Oral Postoperative Antibiotic Prophylaxis for Outpatient Total Hip and Knee Arthroplasty: Describing Current Practices.

BACKGROUND: Despite an increase in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA), large-scale data are lacking on current practice for antibiotic prophylaxis prescribing. We aimed to describe current oral antibiotic prophylaxis practices nationally for outpatient THA and TKA. METHODS: This nationwide retrospective cohort study included primary outpatient THA or TKA procedures in patients aged 18 to 64 years from 2018 to 2021 using a national claims database. Oral antibiotic prescriptions filled perioperatively (defined as 5 days before to 3 days after surgery) were extracted; these were categorized and assumed to represent postoperative prophylaxis. Multivariable logistic regression measured associations between patient and surgery characteristics and perioperative oral antibiotic prophylaxis. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: Oral antibiotic prescriptions were filled in 16.5% of 73,015 outpatient THA and TKA (18.4% of 24,857 THAs, 15.5% of 48,158 TKAs) procedures. Prescriptions were most often for cephalosporins (74.3%), with cephalexin (52.8%), and cefadroxil (19.1%) being the most common. Non-cephalosporin antibiotics prescribed were mainly clindamycin (6.8%), sulfamethoxazole-trimethoprim (6.7%), and doxycycline (6.2%). The odds of receiving oral antibiotic prophylaxis were higher for THA compared to TKA (OR 1.13, 95% CI 1.09 to 1.18, P < .001) and in the presence of obesity, diabetes, and autoimmune conditions (OR 1.08 to 1.13, P < .001 to .01). Ambulatory surgery center procedures also had significantly increased odds of prophylaxis compared to hospital-based outpatient surgeries (OR 2.62, 95% CI 2.51 to 2.73, P < .001). Additionally, regional and time-based variations were noted. CONCLUSIONS: Perioperative oral antibiotic prophylaxis prescriptions were filled in only 16.5% of outpatient THA and TKA cases, with variation in the type of antibiotic prescribed. The receipt of any prophylaxis and specific medications was associated with demographic, clinical, and procedure-related characteristics. Follow-up research will evaluate associations with infection risk reduction.

Adverse Local Tissue Reaction Secondary to Corrosion at Multiple Junctions in a Modular, Segmental, Distal Femoral Replacement.

While adverse local tissue reactions are well described in the total hip arthroplasty literature, there have only been case reports and case series in the total knee arthroplasty literature. There have been no cases described in the setting of a distal femoral replacement. In this case, we describe a 69-year-old female with a complex history of left knee revision arthroplasty with a distal femoral and proximal tibial replacement who presented with left knee pain and was found to have extensive adverse local tissue reaction with corrosion at the femoral stem-extension piece junction and the extension piece-distal femoral component junction. The femoral taper was then manually cleaned and modular components replaced. Corrosion at the stem-distal femoral component junction can result in adverse local tissue reaction in patients with distal femoral replacements. It is important to consider this diagnosis when evaluating patients with knee pain following distal femoral replacement.

Reconstructing Complex Open Back Wounds with a Modified Minimal-Access Keystone Flap: A Case Report.

CASE: A 61-year-old patient was referred 12 days postoperative with complex, infected, and dehisced paraspinal wound. After debridement and revision of hardware, deep dead space was eliminated through bilateral paraspinal muscle flap advancement. After hardware coverage, a large skin and tissue defect remained. The defect was reconstructed using a modified Keystone flap, eliminating the lateral cutaneous incision. Our patient healed without complication. CONCLUSION: The modified Keystone flap is an option for reconstructing spinal wound defects, yielding excellent tissue coverage and advancement, grants additional flap advancement if necessary because of elimination of the lateral cutaneous incision, and an overall pleasing aesthetic result.

Effects of opioid medications on cognitive skills among Emergency Department patients.

INTRODUCTION: Treatment for pain and related conditions has been identified as the most common reason for Emergency Department (ED) visits. Concerns exist regarding the effects of opioid pain medications on cognition and patient ability to consent for procedures, hospital admission, or to refuse recommended medical interventions. This study was undertaken to identify cognitive skills before and after opioid pain medication in the ED setting. METHODS: This was a prospective study comparing performance on the Mini-Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA) before and after administration of opioid pain medications. Eligible participants included ED patients with pain, who received opioid treatment. Participants were randomized to receive either the MMSE before pain medication and the MoCA after medication, or the reverse. MoCA scores were converted to MMSE equivalent scores for comparison. RESULTS: Among 65 participants, the median age was 36 and median triage pain score was 8. 35% of patients were considered cognitively impaired based on their MMSE score prior to any opioid medication (MMSE<27). There was a median decrease in pain scores of 1 point following pain medication, p-value<0.001. There was a median decrease in MMSE scores of 1 point following pain medication, p-value=0.003. The range of change in scores (post minus pre) on the MMSE-equivalent was -7 to 3. 35 patients (56%) had a decrease in scores, 6 (10%) had no change, and 21 (34%) had an increase. After medication, 31 (48%) were abnormal (MMSE score<27). No differences in MMSE scores were identified by gender, ethnicity, mode of arrival, insurance, age, triage pain scores, opioid agent given, or ED diagnosis. CONCLUSIONS: There is an association between opioid pain medication and decrease in cognitive performance on the MMSE. Because of the wide range of cognitive performance following opioid pain medication, assessment of individual patients' cognitive function is indicated.

Unprovoked Pulmonary Embolism in a Young Patient with Marfan Syndrome.

Marfan syndrome is a rare connective tissue disorder with a prevalence of approximately 2 to 3 per 10,000 individuals. There have been some reports of young patients with Marfan syndrome developing arteriovenous thromboembolism. These events were unprovoked and recurrent. Owing to its rarity, hypercoagulopathy and other metabolic derangement in patients with Marfan syndrome remains largely unknown. Herein, we report a case of a young man with Marfan syndrome who had myocardial infarction and pulmonary embolism. We hope that this case adds to the scant body of knowledge about this patient population.