Red Cell Distribution Width: Commonly Performed Test Predicts Mortality in Primary Total Joint Arthroplasty.

INTRODUCTION: Mortality after total joint arthroplasty (TJA) has been thoroughly explored. Short and long-term mortality appear to be correlated with patient comorbidities. Red Cell Distribution Width (RDW) is a commonly performed test that reflects the variation in red blood cell size. This study investigated the utility of RDW, when combined with comorbidity indices, in predicting mortality after TJA. METHODS: Using a single institutional database, 30,437 primary TJA were identified. Patient demographics (age, gender, body mass index (BMI), pre-operative hemoglobin, RDW, and Charlson Comorbidity Index(CCI)) were queried. The primary outcome was 1-year mortality after TJA. Anemia was defined as hemoglobin <12g/dL for women and <13 g/dL for men. The normal range for RDW is 11.5-14.5%. A preliminary analysis assessed the bivariate association between demographics, preoperative anemia, RDW, CCI, and all-cause mortality within 1-year after TJA. A multivariate regression model was conducted to determine independent predictors of 1-year mortality. Finally, ROC curves were used to compare AUC of RDW, CCI and the combination of both in predicting 1-year mortality. RESULTS: The mean RDW was 13.6% ± 1.2. Eighteen percent of patients had pre-operative anemia. The mean CCI was 0.4 ± 0.9. RDW, anemia, CCI, and age were significantly associated with a higher incidence of 1-year mortality. RDW, CCI, age, and male sex were found to be independent risk factors for 1-year mortality. RDW (AUC = 0.68) was a better predictor of mortality compared to CCI (AUC = 0.66). The combination of RDW and CCI (AUC = 0.76) predicted 1-year mortality more accurately than CCI or RDW alone. CONCLUSION: RDW appears to be a useful parameter that, when combined with CCI, can predict the risk for 1-year mortality after TJA.

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.

Irrigation, Débridement, and Implant Retention for Recurrence of Periprosthetic Joint Infection Following Two-Stage Revision Total Knee Arthroplasty: A Matched Cohort Study.

BACKGROUND: We investigated clinical/functional outcomes and implant survivorship in patients who underwent 2-stage revision total knee arthroplasty (TKA) after periprosthetic joint infection (PJI), experienced acute PJI recurrence, and underwent irrigation, débridement, and polyethylene exchange (IDPE) with retention of stable implant. METHODS: Twenty-four patients (24 knees) were identified who underwent 2-stage revision TKA for PJI, experienced acute PJI recurrence, and then underwent IDPE between 2005 and 2016 (minimum 2-year follow-up). After IDPE, intravenous antibiotics (6 weeks) and oral suppression therapy (minimum 6 months) were administered. Data were compared with 1:2 matched control group that underwent 2-stage revision TKA for chronic PJI and did not receive IDPE. RESULTS: Average IDPE group follow-up was 3.8 years (range, 2.4-7.2). Reinfection rate after IDPE was 29% (n = 7): 3 of 7 underwent second IDPE (2 of 3 had no infection recurrence) and 5 (one was patient who had recurrent infection after second IDPE) underwent another 2-stage revision TKA. Control group reinfection rate was 27% (n = 13) (P = .85). For IDPE group, mean time to reinfection after 2-stage revision TKA was 4.6 months (range, 1-8 months) (patients presented with acute symptoms less than 3 weeks duration). At latest follow-up, mean Knee Society Score was 70 (range, 35-85) in IDPE group and 75 (range, 30-85) in control group (P = .53). CONCLUSION: IDPE for acute reinfection following 2-stage revision TKA with well-fixed implants had a 71% success rate. These patients had comparable functional outcome as patients with no IDPE after 2-stage revision TKA. IDPE followed by long-term suppression antibiotic therapy should be considered in patients with acute infection and stable components.

Red Cell Distribution Width: An Unacknowledged Predictor of Mortality and Adverse Outcomes Following Revision Arthroplasty.

BACKGROUND: Revision total joint arthroplasties (TJAs) have been empirically associated with significant postoperative morbidity and mortality. Red blood cell distribution width (RDW), a frequently measured hematological parameter, has been shown to predict mortality in hip fracture patients. However, its utility in risk-stratifying patients before revision TJA remains unknown. The aim of this study was to investigate the possible relationship between preoperative RDW levels and outcome of revision arthroplasty in terms of mortality, adverse outcomes, and length of hospital stay. METHODS: A single-institution retrospective study was conducted on 4633 patients who underwent revision TJA (3289 hips and 1344 knees) between 2000 and September 2016. Of those, 656 (14.1%) surgeries were performed due to periprosthetic joint infection, and 3977 (85.9%) were aseptic revisions. The association between preoperative RDW and various outcomes, including 1-year mortality, in-hospital medical complications, length of hospital stay, and 90-day all-cause readmission, was examined. RESULTS: The average age of patients in the cohort was 65.4 ± 12.9 years. The average Charlson comorbidity index was 0.6 (standard deviation = 1.0), with 691 patients (14.9%) having 2 or more comorbidities. Mean preoperative RDW level was 14.4% (standard deviation = 1.8). After adjusting for covariates, higher RDW levels were statistically significantly associated with mortality (adjusted odds ratio [OR], 1.25; 95% confidence interval [CI], 1.13-1.39; P < .001), any in-hospital medical complications (adjusted OR, 1.12; 95% CI, 1.07-1.18; P < .001), and readmission (adjusted OR, 1.07; 95% CI, 1.02-1.13; P < .001). CONCLUSION: Higher levels of preoperative RDW appeared to be associated with less optimal outcomes after revision TJA. Adult reconstruction orthopedic surgeons should be aware of this predictive factor and exercise caution with TJA revision patients with high values of preoperative RDW. RDW could be included in the routine perioperative workup and used to counsel patients on their postoperative risk.

Time to Reimplantation: Waiting Longer Confers No Added Benefit.

BACKGROUND: While the preferred surgical treatment for chronic periprosthetic joint infection (PJI) in North America is a 2-stage exchange arthroplasty, the optimal time between first-stage and reimplantation surgery remains unknown. This study was conceived to examine the association between time to reimplantation and treatment failure. METHODS: Using an institutional database, we identified PJI cases treated with 2-stage exchange arthroplasty between 2000 and 2016. Musculoskeletal Infection Society criteria were used to define PJI, and treatment failure was defined using Delphi criteria. The interstage interval between first-stage and reimplantation surgery for each case was collected, alongside demographics, patient-related and organism-specific data. Multivariate logistic regression analyses were used to examine association with treatment failure. RESULTS: Our final analysis consisted of 282 patients with an average time to reimplantation of 100.2 days (range, 20-648). Sixty-three patients (22.3%) failed at 1 year based on Delphi criteria. Time to reimplantation was not significantly associated with failure in both univariate (P = .598) and multivariate (P = .397) models. However, patients reimplanted at >26 weeks were twice as likely to fail in comparison to those reimplanted within <26 weeks (43.8% vs 21.1%), and this finding reached marginal significance (P = .057). Patients who failed had significantly more comorbidities (P = .008). Charlson comorbidity index was the only variable significantly associated with treatment failure in regression analysis (odds ratio, 1.40; 95% confidence interval, 1.06-1.86; P = .019). CONCLUSION: The length of the interstage interval was not a statistically significant predictor of failure in patients undergoing 2-stage exchange arthroplasty for PJI.

Mini-Open Femoroacetabular Osteoplasty: Risk Factors for Failure and Conversion to Hip Arthroplasty.

BACKGROUND: Surgical treatment of femoroacetabular impingement (FAI) has been increasing over the past decade with reports of favorable results in alleviating patient symptoms. However, progression of osteoarthritis in these patients may necessitate total hip arthroplasty (THA) for the treatment of unresolved or recurrent hip pain and accompanying disability. Identifying the risk factors for disease progression and treatment failure can help orthopaedic surgeons to select the appropriate patients for joint-preservation procedures and allow more informative discussions. METHODS: With use of the prospective database of hip-preservation surgery at our institution, 652 patients (324 men and 328 women) with FAI who had undergone femoroacetabular osteoplasty (FAO) between December 2004 and April 2016 were identified. Treatment failure was defined as the need for THA. At the latest follow-up, 68 (9.08%)of 749 hips had undergone THA because of the recurrence of symptoms and the development of osteoarthritis. The groups of patients who had or had not undergone conversion to THA were compared with respect to age, sex, body mass index (BMI), surgeon experience, duration of preoperative symptoms, preoperative and postoperative alpha angles, radiographic parameters of hip dysplasia, a perioperative chondral lesion, labral abnormalities and interventions, acetabular retroversion, and severity of osteoarthritis (Tönnis grade). RESULTS: The mean age (and standard deviation) at the time of the index FAO was 41.9 ± 10.5 years for patients who had had a failure of FAO, compared with 33.4 ± 11.1 years for those who had not. Risk factors for treatment failure included a longer mean symptomatic period before the FAO procedure, older age, higher mean BMI, the presence of hip dysplasia, acetabular retroversion, higher preoperative alpha angle, a full-thickness acetabular chondral lesion, Tönnis grade-1 and 2 osteoarthritis, labral hypertrophy, and total labral resection during FAO. The rate of failure was related to the experience of the surgeon, with fewer failures occurring in the later years of surgery as compared with the earlier years. CONCLUSIONS: The present study identified a number of variables that influence the outcome of FAO. Surgeons performing hip-preservation procedures should be aware of these risk factors for failure, and a more cautious approach is recommended for patients with these risk factors. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Venous thromboembolism prophylaxis after hip preservation surgery: a review and presentation of institutional experience.

Venous thromboembolism (VTE) is a serious complication after major orthopedic procedures. The best options for prevention of the VTE are still debated. The most popular evidence-based guidelines for prevention and treatment of VTE in orthopedic surgery addressed the total hip or knee arthroplasty and hip fractures as the major orthopedic surgeries. Majority of studies have evaluated the different modalities of the VTE prophylaxis in patients undergiong hip or knee arthroplasty. Hip preservation surgeries (HPS) including mini-open femoroacetabular osteoplasty, surgical dislocation of the hip, arthroscopic procedures, and periacetabular osteotomy (PAO) are gained popularity in recent two decades. The majority of these patients are young, healthy and active and may not be considered at high risk for VTE. The frequency of VTE in patients undergoing PAO seems to be low between 0 and 5%. There is a paucity of data regarding rates of VTE in young healthy patients undergoing HPS as well as the optimal prevention methods for VTE. Hence current VTE prevention guidelines do not cover HPS adequately. We aimed to review the available literature regarding VTE events and VTE prophylaxis options after HPS. We discussed the available and potential options for prophylaxis of VTE events in these procedures along with our experience in a large cohort of hip preservation surgery.