Intrawound Vancomycin Powder Reduces Early Prosthetic Joint Infections in Revision Hip and Knee Arthroplasty.

Intrawound vancomycin powder has shown efficacy and safety in decreasing postoperative spine infections, but its use in arthroplasty has not been well established. The purpose of this study was to compare the rate of early prosthetic joint infections (PJI) with and without the use of intrawound vancomycin powder during joint arthroplasty. A retrospective cohort of all patients who underwent primary or revision hip or knee arthroplasty by two surgeons over a two-year period at a single hospital system was evaluated. The control group received standard systemic prophylaxis only, whereas the treatment group received 1 g of vancomycin powder in the surgical wound in addition to systemic prophylaxis. A statistically significant decrease in the overall PJI rate was found in the treatment group (4/816=0.49%) compared to the control group (13/824=1.57%; p=0.0479). Subgroup analysis demonstrated a trend toward fewer PJIs in the vancomycin group, however, only the revision procedures showed a statistically significant reduction in early PJIs after the initiation of vancomycin (7/180=3.89% to 0/134=0%; p=0.0217). The use of intrawound vancomycin powder was associated with a significant reduction in the overall incidence of early PJIs following joint arthroplasty, however, only the revision procedures demonstrated a significant reduction in the rate of early PJIs.

Randomized Prospective Trial Comparing the Use of Intravenous versus Oral Acetaminophen in Total Joint Arthroplasty.

BACKGROUND: Multimodal pain management has had a significant effect on improving total joint arthroplasty recovery and patient satisfaction. There is literature supporting that intravenous (IV) acetaminophen reduces postoperative pain and narcotic use in the total joint population. However, there are no studies comparing the effectiveness of IV vs oral (PO) acetaminophen as part of a standard multimodal perioperative pain regimen. METHODS: One hundred twenty patients undergoing hip and knee arthroplasty surgeries performed by one joint arthroplasty surgeon were prospectively randomized into 2 groups. Group 1 (63 patients) received IV and group 2 (57 patients) received PO acetaminophen in addition to a standard multimodal perioperative pain regimen. Each group received 1 gram of acetaminophen preoperatively and then every 6 hours for 24 hours. Total narcotic use and visual analog scale (VAS) scores were collected every 4 hours postoperatively. RESULTS: The 24-hour average hydromorphone equivalents given were not different between groups (3.71 vs 3.48) at 24 hours (P = .76), or at any of the individual 4-hour intervals. The 24-hour average visual analog scale scores in group 1 (IV) was 3.00 and in group 2 (PO) was 3.40 (P = .06). None of the 4-hour intervals were significantly different except the first interval (0-4 hour postoperatively), which favored the IV group (P = .03). CONCLUSION: The use of IV acetaminophen may have a role when given intraoperatively to reduce the immediate pain after surgery. Following that, it does not provide a significant benefit in reducing pain or narcotic use when compared with the much less expensive PO form.

Repeat Manipulation Under Anesthesia For Persistent Stiffness After Total Knee Arthroplasty Achieves Functional Range of Motion.

Poor range of motion may decrease a patient's ability to participate in activities of daily living after total knee arthroplasty. Manipulation under anesthesia has been shown to improve range of motion; however, some patients have persistent stiffness even after manipulation. The goal of this study was to evaluate the outcomes and complications of patients who underwent a second manipulation under anesthesia for persistent stiffness after total knee arthroplasty. The review of surgical records of two joint arthroplasty surgeons identified 226 knees in 210 patients who underwent a manipulation under anesthesia for poor range of motion after total knee arthroplasty. Of these patients, 16 patients underwent a second manipulation under anesthesia. For patients undergoing two manipulations under anesthesia procedures, at latest follow up (mean 539 days), mean extension improved from 10.50° to 2.50° (p=0.001) and mean flexion improved from 87.50° to 112.69° (p=0.001) respectively. SF-12 scores were available for 12 of 16 knees with a mean score of 34.42. Two of 16 patients (12.5%) experienced a complication. Three of 16 (18.8%) patients who underwent a second manipulation required a revision arthroplasty procedure. In conclusion, a second manipulation under anesthesia can achieve functional range of motion that is sustained after total knee arthroplasty.

Adverse reaction to metal debris in a patient with acetabular shell loosening 8 years after ceramic-on-metal total hip arthroplasty.

A 41-year-old woman presented 8 years after a left total hip arthroplasty. She complained of progressive groin pain for several months. Radiographs demonstrated a hard-on-hard bearing surface combination and radiolucent lines surrounding the acetabular shell. Laboratory analysis revealed a mild leukocytosis, a normal erythrocyte sedimentation rate, and a mildly elevated C-reactive protein. Serum cobalt and chromium levels were markedly elevated. Aspiration of the hip joint was negative for infection. Magnetic resonance imaging failed to demonstrate a pseudotumor. Revision total hip arthroplasty was performed, and a ceramic-on-metal bearing surface combination was explanted. Significant intraoperative findings included dark gray synovial fluid, metal transfer onto the ceramic femoral head, and a grossly loose acetabular shell pivoting about a single well-fixed screw. The explanted components otherwise appeared normal macroscopically. Histologic analysis of the capsular tissue demonstrated aseptic lymphocyte-dominated vasculitis-associated lesion and inclusion bodies consistent with third-body wear. Revision arthroplasty to a ceramic-on-polyethylene bearing surface combination was performed with a good clinical result and laboratory normalization at 9-month follow-up.

Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial.

Controlling postoperative pain and nausea after total joint arthroplasty remains an important challenge. We conducted a prospective, randomized controlled trial with 120 patients to determine if the addition of perioperative dexamethasone to a multimodal regimen improves antiemetic and analgesic control, enhances mobility, and shortens hospital length of stay after total hip and knee arthroplasty. Patients administered 10mg of intravenous dexamethasone intraoperatively consumed less daily rescue anti-emetic and analgesic medication, reported superior VAS nausea and pain scores, ambulated further distances, and had a significantly shorter length of stay compared to the control group (P<0.05). A second, 24-hour postoperative dose of 10mg intravenous dexamethasone provided significant additional pain and nausea control and further reduced length of stay (P<0.05). No adverse events were detected with the administration of the intraoperative and/or postoperative dexamethasone.

The incidence of femoral component version change in primary THA using the S-ROM femoral component.

Although use of modular femoral components in revision total hip arthroplasty (THA) is widely accepted, many still question the need for modular versatility in primary THA. This study examined a large cohort of primary THA patients implanted with a modular S-ROM femoral component (DePuy Orthopaedics, Warsaw, Indiana) to determine the percentage of hips in which the surgeon changed version of the femoral component to increase the intraoperative stability of the THA construct and/or to maximize hip range of motion without impingement.In a group of 1000 routine, primary THAs, femoral component version was changed in 479 hips (47.9%). This change in rotational position of the femoral stem ranged from 60° retroversion with respect to the position of the sleeve to 80° of anteversion with respect to the sleeve. Ten hips (1%) experienced dislocation within the first 3 postoperative months. There was no difference in the dislocation rate between those patients in which femoral component version was changed versus those in which version was not changed. Statistical analysis showed no correlation between the likelihood of changing stem version and any of the following clinical variables: patient age, sex, diagnosis, or surgeon.The high percentage of straightforward primary THAs in which it was deemed beneficial to change version of the stem combined with the lack of correlation between femoral version change and clinical variables leads us to conclude that the routine use of a stem that allows variable version may be advantageous when compared to a nonmodular stem, as it is not possible to preoperatively determine when changing version will be required.

Evaluation of postoperative fever and leukocytosis in patients after total hip and knee arthroplasty.

Fever and leukocytosis are common after joint arthroplasty, often resulting in additional studies. This study was conducted to determine the incidence of fever and leukocytosis after joint arthroplasty and the use of tests. We retrospectively reviewed records (n = 426) of patients who underwent knee or hip arthroplasty between February 2006 and April 2008 to determine the incidence of fever and leukocytosis, tests, and results. Sixty-four had fever, and 247 had postoperative leukocytosis. Sixty additional tests were performed; 6 (10%) of 60 tests were clinically relevant. After joint arthroplasty, more than half of patients developed leukocytosis, and nearly 15% developed fever. Diagnostic testing should be based on physical examination or symptomatic findings and not solely on laboratory values or vital signs, decreasing the patient discomfort and potentially lower costs.

S-ROM hip prosthesis: 10- to 14-year results.

This retrospective study evaluated the results of 55 S-ROM femoral components (45 patients) at 10 to 14 years postoperatively. Twelve patients (15 hips) were lost to follow-up. Survivorship of the prosthesis was determined in the remaining 33 patients (40 hips). Harris hip scores and radiographic analyses were performed. Thirty-four hips were performed in a primary fashion and 6 for revision arthroplasty. There was 100% survival for aseptic loosening in the primary arthroplasty group and 1 failure in the revision group. This study shows excellent long-term results of the S-ROM prosthesis at 10 to 14 years.