The Practice of Overlapping Surgery Is Safe in Total Knee and Hip Arthroplasty.

BACKGROUND: Overlapping surgery occurs when a surgeon performs 2 procedures in an overlapping time frame. This practice is commonplace in the setting of total joint arthroplasty and is intended to increase patient access to experienced surgeons, improve efficiency, and advance the surgical competence of surgeons and trainees. The practice of overlapping surgery has been questioned because of safety and ethical concerns. As the literature is scarce on this issue, we evaluated the unplanned hospital readmission and reoperation rates associated with overlapping and non-overlapping total joint arthroplasty procedures. METHODS: We reviewed 3,290 consecutive primary total knee and hip arthroplasty procedures that had been performed between November 2010 and July 2016 by 2 fellowship-trained senior surgeons at a single institution. Overlapping surgery was defined as the practice in which the attending surgeon performed a separate procedure in another room with an overlapping room time of at least 30 minutes. Patient baseline characteristics and 90-day rates of complications, readmissions, and reoperations were compared between overlapping and non-overlapping procedures. Subanalyses also were done on patients with a body mass index (BMI) of ≥30 kg/m2 and those with an American Society of Anesthesiologists (ASA) score of 3 or 4. The level of significance was set at 0.05. RESULTS: Of the 2,833 procedures that met the inclusion criteria, 57% (1,610) were overlapping and 43% (1,223) were non-overlapping. Baseline demographics, BMI, and ASA scores were similar between the groups. No significant differences were found between the overlapping and non-overlapping procedures in terms of the 90-day rates of complications (5.2% vs. 6.6%, respectively; p = 0.104), unplanned readmissions (3.4% vs. 4.3%; p = 0.235), or reoperations (3.1 vs. 3.1; p = 1.0) in the analysis of the entire cohort or in subgroup analyses of obese patients and patients with an ASA score of 3 or 4. The total mean operating room time was 5.8 minutes higher for overlapping procedures. CONCLUSIONS: Overlapping procedures showed no increase in terms of the 90-day rates of complications, readmissions, or reoperations when compared with non-overlapping procedures. There was just over a 5-minute increase in mean operating room time for overlapping procedures. Our data suggest that overlapping surgery does not lead to detrimental outcomes following total knee arthroplasty or total hip arthroplasty. Future investigations evaluating patient-oriented outcomes and satisfaction are warranted. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of Novel Adjuncts in Pain Management Following Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND: Total knee arthroplasty (TKA) can be associated with significant pain which can negatively impact outcomes. Multiple strategies have been employed to reduce pain. The aim of this study is to compare the effectiveness of 3 different pain management modalities after TKA that included (1) our standardized knee injection cocktail and oral acetaminophen, (2) liposomal bupivacaine periarticular injection and oral acetaminophen, and (3) our standardized knee injection cocktail and intravenous (IV) acetaminophen. METHODS: A prospective randomized clinical trial was conducted with 3 perioperative pain management regimes: oral acetaminophen and our standardized knee injection cocktail (standard group), oral acetaminophen and liposomal bupivacaine periarticular injection (LB group), and IV acetaminophen and our standardized knee injection cocktail (IVA group). Primary outcome measures included visual analog scale, total morphine equivalents, and the opioid-related symptoms distress scale at 24 and 48 hours postoperatively. RESULTS: There were no significant differences on visual analog scale/opioid-related symptoms distress scale scores 24 hours after surgery. The LB group required significantly more narcotics (total morphine equivalents) than the standard (P = .025) and IVA groups (P = .032). No significant differences were observed on any of the outcomes measured at 48 hours after surgery. CONCLUSION: Our data suggest that there is no added benefit in the routine use of IV acetaminophen or liposomal bupivacaine after TKA.

What Is the Optimal Criteria to Use for Detecting Periprosthetic Joint Infections Before Total Joint Arthroplasty?

BACKGROUND: The purposes of this study were to (1) test the accuracy of α-defensin and combined α-defensin-aspiration cultures in diagnosing periprosthetic joint infection (PJI) before revision total knee and hip arthroplasty and (2) evaluate Musculoskeletal Infection Society (MSIS) criteria and α-defensin as predictors of successful reimplantation (second-stage) at 1 year after surgery. METHODS: We retrospectively evaluated a total of 97 synovial fluid aspirations performed between August 2014 and September 2016 before revision due to septic or aseptic failures (n = 70) or before second-stage (n = 27) joint arthroplasty. Revisions were categorized as either septic or aseptic according to the MSIS criteria. Synovial fluid was tested for α-defensin, cell count with differential, and cultures. Reimplantations were assessed for success or failure (defined as the need for reoperation due to infection) within 1 year after surgery. RESULTS: For septic and aseptic revision arthroplasty, the sensitivity, specificity, positive predictive value, and negative predicted value of α-defensin was 97% while for the combined α-defensin and aspiration culture, it was 96%, 100%, 100%, and 97%. Despite being performed with negative MSIS criteria and α-defensin test results, 11% (3/27) of reimplantations (second-stage) failed within 1 year postoperatively because of infection. CONCLUSION: Alpha-defensin is an accurate diagnostic test for the diagnosis of PJI before revision arthroplasty. The combination of α-defensin and aspiration cultures has higher specificity and positive predictive value. MSIS criteria and α-defensin may help predict the success of reimplantations within 1 year after surgery.