Early Clinical Outcomes of "Lemon-Dropped" Complex Primary Total Joint Arthroplasty Patients to a Tertiary Care Center.

BACKGROUND: In the era of value-based care, pressures lead to cherry-picking healthier patients and lemon-dropping riskier patients to higher levels-of-care. This study examined whether "lemon-dropped" primary total joint arthroplasty (pTJA) patients require increased health care resources and experience worse outcomes. METHODS: This was a retrospective cohort study of all pTJAs at one tertiary care center in 2022, excluding bilaterals, acute fractures, oncologic cases, and conversion hips. Patients were classified via referral pattern as simple or complex (referred for medical or surgical complexity). Primary outcomes were implant costs and any emergency department visit, readmission, reoperation, or complication within 90 days. Secondary outcomes were distance traveled to the hospital, anesthesia type, estimated blood loss, case duration, time in the recovery unit, length of stay, and discharge disposition. Outcomes were assessed via electronic medical record review and analyzed via Fisher's exact and unpaired Welch's t-tests. RESULTS: In total 641 pTJAs (322 hips, 319 knees) met inclusion criteria; 10.3% were complex referrals. Complex patients were younger (59 versus 66 years, P < .05) and more often non-White (41 versus 31%, P < .001), non-English speaking (11 versus 7%, P < .001), and had nonprimary osteoarthritis as a surgical indication (59 versus 12%, P < .001), but had similar Charlson Comorbidity Index and American Society of Anesthesiologists scores. Complex patients had increased odds of 90-day emergency department visits (OR [odds ratio] = 2.11, P = .04), 90-day complications (OR = 2.63, P < .001), and non-home discharge (OR = 2.60, P = .006); higher mean relative implant costs (1.31x, P < .001); longer time in the operating room (181 versus 158 minutes P < .001), time in surgery (125 versus 105 minutes, P < .001), and length of stay (3.2 versus 1.7 days, P = .005). CONCLUSIONS: "Lemon-dropped" pTJAs had worse early clinical outcomes and higher health care utilization, despite a control group with patients ill enough to utilize a tertiary care center as their medical home. Reimbursement models and evaluation metrics must account for these differences.

Imaging joint infections using D-methyl-11C-methionine PET/MRI: initial experience in humans.

PURPOSE: Non-invasive imaging is a key clinical tool for detection and treatment monitoring of infections. Existing clinical imaging techniques are frequently unable to distinguish infection from tumors or sterile inflammation. This challenge is well-illustrated by prosthetic joint infections that often complicate joint replacements. D-methyl-11C-methionine (D-11C-Met) is a new bacteria-specific PET radiotracer, based on an amino acid D-enantiomer, that is rapidly incorporated into the bacterial cell wall. In this manuscript, we describe the biodistribution, radiation dosimetry, and initial human experience using D-11C-Met in patients with suspected prosthetic joint infections. METHODS: 614.5 ± 100.2 MBq of D-11C-Met was synthesized using an automated in-loop radiosynthesis method and administered to six healthy volunteers and five patients with suspected prosthetic joint infection, who were studied by PET/MRI. Time-activity curves were used to calculate residence times for each source organ. Absorbed doses to each organ and body effective doses were calculated using OLINDA/EXM 1.1 with both ICRP 60 and ICRP 103 tissue weighting factors. SUVmax and SUVpeak were calculated for volumes of interest (VOIs) in joints with suspected infection, the unaffected contralateral joint, blood pool, and soft tissue background. A two-tissue compartment model was used for kinetic modeling. RESULTS: D-11C-Met was well tolerated in all subjects. The tracer showed clearance from both urinary (rapid) and hepatobiliary (slow) pathways as well as low effective doses. Moreover, minimal background was observed in both organs with resident micro-flora and target organs, such as the spine and musculoskeletal system. Additionally, D-11C-Met showed increased focal uptake in areas of suspected infection, demonstrated by a significantly higher SUVmax and SUVpeak calculated from VOIs of joints with suspected infections compared to the contralateral joints, blood pool, and background (P < 0.01). Furthermore, higher distribution volume and binding potential were observed in suspected infections compared to the unaffected joints. CONCLUSION: D-11C-Met has a favorable radiation profile, minimal background uptake, and fast urinary extraction. Furthermore, D-11C-Met showed increased uptake in areas of suspected infection, making this a promising approach. Validation in larger clinical trials with a rigorous gold standard is still required.

Length of Endoprosthetic Reconstruction in Revision Knee Arthroplasty Is Associated With Complications and Reoperations.

BACKGROUND: Complex revision total knee arthroplasty (TKA) often calls for endoprosthetic reconstruction to address bone loss, poor bone quality, and soft tissue insufficiency. Larger amounts of segmental bone loss in the setting of joint replacement may be associated with greater areas of devascularized tissue, which could increase the risk of complications and worsen functional results. QUESTIONS/PURPOSES: Are longer endoprosthetic reconstructions associated with (1) higher risk of deep infection; (2) increased risk of reoperation and decreased implant survivorship; or (3) poorer ambulatory status? METHODS: This is a single-institution retrospective case series of nononcologic femoral endoprosthetic reconstructions for revision TKA from 1995 to 2013 (n = 32). Cases were categorized as distal (n = 17) or diaphyseal (n = 15) femoral reconstructions based on extension to or above the supracondylar metaphyseal-diaphyseal junction, respectively. Five patients from each group were lost to followup before 2 years (distal mean 4 years [range, 2-8 years]; diaphyseal mean = 6 years [range, 2-16 years]), and one of the 12 distal reconstructions and two of the 10 diaphyseal reconstructions had not been evaluated within the past 5 years. Clinical outcomes and ambulatory status (able to walk or not) were assessed through chart review by authors not involved in any cases. Prior incidence of periprosthetic joint infection was high in both groups (distal = seven of 12 versus diaphyseal = four of 10; p = 0.670). RESULTS: Patients with diaphyseal femoral replacements were more likely to develop postoperative deep infections than patients with distal femoral replacements (distal = three of 12 versus diaphyseal = nine of 10; p = 0.004). Implant survivorship (revision-free) for diaphyseal reconstructions was worse at 2 years (distal = 100%, 95% confidence interval [CI], 100%-100% versus diaphyseal = 40%, 95% CI, 19%-86%; p = 0.001) and 5 years (distal = 90%, 95% CI, 75%-100% versus diaphyseal = 30%, 95% CI, 12%-73%; p = 0.001). Infection-free, revision-free survival (retention AND no infection) was worse for diaphyseal femoral replacing reconstructions than for distal femoral replacements at 2 years (distal = 70%, 95% CI, 48%-100% versus diaphyseal = 20%, 95% CI, 6%-69%; p = 0.037) and 5 years (distal = 70%, 95% CI, 48%-100% versus diaphyseal = 10%, 95% CI, 2%-64%; p = 0.012). There was no difference with the small numbers available in proportion of patients able to walk (distal reconstruction = eight of 11 versus diaphyseal = seven of 10; p = 1.000), although all but one patient in each group required walking aids. CONCLUSIONS: Endoprosthetic femoral reconstruction is a viable salvage alternative to amputation for treatment of failed TKA with segmental distal femoral bone loss. In our small series even with substantial loss to followup and likely best-case estimates of success, extension proximal to the supracondylar metaphyseal-diaphyseal junction results in higher infection and revision risk. In infection, limb salvage remains possible with chronic antibiotic suppression, which we now use routinely for all femoral replacement extending into the diaphysis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Early Outcomes of Primary Total Hip Arthroplasty After Prior Lumbar Spinal Fusion.

BACKGROUND: The coexistence of degenerative hip disease and spinal pathology is not uncommon with the number of surgical treatments performed for each condition increasing annually. The limited research available suggests spinal pathology portends less pain relief and worse outcomes after total hip arthroplasty (THA). We hypothesize that primary THA patients with preexisting lumbar spinal fusions (LSF) experience worse early postoperative outcomes. METHODS: This study is a retrospective matched cohort study. Primary THA patients at 1 institution who had undergone prior LSF (spine arthrodesis-hip arthroplasty [SAHA]) were identified and matched to controls of primary THA without LSF. Early outcomes (<90 days) were compared. RESULTS: From 2012 to 2014, 35 SAHA patients were compared to 70 matched controls. Patients were similar in age, sex, American Society of Anesthesiologist score, body mass index, and Charlson Comorbidity Index. SAHA patients had higher rates of complications (31.4% vs 8.6%, P = .008), reoperation (14.3% vs 2.9%, P = .040), and general anesthesia (54.3% vs 5.7%, P = .0001). Bivariate analysis demonstrated SAHA to predict reoperation (odds ratio, 5.67; P = .045) and complications (odds ratio, 4.89; P = .005). With the numbers available, dislocations (0% vs 2.8%), infections (0% vs 8.6%), readmissions, postoperative walking distance, and disposition only trended to favor controls (P > .05). Comparing controls to SAHA patients with <3 or ≥3 levels fused, longer fusions had increased cumulative postoperative narcotic consumption (mean morphine equivalents, 44.3 vs 46.9 vs 169.4; P = .001). CONCLUSION: Patients with preexisting LSF experience worse early outcomes after primary THA including higher rates of complications and reoperation. Lower rates of neuraxial anesthesia and increased narcotic usage represent potential contributors. The complex interplay between the lumbar spine and hip warrants attention and further investigation.

Long-Acting Opioid Use Independently Predicts Perioperative Complication in Total Joint Arthroplasty.

BACKGROUND: Opioid therapy is an increasingly used modality for treatment of musculoskeletal pain despite multiple associated risks. The purpose of this study was to evaluate how preoperative opioid use affects early outcomes after total joint arthroplasty. METHODS: A total of 174 patients undergoing total joint arthroplasty were matched by age, gender, and procedure into 3 groups stratified by preoperative opioid use (nonuser, short acting [eg, Vicodin], long acting [eg, Oxycontin]). RESULTS: Compared to nonusers, preoperative long-acting use was associated with increased postoperative mean opioid consumption (46 mg vs 366 mg mean morphine equivalents, P < .001) and independently predicted complications within 90 days (odds ratio: 6.15, confidence interval: [1.46, 25.95], P = .013). CONCLUSION: Preoperative opioid use should be disclosed as a risk factor for complication to patients and taken into consideration by physicians before initiating opioid management.

Prior Lumbar Spinal Arthrodesis Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty.

BACKGROUND: Degenerative hip disorders often coexist with degenerative changes of the lumbar spine. Limited data on this patient population suggest inferior functional improvement and pain relief after surgical management. The purpose of this study is to compare the rates of prosthetic-related complication after primary total hip arthroplasty (THA) in patients with and without prior lumbar spine arthrodesis (SA). METHODS: Medicare patients (n = 811,601) undergoing primary THA were identified and grouped by length of prior SA (no fusion, 1-2 levels fused [S-SAHA], and ≥3 levels fused [L-SAHA]). RESULTS: Compared with controls, patients with prior SA had significantly higher rates of complications including dislocation (control: 2.36%; S-SAHA: 4.26%; and L-SAHA: 7.51%), revision (control: 3.43%, S-SAHA: 5.55%, and L-SAHA: 7.77%), loosening (control: 1.33%, S-SAHA: 2.10%, and L-SAHA: 3.04%), and any prosthetic-related complication (control: 7.33%, S-SAHA: 11.15% [relative risk: 1.52], and L-SAHA: 14.16% [relative risk: 1.93]) within 24 months (P < .001). CONCLUSION: The interplay of coexisting degenerative hip and spine disease deserves further attention of both arthroplasty and spine surgeons.

Loss of tumor suppressor PTEN function increases B7-H1 expression and immunoresistance in glioma.

Cancer immunoresistance and immune escape may play important roles in tumor progression and pose obstacles for immunotherapy. Expression of the immunosuppressive protein B7 homolog 1 (B7-H1), also known as programmed death ligand-1 (PD-L1), is increased in many pathological conditions, including cancer. Here we show that expression of the gene encoding B7-H1 increases post transcriptionally in human glioma after loss of phosphatase and tensin homolog (PTEN) and activation of the phosphatidylinositol-3-OH kinase (PI(3)K) pathway. Tumor specimens from individuals with glioblastoma multiforme (GBM) had levels of B7-H1 protein that correlated with PTEN loss, and tumor-specific T cells lysed human glioma targets expressing wild-type PTEN more effectively than those expressing mutant PTEN. These data identify a previously unrecognized mechanism linking loss of the tumor suppressor PTEN with immunoresistance, mediated in part by B7-H1.

Discontinuation and nonpublication of clinical trials in orthopaedic oncology.

BACKGROUND: Despite the pivotal role of clinical trials in advancing orthopaedic oncology knowledge and treatment strategies, the persistent issues of trial discontinuation and nonpublication are significant problems. This study conducted an analysis examining clinical trial discontinuation rates, associations between intervention types and discontinuation/nonpublication, and the role of funding, enrollment size, and their implications for trial success and completion. METHODS: This study, conducted on May 1, 2023, utilized a cross-sectional design to comprehensively analyze phase 3 and 4 randomized controlled trials within the realm of orthopaedic oncology. We specifically incorporated Phase 3 and 4 trials as they are designed to evaluate prolonged outcomes in human subjects and are more likely to reach publication. Study characteristics of interest included the intervention utilized in the clinical trial, presence of funding, whether the trial was published, completed, and trial enrollment size. The investigation involved an examination of ClinicalTrials.gov, a prominent online repository of clinical trial data managed by the National Library of Medicine of the USA. Descriptive statistics and multivariate logistic regressions were used to determine statistical significance. RESULTS: Among the cohort of 130 trials, 19.2% were prematurely discontinued. Completion rates varied based on intervention type; 111 pharmaceutical trials demonstrated a completion rate of 83.8%, whereas 19 non-pharmaceutical trials exhibited a completion rate of 8.0% (P < .001). Surgical trials, totaling 10, showed a completion rate of 90%. The overall trial publication rate was 86.15%, with pharmaceutical interventions achieving a publication rate of 91.96%. Larger-scale trials (≥ 261 participants) emerged as a protective factor against both discontinuation (Adjusted Odds Ratio [AOR]: 0.85, 95% Confidence Interval [CI] 0.42-0.95) and nonpublication (AOR: 0.19, 95% CI 0.13-.47), compared to smaller-scale trials. CONCLUSION: This study accentuates the heightened vulnerability of non-pharmaceutical interventions and trials exhibiting lower rates of enrollment to the issues of discontinuation and nonpublication. Moving forward, the advancement of clinical trials necessitates a concerted effort to enhance trial methodologies, especially concerning nonpharmaceutical interventions, along with a meticulous refinement of participant enrollment criteria.

Effect of Antibiotic Spacer Dosing on Treatment Success in Two-Stage Exchange for Periprosthetic Joint Infection.

INTRODUCTION: In two-stage exchange for periprosthetic joint infection (PJI), adding antibiotics to cement spacers is the standard of care; however, little is known about optimal dosage. There is emphasis on using >3.6 g of total antibiotic, including ≥2.0 g of vancomycin, per 40 g of cement, but these recommendations lack clinical evidence. We examined whether recommended antibiotic spacer doses affect treatment success. METHODS: This was a retrospective review of 202 patients who underwent two-stage exchange for PJI from 2004 to 2020 with at least 1-year follow-up. Patients were separated into high (>3.6 g of total antibiotic per 40 g of cement) and low-dose spacer groups. Primary outcomes were overall and infectious failure. RESULTS: High-dose spacers were used in 80% (162/202) of patients. High-dose spacers had a reduced risk of overall (OR, 0.37; P = 0.024) and infectious (OR, 0.35; P = 0.020) failure for infected primary arthroplasties, but not revisions. In multivariate analysis, vancomycin dose ≥2.0 g decreased the risk of infectious failure (OR, 0.31; P = 0.016), although not overall failure (OR, 0.51; P = 0.147). CONCLUSION: During two-stage exchange for PJI, spacers with greater than 3.6 g of total antibiotic may reduce overall and infectious failure for infected primary arthroplasties. Furthermore, using at least 2.0 g of vancomycin could independently decrease the risk of infectious failure.

The relationship between tear severity, fatty infiltration, and muscle atrophy in the supraspinatus.

BACKGROUND: Fatty infiltration and muscle atrophy have been described as interrelated characteristic changes that occur within the muscles of the rotator cuff after cuff tears, and both are independently associated with poor outcomes after surgical repair. We hypothesize that fatty infiltration and muscle atrophy are two distinct processes independently associated with supraspinatus tears. MATERIALS AND METHODS: A retrospective review of 377 patients who underwent shoulder magnetic resonance imaging at one institution was performed. Multivariate analysis was performed based on parameters including age, sex, rotator cuff tear severity, fatty infiltration grade, and muscle atrophy. RESULTS: A total of 116 patients (30.8%) had full-thickness tears of the supraspinatus, 153 (40.6%) had partial thickness tears, and 108 (28.7%) had no evidence of tear. With increasing tear severity, the prevalence of substantial fatty infiltration (grade ≥2) increased: 6.5% of patients with no tears vs 41.4% for complete tears (P < .001). Similarly, the prevalence of supraspinatus atrophy increased with worsening tear severity: 36.1% of no tears vs 77.6% of complete tears (P < .001). Multivariate analysis demonstrated a significant independent association between fatty infiltration and muscle atrophy when taking into account sex, age, and tear severity. CONCLUSIONS: Fatty infiltration and muscle atrophy are independently associated processes. Fatty infiltration is also related to increasing age, muscle tear severity, and sex, whereas muscle atrophy is related to increasing age but not tear severity. In patients without rotator cuff tears, fatty infiltration and atrophy prevalence increased independently with increasing age.

Comparison of Static and Articulating Spacers After Periprosthetic Joint Infection.

INTRODUCTION: There is no consensus on whether articulating or static spacers are superior during two-stage exchange arthroplasty for periprosthetic joint infection. We aimed to compare surgical time, need for extensile exposure, surgical costs, and treatment success for articulating and static spacers. METHODS: This was a retrospective review of 229 periprosthetic joint infections treated with two-stage exchange with a minimum of one-year follow-up. For articulating and static spacers, we compared the need for extensile exposure during reimplantation and treatment failure based on an updated definition. Surgical time and costs at both stages were also compared. Subgroup analysis was performed for total knee and hip arthroplasties. RESULTS: There was no difference in the surgical time for spacer insertion; however, articulating spacers demonstrated reduced surgical time during reimplantation (181 vs. 234 minutes, P < 0.001). In multivariate analysis, there was no difference in extensile exposures (odds ratio 2.20, P = 0.081), but treatment failure was more likely for static spacers (odds ratio 2.17, P = 0.009). Overall surgical costs for two-stage exchange were similar between groups (23,782 vs. 23,766, P = 0.495). CONCLUSION: Articulating spacers demonstrated shorter surgical times and a trend toward decreased extensile exposures during reimplantation. They also had higher treatment success rates and similar surgical costs for overall two-stage exchange.

Virtual Reality as a Learning Tool for Trainees in Unicompartmental Knee Arthroplasty: A Randomized Controlled Trial.

INTRODUCTION: The efficacy of virtual reality (VR) as a teaching augment for arthroplasty has not been well examined for unfamiliar multistep procedures such as unicompartmental knee arthroplasty (UKA). This study sought to determine whether VR improves surgical competence over traditional procedural preparation when performing a UKA. METHODS: Twenty-two orthopaedic surgery trainees were randomized to two surgical preparation cohorts: (1) "Guide" group (control) with access to manufacture's technique guide and surgical video and (2) "VR" group with access to an immersive commercially available VR learning module. Surgical performance of UKA on a SawBone model was assessed through time and the Objective Structured Assessment of Technical Skills (OSATS) validated rating system. RESULTS: Participants were equally distributed among all training levels and previous exposure to UKA. No difference in mean surgical times was observed between Guide and VR groups (Guide = 42.4 minutes versus VR = 43.0 minutes; P = 0.9) or mean total OSATS (Guide = 15.7 versus VR = 14.2; P = 0.59). Most trainees felt VR would be a useful tool for resident education (77%) and would use VR for case preparation if available (86.4%). CONCLUSION: In a randomized controlled trial of trainees at a single, large academic center performing a complex, multistep, unfamiliar procedure (UKA), VR training demonstrated equivalent surgical competence compared with the use of traditional technique guides, as measured by surgical time and OSATS scores. Most of the trainees found the VR technology beneficial. This study suggests that VR technology may be considered as an adjunct to traditional surgical preparation/training methods.

2021 John Charnley Award: A protocol-based strategy when using hemiarthroplasty or total hip arthroplasty for femoral neck fractures decreases mortality, length of stay, and complications.

AIMS: While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty. METHODS: In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol. RESULTS: A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024). CONCLUSION: The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J 2021;103-B(7 Supple B):3-8.

Reducing Time to Surgery for Hip Fragility Fracture Patients: A Resident Quality Improvement Initiative.

ABSTRACT: As part of an institutional quality improvement (QI) initiative for the 2018-2019 academic year, orthopedic residents at our tertiary center were incentivized to bring over 75% of hip fracture patients with American Society of Anesthesiologists (ASA) Class 2 or less to surgery in under 24 hours, compared to the baseline rate of 55.9%. The time between admission and surgery for hip fracture patients with ASA class 2 or less was prospectively recorded. At the end of the study period, a retrospective comparison was performed between patients treated before and after the resident QI initiative. The percentage of patients who underwent surgery within 24 hours of admission increased significantly in the Study Cohort compared to the Baseline Cohort (78.6% vs. 55.9%, p = .037). Length of stay was shorter in the Study Cohort compared to the Baseline Cohort (3 days vs. 4 days, p = .01), whereas readmissions (3.6% vs. 4.4%, p = .85) and discharges to skilled nursing facilities (60.7% vs. 57.4%, p = .76) were comparable between both cohorts. A goal-directed, resident-led QI initiative was associated with a significantly increased percentage of hip fragility fracture patients who underwent surgery in less than 24 hours.

Irrigation and Debridement with Chronic Antibiotic Suppression Is as Effective as 2-Stage Exchange in Revision Total Knee Arthroplasty with Extensive Instrumentation.

BACKGROUND: Extraction of implants because of periprosthetic infection (PJI) following complex revision total knee arthroplasty (rTKA) with extensive instrumentation is a daunting undertaking for surgeon and patient alike. The purpose of the present study was to evaluate whether infections following complex rTKA are better treated with 2-stage exchange or irrigation and debridement (I&D) with modular component exchange and antibiotic suppression in terms of infection control, reoperation, and function. METHODS: We reviewed rTKAs that had been performed for the treatment of PJI from 2005 to 2016. Extensive instrumentation was defined as the presence ≥1 of the following: metaphyseal cones/sleeves, distal femoral replacement, periprosthetic fracture instrumentation, or fully cemented stems measuring >75 mm. Cases were categorized according to the initial treatment (I&D with antibiotic suppression or initiation of 2-stage exchange). RESULTS: Eighty-seven patients with PJI and extensive instrumentation were identified: 56 patients who were managed with I&D with suppression and 31 who were managed with the initiation of 2-stage exchange. The rate of success (defined as no reoperation for infection) was similar for the 2 groups (62.5% the I&D group compared with 67.7% for the 2-stage group; p = 0.62). The rate of mortality was also similar (39.3% for the I&D group compared with 38.7% for the 2-stage group; p = 0.96). Of the 31 patients in the 2-stage group, 18 (58.1%) underwent reimplantation with a revision replacement. Of those 18 patients, 13 were still infection-free at the time of the most recent follow-up; however, when the analysis was expanded to all 31 patients in the 2-stage group, only 13 (41.9%) both had a successful reimplantation and did not require additional surgery for infection. Nine (29.0%) of the 31 patients in the 2-stage group never underwent the second stage, and 4 (12.9%) of the 31 required arthrodesis at the second stage. In contrast, 35 (62.5%) of the 56 patients in the I&D group were successfully managed, without additional surgery for the treatment of infection. At the time of the latest follow-up (mean, 3.2 years; range, 2 to 13 years), more patients in the I&D group were ambulatory (76.8% in the I&D group compared with 54.8% in the 2-stage group; p = 0.05) and maintained a functional bending knee joint (85.7% in the I&D group compared with 45.2% in the 2-stage group; p < 0.001). CONCLUSIONS: In the treatment of periprosthetic infection of rTKA with extensive instrumentation, I&D with chronic antibiotic suppression was as effective as 2-stage exchange in terms of preventing reoperation for infection and was more effective in terms of maintaining function. These data apply to rTKA with extensive periarticular instrumentation and should not be extrapolated to primary or simple revision implants. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Barriers to cross--institutional health information exchange: a literature review.

While the development of health information technology, particularly electronic health records (EHR), is a triumph for the advancement of healthcare, non-interoperable clinical data systems lead to fragmented communication and incomplete records. If interoperable HIT systems could be achieved integrated HIT could be leveraged to lessen medical errors, improve patient care and optimize epidemiological research. To understand the barriers to interoperability or health information exchange (HIE), we reviewed the literature on HIT and barriers to HIE. Our search yielded 492 articles, 25 meeting our inclusion criteria. In general, we found that the predominant barriers to HIE are need for standards, security concerns, economic loss to competitors, and federated systems. Research on interoperability is limited because most HIE programs are still in formative stages. More research is needed to fully understand interoperability of HIT, how to overcome the barriers to interoperability, and how to design HIT to better facilitate HIE.

Hypersensitivity pneumonitis, allergic bronchopulmonary aspergillosis and other eosinophilic lung diseases.

Hypersensitivity pneumonitis (HP) is traditionally classified into acute, subacute and chronic forms. A high index of suspicion and a detailed investigation into the patient's environment is the key to diagnosis and treatment of HP. Eosinophilic lung diseases can be broadly categorized as idiopathic (acute eosinophilic pneumonia, chronic eosinophilic pneumonia, eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndromes), those with known cause (allergic bronchopulmonary aspergillosis, drugs, parasitic and non-parasitic infections), and those associated with other known lung diseases (asthma, interstitial lung diseases and lung cancers). A detailed review of drug intake, toxin exposures, and travel history is essential in the differential diagnosis of eosinophilic lung diseases.

Antibiotic-Laden Bone Cement Use and Revision Risk After Primary Total Knee Arthroplasty in U.S. Veterans.

BACKGROUND: It is controversial whether the use of antibiotic-laden bone cement (ALBC) in primary total knee arthroplasty (TKA) affects periprosthetic joint infection (PJI) or revision rates. The impact of ALBC on outcomes of primary TKA have not been previously investigated in U.S. veterans, to our knowledge. The purposes of this study were to quantify utilization of ALBC among U.S. veterans undergoing primary TKA and to determine if ALBC usage is associated with differences in revision TKA rates. METHODS: Patients who had TKA with cement from 2007 to 2015 at U.S. Veterans Health Administration (VHA) hospitals with at least 2 years of follow-up were retrospectively identified. Patients who received high-viscosity Palacos bone cement with or without gentamicin were selected as the final study cohort. Patient demographic and comorbidity data were collected. Revision TKA was the primary outcome. All-cause revisions and revisions for PJI were identified from both VHA and non-VHA hospitals. Unadjusted and adjusted regression analyses were performed to identify variables that were associated with increased revision rates. RESULTS: The study included 15,972 patients who had primary TKA with Palacos bone cement at VHA hospitals from 2007 to 2015. Plain bone cement was used for 4,741 patients and ALBC was used for 11,231 patients. Utilization of ALBC increased from 50.6% in 2007 to 69.4% in 2015. At a mean follow-up of 5 years, TKAs with ALBC had a lower all-cause revision rate than those with plain bone cement (5.3% versus 6.7%; p = 0.0009) and a lower rate of revision for PJI (1.9% versus 2.6%; p = 0.005). On multivariable regression, ALBC use was associated with a lower risk of all-cause revision compared with plain bone cement (hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.68 to 0.92; p = 0.0019). Seventy-one primary TKAs needed to be implanted with ALBC to avoid 1 revision TKA. CONCLUSIONS: The utilization of ALBC for primary TKAs performed at VHA hospitals has increased over time and was associated with a lower all-cause revision rate and a lower rate of revision for PJI. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Wearable activity sensors and early pain after total joint arthroplasty.

A prospective observational cohort of 20 primary total hip arthroplasty (n = 12) and total knee arthroplasty (n = 8) patients (mean age: 63 ± 6 years) was passively monitored with a consumer-level wearable activity sensor before and 6 weeks after surgery. Patients were clustered by minimal change or decreased activity using sensor data. Decreased postoperative activity was associated with greater pain reduction (-5.5 vs -2.0, P = .03). All patients surpassed minimal clinical benefit thresholds of total joint arthroplasty (TJA) (Hip Disability and Osteoarthritis Score Junior 30.5 vs 20.8, P = .23; Knee Injury and Osteoarthritis Outcome Score Junior 23.3 vs 18.2, P = .77) within 6 weeks. Patients who objectively "take it easy" after TJA may experience less pain with no difference in early subjective outcome. Remote, passive analysis of outpatient wearable sensor data may permit real-time detection of early problems after TJA.