The Effect of the IPACK Block on Pain After Primary TKA: A Double-Blinded, Prospective, Randomized Trial.

BACKGROUND: The purpose of this study was to determine if infiltration of local anesthetic between the interspace between the popliteal artery and capsule of the knee (IPACK) provides benefit in total knee arthroplasty. METHODS: Patients were randomized into continuous adductor canal block with IPACK block or continuous adductor canal block with sham subcutaneous saline injection. Only the anesthesiologist performing the block was aware of randomization status. After surgery, a blinded assessor recorded opioid consumption, pain scores, and gait distance. RESULTS: There were 35 patients in the IPACK group and 34 in the NO IPACK group. There was no difference demographically between the groups. In the postanesthesia care unit (PACU), the average (P = .0122) and worst (P = .0168) pain scores at rest were statistically lower in the IPACK group. There was no difference in the pain scores during physical therapy (P = .2080). There was no difference in opioid consumption in the PACU (P = .7928), or at 24 hours (P = .7456). There was no difference in pain scores on POD 1 in the AM (P = .4597) or PM (P = .6273), or in the walking distance (P = .5197). There was also no difference in length of stay in the PACU (P = .9426) or hospital (P = .2141). CONCLUSION: The IPACK group had lower pain scores at rest in the PACU, but this is likely not clinically significant. The routine use of the IPACK is not supported by the results of this study. There may be indications for the use of the IPACK block as a rescue block or in patients who have contraindications to our standard multimodal treatment regimen or in patients with chronic pain or opioid dependence.

Insulin-Dependent Diabetic Patients are at Increased Risk of Postoperative Hyperglycemia When Undergoing Total Joint Arthroplasty.

BACKGROUND: Diabetic patients are at an increased risk of prosthetic joint infection (PJI) after total joint arthroplasty (TJA). The relationship between insulin-dependence and PJI has not been investigated. We aimed at evaluating whether insulin-dependent diabetes mellitus (IDDM) patients were more susceptible to postoperative hyperglycemia and PJI than their non-insulin-dependent diabetes mellitus (NIDDM) counterparts. METHODS: A retrospective review was conducted of diabetic patients undergoing TJA (hip or knee) from January 2011 to December 2016. Preoperative hemoglobin A1c (A1c) and postoperative glucose measurements were observed. Patients were stratified as IDDM or NIDDM. The A1c values that predicted hyperglycemia >200 mg/dL for each group were calculated. Primary end point was postoperative hyperglycemia >200 mg/dL and secondary end point was PJI. RESULTS: There were 773 patients meeting inclusion criteria. The IDDM cohort had a higher preoperative A1c (6.97% vs 6.28%, P < .0001) and postoperative glucose (235.2 vs 163.5, P < .0001). IDDM patients were more likely to have postoperative hyperglycemia (63.84% vs 20.83%, P < .0001; odds ratio, 5.2; 95% confidence interval, 3.66-7.4). Overall, an A1c of >7.45% predicted postoperative hyperglycemia >200 mg/mL (odds ratio, 6.94; 95% confidence interval, 4.32-11.45). When separating our 2 cohorts, an A1c of >6.59% in IDDM, and >6.60% in NIDDM, was associated with an increased risk of postoperative hyperglycemia (P < .0001). PJI was similar between the 2 cohorts (2.52% vs 2.38%, P = .9034). CONCLUSION: IDDM patients undergoing TJA are 5.2 times more likely to have postoperative hyperglycemia >200 mg/dL than their NIDDM counterparts, although increased risk of PJI was not found in this study. Despite the higher A1c and postoperative hyperglycemia in IDDM patients, there was found to be no clinical difference between A1c cutoff values for postoperative hyperglycemia between IDDM and NIDDM patients.

The Effects of Peri-Operative Dexamethasone on Patients Undergoing Total Hip or Knee Arthroplasty: Is It Safe for Diabetics?

BACKGROUND: Peri-operative dexamethasone has been shown to effectively reduce post-operative nausea and vomiting and aide in analgesia after total joint arthroplasty (TJA); however, systemic glucocorticoid therapy has many adverse effects. The purpose of this study is to determine the effects of dexamethasone on prosthetic joint infection (PJI) and blood glucose levels in patients undergoing TJA. METHODS: A retrospective chart review of all patients receiving primary TJA from 2011 to 2015 (n = 2317) was conducted. Patients were divided into 2 cohorts: dexamethasone (n = 1426) and no dexamethasone (n = 891); these groups were subdivided into diabetic and non-diabetic patients. The primary outcome was PJI; secondary measures included glucose levels and pre-operative hemoglobin A1c (A1c) values. Statistics were carried out using logistic and regression models. RESULTS: Of the 2317 joints, 1.12% developed PJI; this was not affected by dexamethasone (P = .166). Diabetics were found to have higher rate of infection (P < .001); however, diabetics who received dexamethasone were not found to have a significantly higher infection rate that non-diabetics (P = .646). Blood glucose levels were found to increase post-operatively, and dexamethasone did not increase this change (P = .537). Diabetes (P < .001) and increasing hemoglobin A1c (P < .001) were also associated with increased serum glucose levels; however, this was not influenced by dexamethasone (P = .595). CONCLUSION: Although diabetic patients were found to have a higher infection rate overall, this was not affected by administration of intravenous dexamethasone, nor was the post-operative elevation in serum glucose levels. In this study population, peri-operative intravenous dexamethasone did not increase the rate of PJI and was safe to administer in patients undergoing TJA.

Preoperative Glycemic Control Predicts Perioperative Serum Glucose Levels in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Diabetic patients undergoing total joint arthroplasty (TJA) with postoperative hyperglycemia >200 mg/dL have increased the risk of prosthetic joint infection (PJI). We investigated the correlation between preoperative hemoglobin A1c (A1c) and postoperative hyperglycemia in diabetic patients undergoing TJA. METHODS: A retrospective review of 773 diabetic patients undergoing TJA was conducted. A Youden's J computational analysis determined the A1c where postoperative glucose levels >200 mg/dL were statistically more likely. Patients were then stratified into 3 groups: A1c <7%, A1c 7.0-8.0%, and A1c >8.0%. Outcomes included the highest postoperative in-hospital serum glucose level and PJI. RESULTS: We determined an A1c >7.45% resulted in a greater chance of postoperative hyperglycemia >200 mg/dL. Average postoperative serum glucose increased with A1c (A1c < 7 = 167 mg/dL, A1c 7.0-8.0 = 240 mg/dL, and A1c > 8 = 276 mg/dL, P < .0001). PJI did not statistically increase with A1c (2.25%, 1.99%, and 4.55%, respectively, P = .4319). CONCLUSION: Preoperative hemoglobin A1c levels correlate with postoperative glucose levels. We recommend using an A1c cutoff of 7.45% for patients undergoing TJA and suggest that caution should be exercised in patients with elevated A1c levels undergoing TJA.

Hip and Knee Arthroplasty Outcomes After Abdominal Organ Transplantation.

This case control study retrospectively compares patients who underwent solid organ transplantation and total joint replacement with a control group that only underwent joint replacement. The study compares 42 transplant patients who underwent liver or kidney transplantation and total hip arthroplasty (THA) or total knee arthroplasty (TKA) to a matched group of 42 nontransplant patients who underwent only THA or TKA. The transplant cohort had significantly more complications (18) than the nontransplant cohort (7) (p D .022). Renal transplant patients had 6.75 times higher odds (95% CI, 1.318-34.565) of experiencing a complication compared with liver transplant patients. The average time between transplant and joint replacement was 2 s 4.9 years. Transplant patients undergoing joint arthroplasty at an average of 2 years posttransplant are at higher risk for complications than a matched cohort of patients undergoing only joint arthroplasty, with renal transplant patients being more at risk for complications than liver transplant patients. (Journal of Surgical Orthopaedic Advances 27(2):119-124, 2018).

Financial Analysis of Treating Periprosthetic Joint Infections at a Tertiary Referral Center.

BACKGROUND: Periprosthetic joint infection (PJI) is a significant challenge to the orthopedic surgeon, patient, hospital, and insurance provider. Our study compares the financial information of self-originating and referral 2-stage revision hip and knee surgeries at our tertiary referral center for hip or knee PJI over the last 4 years. METHODS: We performed an in-house retrospective financial review of all patients who underwent 2-stage revision hip or knee arthroplasty for infection between January 2008 and August 2013, comparing self-originating and referral cases. RESULTS: We found an increasing number of referrals over the study period. There was an increased cost of treating hips over knees. All scenarios generated a positive net income; however, referral hip PJIs offered lower reimbursement and net income per case (although not statistically significant), whereas knee PJIs offered higher reimbursement and net income per case (although not statistically significant). CONCLUSION: With referral centers treating increased numbers of infected joints performed elsewhere, we show continued financial incentive in accepting referrals, although with less financial gain than when treating one's own hip PJI and an increased financial gain when treating referral knee PJIs.

The Effects of a Hospitalist Comanagement Model for Joint Arthroplasty Patients in a Teaching Facility.

BACKGROUND: The goal of this study was to compare postoperative medical comanagement of total hip arthroplasty and total knee arthroplasty patients using a hospitalist (H) and nonhospitalist (NH) model at a single teaching institution to determine the clinical and economic impact of the hospitalist comanagement. METHODS: We retrospectively reviewed the records of 1656 patients who received hospitalist comanagement with 1319 patients who did not. The NH and H cohorts were compared at baseline via chi-square test for the American Society of Anesthesiologists classification, the t test for age, and the Wilcoxon test for the unadjusted Charlson Comorbidity Index score and the age-adjusted Charlson Comorbidity Index score. Chi-square test was used to compare the postoperative length of stay, readmission rate at 30 days after surgery, diagnoses present on admission, new diagnoses during admission, tests ordered postoperatively, total direct cost, and discharge location. RESULTS: The H cohort gained more new diagnoses (P < .001), had more studies ordered (P < .001), had a higher cost of hospitalization (P = .002), and were more likely to be discharged to a skilled nursing facility (P < .001). The H cohort also had a lower length of stay (P < .001), but we believe evolving techniques in both pain control and blood management likely influenced this. There was no significant difference in readmissions. CONCLUSION: Any potential benefit of a hospitalist comanagement model for this patient population may be outweighed by increased cost.

The Financial Impact of a Multidisciplinary Preoperative Risk Stratification Program for Joint Arthroplasty.

This study's purpose was to assess the impact of a preoperative risk stratification program on joint arthroplasty outcomes at a single institution. We hypothesized that by using a standardized preoperative risk stratification center we would see better outcomes and decreased costs. The triage cohort (T) included 1498 patients assessed at a standardized risk stratification center, and the non-triage cohort (NT) included 1100 patients who did not utilize the center. The T cohort had significantly higher ASA classification (P<0.0001) and ACCI scores (P=0.028). We found no significant difference in complication rates. The T cohort showed a significant decrease in LOS (P<0.0001) and an increase in average reimbursement (P=0.009). A standardized preoperative risk stratification center can contribute to decreased LOS, increased reimbursement and help prevent complications.

Risk stratified usage of antibiotic-loaded bone cement for primary total knee arthroplasty: short term infection outcomes with a standardized cement protocol.

Efficacy of antibiotic cement (ALBC) in primary knee arthroplasty (pTKA) has been debated. The study's purpose was to examine efficacy of ALBC versus plain cement (PBC) in preventing infection in high-risk patients undergoing pTKA. 3292 consecutive pTKAs were divided into three cohorts: (1) patients receiving only PBC, (2) patients receiving only ALBC, and (3) only high-risk patients receiving ALBC. Cohorts' infections were compared. The 30-day infection rates for cohorts 1, 2, 3 were 0.29%, 0.20%, and 0.13% respectively. 6-month rates were 0.39%, 0.54% and 0.38%. 1-year rates were 0.78%, 0.61%, and 0.64%. Differences in infection rates at all time intervals were not statistically significant. The study supports that even judicious risk-stratified usage of ALBC may not confer added benefit in decreasing infection at one year.

Establishing a role for vancomycin powder application for prosthetic joint infection prevention-results of a wear simulation study.

Topical vancomycin powder (VP) has shown efficacy and safety in decreasing post-operative spine infections. VP use in arthroplasty has not been established. Concerns remain for third-body wear with the addition of crystalline substrate at the implant interface. The study's purpose was to compare wear behavior of CoCr on UHMWPE to identical wear couples with VP. A six-station wear simulator was utilized and cyclic articulations were run for 10 million cycles (Mc). UHMWPE wear was measured using photography, stereomicroscopy, and gravimetric measurement. There were no differences in wear mark length (P = 0.43), width (P = 0.49), or gravimetric wear at 10 Mc (P = 0.98). VP and control groups lost 0.32 and 0.33 mg, respectively. VP may have a role in PJI prevention. A well-designed clinical study is needed.

Accuracy and clinical utility of a peri-operative risk calculator for total knee arthroplasty.

Utilizing the Medicare Provider Analysis and Review dataset, a, peri-operative total knee arthroplasty (TKA) risk calculator was created based on select preoperative comorbidities. We retrospectively identified and reviewed 2284 primary TKAs at a single institution from 2000-2008. A numerical, predicted complication risk was established for each patient. Actual complications occurring within the first 14 post-operative days were recorded. Statistical analysis was performed using the C-statistic and ANOVA test. Patients with higher predicted probability of a complication did show higher complication rates. The corresponding C-statistic was 0.609. (95% Confidence Interval: 0.542-0.677). When the patients were divided into 4 groups based on their calculated complication risk (0-5%, 5-10%, 10-25%, >25%) the statistical significance of the associated ANOVA was P < .001, showing that patients with higher predicted risk experienced more complications, and those with lower predicted risk experienced fewer complications. Based on our results, the calculator has predictive value and is clinically relevant.

An evaluation of the use of topical tranexamic acid in total knee arthroplasty.

The purpose of this study was to evaluate the effectiveness of topical tranexamic acid in primary TKA from a clinical and economic standpoint. We retrospectively reviewed 683 primary total knee arthroplasties performed at a single institution over a 2-year period. We compared 373 cases performed in 2010 without tranexamic acid to 310 cases performed in 2011 with tranexamic acid. Demographic data, hemoglobin levels, transfusion rates, hospital length of stay, cost, and perioperative complications during the first 3 months were collected. Statistical analysis was performed using two sample t-tests and Fisher's exact tests. There was no difference in age, sex, height, or pre-operative hemoglobin between the two groups. The tranexamic acid group had significantly higher post-operative hemoglobin (P<0.0001), lower transfusion rate (P<0.0001), decreased length of stay (P<0.0001), decreased blood bank costs (P<0.0001), increased pharmacy cost (P<0.0001), and decreased total direct cost to the hospital (P<0.0001). The average savings was approximately $1500 per patient. There were no differences in thromboembolic events or infection. The use topical tranexamic acid in primary TKA is safe, effective, and results in significant cost savings.

Pseudotumor recurrence in a post-revision total hip arthroplasty with stem neck modularity: A case report.

BACKGROUND: This unique presentation of hip swelling is only the seventh reported case of pseudotumor recurrence in a non-metal-on-metal total hip arthroplasty (THA) construct. The constellation of patient symptoms and laboratory findings contradict the expected elevated serum metal ion levels associated with the formation of pseudotumor. The presentation, lab trends, and imaging findings contribute to the growing base of knowledge surrounding the effects of corrosion in arthroplasty constructs with stem-neck modularity. CASE SUMMARY: A 74-year-old man status post primary THA presented with left hip swelling and elevated serum metal ions five years after implantation of a modular stem-neck prosthesis. The swelling was diagnosed as pseudotumor based on laboratory trends and imaging findings and was treated with revision arthroplasty that completely resolved the initial hip swelling. The patient presented with recurrent hip swelling and recurrent pseudotumor findings on imaging in the same hip four months later. Non-operative management with ultrasound-guided hip aspiration resulted in symptom relief and resolution of the recurrent swelling. After one year of follow-up, the patient had no further recurrences of hip swelling. CONCLUSION: This case of post-revision pseudotumor recurrence elucidates attributable patient, surgical, and implant factors with a discussion of diagnostics, management, and prognosis for patients with pseudotumor in non-metal-on-metal arthroplasty constructs.

The Perioperative Surgical Home: Improving the Value and Quality of Care in Total Joint Replacement.

PURPOSE OF REVIEW: The perioperative surgical home (PSH) is a patient-centered, physician-led, multidisciplinary care pathway developed to deliver value-based care based on shared decision-making. Physician and hospital reimbursement will be tied to providing quality care at lower cost, and the PSH model has been used in providing care to patients undergoing lower extremity arthroplasty. The purpose of this review is to discuss the rationale, definition, development, current state, and future direction of the PSH. RECENT FINDINGS: The PSH model guides the patient throughout the pre and perioperative process and into the postoperative phase. It has been shown in multiple studies to decrease length of stay, improve functional outcomes, allow more home discharges, and lower costs. There is no increase in complications or readmission rates. The PSH pathway is a safe and effective method of providing value-based care to patients undergoing hip and knee arthroplasty.

Cytokine levels after transfusion of washed wound drainage in total knee arthroplasty: a randomized trial comparing autologous blood and washed wound drainage.

Forty patients undergoing total knee arthroplasty (TKA) were prospectively randomized to autologous blood transfusion or retransfusion of washed wound drainage. The wound drainage was washed using a dynamic disk separation chamber. Interleukin (IL)-1 beta, IL-6, IL-8, and tumor necrosis factor (TNF) alpha blood levels were measured prior to epidural anesthesia and at 0, 30, 60, and 120 minutes after initiation of the transfusion. Washed wound drainage contained significantly higher amounts of IL-6 (P < .05) and IL-8 (P < .05) than predonated autologous blood. No significant difference was found for IL-1 beta (P = .28) and TNF-alpha (P = .14). The patients' IL-6 and IL-8 blood levels increased in both groups within 2 hours after the transfusion. This increase was correlated to the time interval between surgery and transfusion (P < .05) and was not significantly different between both groups. No correlation was found between the increase in patients' cytokine levels and the amount of washed wound drainage transfused. According to these results, the increase in IL-6 and IL-8 after transfusion is related to the surgical trauma response and not the transfusion protocol.

Minimally invasive total hip arthroplasty: a prospective randomized study.

Patients without prior hip surgery and body mass index lower than 30 undergoing primary total hip arthroplasty were eligible to participate in a randomized prospective study comparing a minimally invasive with a standard approach. The patients were randomized to receive incisions of 8 cm (group A, n = 28) or 15 cm (group B, n = 32). The groups were similar demographically. Patients in group A had significantly less intraoperative blood loss (P < .003) and less total blood loss (P < .009). Fewer patients in group A limped at 6 weeks (P < .04). Operative time, transfusion requirements, narcotic usage, length of hospital stay, achievement of rehabilitation milestones, cane usage, and complications were similar in both groups. There was no difference between the groups at 1- and 2-year follow-up. Compared with a standard incision, patients who underwent a minimally invasive total hip arthroplasty demonstrated decreased blood loss and limped less at 6-week follow-up.

Possible bupivacaine toxicity after intraarticular injection for postarthroscopic analgesia of the knee: implications of the surgical procedure.

IMPLICATIONS: We report a case of possible bupivacaine toxicity after intraarticular injection during knee arthroscopy. The importance of the specific type of surgical procedure performed during arthroscopy and its relationship to potential local anesthetic toxicity are highlighted.