Erratum to 'Adductor Canal Block vs Liposomal Bupivacaine Periarticular Injection in Total Knee Arthroplasty: A Randomized Controlled Trial' [Arthroplasty Today 9 (2021) 21-28].

[This corrects the article DOI: 10.1016/j.artd.2021.03.008.].

Intra-Articular Corticosteroid Injections Into a Preexisting Total Knee Arthroplasty are Associated With Increased Risk of Periprosthetic Joint Infection and Revision.

Background: This study aims to determine the risks of periprosthetic joint infection (PJI) and revision associated with injecting a preexisting total knee arthroplasty (TKA) with intra-articular corticosteroids (IACSs). Methods: The PearlDiver database was used to identify patients who underwent elective, primary TKA between 2015 and 2019. Patients who received IACS injections into the ipsilateral knee within 1 year after their primary TKA were matched 2:1 on age, gender, and Charlson comorbidity index and compared to a no-injection control group. The incidence of PJI at 1 year postoperatively and revision at 2 years postoperatively were compared between groups. Results: A total of 27,059 patients were in the injection cohort and 54,116 patients in the control cohort. The overall PJI rate was 1.3% in the injection cohort and 0.8% in the control cohort (P < .001). The rate of PJI increased with the number of post-TKA IACS injections received: 1 injection (1.3%), 2 injections (1.4%), and >3 injections (1.8%) (P < .001 for all, compared to controls). The revision rate was 3.1% in the injection cohort and 1.3% in the control cohort (P < .001). Revision rates increased with the number of post-TKA IACS injections received: 1 injection (2.5%), 2 injections (4.2%), and >3 injections (7.3%) (P < .001 for all, compared to controls). Conclusions: IACS injections into a preexisting TKA are associated with an incremental increased risk of prosthetic joint infection and revision. Considering the potential deleterious impact of PJI and complexity of revision procedures, IACS injections into a preexisting TKA should be strongly discouraged.

Higher Complication Rate in COVID-19 Recovered Patients Undergoing Primary Total Joint Arthroplasty.

BACKGROUND: There is limited data reviewing complication risks associated with total joint arthroplasty (TJA) after recovering from COVID-19. This study evaluated complications within 90 days of TJA in patients who had a COVID-19 diagnosis at varying intervals prior to surgery versus a non-COVID-19 cohort. METHODS: A large national database was used to identify patients diagnosed with COVID-19 in the six months prior to total hip arthroplasty (THA) or total knee arthroplasty. The incidence of complications within 90 days of surgery was recorded and compared to a COVID-19 negative control group matched 1:3 for age range in 5-year intervals, Charlson Comorbidity Index, and sex. There were 7,780 patients included in the study; 5,840 (75.1%) never diagnosed with COVID-19, 1,390 (17.9%) who had a COVID-19 diagnosis 0 to 3 months prior to surgery, and 550 (7.1%) who had a COVID-19 diagnosis 3 to 6 months prior to surgery. RESULTS: When compared to their COVID negative controls, patients who had a COVID-19 diagnosis 0 to 3 months prior to surgery had significantly higher rates of readmission (14.0 versus 11.1%, P = .001), pneumonia (2.2 versus 0.7%, P < .001), deep vein thrombosis (DVT) (3.3 versus 1.9%, P = .001), kidney failure (2.4 versus 1.4%, P = .006), and acute respiratory distress syndrome (1.4 versus 0.7%, P = .01). Patients who had a COVID-19 diagnosis 3 to 6 months prior to surgery had significantly higher rates of pneumonia (2.0 versus 0.7%, P = .002) and DVT (3.6 versus 1.9%, P = .005) when compared to their COVID negative controls. CONCLUSION: Patients diagnosed with COVID-19 within three months prior to TJA have an increased risk of 90-day postoperative complications. Risk for pneumonia and DVT remains elevated even when surgery was performed as far as 3 to 6 months after COVID-19 diagnosis.

The Efficacy of Tranexamic Acid for Reducing Blood Transfusion Rates in Extracapsular Hip Fractures: A Single-Center Randomized Controlled Trial.

Perioperative allogenic blood transfusions for patients with hip fractures are associated with increased costs and complications. This prospective randomized controlled trial evaluated whether tranexamic acid (TXA) reduces blood transfusion rates and blood loss in extracapsular hip fractures, when administered at the time of hospital admission. Patients with closed intertrochanteric or subtrochanteric femur fractures undergoing intramedullary nailing (n=100) were enrolled from October 2015 to January 2019. On arrival to the hospital, patients were randomized to receive either 1 g of intravenous TXA or normal saline. Blood transfusion rates from hospital arrival to postoperative day 5 or discharge, blood loss from hospital arrival to postoperative day 3 or 4, intraoperative blood loss, length of hospital stay, 30-day mortality, and major complications were evaluated. Six patients from the TXA group and five from the placebo group were excluded because of canceled surgery, study drug infusion after incision, multiple fractures, or dropout. Patient characteristics were similar between the groups. Postoperative transfusion rates were 17.5% (7 of 40) in the TXA group and 36.7% (18 of 49) in the placebo group (relative risk, 0.48; 95% CI, 0.22-1.03; P=.046). Total blood loss was significantly less in the TXA group (mean difference, 367 mL; 95% CI, 76-657; P=.01). No significant differences were found for intraoperative blood loss, length of hospital stay, 30-day mortality, or 30-day major complications. TXA administered on hospital arrival decreased the risk of postoperative blood transfusion and mean perioperative blood loss in patients with extracapsular hip fractures. We recommend a single-dose intravenous administration of TXA at the time of hospital admission for patients with extracapsular hip fractures. [Orthopedics. 2023;46(5):e303-e309.].

Effects of Hypercarbia on Lower Extremity Primary Total Joint Replacement Infections.

INTRODUCTION: Prosthetic joint infection (PJI) is a serious complication after total joint replacement (TJR). Adequate wound oxygenation is critical for wound healing and infection prevention. As carbon dioxide (CO2) is exchanged for oxygen (O2) in the lungs, serum bicarbonate (HCO3 -) may be used as a marker for predicting relative serum O2 levels, and therefore, healing potential. No currently published literature explores the relationship between serum bicarbonate levels and PJI in TJR patients. METHODS: We performed this retrospective review of lower extremity TJR patients to determine whether the risk of PJI and wound complications within one year was correlated with hypercarbia, which was defined as a preoperative serum bicarbonate level >30 mEq/L. RESULTS: Out of 1,690 TJR procedures, 1.6% (N=27) had a PJI or superficial wound infection within one year postoperatively. The average preoperative serum bicarbonate was 26.9 (SD 2.6) among patients without PJI and 27.2 (SD 2.1) among patients with PJI (p=0.46). Hypercarbia was present in 9.2% of non-PJI patients and in 7.4% of PJI patients. The relative risk of PJI and wound complications did not differ for patients with vs without hypercarbia (RR = 0.79, 95% CI = 0.19-3.31, p=0.75). CONCLUSION: The results of this study provide preliminary evidence that preoperative hypercarbia may not be correlated with an increase in the risk of PJI or wound complications. However, due to the rarity of both PJI and hypercarbia, a larger patient population is needed to ensure adequate power to detect clinically meaningful effect sizes.

A Single Dose Versus Two Doses of Tranexamic Acid for Extracapsular Hip Fractures.

Objective In this study, we aimed to compare the effectiveness of one dose of tranexamic acid (TXA) at the time of hospital admission versus two doses of TXA (one at the time of hospital admission and another dose intraoperatively) in reducing perioperative total blood loss in patients with extracapsular hip fractures. Methods This retrospective cohort study included 80 patients from a single institution who underwent surgical fixation for extracapsular hip fractures. Forty patients received a single dose of 1 gram of TXA at the time of hospital admission (per standardized protocol of an ongoing research study at the time), and 40 patients received the same dose of TXA on hospital admission as well as a second dose of 1 gram of TXA intraoperatively at the time of incision (per standard practice change following the completion of the research study). The primary study outcome of interest was total blood loss, which was calculated by estimating blood volume via Nadler's formula followed by calculating the total blood loss with the hemoglobin dilution method. Secondary outcomes included blood transfusion rates, hospital length of stay (LOS), and 30-day mortality. Results Patient gender, age, the American Society of Anesthesiologists (ASA) score, procedure length, fracture type, hardware type, and hemoglobin on hospital arrival were similar across the study groups (all p>0.05), though the twice-dosed group had a higher average BMI (26.4 kg/m2 vs. 24 kg/m2, p=0.04). When adjusting for BMI, the twice-dosed group was estimated to have a slightly larger but non-significant difference in total blood loss (115-ml difference, 95% CI: 158.2-389.3, p=0.40) compared to the single-dose TXA group. More patients in the twice-dosed group required blood transfusion compared to the single-dose TXA group, though this was not statistically significant (30.0% vs. 17.5%, adjusted OR=1.64, 95% CI: 0.55-5.12, p=0.38). The distribution of hospital LOS and 30-day mortality rates were similar across the groups (p=0.13 and p>0.99). Conclusion In the setting of surgically treated extracapsular hip fractures, patients who received one dose of TXA at the time of hospital admission and a second intraoperative dose of TXA did not demonstrate significant differences in total blood loss or a need for blood transfusion compared to patients who only received a single dose of TXA at the time of hospital admission.

Simultaneous primary bilateral hip resection arthroplasty.

Hip resection arthroplasty is a useful procedure for the management of complex hip problems and in patients with high surgical and anesthetic risk factors. Unilateral procedures performed for failed total hip arthroplasty have been shown to be successful for pain relief with acceptable functional outcomes; however, to our knowledge, no research exists on simultaneous bilateral hip resection arthroplasty for femoral head osteonecrosis. We present two cases of single-stage bilateral hip resection arthroplasty performed under singular anesthetic procedures for femoral head osteonecrosis. The patients were each able to stand for transfers postoperatively and had no deterioration in pain or function. These two cases demonstrate that satisfactory pain control with preservation of function may be achievable with bilateral hip resection arthroplasty procedures in patients who are not a candidate for more advanced reconstructive procedures.

Adductor Canal Block vs Liposomal Bupivacaine Periarticular Injection in Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: This study compares postoperative pain scores and functional outcomes between liposomal bupivacaine peri-articular injection (LB-PAI) vs a single-shot adductor canal block (ACB) using bupivacaine HCl in patients undergoing primary total knee arthroplasty (TKA). METHODS: This is a randomized controlled trial of 56 patients who were treated with TKA for arthritis. Patients were randomized to receive an intraoperative LB-PAI (n = 27) or preoperative ACB using bupivacaine HCl (n = 29). Both groups were otherwise given our institutional standard multimodal pain protocol. Data on Visual Analog Scale (VAS) pain scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, knee range of motion, postoperative ambulation distance, hospital length of stay, and opioid use were collected. The total cost of each intervention was compared at the conclusion of the study. RESULTS: Age, gender, or body mass index was similar between groups. Compared to the ACB group, the LB-PAI group trended to lower average VAS pain scores on postoperative days 0, 1, and 2 (average difference [95% confidence interval] = -0.5 [-0.7, 1.7], -1.0 [-0.1, 2.0], -0.2 [-0.8, 1.3]), and identical average VAS pain scores on postoperative days 4 and 7. These differences and all postoperative outcome measures were not statistically significant at any time point. A single 266-milligram vial of liposomal bupivacaine costs $351, and a single-shot ACB costs $893 at our institution. CONCLUSIONS: This randomized controlled trial shows similar postoperative pain control, functional outcomes, and opioid use between LB-PAI and a single-shot ACB in patients undergoing primary TKA. However, the single-shot ACB costs $542 more than the LB-PAI at our institution.