The Effect of Anesthetic Regimen on Bone Cement Implantation Syndrome in Cemented Hemiarthroplasty for Hip Fracture.

INTRODUCTION: Bone cement implantation syndrome (BCIS) is characterized by hypoxia, hypotension, and cardiovascular compromise during cementation in arthroplasty cases. This study examines the association between anesthetic regimen and risk of BCIS in cemented hemiarthroplasty for hip fractures. We hypothesized that neuraxial anesthesia would be associated with markedly lower BCIS incidence compared with general anesthesia alone or in combination with regional anesthesia. METHODS: This retrospective cohort study included patients aged 50 years or older who underwent cemented hemiarthroplasty for hip fractures at a single institution between January 2017 and December 2022. Patient demographics, comorbidities, procedural factors, anesthetic characteristics including anesthetic regimen (general, general plus regional, or neuraxial), cement timing, BCIS development, postoperative complications, and mortality data were extracted. BCIS was identified by changes in postcementation vitals and its severity classified according to previously established criteria. Univariate statistical analyses and multivariate logistic regression were conducted. RESULTS: Of the 137 included patients, 58 (43%) developed BCIS. No notable differences were observed in demographics, comorbidities, or procedural characteristics between patients who developed BCIS and those who did not. However, anesthetic regimen was markedly correlated with BCIS development, with general anesthesia demonstrating the highest rates (26/43, 55%), followed by general plus regional anesthesia (26/58, 45%) and neuraxial anesthesia (6/32, 19%; P = 0.005). Compared with neuraxial anesthesia, general anesthesia and general plus regional anesthesia conferred 6.8 and 5.5 times greater odds of developing BCIS, respectively. The development of BCIS was associated with significantly higher rates of postoperative hypoxia (P = 0.04) and unplanned prolonged intubation (P = 0.04). CONCLUSION: BCIS was highly prevalent among patients undergoing cemented hemiarthroplasty for hip fractures. The anesthetic regimen was the only variable markedly associated with BCIS development and is a potentially modifiable risk factor. LEVEL OF EVIDENCE: III.

Comparison of estimated glomerular filtration rate using five equations to predict acute kidney injury following hip fracture surgery.

BACKGROUND: Decreased estimated glomerular filtration rate (eGFR) is associated with acute kidney injury (AKI) following hip fracture surgery. Delaying surgery for preoperative treatment of comorbidities is controversial in this patient population. The purpose of this study was 1) to assess differences in demographics and comorbidities between AKI and non-AKI groups, 2) to analyze equations used in calculating eGFR, and 3) to identify the equation which best predicts the development of AKI following hip fracture surgery. We hypothesize that one of the equations used to calculate eGFR will be superior to the others. PATIENTS AND METHODS: 124,002 cases of hip fracture surgery were performed from 2012 to 2019, based upon a query of the National Surgical Quality Improvement Program (NSQIP). Preoperative eGFR was calculated using the following: Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Chronic Kidney Disease Epidemiology Collaboration, Mayo quadratic, and Cockcroft-Gault equations. Independent associations between preoperative eGFR and postoperative renal failure were evaluated using multivariate regression analysis. The predictive ability of each equation was determined using the Akaike information criterion (AIC). RESULTS: AKI was diagnosed in 584 (0.71%) out of the 82,326 patients following hip fracture surgery. The AKI and no AKI cohorts differed significantly by patient sex (p = <0.001), race (p = <0.001), BMI (p = < 0.001), preoperative hematocrit (p = <0.001), preoperative albumin (p = <0.001), diabetes mellitus (p = <0.001), hypertension (p = <0.001), and congestive heart failure (p = <0.001). The Mayo equation (84.0 ± 23.7) was the equation with the highest calculated mean eGFR, followed by the CKD-EPI equation (83.6 ± 20.0), MDRD II equation (83.0 ± 38.9), CG equation (74.7 ± 35.5), and finally the re-expressed MDRD II equation (68.5 ± 36.0) which had the lowest calculated mean eGFR.. All five equations detected that a decrease in preoperative eGFR was associated with an increased risk of postoperative AKI. Lower preoperative eGFR, as calculated by each of the five equations, was significantly associated with an increased risk of AKI following surgical fixation of hip fracture. The AIC was the lowest in the Mayo equation, demonstrating the best fit of the equations to predict postoperative AKI CONCLUSIONS: We propose that using the equation that best identifies those at risk of developing postoperative AKI may help with perioperative decision making and treatment to improve outcomes, which we found to be the Mayo equation. The risk of postoperative AKI was independently associated with decreased preoperative eGFR. The results of this study may warrant further investigation utilizing prospective studies. LEVEL OF EVIDENCE: III; retrospective cohort study.

Early Prosthetic Hip Dislocation: Does the Timing of the Dislocation Matter?

BACKGROUND: Early dislocation following total hip arthroplasty (THA) is a common reason for revision. The purpose of this study was to determine if the acuity of the dislocation episode affects the risk of revision surgery. METHODS: A retrospective review of a national, all-payer administrative database comprised of claims from 2010 to 2020 was used to identify patients who had a prosthetic hip dislocation at various postoperative time intervals (0 to 7, 7 to 30, 30 to 60, and 60 to 90 days). Of the 45,352 primary unilateral THA patients who had sufficient follow-up, there were 2,878 dislocations within 90 days. Dislocators were matched 1:1 based on age, sex, and a comorbidity index with a control group (no dislocation). Demographics, surgical indications, comorbidities, ten-year revision rates, and complications were compared among cohorts. Multivariable logistic regression analysis was performed to identify risk factors for revision THA following early dislocation. RESULTS: Among matched cohorts, dislocation at any time interval was associated with significantly increased odds of subsequent 10-years revision (OR [odds ratio] = 25.60 to 33.4, P < .001). Acute dislocators within 7 days did not have an increased risk of all cause revisions at 10 years relative to other early dislocators. Revision for indication of instability decreased with time to first dislocation (<7 days: 85.7% versus 60 to 90 days: 53.9%). Primary diagnoses of posttraumatic arthritis (OR = 2.53 [1.84 to 3.49], P < .001), hip fracture (OR = 3.8 [2.53 to 5.72], P < .001), and osteonecrosis (OR = 1.75 [1.12 to 2.73], P = .010) were most commonly associated with revision surgery after an early dislocation. CONCLUSIONS: Dislocation within 90 days of THA is associated with increased odds of subsequent revision. Early dislocation within 7 days of surgery has similar all cause revision-free survivorship, but an increased risk of a subsequent revision for instability when compared to patients who dislocated within 7 to 90 days.

Trend of using cementless total knee arthroplasty: a nationwide analysis from 2015 to 2021.

BACKGROUND: Modern cementless total knee arthroplasty (TKA) fixation has shown comparable long-term outcomes to cemented TKA, but the trend of using cementless TKA remains unclear. This study aimed to investigate the trend of using cementless TKA based on a national database. METHODS: The patients undergoing cementless TKA between 2015 and 2021 were retrospectively extracted from the PearlDiver (Mariner dataset) Database. The annual percentage of cementless TKA was calculated using the following formula: annual number of cementless TKA/annual number of TKA. The trend of the number of patients undergoing cementless TKA was created according to a compounded annual growth rate (CAGR) calculation of annual percentages. Patient age, comorbidity, region, insurance type, etc., were also investigated. Differences were considered statistically significant at P < 0.05. RESULTS: Of the 574,848 patients who received TKA, 546,731 (95%) underwent cemented fixation and 28,117 (5%) underwent cementless fixation. From 2015 to 2021, the use of cementless TKA significantly increased by 242% from 3 to 9% (compounded annual growth rate (CAGR): + 20%; P < 0.05). From 2015 to 2021, we observed a CAGR greater than 15% for all age groups (< 50, 50-59, 60-69, 70-74, 75 +), insurance types (cash, commercial, government, Medicare, Medicaid), regions (Midwest, Northeast, South, West), sex (male and female), and certain comorbidities (osteoporosis, diabetes mellitus, tobacco use, underweight (BMI < 18.5), rheumatoid arthritis) (P < 0.05 for all). Patients undergoing TKA with chronic kidney disease, prior fragility fractures, and dementia demonstrated a CAGR of + 9%-13% from 2015 to 2021 (P < 0.05). CONCLUSION: From 2015 to 2021, the use of cementless TKA saw a dramatic increase in all patient populations. However, there is still no consensus on when to cement and in whom. Clinical practice guidelines are needed to ensure safe and effective use of cementless fixation.

The Association Between Oral Bone Mineral Density-Reducing Medications and the Risk of 2-Year Implant-Related Complications Following Total Knee Arthroplasty.

BACKGROUND: Certain medications interfere with the bone remodeling process and may potentially increase the risk of complications after total knee arthroplasty (TKA). As patients undergoing TKA may be taking these bone mineral density (BMD)-reducing medications, it is unclear as to whether and which medications impact TKA outcomes. Therefore, the purpose of this study was to observe the impact of various BMD-reducing medications on 2-year implant-related complications following TKA. METHODS: A retrospective analysis of patients undergoing primary TKA was conducted using a national administrative claims database. Patients were identified if they were taking any known BMD-reducing medication and were compared to control patients. To control for confounders associated with taking multiple agents, multivariable logistic regression analyses were conducted for each 2-year outcome (all-cause revision, loosening-indicated revision, and periprosthetic fracture--indicated revision), with the output recorded as odds ratios (ORs). RESULTS: In our study, 502,927 of 1,276,209 TKA patients (39.4%) were taking at least one BMD-reducing medication perioperatively. On multivariable analysis, medications associated with a higher likelihood of 2-year all-cause revision included first- and second-generation antipsychotics (SGAs) (OR: 1.42 and 1.26, respectively), selective serotonin reuptake inhibitors (SSRIs) (OR: 1.14), glucocorticoids (1.13), and proton pump inhibitors (PPIs) (OR: 1.23) (P < .05 for all). Medications associated with a higher likelihood of 2-year periprosthetic fracture included SGAs (OR: 1.51), SSRIs (OR: 1.27), aromatase inhibitors (OR: 1.29), and PPIs (OR: 1.42) (P < .05 for all). CONCLUSIONS: Of the drug classes observed, the utilization of perioperative PPIs, SSRIs, glucocorticoids, first-generation antipsychotics, and SGAs was associated with the highest odds of all-cause revision. Our findings suggest a relationship between these medications and BMD-related complications; however, further studies should seek to determine the causality of these relationships.

Osteoporotic Patients Undergoing Total Hip Arthroplasty Have a Similar 5-Year Cumulative Incidence Rate of Periprosthetic Fracture Regardless of Cemented Versus Cementless Femoral Stem Fixation.

BACKGROUND: In osteoporotic patients, surgeons may utilize cemented femoral fixation to minimize risk of fracture. The purpose of this study was to compare 5-year implant survivability in patients who have osteoporosis who underwent elective total hip arthroplasty (THA) with cementless versus cemented fixation. METHODS: A retrospective analysis of patients who have osteoporosis undergoing THA with either cemented or cementless femoral fixation was conducted using a national administrative claims database. Of the 18,431 identified THA patients who have osteoporosis, 15,867 (86.1%) underwent cementless fixation. The primary outcome was a comparison of the 5-year cumulative incidences of aseptic revision, mechanical loosening, and periprosthetic fracture (PPF). Kaplan-Meier and Multivariable Cox Proportional Hazard Ratio analyses were used, controlling for femoral fixation method, age, sex, a comorbidity scale, use of osteoporosis medication, and important comorbidity. RESULTS: There was no difference in aseptic revision (Hazard's Ratio (HR): 1.13; 95% Confidence Interval (CI): 0.79 to 1.62; P value: .500) and PPF (HR: 0.96; 95% CI: 0.64 to 1.44; P value: .858) within 5 years of THA between fixation cohorts. However, patients who had cemented fixation were more likely to suffer mechanical loosening with 5 years post-THA (HR: 1.79; 95% CI: 1.17 to 2.71; P-value: .007). CONCLUSIONS: We found a similar 5-year rate of PPF when comparing patients who underwent cementless versus cemented femoral fixation for elective THA regardless of preoperative diagnosis of osteoporosis. While existing registry data support the use of cemented fixation in elderly patients, a more thorough understanding of the interplay between age, osteoporosis, and implant design is needed to delineate in whom cemented fixation is most warranted for PPF prevention.

Can Hip and Knee Arthroplasty Surgeons Help Address the Osteoporosis Epidemic?

BACKGROUND: Osteoporosis is a known, modifiable risk factor for lower extremity periprosthetic fractures. Unfortunately, a high percentage of patients at risk of osteoporosis who undergo THA or TKA do not receive routine screening and treatment for osteoporosis, but there is insufficient information determining the proportion of patients undergoing THA and TKA who should be screened and their implant-related complications. QUESTIONS/PURPOSES: (1) What proportion of patients in a large database who underwent THA or TKA met the criteria for osteoporosis screening? (2) What proportion of these patients received a dual-energy x-ray absorptiometry (DEXA) study before arthroplasty? (3) What was the 5-year cumulative incidence of fragility fracture or periprosthetic fracture after arthroplasty of those at high risk compared with those at low risk of osteoporosis? METHODS: Between January 2010 and October 2021, 710,097 and 1,353,218 patients who underwent THA and TKA, respectively, were captured in the Mariner dataset of the PearlDiver database. We used this dataset because it longitudinally tracks patients across a variety of insurance providers throughout the United States to provide generalizable data. Patients at least 50 years old with at least 2 years of follow-up were included, and patients with a diagnosis of malignancy and fracture-indicated total joint arthroplasty were excluded. Based on this initial criterion, 60% (425,005) of THAs and 66% (897,664) of TKAs were eligible. A further 11% (44,739) of THAs and 11% (102,463) of TKAs were excluded because of a prior diagnosis of or treatment for osteoporosis, leaving 54% (380,266) of THAs and 59% (795,201) of TKAs for analysis. Patients at high risk of osteoporosis were filtered using demographic and comorbidity information provided by the database and defined by national guidelines. The proportion of patients at high risk of osteoporosis who underwent osteoporosis screening via DEXA scan within 3 years was observed, and the 5-year cumulative incidence of periprosthetic fractures and fragility fracture was compared between the high-risk and low-risk cohorts. RESULTS: In total, 53% (201,450) and 55% (439,982) of patients who underwent THA and TKA, respectively, were considered at high risk of osteoporosis. Of these patients, 12% (24,898 of 201,450) and 13% (57,022 of 439,982) of patients who underwent THA and TKA, respectively, received a preoperative DEXA scan. Within 5 years, patients at high risk of osteoporosis undergoing THA and TKA had a higher cumulative incidence of fragility fractures (THA: HR 2.1 [95% CI 1.9 to 2.2]; TKA: HR 1.8 [95% CI 1.7 to 1.9]) and periprosthetic fractures (THA: HR 1.7 [95% CI 1.5 to 1.8]; TKA: HR 1.6 [95% CI 1.4 to 1.7]) than those at low risk (p < 0.001 for all). CONCLUSION: We attribute the higher rates of fragility and periprosthetic fractures in those at high risk compared with those at low risk to an occult diagnosis of osteoporosis. Hip and knee arthroplasty surgeons can help reduce the incidence and burden of these osteoporosis-related complications by initiating screening and subsequently referring patients to bone health specialists for treatment. Future studies might investigate the proportion of osteoporosis in patients at high risk of having the condition, develop and evaluate practical bone health screening and treatment algorithms for hip and knee arthroplasty surgeons, and observe the cost-effectiveness of implementing these algorithms. LEVEL OF EVIDENCE: Level III, therapeutic study.

Acute kidney injury in the context of staged revision arthroplasty and the use of antibiotic-laden cement spacers: a systematic review.

BACKGROUND: The most common cause of revision arthroplasty is prosthetic joint infection (PJI). Chronic PJI is commonly treated with two-stage exchange arthroplasty involving the placement of antibiotic-laden cement spacers (ACS) in the first stage, often containing nephrotoxic antibiotics. These patients often have significant comorbidity burdens and have higher rates of acute kidney injury (AKI). This systematic review aims to assess the current literature to identify (1) AKI incidence, (2) associated risk factors, and (3) antibiotic concentration thresholds in ACS that increase AKI risk following first-stage revision arthroplasty. METHODS: An electronic search was performed of the PubMed database of all studies involving patients undergoing ACS placement for chronic PJI. Studies assessing AKI rates and risk factors were screened by two authors independently. Data synthesis was performed when possible. Significant heterogeneity prevented meta-analysis. RESULTS: Eight observational studies consisting of 540 knee PJIs and 943 hip PJIs met inclusion criteria. There were 309 (21%) cases involving AKI. The most commonly reported risk factors included perfusion-related factors (lower preoperative hemoglobin, transfusion requirement, or hypovolemia), older age, increased comorbidity burden, and nonsteroidal anti-inflammatory drug consumption. Only two studies found increased risk with greater ACS antibiotic concentration (> 4 g vancomycin and > 4.8 g tobramycin per spacer in one study, > 3.6 g of vancomycin per batch or > 3.6 g of aminoglycosides per batch in the other); however, these were reported from univariate analyses not accounting for other potential risk factors. DISCUSSION: Patients undergoing ACS placement for chronic PJI are at an increased risk for AKI. Understanding the risk factors may lead to better multidisciplinary care and safer outcomes for chronic PJI patients.

Risk factors for pain after total hip arthroplasty: a systematic review.

BACKGROUND: Approximately 23% of patients develop hip pain after total hip arthroplasty (THA). In this systematic review, we aimed to identify risk factors associated with postoperative pain after THA to optimize preoperative surgical planning. METHODS: Six literature databases were searched for articles published from January 1995 to August 2020. Controlled trials and observational studies that reported measurements of postoperative pain with assessments of preoperative modifiable and non-modifiable risk factors were included. Three researchers performed a literature review independently. RESULTS: Fifty-four studies were included in the study for analysis. The most consistent association between worse pain outcomes and the female sex is poor preoperative pain or function, and more severe medical or psychiatric comorbidities. The correlation was less strong between worse pain outcomes and preoperative high body mass index value, low radiographic grade arthritis, and low socioeconomic status. A weak correlation was found between age and worse pain outcomes. CONCLUSIONS: Preoperative risk factors that were consistently predictive of greater/server postoperative pain after THA were identified, despite the varying quality of studies that prohibited the arrival of concrete conclusions. Modifiable factors should be optimized preoperatively, whereas non-modifiable factors may be valuable to patient education, shared decision-making, and individualized pain management.

Comparison of two high dose rate intracavitary brachytherapy regimens in treatment of cervical cancer: a preliminary report.

BACKGROUND: To assess and compare the local control and toxicities between HDR Intracavitary Brachytherapy with 7.5 Gy and 9 Gy per fraction after EBRT in treatment of carcinoma cervix. METHODOLOGY: A total of 180 patients were randomly assigned to 2 arms. Arm A received HDR intracavitary brachytherapy with a dose of 7.5 Gy per fraction, 1 fraction per week for 3 fractions and Arm B received 9 Gy per fraction, 1 fraction per week for 2 fractions. Patients were evaluated on follow up for assessment of local control and toxicities. RESULTS: The median follow up was 12 months (6-18 months). In arm A 89% of the patient had complete response and 11% had recurrence or metastasis. In arm B 93% of the patient had complete response and 7% had recurrence or metastasis. Grade 2/3 diarrhoea was seen in 4.4% of patients in Arm A and in 7.7% in Arm B. Grade 2/3 proctitis was seen in 3.3% of patients in 7.5 Gy arm and in 6.6% in 9 Gy arm. One patient in each arm had grade 1 haematuria. The overall duration of treatment was significant lower in Arm B compared to Arm A (59 days vs 68 days, p = 0.01). CONCLUSION: The result of this clinical study shows that Intracavitary brachytherapy with a dose of 9 Gy per fraction is non inferior to other schedules in term of local control and does not result in increased toxicity.

Comparing five equations to calculate estimated glomerular filtration rate to predict acute kidney injury following total joint arthroplasty.

BACKGROUND: Acute kidney injury (AKI) following total joint arthroplasty (TJA) is associated with increased morbidity and mortality. Estimated glomerular filtration rate (eGFR) is used as an indicator of renal function. The purpose of this study was (1) to assess each of the five equations that are used in calculating eGFR, and (2) to evaluate which equation may best predict AKI in patients following TJA. METHODS: The National Surgical Quality Improvement Program (NSQIP) was queried for all 497,261 cases of TJA performed from 2012 to 2019 with complete data. The Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Cockcroft-Gault, Mayo quadratic, and Chronic Kidney Disease Epidemiology Collaboration equations were used to calculate preoperative eGFR. Two cohorts were created based on the development of postoperative AKI and were compared based on demographic and preoperative factors. Multivariate regression analysis was used to assess for independent associations between preoperative eGFR and postoperative renal failure for each equation. The Akaike information criterion (AIC) was used to evaluate predictive ability of the five equations. RESULTS: Seven hundred seventy-seven (0.16%) patients experienced AKI after TJA. The Cockcroft-Gault equation yielded the highest mean eGFR (98.6 ± 32.7), while the Re-expressed MDRD II equation yielded the lowest mean eGFR (75.1 ± 28.8). Multivariate regression analysis demonstrated that a decrease in preoperative eGFR was independently associated with an increased risk of developing postoperative AKI in all five equations. The AIC was the lowest in the Mayo equation. CONCLUSIONS: Preoperative decrease in eGFR was independently associated with increased risk of postoperative AKI in all five equations. The Mayo equation was most predictive of the development of postoperative AKI following TJA. The mayo equation best identified patients with the highest risk of postoperative AKI, which may help providers make decisions on perioperative management in these patients.

Predictors of Hospice Discharge After Surgical Fixation of Hip Fractures.

BACKGROUND: Each year, over 300,000 people older than 65 years are hospitalized for hip fractures. Given the notable morbidity and mortality faced by elderly patients in the postinjury period, recommendations have been put forth for integrating palliative and, when needed, hospice care to improve patients' quality of life. Our objective was to (1) understand the proportion of patients discharged to hospice after hip fracture surgery and their 30-day mortality rates and (2) identify the independent predictors of discharge to hospice. METHODS: We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program for all hip fracture surgeries between the years of 2016 and 2018. Included cases were stratified into two cohorts: cases involving a discharge to hospice and nonhospice discharge. Variables assessed included patient demographics, comorbidities, perioperative characteristics, and postoperative outcomes. Differences between hospice and nonhospice patients were compared using chi-squared analysis or the Fisher exact test for categorical variables and Student t -tests for continuous variables. A binary logistic regression model was used to assess independent predictors of hospice discharge with 30-day mortality. RESULTS: Overall, 31,531 surgically treated hip fractures were identified, of which only 281 (0.9%) involved a discharge to hospice. Patients discharged to hospice had a 67% 30-day mortality rate in comparison with 5.6% of patients not discharged to hospice ( P < 0.001). Disseminated cancer, dependent functional status, >10% weight loss over 6 months preoperatively, and preoperative cognitive deficit were the strongest predictors of hospice discharge with 30-day mortality after hip fracture surgery. CONCLUSIONS: Current hospice utilization in hip fracture patients remains low, but 30-day mortality in these patients is high. An awareness of the associations between patient characteristics and discharge to hospice with 30-day mortality is important for surgeons to consider when discussing postoperative expectations and outcomes with these patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Transfusion Rates in the Operative Treatment of Prosthetic Hip and Knee Infection.

Surgery for prosthetic joint infection (PJI) can often lead to significant blood loss, necessitating allogeneic blood transfusion (ABT). The use of ABT is associated with higher rates of morbidity and death in revision total joint arthroplasty, particularly in the treatment of PJI. We compared ABT rates by procedure type among patients treated for PJI. We retrospectively reviewed 143 operative cases of hip and knee PJI performed at our institution between 2016 and 2018. Procedures were categorized as irrigation and debridement (I&D) with modular component exchange (modular component exchange), explantation with I&D and placement of an antibiotic spacer (explantation), I&D with antibiotic spacer exchange (spacer exchange), or antibiotic spacer removal and prosthetic reimplantation (reimplantation). Rates of ABT and the number of units transfused were assessed. Factors associated with ABT were assessed with a multilevel mixed-effects regression model. Of the cases, 77 (54%) required ABT. The highest rates of ABT occurred during explantation (74%) and spacer exchange (72%), followed by reimplantation (36%) and modular component exchange (33%). A lower preoperative hemoglobin level was associated with higher odds of ABT. Explantation, reimplantation, and spacer exchange were associated with greater odds of ABT. Antibiotic spacer exchange and explantation were associated with greater odds of multiple-unit transfusion. Rates of ABT remain high in the surgical treatment of PJI. Antibiotic spacer exchange and explantation procedures had high rates of multiple-unit transfusions, and additional units of blood should be made available. Preoperative anemia should be treated when possible, and further refinement of blood management protocols for prosthetic joint infection is necessary. [Orthopedics. 2022;45(6):353-359.].

Preoperative Patient Optimization in Total Joint Arthroplasty-The Paradigm Shift from Preoperative Clearance: A Narrative Review.

Background: Total joint arthroplasty (TJA) is one of the most common procedures performed in the United States. Outcomes of this elective procedure may be improved via preoperative optimization of modifiable risk factors. Purposes: We sought to summarize the literature on the clinical implications of preoperative risk factors in TJA and to develop recommendations regarding preoperative optimization of these risk factors. Methods: We searched PubMed in August 2019 with an update in September 2020 for English-language, peer-reviewed publications assessing the influence on outcomes in total hip and knee replacement of 7 preoperative risk factors-obesity, malnutrition, hypoalbuminemia, diabetes, anemia, smoking, and opioid use-and recommendations to mitigate them. Results: Sixty-nine studies were identified, including 3 randomized controlled trials, 8 prospective cohort studies, 42 retrospective studies, 6 systematic reviews, 3 narrative reviews, and 7 consensus guidelines. These studies described worse outcomes associated with these 7 risk factors, including increased rates of in-hospital complications, transfusions, periprosthetic joint infections, revisions, and deaths. Recommendations for strategies to screen and address these risk factors are provided. Conclusions: Risk factors can be optimized, with evidence suggesting the following thresholds prior to surgery: a body mass index <40 kg/m2, serum albumin ≥3.5 g/dL, hemoglobin A1C ≤7.5%, hemoglobin >12.0 g/dL in women and >13.0 g/dL in men, and smoking cessation and ≥50% decrease in opioid use by 4 weeks prior to surgery. Surgery should be delayed until these risk factors are adequately optimized.

Preoperative Hypoalbuminemia Is Associated With Early Morbidity and Mortality After Revision Total Hip Arthroplasty.

Hypoalbuminemia is associated with early morbidity and mortality in revision total knee arthroplasty. We evaluated the effect of preoperative hypoalbuminemia on 30-day morbidity and mortality in revision total hip arthroplasty (THA). The National Surgical Quality Improvement Program (NSQIP) database was queried from 2015 to 2018 to identify patients who underwent revision THA. Patients were stratified based on the presence or absence of preoperative hypoalbuminemia and their odds of a major complication or death within 30 days of revision THA with multivariate logistic regression. After Bonferroni correction for these 2 primary outcomes, statistical significance was defined as P<.025. A total of 2492 revision THAs with complete data were identified, of which 486 (20%) had preoperative hypoalbuminemia. Preoperative hypoalbuminemia increased the absolute risk of a major complication by 15.3% compared with patients with revision THA without hypoalbuminemia (30% vs 14.7%, P<.001). Patients with preoperative hypoalbuminemia also had nearly a 7-fold higher incidence of death (3.3%) compared with those with revision THA without preoperative hypoalbuminemia (0.5%, P<.001). After logistic regression, the odds of having a major complication after revision THA with preoperative hypoalbuminemia within 30 days were increased by 80% (odds ratio, 1.8; 95% CI, 1.4-2.3; P<.001), and the odds of death within 30 days were increased by 210% (odds ratio, 3.1; 95% CI, 1.2-7.8; P=.020). Hypoalbuminemia is associated with early morbidity and mortality after revision THA. [Orthopedics. 2022;45(5):281-286.].

Survey of sarcoma surgery principles among orthopaedic oncologists.

BACKGROUND: Surgical principles and techniques used during primary sarcoma excision focus on acquiring negative margins, reducing the risk of local recurrence, and minimizing contamination. These principles and techniques within orthopaedic oncology are not well documented in the literature. No standardized surgical hand-off or approach to education across disciplines on orthopaedic oncology principles and techniques has been published. Currently, education on intraoperative approaches is passed down by oral tradition. OBJECTIVES: Our objective was to survey members of the Musculoskeletal Tumor Society (MSTS) to identify their core principles and practices in orthopaedic oncology. We aimed to 1) provide descriptive analyses of surgeon technique patterns; 2) determine correlations between individual practice patterns; and 3) identify distinct clusters of surgeons on the basis of common practice tendencies. METHODS: A web-based, 16-question survey regarding orthopaedic oncology intraoperative principles and techniques was distributed online to all 349 members of the MSTS in 2021. There were 137 (39%) unique respondents, all of whom completed the entire survey. The 16 survey questions were grouped into 4 key aspects of sarcoma excision: pre-incision, exposure of the mass, delivery of the mass, and closure. The questions inquired about respondent preference on draping, back table setup, instrument use, and intraoperative decision making. These questions were selected on the basis of existing reports, as well as the senior author's experience. We analyzed the responses using 3 methods: 1) descriptive statistics, 2) correlations between question responses, and 3) clustering analysis. We used an artificial intelligence-based clustering algorithm to cluster respondents according to their practice patterns. The results of our correlation analyses are reported as Spearman's rho (ρ) correlation coefficients. RESULTS: Most respondents (mean, 71%; standard deviation, 22%) reported using the described surgical techniques "most of the time" or "in all cases." A strong positive correlation was found between respondents who answered "yes" to both of the following questions: "Do you change your surgical gloves after passing off the tumor specimen?" and "Does your entire surgical team change their gloves after passing off the tumor specimen?" (ρ = 0.88). A moderate positive correlation was found between those who answered "yes" to both of the following questions: "Do you change your surgical gloves after passing off the tumor specimen (i.e., prior to closure)?" and "Do you use new and/or unused surgical instruments for the final closure?" (ρ = 0.60). The cluster analysis identified 3 distinct clusters of respondents. The conservative technique cluster (N = 42) was more likely to answer "yes" to 9 of the 10 questions regarding incision management, consultant team communication, gloving, and instrument use, whereas the permissive technique cluster (N = 41) was more likely to answer "no" to questions regarding gloving, draping, and instrument use. CONCLUSIONS: Our findings indicate that most respondents perform the surveyed techniques, and there is homogeneity in the practice patterns of members of the MSTS; however, we identified distinct clusters of respondents who were significantly more likely to perform certain techniques. These results support establishing a standardized set of intraoperative techniques and formal surgical education regarding intraoperative principles and techniques in orthopaedic oncology.

A Novel Method for Stratification of Major Complication Risk Using Body Mass Index Thresholds for Patients Undergoing Total Hip Arthroplasty: A National Cohort of 224,413 Patients.

INTRODUCTION: Elevated body mass index (BMI) is associated with complications following Total Hip Arthroplasty (THA). Since obese individuals are almost 10 times more likely to require THA compared to non-obese individuals, we need to understand the risk-benefit continuum while considering THA in obese patients. We aimed to determine data-driven thresholds for BMI at which the risk of major complications following THA increases significantly. METHODS: Patients were identified in a national database who underwent primary THA from 2010 to 2020. BMI thresholds were identified using the stratum-specific likelihood ratio (SSLR) methodology, which is an adaptive technique that allows for identification of BMI cut-offs, at which the risk of major complications is increased significantly . BMI cutoffs identified using SSLR were used to create a logistic regression model. RESULTS: A total of 224,413 patients were identified with a mean age of 66 ± 10, BMI 32 ± 6.7, and 7,186 (3%) sustained a major complication. BMI thresholds were defined as 19-31, 32-37, 38-49 and 50+. Overall, the absolute risk of major complications increased from 2.9% in the lowest BMI strata to 7.5% in the highest BMI strata. Compared to patients with a BMI between 19-31, the odds of sustaining a major complication sequentially increased by 1.2, 1.6, and 2.5-times for patients in each higher BMI strata (all, P < .05). CONCLUSIONS: We have identified BMI cutoffs using SSLR that categorizes patients into four categories of risk for major complications in a nationally representative patient sample. These thresholds can be used in the surgical decision-making process between patients and surgeons.

Outpatient Simultaneous Bilateral Total Knee Arthroplasty: Is It Safe?

BACKGROUND: It is currently unknown if simultaneous bilateral total knee arthroplasty (si-BTKA) can also be safely performed in the outpatient setting. The primary aim of this study was to compare 30-day postoperative complication rates between outpatient and inpatient si-BTKA. METHODS: Adults undergoing simultaneous bilateral total knee arthroplasty (si-BTKA) from 2015-2019 were queried using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Our primary analysis compared the rates of complications between outpatient si-BTKA and inpatient si-BTKA using bivariate comparisons and multivariable logistic regression of outpatient and inpatient cases controlling for differences in baseline demographics and comorbidities. RESULTS: From 2015 to 2019, the utilization of outpatient si-BTKA increased from 0.6% to 10.5%. Outpatient si-BTKA were found to have significantly lower odds of any complication (OR = 0.49), minor complication (OR = 0.50), and postoperative transfusion (OR = 0.66) compared to inpatient cases. Outpatient si-BTKA also had a significantly shorter operative time. CONCLUSION: Compared to inpatient si-BTKA, patients who undergo outpatient si-BTKA do not demonstrate increased rates of any complication, severe complications, and minor complications within 30-days postoperatively. Further insight is needed on the effect of outpatient si-BTKA on long-term outcomes.

Predictors and Outcomes of Postoperative Hemoglobin of <8 g/dL in Total Joint Arthroplasty.

BACKGROUND: Restrictive transfusion practices have decreased transfusions in total joint arthroplasty (TJA). A hemoglobin threshold of <8 g/dL is commonly used. Predictors of this degree of postoperative anemia in TJA and its association with postoperative outcomes, independent of transfusions, remain unclear. We identified predictors of postoperative hemoglobin of <8 g/dL and outcomes with and without transfusion in TJA. METHODS: Primary elective TJA cases performed with a multimodal blood management protocol from 2017 to 2018 were reviewed, identifying 1,583 cases. Preoperative and postoperative variables were compared between patients with postoperative hemoglobin of <8 and ≥8 g/dL. Logistic regression and receiver operating characteristic curves were used to assess predictors of postoperative hemoglobin of <8 g/dL. RESULTS: Positive predictors of postoperative hemoglobin of <8 g/dL were preoperative hemoglobin level (odds ratio [OR] per 1.0-g/dL decrease, 3.0 [95% confidence interval (CI), 2.4 to 3.7]), total hip arthroplasty (OR compared with total knee arthroplasty, 2.1 [95% CI, 1.3 to 3.4]), and operative time (OR per 30-minute increase, 2.0 [95% CI, 1.6 to 2.6]). Negative predictors of postoperative hemoglobin of <8 g/dL were tranexamic acid use (OR, 0.42 [95% CI, 0.20 to 0.85]) and body mass index (OR per 1 kg/m2 above normal, 0.90 [95% CI, 0.86 to 0.94]). Preoperative hemoglobin levels of <12.4 g/dL in women and <13.4 g/dL in men best predicted postoperative hemoglobin of <8 g/dL. Overall, 5.2% of patients with postoperative hemoglobin of 7 to 8 g/dL and 95% of patients with postoperative hemoglobin of <7 g/dL received transfusions. Patients with postoperative hemoglobin of <8 g/dL had longer hospital stays (p < 0.001) and greater rates of emergency department visits or readmissions (p = 0.001) and acute kidney injury (p < 0.001). Among patients with postoperative hemoglobin of <8 g/dL, patients who received transfusions had a lower postoperative hemoglobin nadir (p < 0.001) and a longer hospital stay (p = 0.035) than patients who did not receive transfusions. CONCLUSIONS: Postoperative hemoglobin of <8 g/dL after TJA was associated with worse outcomes, even for patients who do not receive transfusions. Optimizing preoperative hemoglobin levels may mitigate postoperative anemia and adverse outcomes. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Regional or Neuraxial Anesthesia May Help Mitigate the Effects of Bone Cement Implantation Syndrome in Patients Undergoing Cemented Hip and Knee Arthroplasty for Oncologic Indications.

INTRODUCTION: Bone cement implantation syndrome (BCIS) occurs during and after cementation of implants and is associated with hypotension, hypoxia, and cardiovascular collapse. In this study, we aimed to identify risk factors and potential mitigating factors of BCIS in the oncologic adult cohort undergoing cemented arthroplasty. METHODS: We retrospectively reviewed oncologic patients aged 18 years or older who underwent cemented arthroplasty of either the hip or knee from 2015 to 2020. All implants were stemmed. We classified BCIS into three separate categories: (1) grade 1: intraoperative moderate hypoxia (<94%) or drop in systolic blood pressure >20%; (2) grade 2: intraoperative severe hypoxia or drop in systolic blood pressure >40%; and (3) grade 3: cardiovascular collapse requiring cardiopulmonary resuscitation. Demographics, primary malignancy diagnosis, intraoperative factors including cement timing, development of BCIS, 30-day postoperative outcomes, and mortality up to 2 years postoperatively were evaluated. Bivariate analyses and multivariate logistic regression were performed. RESULTS: Sixty-seven patients met inclusion criteria. Of these, 31 patients (46%) developed BCIS. No difference was found in age (65.5 versus 60.9 years; P = 0.15) or body mass index (28.8 kg/m2 versus 29.3 kg/m2; P = 0.76), comorbidities, intraoperative factors, or postoperative surgical outcomes between those who developed BCIS and those who did not (all; P > 0.05). An association with the type of anesthesia administered and development of BCIS in patients receiving general anesthesia alone (17/24 patients, 71%), neuraxial and general (4/15 patients, 27%), and regional and general anesthesia (10/28 patients 36%, P = 0.01) was found. Compared With neuraxial and regional anesthesia, general anesthesia alone had 5.8 (P = 0.007) and 4.5 times (P = 0.006) greater odds of developing BCIS, respectively. No differences were noted in rates of BCIS between regional and neuraxial anesthesia (P = 0.81). DISCUSSION: Addition of regional or neuraxial anesthesia may be protective in reducing development of BCIS in the orthopaedic oncologic cohort undergoing hip and knee arthroplasty. LEVEL OF EVIDENCE: III.