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BACKGROUND: Intraoperative dexamethasone can reduce postoperative pain and nausea following total knee (TKA) and total hip arthroplasty (THA). To the best of our knowledge, no study to date has been adequately powered to detect the risk of periprosthetic joint infection (PJI) from early dexamethasone exposure. This study aimed to assess PJI rates and complications in patients undergoing primary elective TKA and THA who received intraoperative dexamethasone. METHODS: A national database was used to identify adults undergoing primary elective TKA and THA between 2015 and 2020. Patients who received intraoperative dexamethasone and those who did not were identified. The primary endpoint was 90-day risk of infectious complications. Secondary end points included thromboembolic, pulmonary, renal, and wound complications. Multivariate analyses were performed to assess the risk of all endpoints between cohorts. Between 2015 and 2020, 1,322,025 patients underwent primary elective TJA, of which 857,496 (64.1%) underwent TKA and 474,707 (35.9%) underwent TKA. RESULTS: In patients who underwent TKA, dexamethasone was associated with lower risk of PJI (adjusted odds ratio: 0.87, 95% CI: 0.82-0.93, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, and acute kidney injury. In patients who underwent THA, dexamethasone was associated with a lower risk of PJI (adjusted odds ratio: 0.80, 95% CI: 0.73-0.86, P < .001) as well as other secondary endpoints such as pulmonary embolism, deep vein thrombosis, acute kidney injury, and pneumonia. CONCLUSION: Intraoperative dexamethasone was not associated with increased risk of infectious complications. The data presented here provide evidence in support of intraoperative dexamethasone utilization during primary TKA or THA.
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Artroplastia de Quadril , Artroplastia do Joelho , Infecções Relacionadas à Prótese , Embolia Pulmonar , Trombose Venosa , Adulto , Humanos , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/prevenção & controle , Artroplastia do Joelho/efeitos adversos , Artroplastia de Quadril/efeitos adversos , Embolia Pulmonar/etiologia , Trombose Venosa/etiologia , Fatores de Risco , Estudos RetrospectivosRESUMO
BACKGROUND: An optimal venous thromboembolism prophylaxis agent should balance efficacy and safety. While rivaroxaban provides effective venous thromboembolism prophylaxis after total joint arthroplasty, it may be associated with higher rates of bleeding. This study aimed to compare the safety and efficacy of rivaroxaban to aspirin and enoxaparin. METHODS: A large national database was queried for patients who underwent elective primary total hip (THA) or total knee arthroplasty (TKA) from January 2015 through December 2020 who received rivaroxaban, aspirin, or enoxaparin. Multivariate analyses were performed to assess the 90-day risk of bleeding and thromboembolic complications. Among TKA patients identified, 86,721 (10.8%) received rivaroxaban, 408,038 (50.8%) received aspirin, and 108,377 (13.5%) received enoxaparin. Among THA patients, 42,469 (9.5%) received rivaroxaban, 242,876 (54.5%) received aspirin, and 59,727 (13.4%) received enoxaparin. RESULTS: After accounting for confounding factors, rivaroxaban was associated with increased risk of transfusion (TKA: adjusted odds ratio [aOR] = 2.58, P < .001; THA: aOR 1.64, P < .001), pulmonary embolism (TKA: aOR = 1.25, P = .007), and deep vein thrombosis (TKA: aOR = 1.13, P = .022) compared to aspirin. Compared to enoxaparin, rivaroxaban was associated with an increased risk of combined bleeding events (TKA: aOR = 1.07, P < .001, THA: aOR = 1.11, P < .001), but decreased risk of combined prothrombotic events (THA: aOR = 0.85, P = .036). CONCLUSION: Rivaroxaban chemoprophylaxis following TKA and THA was associated with an increased risk of bleeding and prothrombotic complications compared to aspirin and enoxaparin.
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Artroplastia de Quadril , Artroplastia do Joelho , Tromboembolia Venosa , Humanos , Rivaroxabana/efeitos adversos , Enoxaparina/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Artroplastia de Quadril/efeitos adversos , Anticoagulantes/efeitos adversos , Aspirina/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologiaRESUMO
BACKGROUND: Aspirin may be effective at preventing venous thromboembolism following total knee arthroplasty (TKA) or total hip arthroplasty (THA). Current evidence is limited by bias as many surgeons who use aspirin prescribe for high-risk patients alternative chemoprophylactic agents. Therefore, this study aimed to evaluate the risk of pulmonary embolism (PE) and deep vein thrombosis (DVT) in patients who received aspirin and warfarin while accounting for surgeon selection bias. METHODS: A national database was queried for patients undergoing primary elective TKA or THA from 2015 to 2020. Patients whose surgeon used aspirin in >90% of their patients were compared to patients whose surgeon used warfarin in >90% of cases. Instrumental variable analyses were performed to assess for PE, DVT, and transfusion while accounting for selection bias. Among TKA patients, 26,657 (18.8%) were in the warfarin cohort and 115,005 (81.2%) were in the aspirin cohort. Among THA patients, 13,035 (17.7%) were in the warfarin cohort and 60,726 (82.3%) were in the aspirin cohort. RESULTS: Analyses were unable to identify a difference in the risk of PE (TKA: adjusted odds ratio [aOR]: 0.98, P = .659; THA: aOR = 0.93, P = .310) and DVT (TKA: aOR = 1.05, P = .188; THA: aOR = 0.96, P = .493) between the aspirin and warfarin cohorts. However, the aspirin cohort was associated with a lower risk of transfusion (TKA: aOR = 0.58, P < .001, THA: 0.84, P < .001). DISCUSSION: After accounting for surgeon selection bias, aspirin was as effective as warfarin at preventing PE and DVT following TKA and THA. Furthermore, aspirin was associated with a lower risk of transfusion compared to warfarin.
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Artroplastia de Quadril , Artroplastia do Joelho , Embolia Pulmonar , Cirurgiões , Tromboembolia Venosa , Humanos , Aspirina/uso terapêutico , Varfarina/uso terapêutico , Anticoagulantes/uso terapêutico , Artroplastia do Joelho/efeitos adversos , Viés de Seleção , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Artroplastia de Quadril/efeitos adversosRESUMO
BACKGROUND: Prednisone use is associated with higher rates of periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). However, the relationship between prednisone dosage and infection risk is ill-defined. Therefore, this study aimed to assess the relationship between prednisone dosage and rates of PJI following TJA. METHODS: A national database was queried for all elective total hip (THA) and total knee arthroplasty (TKA) patients between 2015 and 2020. Patients who received oral prednisone following TJA were matched in a 1:2 ratio based on age and sex to patients who did not. Univariate and multivariate regression analyses were performed to assess the 90-day risk of infectious complications based on prednisone dosage as follows: 0 to 5, 6 to 10, 11 to 20, 21 to 30, and >30 milligrams. Overall, 1,322,043 patients underwent elective TJA (35.9% THA, 64.1% TKA). Of these, 14,585 (1.1%) received prednisone and were matched to 29,170 patients who did not. RESULTS: After controlling for confounders, TKA patients taking prednisone were at increased risk for sepsis (adjusted odds ratio [aOR] 2.76, P < .001), PJI (aOR 2.67, P < .001), and surgical site infection (aOR: 2.56, P = .035). THA patients taking prednisone were at increased risk for sepsis (aOR: 3.21, P < .001) and PJI (aOR: 1.73, P = .001). No dose-dependent relationship between prednisone and infectious complications was identified when TJA was assessed in aggregate. CONCLUSION: Patients receiving prednisone following TJA were at increased risk of PJI and sepsis. A dose-dependent relationship between prednisone and infectious complications was not identified. Arthroplasty surgeons should be aware of these risks and counsel TJA patients who receive prednisone therapy.
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Artrite Infecciosa , Artroplastia do Joelho , Prednisona , Infecções Relacionadas à Prótese , Humanos , Artrite Infecciosa/etiologia , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Prednisona/efeitos adversos , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/complicações , Estudos Retrospectivos , Fatores de Risco , Sepse/complicaçõesRESUMO
BACKGROUND: This study analyzed complication rates following primary elective total joint arthroplasty (TJA) in patients who subsequently contracted COVID-19. METHODS: A large national database was queried for adult patients who underwent primary elective TJA in 2020. Patients who contracted COVID-19 after total knee arthroplasty (TKA) or total hip arthroplasty (THA) underwent 1:6 matching (age [±6 years], sex, month of surgery, COVID-19-related comorbidities) to patients who did not. Differences between groups were assessed using univariate and multivariate analyses. Overall, 712 COVID-19 patients were matched to 4,272 controls (average time to diagnosis: 128-117 days [range, 0-351]). RESULTS: Of patients diagnosed <90 days postoperatively, 32.5%-33.6% required COVID-19-driven readmission. Discharge to a skilled nursing facility (adjusted odds ratio [aOR] 1.72, P = .003) or acute rehabilitation unit (aOR 4.93, P < .001) and Black race (aOR 2.28, P < .001) were associated with readmission after TKA. Similar results were associated with THA. COVID-19 patients were at increased risk of pulmonary embolism (aOR 4.09, P = .001) after TKA and also periprosthetic joint infection (aOR 4.65, P < .001) and sepsis (aOR 11.11, P < .001) after THA. The mortality rate was 3.51% in COVID-19 patients and 7.94% in readmitted COVID-19 patients compared to 0.09% in controls, representing a 38.7 OR and 91.8 OR of death, respectively. Similar results were observed for TKA and THA separately. CONCLUSION: Patients who contracted COVID-19 following TJA were at greater risk of numerous complications, including death. These patients represent a high-risk cohort who may require more aggressive medical interventions. Given the potential limitations presently, prospectively collected data may be warranted to validate these findings.
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Artroplastia de Quadril , Artroplastia do Joelho , COVID-19 , Adulto , Humanos , Teste para COVID-19 , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , COVID-19/diagnóstico , COVID-19/epidemiologia , Artroplastia do Joelho/efeitos adversos , Artroplastia de Quadril/efeitos adversos , Fatores de Risco , Estudos RetrospectivosRESUMO
BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic has dramatically disrupted orthopaedic surgery practice patterns. This study aimed to examine differences between patients who underwent total joint arthroplasty (TJA) before the pandemic compared to 2020 and 2021. METHODS: A retrospective cohort study was performed on all patients who underwent elective inpatient TJA from January 2017 to December 2021 using a national large database. Descriptive statistics were utilized to trend length of stay (LOS) and patient age. Patient demographics, discharge destinations, and rates of medical comorbidities were assessed for patients undergoing TJA in 2020 and 2021 compared to patients from prepandemic years (2017 to 2019). Overall, 1,173,366 TJAs were identified (2017 to 2019: 810,268 TJAs, average 270,089 cases/year; 2020: 175,185 TJAs; 2021: 187,627 TJAs). There was a 35.3% and 30.5% decrease in 2020 and 2021, respectively, when compared to the prepandemic annual average. RESULTS: Average LOS decreased from 1.6 days in January 2020 to 0.9 days by December 2021. Same-day discharges increased from 6.2% of cases in 2019 to 30.5% in 2021. Discharge to skilled nursing facilities (SNF) reduced from 11.3% in 2017 to 2019 to 4.3% and 4.5% in 2020 and 2021, respectively. Patients ≥70 years old undergoing elective TJA decreased from 39.6% in 2017 to 2019 to 29.2% in April 2020. CONCLUSION: In response to the COVID-19 pandemic, same-day discharges following primary elective TJA increased markedly, the average LOS decreased, discharges to SNFs decreased, and a preferential shift toward younger patients was observed. LEVEL OF EVIDENCE: Therapeutic Level III.
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Artroplastia de Quadril , Artroplastia do Joelho , COVID-19 , Humanos , Estados Unidos/epidemiologia , Idoso , Pandemias , Estudos Retrospectivos , COVID-19/epidemiologia , SARS-CoV-2RESUMO
BACKGROUND: The utility of the synovial alpha-defensin test in diagnosing periprosthetic joint infections (PJIs) remains controversial. This study aimed to examine the diagnostic utility of this test. METHODS: A retrospective review was conducted to identify adults evaluated for PJI following total knee arthroplasty at a single institution. Patient demographics, laboratory results, and operative details were recorded. Using the 2018 Musculoskeletal Infection Society (MSIS) criteria, cases were categorized as definitive, inconclusive, or negative for PJI. The sensitivity, specificity, positive predictive value, and negative predictive value of each MSIS criterion was determined. The number of patients whose PJI diagnosis was contingent on alpha-defensin positivity was calculated. RESULTS: Overall, 172 total knee arthroplasty patients were included, who had an average age of 70.4 years (range, 39 to 95). Of the 21 patients who met major criteria, 20 (95.2%) were alpha-defensin positive. Of the remaining 151 patients, 85 did not meet minor criteria, all of whom were alpha-defensin negative. Among the 30 patients who met minor criteria, 28 (93.3%) were alpha-defensin positive and 2 (6.7%) were negative. The remaining 36 patients were deemed inconclusive preoperatively. In total, alpha-defensin testing changed the diagnosis in only 9 of 172 patients (5.2%). The sensitivity, specificity, positive predictive value, and negative predictive value of alpha-defensin in this cohort were 94.1, 100, 100, and 97.6, respectively. CONCLUSION: Alpha-defensin may assist in the diagnosis of PJI when a preoperative workup is inconclusive. However, this test is often unnecessary when the diagnosis of PJI can be made using the 2018 MSIS criteria.
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Artrite Infecciosa , Artroplastia de Quadril , Artroplastia do Joelho , Infecções Relacionadas à Prótese , alfa-Defensinas , Adulto , Humanos , Idoso , Artroplastia do Joelho/efeitos adversos , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/cirurgia , Artroplastia de Quadril/efeitos adversos , Sensibilidade e Especificidade , Artrite Infecciosa/cirurgiaRESUMO
BACKGROUND: Data on the clinical impact of computer navigation (CN) and robotic assistance (RA) in total knee arthroplasty (TKA) are mixed. This study aims to describe modern utilization trends in CN-TKA, RA-TKA, and traditionally-instrumented (TD) TKA and to assess for differences in postoperative complications and opioid consumption by procedure type. METHODS: A national database was queried to identify primary, elective TKA patients from 2015 to 2020. Trends in procedural utilization rates were assessed. Differences in 90-day postoperative complications and inpatient opioid consumption were assessed. Multivariate regression analyses were performed to account for potential confounders. RESULTS: Of the 847,496 patients included, 49,317 (5.82%) and 24,460 (2.89%) underwent CN-TKA and RA-TKA, respectively. CN-TKA utilization increased from 5.64% (2015) to 6.41% (2020) and RA-TKA utilization increased from 0.84% (2015) to 5.89% (2020). After adjusting for confounders, CN-TKA was associated with lower periprosthetic joint infection (P = .001), pulmonary embolism (P < .001), and acute respiratory failure (P = .015) risk compared to traditional (TD) TKA. RA-TKA was associated with lower deep vein thrombosis (P < .001), myocardial infarction (P = .013), and pulmonary embolism (P = .001) risk than TD-TKA. Lower postoperative day 1 opioid usage was seen with CN-TKA and RA-TKA than TD-TKA (P < .001). Lower postoperative day 0 opioid consumption was also seen in RA-TKA (P < .001). CONCLUSION: From 2015 to 2020, there was a relative 13.7% and 601.2% increase in CN-TKAs and RA-TKAs, respectively. This trend was associated with reductions in hospitalization duration, postoperative complications, and opioid consumption. These data support the safety of RA-TKA and CN-TKA compared to TD-TKA. Further investigation into the specific indications for these technology-assisted TKAs is warranted.
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Artroplastia do Joelho , Embolia Pulmonar , Procedimentos Cirúrgicos Robóticos , Humanos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Analgésicos Opioides/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Computadores , Embolia Pulmonar/complicaçõesRESUMO
BACKGROUND: Periprosthetic joint injection (PJI) is a rare, but life-altering complication of total joint arthroplasty (TJA). Though intrawound vancomycin powder (IVP) has been studied in other orthopedic subspecialties, its efficacy and safety in TJA has not been established. METHODS: PubMed and MEDLINE databases were used to identify studies utilizing IVP in primary and revision total hip (THA) and knee arthroplasty (TKA). Postoperative PJI data were pooled using random effect models with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). Studies were weighted by the inverse variance of their effect estimates. RESULTS: Overall, 16 of the 1871 studies identified were pooled for final analysis, yielding 33,731 patients totally. Of these, 17 164 received IVP. In aggregate, patients who received IVP had a decreased rate of PJI (OR 0.46, P < .05). Separately, TKA and THA patients who received IVP had lower rates of PJI (OR 0.41, P < .05 and OR 0.45, P < .05, respectively). Aggregate analysis of primary TKA and THA patients also revealed a decreased PJI rate (OR 0.44, P < .05). Pooled revision TKA and THA patients had a similar decrease in PJI rates (OR 0.30, P < .05). Although no publication bias was appreciated, these findings are limited by the low-quality evidence available. CONCLUSION: While IVP may reduce the risk of PJI in primary and revision TJA, its widespread use cannot be recommended until higher-quality data, such as that obtained from randomized control trials, are available. This study underscores the continued need for more rigorous studies before general adoption of this practice by arthroplasty surgeons.
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Artroplastia de Quadril , Artroplastia do Joelho , Infecções Relacionadas à Prótese , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Humanos , Razão de Chances , Estudos Prospectivos , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , VancomicinaRESUMO
INTRODUCTION: Magnetic sphincter augmentation (MSA) is a safe and effective treatment for patients with gastroesophageal reflux disease (GERD). MSA was initially indicated for patients with GERD and concomitant hiatal hernias < 3 cm. However, excellent short- and intermediate-term outcomes following MSA and hiatal hernia repair in patients with hiatal hernias ≥ 3 cm have been reported. The purpose of this study is to assess long-term outcomes for this patient population. METHODS AND PROCEDURES: A retrospective review was performed of patients with GERD and hiatal hernias ≥ 3 cm who underwent MSA and hiatal hernia repair. Patients were treated at two tertiary medical centers between May 2009 and December 2016. Follow up included annual video esophagram, upper endoscopy, or both. Outcomes included pre- and post-operative GERD health-related quality of life (GERD-HRQL) scores, length and regression of Barrett's esophagus, resolution of esophagitis, need for endoscopic dilations or implant removal, and clinically significant hiatal hernia recurrence (> 2 cm) on videoesophagram or endoscopy. RESULTS: Seventy-nine patients (53% female) with a median age of 65.56 (58.42-69.80) years were included. Median follow up was 2.98 (interquartile range 1.90-3.32) years. Median DeMeester scores decreased from 42.45 (29.12-60.73) to 9.10 (3.05-24.30) (p < 0.001). Severity of esophagitis (e.g. LA class C to class B) significantly improved (p < 0.01). Forty percent of patients with Barrett's esophagus experienced regression (p < 0.01). Median GERD-HRQL scores improved from 21 to 2. Five (6.3%) hiatal hernia recurrences occurred, and 1 required re-operation. Age, body mass index, size of the initial hiatal hernia, and sex had no significant effect on whether a patient developed a recurrence. CONCLUSIONS: Magnetic sphincter augmentation in conjunction with large hiatal hernia repairs for patients with GERD achieves excellent long-term radiographic and clinical results, and a low overall need for reoperation, without the need for mesh.
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Hérnia Hiatal , Laparoscopia , Idoso , Esfíncter Esofágico Inferior/cirurgia , Feminino , Hérnia Hiatal/cirurgia , Herniorrafia , Humanos , Fenômenos Magnéticos , Masculino , Recidiva Local de Neoplasia , Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: As the volume of technology-assisted total hip arthroplasty (THA) increases, there is a need to characterise the outcomes of robotic-assisted (RA) and computer-navigated (CN) THA. The goal of this study was to assess outcomes and opioid consumption following CN-THA and RA-THA compared to conventionally-instrumented (CON) THA. METHODS: The Premier Database was queried for all patients who underwent primary, elective THA from 2015-2020. Patients were divided into 3 groups: CN, RA, or CON-THA. Yearly usage trends were assessed. Univariate and multivariate analyses were performed to assess the 90-day risk of postoperative complications. Opioid consumption was reported in morphine milligram equivalents (MME) for postoperative days (POD) 0 and 1. RESULTS: Overall, 474,707 elective THAs were identified (95.7% CON, 2.1% CN, 2.2% RA. After accounting for confounders, CN-THA patients were at decreased risk for periprosthetic joint infection (PJI) (aOR: 0.55, p < 0.001) and dislocation (aOR 0.45, p < 0.001), but increased risk for blood transfusion (aOR 1.97, <0.001) compared to CON-THA. RA-THA patients were at decreased risk of dislocation (aOR:0.66, p < 0.001) but increased risk for transfusion (aOR 1.20, p < 0.001), prosthesis breakage (aOR 3.88, p < 0.001), and periprosthetic fracture (aOR 1.72, p < 0.001). Opioid consumption for CN-THA patients was lower on POD1 and lower for RA-THA patients POD0 and 2 compared to CON-THA. DISCUSSION: CN-THA was associated with reduced rates of PJI and dislocation, but increased rates of blood transfusion while RA-THA was associated with decreased rates of dislocation, but increased rates of blood transfusion, prosthesis complications, and periprosthetic fracture compared to CON-THA. Technology-assisted THA was associated with lower postoperative opioid consumption.
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BACKGROUND: Lumbar spinal pathology is known to affect outcomes following total hip arthroplasty (THA). However, the effect of hip osteoarthritis (OA) on outcomes following lumbar fusion has not been well studied. The purpose of this study was to determine the association between hip OA and spinal reoperation following lumbar spinal fusion. METHODS: The 5% Medicare Part B claims database was queried for all patients who underwent primary elective lumbar fusion from 2005 to 2019. Patients were divided into 2 groups: those who underwent elective THA within 1 year after primary lumbar fusion, indicating that they had severe hip OA at the time of lumbar fusion, and those who underwent lumbar fusion with no diagnosed hip OA and no THA during the study period. Exclusion criteria included THA as a result of trauma, revision THA or primary THA in the 5-year period before primary lumbar fusion, <65 years of age, and no enrollment in the database for 5 years before and 1 year after primary lumbar fusion. The primary outcome was spinal reoperation within 1, 3, and 5 years. Multivariable Cox regression was performed with age, sex, diabetes, heart disease, obesity, smoking status, osteoporosis, number of levels fused, use of posterior instrumentation, use of an interbody device, use of bone graft, and surgical approach as covariates. RESULTS: Overall, 1,123 patients (63.4% female; 91.3% White; mean age, 76.8 ± 4.1 years) were included in the hip OA group and 8,893 patients (56.2% female; 91.3% White; mean age, 74.8 ± 4.9 years) were included in the control group. After multivariable analysis, patients with severe hip OA had significantly greater rates of revision surgery at 3 years (odds ratio [OR], 1.61; p < 0.001) and 5 years (OR, 1.87; p < 0.001) after the index lumbar fusion. CONCLUSIONS: Patients with severe hip OA at the time of primary lumbar fusion had a significantly increased risk of spinal reoperation at 3 and 5 years postoperatively. These data provide further evidence to support performing THA prior to lumbar fusion in the unsettled debate regarding which surgery should be prioritized for patients with simultaneous degenerative diseases of the hip and lumbar spine. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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INTRODUCTION: Venous thromboembolism (VTE) remains a dangerous complication after total hip arthroplasty (THA), despite advances in chemoprophylactic measures. This study aimed to identify risk factors of developing pulmonary embolism (PE) and deep vein thrombosis (DVT) after THA using a modern cohort of patients reflecting contemporary practices. METHODS: The Premier Healthcare Database was queried for primary, elective THAs from January 1st, 2015, to December 31st, 2021. Patients who developed PE or DVT within 90 days of THA were compared with patients who did not develop any postoperative VTE. Differences in patient demographics, comorbidities, hospital factors, perioperative medications, chemoprophylactic agents, and allogeneic blood transfusion were compared between cohorts. Multivariable logistic regression models were used to identify independent risk factors of PE and DVT. In total, 544,298 THAs were identified, of which 1,129 (0.21%) developed a PE and 1,799 (0.33%) developed a DVT. RESULTS: Patients diagnosed with a PE had significantly higher rates of in-hospital death (2.6% vs 0.1%, P < 0.001) compared with those without a PE. Age (adjusted odds ratio: 1.02 per year, 95% confidence interval [CI]: 1.01 to 1.03) and Black race (aOR: 1.52, 95% CI: 1.24 to 1.87) were associated with an increased risk of PE. Comorbidities associated with increased risk of PE included chronic pulmonary disease (aOR: 1.58, 95% CI: 1.36 to 1.84), pulmonary hypertension (aOR: 2.06, 95% CI: 1.39 to 3.04), and history of VTE (aOR: 2.38, 95% CI: 1.98 to 2.86). Allogeneic blood transfusion (aOR: 2.40, 95% CI: 1.88 to 3.06) was also associated with an increased risk of PE while dexamethasone utilization was associated with a reduced risk (aOR: 0.83, 95% CI: 0.73 to 0.95). DISCUSSION: Increasing age; Black race; allogeneic blood transfusion; and comorbidities, including chronic pulmonary disease, pulmonary hypertension, and history of VTE, were independent risk factors of PE after THA. Given the increased mortality associated with PE, patients should be carefully evaluated for these factors and managed with an appropriate chemoprophylactic regimen.
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Artroplastia de Quadril , Complicações Pós-Operatórias , Embolia Pulmonar , Trombose Venosa , Humanos , Embolia Pulmonar/etiologia , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/prevenção & controle , Artroplastia de Quadril/efeitos adversos , Fatores de Risco , Feminino , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Pessoa de Meia-Idade , Idoso , Trombose Venosa/etiologia , Trombose Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/prevenção & controle , Mortalidade Hospitalar , Fatores EtáriosRESUMO
Background: This study aims to compare indications, patient characteristics, hospital factors, and complication rates between total hip arthroplasty (THA) patients aged 30 years or younger and those older than 30 years using a large national database. Methods: The Premier Healthcare Database was utilized to identify primary THA patients from 2015 to 2021 who were aged ≤30 or >30 years. Patient demographics, hospital factors, and primary indications were compared for each cohort. Rates of complications and readmissions were assessed for each cohort by primary indication. Differences were assessed through univariate analysis. Results: Overall, 539,173 primary THA patients were identified (age ≤30: 1849; >30: 537,234). Compared to the >30 cohort, the ≤30 cohort was more likely to be male (56.5% vs 44.9%, P < .001) and non-White (34.0% vs 14.2%, P < .001). The most common indications for THA in the ≤30 cohort were osteonecrosis (49.3%), osteoarthritis (17.8%), and congenital hip deformities (16.0%), and in the >30 cohort, they were osteoarthritis (77.0%), other arthritis (11.3%), and osteonecrosis (5.4%). Patients aged ≤30 years had lower rates of respiratory failure (0.16% vs 0.57%, P < .001), acute renal failure (0.32% vs 1.72%, P < .001), and urinary tract infection (0.38% vs 1.11%, P = .003) than those aged >30 years, but higher rates of wound dehiscence (0.59% vs 0.29%, P = .015) and transfusion (3.68% vs 2.21%, P < .001). There were no differences in 90-day readmission rates (P = .811) or 90-day in-hospital death (P = .173) between cohorts. Conclusions: Younger patients undergoing THA differed significantly in indication, patient characteristics, and hospital factors compared to the older population on univariate analysis. Despite differences in indications, the cohorts did not differ markedly with regard to complication rates in this study.
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Background: Inpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) practices were dramatically affected in the United States in 2020 as elective surgeries were paused in response to the COVID-19 pandemic. This study sought to provide an updated estimate of inpatient total joint arthroplasty (TJA) case volumes in the United States in 2020. Methods: A retrospective cohort study was performed by identifying all adult patients who underwent primary, elective TJA from January 1st, 2017 to December 31st, 2020, using the National Inpatient Sample. Monthly and annual case volumes were reported with descriptive statistics. Baseline case volumes were established by taking the average number of monthly cases performed in 2017, 2018, and 2019. These monthly averages were compared to 2020 values. Results: From 2017 to 2019, the average case volume was 1,056,669 cases per year (41.0% THA, 59.0% TKA) and 88,055 cases per month. In 2020, 535,441 cases were identified (45.4% THA, 54.6% TKA), corresponding to a 49.3% reduction from the 2017-2019 annual average. Monthly cases decreased to 4515 in April during the "first wave" of COVID-19, corresponding to a 94.8% decrease from prior years. In June, cases rebounded to 55,520 before decreasing again in July to 50,100 during the "second wave" of COVID-19. During the "third wave," COVID-19 cases decreased month-over-month from October through December (56.5% decrease). Conclusions: This updated estimate identified a 49.3% decrease in inpatient TJA cases in 2020 compared to prior years. This is similar to the 46.5-47.7% decrease in case volume previously reported.
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Tranexamic acid (TXA) effectively reduces blood loss and transfusion risk during total joint arthroplasty. Additionally, intraoperative irrigation with various antiseptic solutions is often utilized for the management and prevention of surgical site infection. However, interactions between various antiseptic solutions and TXA have not been investigated. The purpose of this in vitro study is to evaluate the stability of TXA in the presence of common orthopedic antiseptic solutions. Five antiseptic solutions-0.1% chlorhexidine (CHX) gluconate, 10% povidone-iodine (BTD), 0.5% sodium hypochlorite (Dakin's), 3% hydrogen peroxide (H2 O2 ), and 1.5% H2 O2 -and a 0.9% normal saline (NS) control were obtained. A stock 100 mg/ml TXA solution was diluted in each antiseptic solution to a concentration of 10.0 mg/ml to generate reference standard and stability samples. TXA stability in each solution was measured using high performance liquid chromatography at t = 0 and t = 120 min and reported as mean percent of theoretical concentration (MPT) with associated relative standard deviation (RSD). All experiments were performed in triplicate at room temperature. At t = 0 min, TXA remained stable when mixed with 0.9% NS, 0.1% CHX, 10% BTD, 3% H2 O2 , and 1.5% H2 O2 (MPT range: 102.0%-105.0%, RSD range: 0.80%-2.92%). Only 0.5% Dakin's led to significant degradation of TXA at t = 0 min (MPT: 14.3%, RSD:1.28%). At t = 120 min, TXA stability persisted for all compounds except Dakin's 0.5% (MPT: 18.4%, RSD: 28.7%). TXA efficacy may be significantly diminished when 0.5% Dakin's is used as an intraoperative irrigation solution. CHX, BTD, and H2 O2 do not degrade TXA.
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Anti-Infecciosos Locais , Antifibrinolíticos , Ácido Tranexâmico , Humanos , Povidona-Iodo , Peróxido de Hidrogênio , Perda Sanguínea CirúrgicaRESUMO
Postoperative spinopelvic changes are associated with increased dislocation risk following total hip arthroplasty (THA). The aim of this study was to identify preoperative patient and radiographic factors associated with high-risk postoperative spinopelvic parameters. A retrospective review of consecutive THA patients who received preoperative and postoperative sitting and standing lateral lumbar spine-hip radiographs with minimum radiographic and clinical follow-up of 10 months was performed. Patient demographics were recorded and preoperative standing and sitting sacral slope (SS), anteinclination, pelvic femoral angle (PFA), and combined sagittal index (CSI) were measured. High-risk patients were defined by decreased spinopelvic motion (∆SS from sitting to standing of >10°), increased hip motion (∆PFA from sitting to standing of >10°), or decreased CSI of >10° at final follow-up compared with preoperative measurements. Univariate and multivariate regression analyses were used to identify preoperative demographic and radiographic factors associated with these high-risk categories. One hundred and fifty-three patients were included with an average age of 62 years, average body mass index of 27.8 kg/m2 , and average follow-up of 16.2 months. At 1-year follow-up, 43 (28.1%) patients demonstrated a decreased ∆SS > 10° and 67 (43.7%) patients demonstrated an increased ∆PFA > 10° compared with preoperative values. Sitting CSI decreased by >10° in 17 (11.1%) patients. Preoperative increased sitting PFA (adjusted odds ratio [aOR] 1.057, p < 0.001) and decreased preoperative hip motion (∆PFA) were associated with decreased sitting CSI of >10° at 10-month follow-up. Increased spinopelvic motion (∆SS) and decreased hip motion (∆PFA) preoperatively are associated with postoperative radiographic changes that be associated with increased dislocation risk.
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Artroplastia de Quadril , Luxações Articulares , Humanos , Pessoa de Meia-Idade , Artroplastia de Quadril/efeitos adversos , Pelve/cirurgia , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Sacro/cirurgia , Estudos Retrospectivos , Fatores de RiscoRESUMO
Background: Arthroplasty surgeons use the change in sacral slope (ΔSS) from sitting to standing as a measure of spinal motion. The relationship between ΔSS and the change in lumbar lordosis (ΔLL), an established spinal motion measure, has not been well studied. This study aims to determine the correlation between ΔSS and ΔLL. Methods: Consecutive patients presenting to a spine clinic from 2020 to 2021 at a single institution were retrospectively studied. Standing and sitting lateral radiographs were measured for SS and LL. Patients were divided using ΔSS and ΔLL into stiff (0°-9°), normal (10°-30°), or hypermobile (>30°) category. Patients with a ΔSS-determined normal or hypermobile spine but a ΔLL-determined stiff spine were compared to the rest of the cohort. Results: Overall, 100 patients were included. Of these patients, 47% had the same classification when looking at ΔSS and ΔLL, whereas 53% had conflicting classifications. Twenty percent of patients had a ΔSS-determined normal or hypermobile spine but ΔLL-determined stiff spine. The correlation between ΔSS and ΔLL was 0.510 (P < .001). When isolating patients who underwent lumbar fusion, the correlation between ΔSS and ΔLL was 0.345 (P < .001). Conclusions: ΔSS has a moderate correlation with ΔLL in patients presenting for evaluation of their lumbar spine but low correlation in patients with lumbar fusion. In our cohort, 20% of patients had a ΔSS-determined normal or hypermobile spine but a ΔLL-determined stiff spine, representing a potential high-risk dislocation cohort not captured by ΔSS alone. Arthroplasty surgeons should revisit classifying spinal motion based solely on ΔSS.
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Background: Duloxetine is a Food and Drug Administration-approved selective norepinephrine reuptake inhibitor for treating depression, anxiety, fibromyalgia, and neuropathic and chronic musculoskeletal pain. This meta-analysis aims to evaluate the efficacy of duloxetine in reducing pain and postoperative opioid use following lower extremity total joint arthroplasty. Methods: A literature search was performed, identifying randomized controlled trials investigating duloxetine for pain management after total hip and total knee arthroplasty. Data from the visual analog scale (VAS) for pain during movement and at rest were extracted for postoperative days (PODs) 1, 3, 7, and 14, as well as postoperative week 6 and postoperative month 3. Opioid use data were obtained at 24, 48 and 72 hours. All data were analyzed using inverse variance with random effects and presented as weighted mean difference. Results: Eight unique studies were identified and included, 7 of which were analyzed quantitatively. Duloxetine decreased postoperative opioid consumption at 48 and 72 hours. For VAS for pain at rest, significantly reduced pain was reported by duloxetine-treated patients at POD 3, POD 7, and postoperative week 6. For VAS for pain at movement, significantly reduced pain was reported by duloxetine-treated patients at POD1, POD 3, POD 7, POD 14, postoperative week 6, and postoperative month 3. Conclusions: Duloxetine appears to decrease postoperative pain and opioid consumption following total joint arthroplasty. However, definitive conclusions are limited by small sample size and study heterogeneity. While there is a need for follow-up studies to determine the optimal dose, duration, and patient population, strong preliminary data provide robust support for future large-scale efficacy studies.
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INTRODUCTION: Dexamethasone is increasingly used after total joint arthroplasty (TJA) to reduce postoperative nausea and vomiting (PONV) and pain. The primary aim of this study was to examine the relationship between perioperative intravenous (IV) dexamethasone and length of stay (LOS) in patients undergoing primary, elective TJA. METHODS: All patients who underwent TJA from 2015 to 2020 and received perioperative IV dexamethasone were queried from the Premier Healthcare Database. The cohort of patients who received dexamethasone was randomly truncated by a power of 10 and matched in a 1:2 ratio based on age and sex to patients who did not receive dexamethasone. Patient characteristics, hospital factors, comorbidities, 90-day postoperative complications, LOS, and postoperative morphine milligram equivalents were recorded for each cohort. Univariate and multivariate analyses were conducted to assess differences. RESULTS: Overall, 190,974 matched patients were included, 63,658 (33.3%) of whom received dexamethasone and 127,316 (66.7%) did not. The dexamethasone cohort was composed of fewer patients with uncomplicated diabetes (11.6% vs. 17.5%, P < 0.001). Patients who received dexamethasone had significantly decreased mean LOS compared with patients who did not receive dexamethasone (1.66 vs. 2.03 days, P < 0.001). After controlling for confounding variables, dexamethasone was associated with significantly lower risk of pulmonary embolism (adjusted odds ratio [aOR]: 0.74, 95% CI: 0.61 to 0.90, P = 0.003), deep vein thrombosis (aOR: 0.78, 95% CI: 0.68 to 0.89, P < 0.001), PONV (aOR: 0.75, 95% CI: 0.70 to 0.80, P < 0.001), acute kidney injury (aOR: 0.82, 95% CI: 0.75 to 0.89, P < 0.001), and urinary tract infection (aOR: 0.77, 95% CI: 0.70 to 0.80, P < 0.001). In aggregate, dexamethasone was associated with similar postoperative opioid utilization between cohorts ( P = 0.061). CONCLUSION: Perioperative dexamethasone was associated with reduced LOS and decreased postoperative complications including PONV, pulmonary embolism, deep vein thrombosis, acute kidney injury, and urinary tract infection after TJA. Although perioperative dexamethasone was not associated with notable reductions in postoperative opioid utilization, this study supports the use of dexamethasone to decrease LOS through multifactorial mechanisms beyond decreased pain.