The Association of Glycemic Control Medication Regimens and Preoperative Fructosamine Among Total Joint Artrhoplasty Patients.

BACKGROUND: Although glycated hemoglobin A1C (HbA1c) has classically been used for glycemic control screening before surgery, fructosamine, a short-term glucose variability indicator, has been reported to be a more accurate predictor of postoperative periprosthetic joint infection among patients with diabetes mellitus (DM). Given the variability of diabetic medication management, this study aims to identify the associated effect of glycemic control medication regimen (GCMR) on the incidence rate and associated odds of abnormal preoperative fructosamine levels among diabetic primary total knee arthroplasty or total hip arthroplasty patients. METHODS: Between 2017 and 2018, consecutive series of total hip arthroplasty and total knee arthroplasty patients were identified, and the final cohort included only diabetic patients. All patients reported preoperative HbA1c and fructosamine levels. GCMR categories included insulin, metformin, and other. Independent risk of GCMR and abnormal fructosamine levels (>293 µmol/L) were identified using multivariable logistic regression, while controlling for preoperative baseline factors including HbA1C. RESULTS: Among 420 patients, 15.7% (66/420) were diabetic, of whom 22.7% (15/66) reported an abnormal fructosamine level. Among patients requiring GCMR, 24.0% (18/75), 56.0% (42/75), and 77.7% (58/75) reported using insulin, other, and metformin, respectively. Multivariable logistic regressions demonstrated that insulin-dependent patients with DM reported a 1.71 (95% confidence interval [CI], 0.096 to 30.213, P = 0.716) increased odds of abnormal fructosamine levels compared with nonactive GCMR patients, whereas patients managed with metformin and other glycemic control medications reported a protective 0.48 (95% CI, 0.418 to 5.407, P = 0.549) and 0.32 (95% CI, 0.216 to 4.508, P = 0.393) decreased odds of abnormal fructosamine levels, respectively. CONCLUSION: In this study, insulin and other GCMR medications exhibited a trend for increased and decreased odds of having abnormal preoperative fructosamine levels while controlling for baseline HbA1c level compared with patients with DM without active GCMR. This association may be explained by multifactorial short-term glucose variability in insulin users, indicating the continued need and optimization of short-term glycemic variations instead of HbA1c.

Aspirin is an Effective Prophylaxis for Venous Thromboembolism After Revision Hip and Knee Arthroplasty.

BACKGROUND: Venous thromboembolism (VTE) following revision total joint arthroplasty (TJA) poses significant risks despite prophylactic measures. The optimal VTE prophylaxis agent for revision TJA remains unclear. This study aimed to compare aspirin against various anticoagulant agents regarding efficacy and safety in preventing symptomatic VTE events after revision TJA. METHODS: A retrospective analysis included 4,575 patients undergoing revision TJA between 2008 and 2020. Of these, 2,091 received aspirin, while 2,484 received other anticoagulants. Demographic, procedural, and outcome data were collected. Logistic regression models were used to identify predictors of symptomatic VTE. RESULTS: The aspirin group showed a significantly lower incidence of symptomatic VTE compared to the other anticoagulant group (0.53 versus 2.54%, P < .001). Logistic regression confirmed a higher risk of VTE with other anticoagulants (odds ratio: 0.2 to 0.26, P < .001), while blood transfusion (odds ratio: 2.72, P = .001) were identified as risk factors. CONCLUSIONS: This study demonstrated that aspirin is a viable and potentially safer option than other anticoagulants, exhibiting comparable efficacy in preventing VTE events in revision TJA. Balancing effectiveness and safety is crucial, considering patient-specific risk factors and bleeding tendencies. This large cohort study demonstrated that aspirin was associated with a more effective and safer VTE prophylaxis agent, compared to other anticoagulants, in patients undergoing revision TJA.

Development and Validation of a Risk Calculator for Intensive Care Unit Admission After Total Hip Arthroplasty.

BACKGROUND: The purpose of this study was to develop and validate a risk stratification calculator to determine the risk of a patient requiring intensive care unit (ICU) admission following primary and revision total hip arthroplasty (THA). METHODS: Using a database of 12,342 THA procedures, with 132 ICU admissions, from 2005 to 2017, we developed models of ICU admission risk based on previously identified preoperative factors including age, heart disease, neurologic disease, renal disease, unilateral versus bilateral surgery, preoperative hemoglobin, blood glucose, and smoking status. Prior to developing the calculator, a set of logistic regressions were analyzed to determine weight and scoring for each variable. Once developed, we validated the risk calculator using a second independent institution. RESULTS: A separate risk calculator was developed for primary and revision THA. The area under the curve (AUC) for primary THA was 0.808 (95% confidence interval 0.740 to 0.876) and revision THA was AUC 0.795 (confidence interval 0.740 to 0.850). As an example, the primary THA risk calculator had a Total Points scale of 220, with 50 points associated with a 0.1% chance of ICU admission and 205 points associated with a 95% chance of ICU admission. Validation with an external cohort demonstrated satisfactory AUCs, sensitivities, and specificities for both primary THA (AUC 0.794, sensitivity 0.750, and specificity 0.722) and revision THA (AUC 0.703, sensitivity 0.704, and specificity 0.671) CONCLUSION: The externally validated risk calculators developed in this study can accurately predict ICU admission following primary and revision THA based on a number of readily available preoperative factors.

Angiosarcoma gastrointestinal multifocal, con compromiso extenso de estómago, intestino delgado y colon. Reporte de un caso / Multifocal gastrointestinal angiosarcoma, with extensive gastric, small intestine and colon involvement. A case report

Introducción. El angiosarcoma es una neoplasia vascular originada a nivel del endotelio, de baja frecuencia, conocido por su agresividad y crecimiento acelerado. Alcanza solo el 1 al 2 % del total de los sarcomas. La presentación gastrointestinal es infrecuente y su incidencia es poco conocida debido al escaso reporte de casos en la literatura. Suele identificarse en etapas avanzadas debido a la dificultad del diagnóstico histopatológico por sus características morfológicas, siendo necesario aplicar tinciones especiales o estudio inmunohistoquímico. Caso clínico. Por su interés y singularidad, presentamos el caso de un paciente masculino de 54 años, quien consultó con hemorragia digestiva profusa, anemización y requerimiento de terapia transfusional. Resultados. Durante el proceso diagnóstico, en la endoscopia encontraron diversas lesiones multifocales que se extendían por gran parte del tracto gastrointestinal. El estudio histopatológico mostró angiosarcoma gastrointestinal. Discusión. El angiosarcoma del tracto gastrointestinal es extremadamente infrecuente, de difícil diagnóstico y bajas posibilidades de manejo curativo, con opciones terapéuticas limitadas, lo que configura un mal pronóstico a corto plazo

Introduction. Angiosarcoma is a vascular neoplasm originating from endothelial cells, known for its aggressiveness, accelerated growth and reduced frequency. Reach only 1 to 2% of total sarcomas. Gastrointestinal presentation is extremely rare, the true incidence is poorly known, due to the limited reports of this entity in the literature. It is usually identified in advanced stages in view of the difficulty of the histopathological diagnosis, attributable to its morphological characteristics, being necessary to apply special stains or immunohistochemical study. Case report. Due to their interest and uniqueness, we present the case of a 54-year-old male patient, who presented with a profuse gastrointestinal bleeding, anemia, and requirement for transfusion therapy. Results. The endoscopy detected several multifocal lesions that extended most of the gastrointestinal tract. The histopathological study showed gastrointestinal angiosarcoma. Discussion. Angiosarcoma of the gastrointestinal tract is extremely uncommon, difficult to diagnose and has low possibilities of curative management, with limited therapeutic options, which configures a poor prognosis in the short term

Routine Use of Closed Suction Drains Following Revision Arthroplasty May Not be Necessary.

BACKGROUND: There are numerous studies demonstrating that closed suction drainage (CSD) usage after primary total joint arthroplasty (TJA) has little to no benefit. There are little data on the role of CSDs after revision TJA. The purpose of our study was to evaluate whether there is any clinical advantage to CSD usage after revision TJA. METHODS: This retrospective study evaluated the clinical records of 2,030 patients undergoing revision TJA between 2007 and 2021. CSD was used in 472 patients and not used in 1,558 patients. Primary outcome was blood transfusion rate and secondary outcomes included total blood loss (TBL), as determined by Gross formula, wound complications (hematoma, infection, and dehiscence), and length of hospital stay. Patients undergoing revision TJA for oncologic reasons or those with incomplete datasets were excluded. RESULTS: There were no statistically significant differences in rates of allogeneic blood transfusion, TBL, and wound complications (hematoma, infection, and dehiscence) between the two groups (P = .159, .983, .192, .334, and .548, respectively). When adjusted for demographic and surgical confounders, there was no difference in transfusion and TBL rates between groups (Odds Ratio 1.04, 95% Confidence Interval 0.78-1.38, P = .780 and estimate -105.71 mL, 95% confidence interval -333.96 to 122.55, P = .364, respectively). CSD cohort had a shorter length of stay (4.30 versus 5.82 days, P < .001). CONCLUSION: We acknowledge that there is a role for CSD usage in a selected group of patients. Nevertheless, our study revealed that routine use of CSD after revision TJA does not provide an additional clinical benefit.

Low-Dose Aspirin for Venous Thromboembolism Prophylaxis is Associated With Lower Rates of Periprosthetic Joint Infection After Total Joint Arthroplasty.

BACKGROUND: Aspirin as a venous thromboembolism (VTE) prophylactic agent has been shown to have antistaphylococcal and antibiofilm roles. Optimal acetylsalicylic acid (ASA) dosage would facilitate antimicrobial effects while avoiding over-aggressive inhibition of platelet antimicrobial function. Our purpose was to determine the periprosthetic joint infection (PJI) rate after total joint arthroplasty in patients receiving low-dose ASA (81 mg twice a day), in comparison to high-dose ASA (325 mg twice a day). METHODS: We conducted a retrospective cohort study between 2008 and 2020. Eligible patients were older than 18 years, underwent primary total joint arthroplasty, both total knee arthroplasty and total hip arthroplasty, had a minimum 30-day follow-up, and received a full course ASA as VTE prophylaxis. Patients' records were reviewed for PJI, according to Musculoskeletal Infection Society criteria. Patients were excluded if they underwent revision arthroplasty, had a history of coagulopathy, or had an ASA regimen that was not completed. In total 15,825 patients were identified, 8,761 patients received low-dose ASA and 7,064 received high-dose ASA. RESULTS: The high-dose cohort had a higher PJI rate (0.35 versus 0.10%, P = .001). This relationship was maintained when comparing subgroups comprising total knee arthroplasty (0.32 versus 0.06%, P = .019) or total hip arthroplasty (0.38 versus 0.14%, P = .035) and accounting for potentially confounding demographic and surgical variables (odds ratio = 2.59, 95% CI = 1.15-6.40, P = .028). CONCLUSION: Comparing low-dose to high-dose ASA as a VTE prophylactic agent, low-dose ASA had a lower PJI rate. This may be attributable to a balance of anti-infective properties of ASA and antiplatelet effects.

Routine Laboratory Tests are not Necessary After Primary Total Joint Arthroplasty: A Prospective Study Utilizing a Selective Algorithmic Approach.

BACKGROUND: Laboratory tests are obtained following total joint arthroplasty (TJA) despite a lack of supporting evidence. No prior study has prospectively analyzed the effect of discontinuing routine laboratory tests. This study aimed to determine whether discontinuing routine laboratory tests in TJA patients resulted in a difference in 90-day complications. METHODS: This was a prospective protocol change study at a high-volume center. Prior to protocol change, patients underwent routine laboratory tests following primary unilateral TJA (control group). After the change, an algorithmic approach was used to selectively order laboratory tests (protocol group). Patients with bleeding disorders, chronic obstructive pulmonary disease, arrhythmia, coronary artery disease, congestive heart failure, chronic renal failure, dementia, abnormal preoperative sodium, potassium, or hemoglobin <10 g/dL were excluded. In-hospital and 90-day data were collected. Student's t-test was used to analyze continuous variables and chi-squared test was used for categorical variables. A pre-hoc analysis examining the primary outcome required 607 patients per group to achieve 80% power. RESULTS: The protocol group included 937 patients, whereas the control group included 891 patients. The protocol group had fewer females and total hip arthroplasties. There were no differences in age, body mass index, American Society of Anesthesiologists classification, tranexamic acid administration, or estimated blood loss between the protocol and control groups. There were also no differences in transfusions, electrolyte corrections, unplanned consults, length of stay, or transfers. The protocol cohort had more fluid boluses and home discharges. There was no difference in 90-day complications between the 2 groups. CONCLUSIONS: This study utilizing an algorithmic approach to laboratory collection demonstrates that discontinuing routine laboratory tests following TJA is safe and effective. We believe this protocol can be implemented for most patients undergoing primary unilateral TJA.

Minimum Five-Year Outcomes of Modular Dual Mobility in Primary Total Hip Arthroplasty.

BACKGROUND: Using a modular dual-mobility (MDM) bearing in primary total hip arthroplasty (THA) has not been widely evaluated. The purpose of this study is to evaluate clinical outcomes and survivorship following MDM bearings in primary THA. METHODS: We used our registry database for patients with an MDM bearing on primary THA, performed by 6 surgeons through supine direct lateral or direct anterior approach. MDM bearings were used most often when impingement or subluxation was present intraoperatively despite proper component position. Another indication was a patient with planned activities who might be at a higher risk of instability postoperatively. RESULTS: A total of 127 MDM bearings were used in primary THA in 119 patients. Mean follow-up was 6.77 years (range 5-8.9). Five hips were revised, none of which were due to MDM bearing failure. Preoperative Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement, Veterans RAND/Short Form 12 Physical Health Score and Mental Health Score increased from 25.81 to 52.40 (P < .0001), 30.42 to 44.50 (P < .0001), and 36.21 to 52.70 (P < .0001) at latest completed survey follow-up, respectively. CONCLUSION: This MDM bearing shows excellent functional outcomes at a minimum 5 years of follow-up with no bearing-related failures. It can be an excellent choice in primary THA specifically in females where the use of increased head size to prevent instability is not possible due to anatomical restrictions and liner thickness.

Outcomes of simultaneous bilateral total hip arthroplasty for 256 selected patients in a single surgeon's practice.

AIMS: Total hip arthroplasty (THA) using the direct anterior approach (DAA) is undertaken with the patient in the supine position, creating an opportunity to replace both hips under one anaesthetic. Few studies have reported simultaneous bilateral DAA-THA. The aim of this study was to characterize a cohort of patients selected for this technique by a single, high-volume arthroplasty surgeon and to investigate their early postoperative clinical outcomes. METHODS: Using an institutional database, we reviewed 643 patients who underwent bilateral DAA-THA by a single surgeon between 1 January 2010 and 31 December 2018. The demographic characteristics of the 256 patients (39.8%) who underwent simultaneous bilateral DAA-THA were compared with the 387 patients (60.2%) who underwent staged THA during the same period of time. We then reviewed the length of stay, rate of discharge home, 90-day complications, and readmissions for the simultaneous bilateral group. RESULTS: Patients undergoing simultaneous bilateral DAA-THA had a 3.5% transfusion rate, a 1.8 day mean length of stay, a 98.1% rate of discharge home, and low rates of 90-day infection (0.39%), dislocation (0.39%), periprosthetic fracture (0.77%), venous thromboembolism (0%), haematoma (0.39%), further surgery (0.77%), and readmission (0.77%). These patients were significantly younger (mean 58.2 years vs 62.5 years; p < 0.001), more likely to be male (60.3% vs 46.5%; p < 0.001), and with a trend towards having a lower mean BMI (27.8 kg/m2 vs 28.4 kg/m2; p = 0.071) than patients who underwent staged bilateral DAA-THA. CONCLUSION: Patients selected for simultaneous bilateral DAA-THA in a single surgeon's practice had a 3% rate of postoperative transfusion and a low rate of complications, readmissions, and discharge to a rehabilitation facility. Simultaneous bilateral DAA-THA appears to be a reasonable and safe form of treatment for patients with bilateral symptomatic osteoarthritis of the hip when undertaken by an experienced arthroplasty surgeon with appropriate selection criteria. Cite this article: Bone Joint J 2021;103-B(7 Supple B):116-121.

Routine Postoperative Chemistry Panels Are Not Necessary for Most Total Joint Arthroplasty Patients.

BACKGROUND: The routine use of traditional chemistry-7 (chem-7) laboratory tests following total joint arthroplasty (TJA) has been called into question with the advent of short-stay procedures. Our objective was to determine the incidence, risk factors, and clinical interventions associated with inpatient abnormal routine postoperative chem-7 panels. METHODS: From 2015 to 2017, 3,162 patients underwent a total of 3,721 TJA procedures, including primary total hip arthroplasty (THA) (n = 1,939; 52.1%) or primary total knee arthroplasty (TKA) (n = 1,782; 47.9%). Patients underwent routine preoperative and postoperative chem-7 testing. Clinical interventions were identified. With use of mixed-effects multivariate logistic regression, potential risk factors for abnormal chemistry panel values (including preoperative chem-7 results, type of surgery, age, sex, race, comorbidities, American Society of Anesthesiologists [ASA] score, and medications) were analyzed. RESULTS: The rates of abnormal preoperative laboratory results were 3.4% for sodium (Na+), 7.4% for potassium (K+), 15.8% for blood urea nitrogen (BUN), and 26.4% for creatinine (Cr). The incidence of abnormal postoperative results was low for K+ (9.7%) and higher for Na+ (25.6%), BUN (55.6%), and Cr (27.9%). Preoperative abnormal laboratory results were a significant predictor of a postoperative abnormality for Na+ (odds ratio [OR] = 2.15; 95% confidence interval [CI] = 1.82 to 2.54), K+ (OR = 4.22; 95% CI = 3.03 to 5.88), and Cr (OR = 3.00; 95% CI = 2.45 to 3.68). Bilateral TJA was associated with increased odds of abnormal postoperative Na+ (OR = 1.56; 95% CI = 1.44 to 1.68). Renal disease was associated with increased odds of abnormal postoperative Cr (OR = 15.21; 95% CI = 5.67 to 40.77). Patients taking loop diuretics had increased odds of abnormal postoperative K+ (OR = 2.10; 95% CI = 1.42 to 3.11) and Cr (OR = 2.28; 95% CI = 1.56 to 3.33). Regarding intervention, 6.7% of hypokalemic patients received potassium chloride (KCl) fluid/tablets. Forty percent of hyponatremic patients received sodium chloride (NaCl) fluid/tablets. The electrolyte-related medicine consultation rate was 0.3% (13 of 3,721). CONCLUSIONS: On the basis of our findings, we recommend postoperative chem-7 testing for patients with an abnormal preoperative laboratory result (Na+, K+, BUN, Cr), preexisting renal disease, bilateral TJA, and prescribed angiotensin-converting enzyme inhibitors (ACE), angiotensin II receptor blockers (ARB), and diuretics. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A New Additive-Manufactured Cementless Highly Porous Titanium Acetabular Cup for Primary Total Hip Arthroplasty-Early Two-Year Follow Up.

INTRODUCTION: Additive-manufacturing technologies are increasingly being used, not only to create acetabular components with porous coating architecture very similar to the complex trabecular structure of cancellous bone, but also for producing the entire implant in a single step. The aim of this study is to assess two-year clinical and radiological outcomes of a new additive-manufactured cup in primary total hip arthroplasty (THA). MATERIALS AND METHODS: We reviewed 266 primary THAs (254 patients) performed in our institution between December 2016 and December 2018 using a new highly porous titanium acetabulum shell fabricated via additive manufacturing. Clinical and functional outcomes were measured using SF/VR-12 and HOOS JR to determine patient satisfaction with surgery. Radiographs were assessed to determine the presence of migration, radiolucency, and loosening. Patients records were reviewed to assess cup survivorship in terms of all-cause revisions and revision for aseptic cup loosening. RESULTS: At a minimum of two-year follow up (range: 2-3.45 years), the patient cohort demonstrated significant improvement in postoperative functional scores (hip disability and osteoarthritis outcome score for joint replacement [HOOS JR.] and clinical scores (12-item short-form health survey [SF/VR-12]) (p<0.001). One cup developed progressive radiolucent lines at the prosthesis-bone interface consistent with loosening and was revised. The overall acetabular component two-year survivorship free of all-cause failure was 97.4% (95% confidence interval [CI]: 95.5-99.4%). When aseptic loosening of the acetabular component was used as the failure endpoint, the two-years survivorship rate was 99.6% (95% CI: 98.9-100%). CONCLUSION: Highly porous titanium cementless acetabular cups produced via additive-manufacturing showed promising early clinical and radiological results in primary THA with low rates of aseptic loosening. Further follow-up studies are needed to assess the long-term survivorship and outcomes of this new acetabular component.

Transfusion Rates in Total Hip Arthroplasty Are lower in Patients with Direct Anterior Approach.

BACKGROUND: Blood conservation and reduction in the need for allogeneic blood transfusion (ABT) has been a subject of importance in total hip arthroplasty. There are a number of well-recognized parameters that influence blood loss during total hip arthroplasty (THA). The role of surgical approach on blood loss and the rate of ABT during THA is not well studied. The hypothesis of this study was that blood loss and the need for ABT is lower with direct anterior (DA) approach. METHODS: In a case-control retrospective cohort study, we analyzed 1,524 primary THAs performed at a single institution by seven fellowship-trained surgeons between January 2015 to March 2017. All patients received THA using either the modified direct lateral (DL) or direct anterior (DA) approach using a standard operating table. The overall ABT rate was 10.2% (155/1,524) in the cohort. Demographic, surgical, and postoperative data were extracted and analyzed. Logistic regression was used to identify independent risk factors for transfusion. RESULTS: Higher preoperative hemoglobin (p<0.001), use of DA approach (p<0.016) and administration of tranexamic acid TXA, (p=0.024) were identified as independent factors which reduced the odds of ABT. Operative time (p<0.001) was associated with an increased odd of ABT, while age, BMI and type of anesthesia were not statistically significant. CONCLUSION: Based on the findings of this study, direct anterior approach for THA appears to be protective against blood loss and reduced ABT rate, when controlling for confounding variables.

Short-term results of triathlon cementless versus cemented primary total knee arthroplasty.

BACKGROUND: Recent studies have demonstrated that aseptic loosening remains a leading cause of failure after total knee arthroplasty (TKA). Cementless fixation is a possible strategy for countering this problem. This study compared short-term survivorship and functional results of patients undergoing primary TKA with cementless versus cemented implants. METHODS: A multi-center database was utilized to identify 3849 patients undergoing primary TKA between 2012 and 2017 with a minimum two-year follow-up. Patients were divided into cementless (699), and cemented TKA (3150). The outcome of TKA including revision for aseptic or septic reasons, and other outcome variables were compared. Six hundred five patients from the cementless group (case) were matched with 605 patients from the cemented group (controls). Both groups were compared for outcomes and related variables. RESULTS: Both matched groups were similar in age, race, gender, height, weight, BMI, laterality, femoral component type, follow-up duration, preoperative and postoperative physical and mental health, and functional activities (all p-values>0.05). Although the cementless TKA group had more components in varus alignment (p = 0.015) and were taller (p < 0.001), the aseptic revision rate and time to failure were similar in both groups (p-values = 0.256 and 0.0890 respectively). The rate of revision for infection was also the same in both groups (p = 0.452). CONCLUSION: Cementless TKA demonstrated an equivalent rate of aseptic and septic failure when compared to cemented TKA in the short-term. Time to aseptic failure was also similar in both groups.

Periprosthetic Joint Infection in Patients Who Have Multiple Prostheses in Place: What Should Be Done with the Silent Prosthetic Joints.

BACKGROUND: Although periprosthetic joint infection (PJI) can affect multiple joints concurrently, the majority of patients with multiple prosthetic joints present with PJI of a single joint. Data regarding the optimal management of these patients are limited. We aimed to identify the prevalence, risk factors for a subsequent PJI, and clinical circumstances of PJI in patients with multiple prosthetic joints. METHODS: We retrospectively reviewed the clinical records of 197 patients with ≥2 total joint prostheses in place who presented with PJI from 2000 to 2017. The average follow-up was 3.6 years (range, 0.5 to 17 years). Demographic data and risk factors for synchronous or metachronous PJI were identified. The time from the initial to the second PJI and organism profile data were collected as well. The workup for other joints with a prosthesis in place at the time of the initial PJI was noted. RESULTS: Among the 197 patients with PJI and multiple joint prostheses in situ, 37 (19%) developed PJI in another joint; 11 had a synchronous PJI and 26 had a metachronous PJI. The average time between the first and the second infection in the metachronous cases was 848 days (range, 20 to 3,656 days). Females and patients with an initial PJI with methicillin-resistant Staphylococcus aureus (MRSA) were more likely to have a metachronous PJI, and patients with rheumatoid arthritis had an increased risk of a second (metachronous or synchronous) PJI. Three of 11 patients in the synchronous group and 19% (5) of the 26 in the metachronous group had bacteremia at the time of the initial PJI compared with 12% (19) of the 160 with a single PJI. The percentage of negative cultures increased from 10% for the initial PJIs to 38% for the metachronous PJIs. CONCLUSIONS: Patients who have multiple prosthetic joints in place and present with PJI of a single joint are at risk of developing PJI in another joint. Female sex, rheumatoid arthritis, bacteremia at presentation, and infection with MRSA appear to be risk factors for PJI of another joint. Clinical evaluation of the other prosthetic joint(s) should be carried out in all patients and aspiration of those joint(s) should be considered for patients with any of the above risk factors. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern.

BACKGROUND: Acetabular fractures often require surgical intervention for fracture fixation and can result in premature osteoarthritis of the hip joint. This study hypothesized that total hip arthroplasty (THA) in patients with a prior acetabular fracture who had undergone open reduction and internal fixation (ORIF) is associated with a higher rate of subsequent periprosthetic joint infection (PJI). METHODS: About 72 patients with a history of acetabular fracture that required ORIF, undergoing conversion THA between 2000 and 2017 at our institution, were matched based on age, gender, body mass index, Charlson comorbidity index, and date of surgery in a 1:3 ratio with 215 patients receiving primary THA. The mean follow-up for the conversion THA cohort was 2.9 years (range, 1-12.15) and 3.06 years (range, 1-12.96) for the primary THA. RESULTS: Patients with a previous acetabular fracture, compared with the primary THA patients, had longer operative times, greater operative blood loss, and an increased need for allogeneic blood transfusion (26.4% vs 4.7%). Most notably, PJI rate was significantly higher in acetabular fracture group at 6.9% compared with 0.5% in the control group. Complications, such as aseptic revision, venous thromboembolism, and mortality, were similar between both groups. CONCLUSION: The present study demonstrates that conversion THA in patients with prior ORIF of acetabular fractures is associated with higher complication rate, in particular PJI, and less optimal outcome compared with patients undergoing primary THA. The latter findings compel us to seek and implement specific strategies that aim to reduce the risk of subsequent PJI in these patients.

Risk Factors for Unplanned Admission to the Intensive Care Unit After Elective Total Joint Arthroplasty.

BACKGROUND: Despite improved surgical and anesthesia techniques, as well as advances in perioperative protocols, a number of patients undergoing total joint arthroplasty (TJA) are at risk of serious medical complications that require intensive care unit (ICU) admission. With the recent move toward performing TJA in ambulatory surgical centers and on an outpatient basis, it is important to recognize patients that may require intensive care in the postoperative period. This study aimed to identify risk factors for ICU admission following elective total hip (THA) and knee (TKA) arthroplasty. METHODS: We evaluated 12,342 THA procedures, with 132 ICU admissions, and 10,976 TKA procedures, with 114 ICU admissions from 2005 to 2017. Demographic, preoperative, and surgical variables were collected and compared between cohorts using both univariate and logistic regression analysis. RESULTS: For THA, logistic regression analysis demonstrated older age, bilateral procedure, revision surgery, increased Charlson comorbidity index, general anesthesia, increased estimated blood loss, decreased preoperative hemoglobin, and increased preoperative glucose level were independently associated factors for increased risk of ICU admission. For TKA, increased age, increased body mass index, bilateral procedure, revision surgery, increased Charlson comorbidity index, increased estimated blood loss, general anesthesia, and increased preoperative glucose were independently significantly associated with ICU admission. CONCLUSION: In this study, we identify a number of critical independent risk factors which may place patients at increased risk of ICU admission following THA and TKA. Identification of these risk factors may help surgeons safely select those TJA candidates appropriate for surgery at facilities that do not have ICUs readily available.

Global Perspectives on Arthroplasty of Hip and Knee Joints.

There is a broad variation of implantation rates, indications, and types of prostheses used for hip and knee joint replacement procedures among different countries. The establishment of national joint registers has improved knowledge and quality of data related to joint implantation. Comparing reports of different national registries is crucial to determine potential variations in practices among surgeons and arthroplasty centers and to identify topics for future analysis. In this report, data from these registries in addition to manufacturer reports were used to evaluate procedure volumes and implants utilization trends of primary and revision total hip and knee replacement around the world.

Clinical Results of Revision Hip Arthroplasty for Neck-Taper Corrosion and Adverse Local Tissue Reactions Around a Modular Neck Stem.

BACKGROUND: Adverse local tissue reactions (ALTRs) around a modular neck stem at our institution lead to a 13.5% rate of revision. The purpose of this study was to report the clinical results of revision total hip arthroplasty (THA) in this patient population. METHODS: We identified 80 hips in 77 patients who underwent revision THA due to neck-stem corrosion. Intraoperative and postoperative complications, clinical outcomes, re-revision rates, and the postoperative ion levels were recorded. RESULTS: The mean follow-up period after revision was 45.3 ± 16.3 months (range 24-81 months). There were no intraoperative mechanical complications during the revision surgery. Eight hips (10%) had postoperative complications related to the revision implant, of which 6/8 came to re-revision: postoperative implant dislocation in 4 hips-2 treated nonsurgically, aseptic loosening of femoral component in 2 hips, and periprosthetic femoral fracture in 2 hips. No patients had recurrence of ALTR nor the recurrence of groin pain within the follow-up period. With 2 exceptions, ion levels normalized within one year of the revision surgery. The survival rate was 94% (95% confidence interval 84-98) at 32 months and 82% (95% confidence interval 56-93) at 63 months after revision THA (using re-revision THA due to any reason as the endpoint). CONCLUSION: Intraoperative complication, postoperative complication, and re-revision rates are equivalent to femoral revision surgeries for other causes (infection, fracture, loosening). We recommend selecting revision-type stems to minimize the risk of femoral loosening or periprosthetic fracture, and larger femoral heads or dual mobility bearings to minimize the risk of dislocation.