKGROUND: Morbidly obese (body mass index [BMI] >40 kg/m2) patients undergoing total joint arthroplasty (TJA) are at high risk for postoperative venous thromboembolism (VTE); however, there is debate surrounding the optimal pharmacologic agent for prevention of VTE after TJA in this patient subset. Current guidelines recommend against direct-acting oral anticoagulants (DOACs) in patients of BMI >40 kg/m2 due to low quality evidence justifying their use. We evaluated whether patients of BMI >40 kg/m2 undergoing primary unilateral TJA would have increased risk of postoperative VTE if prescribed DOACs compared to non-DOAC agents such as aspirin. METHODS: This retrospective study analyzed 897 patients of BMI >40 kg/m2 undergoing primary unilateral TJA. Demographic and comorbidity-related variables were collected. The association between postoperative VTE and prophylactic pharmacologic agent prescribed was evaluated by multivariate logistic regression. RESULTS: After controlling for comorbidities, we found that the sole use of DOACs, specifically apixaban, for VTE prophylaxis was associated with an increased risk of developing VTE compared to prophylaxis with aspirin alone in patients of BMI >40 kg/m2 (odds ratio 2.962, P = .016). Regardless of VTE prophylactic agent, patients with BMI >40 kg/m2 undergoing TKA had at least 4.5-fold increased odds of developing VTE compared to patients undergoing THA (OR 4.830, P = .019). CONCLUSION: In our retrospective study of a large sample size of patients with BMI >40 kg/m2, we found that the use of DOACs, specifically apixaban, for VTE prophylaxis following TJA was associated with increased odds of a VTE complication compared to the use of aspirin alone.

Nonoperative Management of Chronically Subluxated Bilateral Cervical Facets with Bony Fusion: A Case Report.

CASE: We describe a case of a 65-year-old woman with bilateral chronically subluxated C6 to 7 facets with facet fusion, who presented for care for the first time 1 year after a motor vehicle accident. The patient was minimally symptomatic at the time of her evaluation; thus, nonoperative treatment was provided. At 3-year follow-up, our patient remained minimally symptomatic with no progression of neurologic deficits. CONCLUSION: Consistent with previous reports, conservative management was used rather than surgical fusion in a patient with stable osseous fusion complexes and minimal neurologic symptoms.

Opioid over-prescription after total joint arthroplasty: Findings from patient reported opioid consumption journals.

We sought to determine postoperative opioid consumption for opioid-naïve patients undergoing total knee and hip arthroplasty (THA and TKA) procedures via an observational cohort study, consisting of 55 patients who underwent either primary unilateral TKA (n = 28) or THA (n = 27). Patients were provided with a journal to track daily consumption of pain medicine. Patients were prescribed an average of 67 opioid pills post-operatively; however, they consumed an average of 31 pills (214 morphine equivalent doses - MED). TKA patients received (p = 0.01) and consumed (p = 0.005) higher amounts of opioids. On average, patients ceased opioid usage at 14 days post-operatively.

Defining Failure in Primary Total Joint Arthroplasty: The Minimal Clinically Important Difference for Worsening Score.

BACKGROUND: We define the value of the Minimal Clinically Important Difference for Worsening (MCID-W) for Patient-Reported Outcomes Measurement Information System Physical Function short form 10-a (PROMIS-PF-10a) score for primary total joint arthroplasty (TJA) of the hip and knee and describe the risk factors for patients scoring worse than the MCID-W. METHODS: This retrospective study was performed using 3414 primary TJA patients. PROMIS-PF-10a scores were collected at the preoperatively and postoperatively, and patients were classified based on reaching Minimal Clinically Importance Difference for Improvement (MCID-I), MCID-W, or "no significant change" after TJA (scores betweex`n MCID-W and MCID-I). MCID-W and MCID-I values were determined by a distribution method. The association between numerous variables and scoring worse than the MCID-W of PROMIS-PF-10a was then evaluated through multiple logistic regression. A threshold for preoperative PROMIS-PF-10a score predicting decline past MCID-W was determined using the Youden index and receiver operating characteristic curve. RESULTS: The MCID-W for TJA was -1.89. Notably, increasing length of stay (odds ratio [OR] 1.073, 95% confidence interval [CI] 1.029-1.119, P < .001) and increasing preoperative PROMIS-PF-10a scores (OR 1.117, 95% CI 1.091-1.144, P < .001) were associated with increased likelihood of decline past the MCID-W of the PROMIS-PF-10a for TJA compared with patients who achieved the MCID-I. A community hospital with a dedicated joint replacement center was associated with a decreased risk for decline past the MCID-W (OR 0.601, 95% CI 0.402-0.899; P = .013). CONCLUSION: We described the MCID-W value (-1.89) for the PROMIS-PF-10a questionnaire for knee and hip TJA and associated patient- and hospital-level risk factors for failure after TJA. Healthcare funding initiatives should be directed toward modifiable factors associated with clinically significant worse outcomes after TJA.

Superior Cluneal Nerve Stimulator Lead Displacement to the Thigh: A Case Report and Management Recommendations.

CASE: An 82-year-old man with a history of lumbar spinal stenosis and prior laminectomy presented with chronic lower back pain and was treated with placement of bilateral superior cluneal nerve stimulators. At the 2-week follow-up, the patient reported loss of efficacy and new-onset paresthesia of the left lower extremity. Fluoroscopic evaluation revealed lead breakage and distal migration of the left-sided stimulator lead to the left anteromedial thigh. CONCLUSION: Lead breakage and migration remains a challenge in peripheral nerve stimulation. This report illustrates the case of a nerve stimulator lead breakage and migration resulting in treatment failure and new-onset sensory disturbance.