The sensitivity and specificity of using the McGill pain subscale for diagnosing neuropathic and non-neuropathic chronic pain in the total joint arthroplasty population.

BACKGROUND: The purpose of this study was to describe the diagnostic performance of the Neuropathic Pain Subscale of McGill [NP-MPQ (SF-2)] and the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire in differentiating people with neuropathic chronic pain post total joint arthroplasty (TJA). METHODS: This study was a survey of a cohort of individuals who had undergone primary, unilateral total knee, or hip joint arthroplasty. The questionnaires were administered by mail. The time interval from operation to the completion of the postal survey varied from 1.5 to 3.5 years post-surgery. Receiver Operating Characteristic (ROC) analysis was used to assess the overall diagnostic power and determine the optimal threshold value of the NP-MPQ (SF-2) in identification of neuropathic pain. RESULTS: S-LANSS identified 19 subjects (28%) as having neuropathic pain (NP), while NP-MPQ (SF-2) subscale identified 29 (43%). When using the S-LANSS as the reference standard, a Receiver Operating Characteristic (ROC) analysis for NP-MPQ (SF-2) had an area under the curve of 0.89 (95% CI: 0.82, 0.97); a cut off score of 0.91 NP-MPQ (SF-2) maximized sensitivity (89.5%) and specificity (75.0%). Correlation between the measures was moderate (r = 0.56; 95% CI: 0.40, 0.68). CONCLUSION: These finding suggest some conceptual overlap but some variability in diagnosis of NP which may relate to scale-tapping into different dimensions of the pain experience, or the different scoring metrics.

Routine use of antibiotic-laden bone cement in total knee arthroplasty is a cost-effective practice in the single-payer healthcare system.

PURPOSE: The purpose of this study was to determine the cost-effectiveness of antibiotic-laden bone cement (ALBC) in primary total knee arthroplasty (TKA) from the perspective of a single-payer healthcare system. METHODS: A cost-utility analysis (CUA) was performed over a 2-year time horizon comparing primary TKA with either ALBC or regular bone cement (RBC) from the perspective of the single-payer Canadian healthcare system. All costs were in 2020 Canadian dollars. Health utilities were in the form of quality-adjusted life years (QALYs). Model inputs for cost, utilities and probabilities were derived from the literature as well as regional and national databases. One-way deterministic sensitivity analysis was performed. RESULTS: Primary TKA with ALBC was found to be more cost-effective compared to primary TKA with RBC with an incremental cost-effectiveness ratio (ICER) of -3,637.79 CAD/QALY. The use of routine ALBC remained cost-effective even with cost increases of up to 50% per bag of ALBC. TKA with ALBC was no longer cost-effective if the rate of PJI following this practice increased 52%, or the rate of PJI following the use of RBC decreased 27%. CONCLUSIONS: The routine use of ALBC in TKA is a cost-effective practice in the single-payer Canadian healthcare system. This remains to be the case even with a 50% increase in the cost of ALBC. Policy makers and hospital administrators of single-payer healthcare systems can leverage this model to inform their local funding policies. Future prospective reviews and randomized controlled trials from the perspective of various healthcare models can further shed light on this issue. LEVEL OF EVIDENCE: III.

Risk factors for recurrence of periprosthetic joint infection following operative management: a cohort study with average 5-year follow-up.

Background: Periprosthetic joint infections (PJIs) remain challenging to eradicate even after surgical management, which in most cases involves either debridement, antibiotics and implant retention (DAIR) or single- or two-staged revision. The purpose of this study is to determine predictors of PJI recurrence after operative management for PJI, and to determine differences in recurrence-free survival between DAIR and staged revision. Methods: This is a retrospective analysis of prospectively collected data of revision hip and knee arthroplasty surgeries due to PJI between 2011 and 2018 at an academic hospital. Any patient undergoing revision surgery for PJI was included except if the index surgery information was unknown. The primary outcome was confirmed PJI recurrence. Multivariable logistic regression analysis was utilized to determine the relationship between the predictor variables and outcome variable. Log rank testing was used to compare recurrence-free survival between DAIR and staged revision. Results: A total of 89 patients (91 joints) underwent revision surgery due to PJI. Younger age and presence of a sinus tract were statistically significant for risk of PJI recurrence. A multivariable logistic regression model including both variables was significant for predicting recurrence of PJI (χ2=10.2, P=0.006). Survival was not significantly different between patients who underwent DAIR versus a staged revision. Conclusions: Younger patients and those with a chronic sinus tract are at significantly higher risk of recurrent PJI. This study also demonstrated that PJI can be successfully managed in the majority of cases with DAIR or staged revision.

Prevalence of Persistent Pain of the Neuropathic Subtype after Total Hip or Knee Arthroplasty.

Purpose: This study aimed to (1) estimate the point prevalence of persistent postoperative pain (PPP) identified using the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) after unilateral primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) using data from a registry of total joint arthroplasty (TJA) patients in Ontario, (2) estimate the effect of PPP on function, (3) estimate the prevalence of neuropathic pain (NP) features among patients with persistent pain, (4) determine participant characteristics in order to estimate the potential predictors of NP classification among individuals with persistent pain after TJA, (5) estimate the extent to which the estimates of prevalence depended on the measure used (i.e., S-LANSS vs. NP sub-scale of the Short-Form McGill Pain Questionnaire 2 [NP-SF-MPQ-2]), and (6) determine the difference in characteristics between those with and without NP. Method: This was a prospective follow-up study of a historical cohort of individuals who had undergone primary unilateral THA or TKA. Persistent pain was operationally defined as pain rated as 3 or more (out of 5) on the Oxford Pain Questionnaire 6 months or 1 year after THA or TKA. Participants with persistent pain completed the S-LANSS and the NP-SF-MPQ-2. Results: A total of 1,143 participants were identified as having had a TJA, 148 (13%) of whom had PPP. A total of 67 recipients completed the S-LANSS and the NP-SF-MPQ-2. Of these, an NP subtype was identified among 19 (28%; those with an S-LANSS score ≥ 12) to 29 (43%; those with an NP-SF-MPQ-2 score ≥ 0.91). Individuals with persistent pain of the NP subtype after TJA reported severe pain intensity and higher disability levels 1.5-3.5 years after surgery compared with those without persistent pain. Conclusions: A significant proportion of patients have persistent pain post-unilateral THA or TKA.

Objectif : 1) évaluer la prévalence ponctuelle de la douleur postopératoire persistante indéterminée au moyen de l'évaluation autoadministrée des signes et symptômes de la douleur neuropathique de Leeds (S-LANSS) après une intervention unilatérale primaire sous forme d'arthroplastie totale de la hanche (ATH) ou d'une arthroplastie totale du genou (ATG), à partir d'un registre de patients ayant subi une arthroplastie par prothèse totale (APT) en Ontario; 2) évaluer l'effet de cette douleur sur la fonction; 3) évaluer la prévalence des manifestations de douleur neuropathique (DN) chez les patients souffrant des douleurs persistantes; 4) déterminer les caractéristiques des participants pour évaluer les prédicteurs potentiels de DN chez les personnes qui souffrent de douleur persistante après une APT; 5) évaluer dans quelle mesure les évaluations de prévalence dépendaient de la mesure utilisée (S-LANSS ou sous-échelle de DN du questionnaire court de la douleur de McGill 2 [SF-MPQ-2 ou NP-SF-MPQ-2]); 6) déterminer la différence entre les caractéristiques de ceux qui souffrent de DN et de ceux qui n'en souffrent pas. Méthodologie : étude prospective de suivi auprès d'une cohorte historique de personnes ayant subi une ATH ou un ATG unilatérale primaire. La douleur persistante était définie sur le plan opérationnel comme une douleur d'au moins 3 sur 5 au questionnaire de la douleur d'Oxford, de six mois à un an après l'ATH ou l'ATG. Les participants souffrant de douleur persistante ont rempli l'évaluation S-LANSS et la sous-échelle NP-SF-MPQ-2. Résultats : il a été établi que 148 des 1 143 participants ayant subi une APT ont souffert de douleur postopératoire persistante (13 %). Au total, 67 ont rempli l'évaluation S-LANSS et la sous-échelle NP-SF-MPQ-2. De ce nombre, 19 (28 %; S-LANSS ≥ 12) à 29 (43 %; NP-SF-MPQ-2 ≥ 0,91) personnes ont présenté un sous-type de DN. Les personnes souffrant de douleur persistante du sous-type des DN après une APT ont déclaré une douleur d'intensité marquée et un taux d'incapacité élevé de 1,5 à 3,5 ans après l'opération par rapport à ceux qui ne souffraient pas de douleur persistante. Conclusion : une forte proportion de patients souffre de douleurs persistantes après une ATH ou une ATG unilatérale.

The Changing Characteristics of Arthroplasty Patients: A Retrospective Cohort Study.

BACKGROUND: Total joint arthroplasty (TJA) is among the most common operations performed worldwide, with global volumes on the rise. It is important to understand if the characteristics of this patient population are changing over time for resource allocation and surgical planning. The purpose of this study is to examine how this patient population has changed between 2003 and 2017. METHODS: A retrospective review of a prospective TJA database was conducted. Age, gender, body mass index, comorbidities, American Society of Anesthesiologists class, responsible diagnoses, and comorbidities were compared over 5-year intervals between 2003 and 2017. All patients undergoing primary, elective TJA were included. RESULTS: Overall, 17,138 TJAs were included. Mean body mass index increased over the study period for total hip arthroplasty (THA; 29.4-30.4 kg/m2, P < .0001) and total knee arthroplasty (TKA; 32.0-3.1 kg/m2, P < .0001) patients. THA patients were significantly younger in more recent years (68.0-66.8 years old, P = .0026); this trend was not observed among TKA patients. Over the study period, a significantly higher proportion of patients were American Society of Anesthesiologists class III/IV for THA (50.5%-72.3%) and TKA (57.5%-80.7%) (P < .00001). Prevalence of common comorbidities did not change significantly. CONCLUSION: The key findings of this retrospective analysis of a large prospective database are that patients undergoing TJA are becoming younger and more obese. It is unclear whether patients are becoming more medically complex. These trends paint a concerning picture of a population that is increasingly complex, and may require a greater allocation of resources in the future. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Preoperative prediction of Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study.

BACKGROUND: Diagnostic criteria for Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS) have been defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, leads to blood transfusion, or is judged to be the direct cause of death. Preoperative prediction guides for BIMS can facilitate informed consent and planning of perioperative care. METHODS: In a prospective cohort study of 16 079 participants aged ≥45 yr having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011, 17.3% (2782) experienced BIMS. An electronic risk calculator for BIMS was developed and internally validated by logistic regression with bootstrapping, and further simplified to a risk index. Decision curve analysis assessed the potential utility of each prediction guide compared with a strategy of identifying risk of BIMS based on preoperative haemoglobin <120 g L-1. RESULTS: With information about the type of surgery, preoperative haemoglobin, age, sex, functional status, kidney function, history of high-risk coronary artery disease, and active cancer, the risk calculator accurately predicted BIMS (bias-corrected C-statistic, 0.84; 95% confidence interval, 0.837-0.852). A simplified index based on preoperative haemoglobin <120 g L-1, open surgery, and high-risk surgery also predicted BIMS, but less accurately (C-statistic, 0.787; 95% confidence interval, 0.779-0.796). Both prediction guides could improve decision making compared with knowledge of haemoglobin <120 g L-1 alone. CONCLUSIONS: BIMS, defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, leads to blood transfusion, or that is judged to be the direct cause of death, can be predicted by a simple risk index before surgery. CLINICAL TRIAL REGISTRATION: NCT00512109.

Randomized Controlled Trial of Sensor-Guided Knee Balancing Compared to Standard Balancing Technique in Total Knee Arthroplasty.

BACKGROUND: Despite advances in total knee arthroplasty (TKA) technology, up to 1 in 5 patients remain dissatisfied. This study sought to evaluate if sensor-guided knee balancing improves postoperative clinical outcomes and patient satisfaction compared to a conventional gap balancing technique. METHODS: We undertook a prospective double-blind randomized controlled trial of patients presenting for elective primary TKA to determine a difference in TKA soft tissue balance between a standard gap balancing (tensiometer) approach compared to augmenting the balance using a sensor-guided device. The sensor-guided experimental group had adjustments made to achieve a balanced knee to within 15 pounds of intercompartmental pressure difference. Secondary outcomes included differences in clinical outcome scores at 6 months and 1 year postoperative, including the Oxford Knee Score and Knee Society Score and patient satisfaction. RESULTS: The sample comprised of 152 patients, 76 controls and 76 experimental sensor-guided cases. Within the control group, 36% (27/76) of knees were unbalanced based on an average coronal plane intercompartmental difference >15 pounds, compared to only 5.3% (4/76) within the experimental group (P < .0001). There were no significant differences in 1-year postoperative flexion, Knee Society Score, or Oxford scores. Overall, TKA patient satisfaction at 1 year was comparable, with 81% of controls and experimental cases reporting they were very satisfied (P = .992). CONCLUSION: Despite the use of the sensor-guided knee balancer device to provide additional quantitative feedback in the evaluation of the soft tissue envelope during TKA, we were unable to demonstrate improved clinical outcomes or patient satisfaction compared to our conventional gap balancing technique.

Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study establishing diagnostic criteria and prognostic importance.

BACKGROUND: We aimed to establish diagnostic criteria for bleeding independently associated with mortality after noncardiac surgery (BIMS) defined as bleeding during or within 30 days after noncardiac surgery that is independently associated with mortality within 30 days of surgery, and to estimate the proportion of 30-day postoperative mortality potentially attributable to BIMS. METHODS: This was a prospective cohort study of participants ≥45 yr old having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011. Cox proportional hazards models evaluated the adjusted relationship between candidate diagnostic criteria for BIMS and all-cause mortality within 30 days of surgery. RESULTS: Of 16 079 participants, 2.0% (315) died and 36.1% (5810) met predefined screening criteria for bleeding. Based on independent association with 30-day mortality, BIMS was identified as bleeding leading to a postoperative haemoglobin <70 g L-1, transfusion of ≥1 unit of red blood cells, or that was judged to be the cause of death. Bleeding independently associated with mortality after noncardiac surgery occurred in 17.3% of patients (2782). Death occurred in 5.8% of patients with BIMS (161/2782), 1.3% (39/3028) who met bleeding screening criteria but not BIMS criteria, and 1.1% (115/10 269) without bleeding. BIMS was associated with mortality (adjusted hazard ratio: 1.87; 95% confidence interval: 1.42-2.47). We estimated the proportion of 30-day postoperative deaths potentially attributable to BIMS to be 20.1-31.9%. CONCLUSIONS: Bleeding independently associated with mortality after noncardiac surgery (BIMS), defined as bleeding that leads to a postoperative haemoglobin <70 g L-1, blood transfusion, or that is judged to be the cause of death, is common and may account for a quarter of deaths after noncardiac surgery. CLINICAL TRIAL REGISTRATION: NCT00512109.

Association Between Myocardial Injury and Cardiovascular Outcomes of Orthopaedic Surgery: A Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Substudy.

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia. METHODS: We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom. RESULTS: Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%). CONCLUSIONS: One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Screening for and decolonization of Staphylococcus aureus carriers before total joint replacement is associated with lower S aureus prosthetic joint infection rates.

BACKGROUND: Prosthetic joint infections (PJI) can be devastating postoperative complications after total joint replacement (TJR). The role of decolonization of Staphylococcus aureus carriers prior to surgery still remains unclear, and the most recent guidelines do not state a formal recommendation for such strategy. Our purpose was to seek further evidence supporting preoperative screening and S aureus decolonization in patients undergoing TJR. METHODS: This was a quasiexperimental quality improvement study comparing a 5-year baseline of deep and organ-space PJIs (2005- 2010) to a 1-year intervention period (May 2015 to July 2016). The intervention consisted of nasal and throat screening for S aureus preoperatively and decolonization of carriers over 5 days prior to surgery. RESULTS: Prior to the intervention, we identified 42 deep and/or organ-space PJIs in 8,505 patients undergoing TJR (0.5%). S aureus was the causal microorganism in 28 of 42 (66.6%) cases. During the intervention, 22.5% (424 of 1,883) of patients were S aureus carriers. The PJI rate was similar overall (0.4%, 7 of 1,883; odds ratio, 0.75; 95% confidence interval, 0.34-1.67; P = .58), but there was a significant reduction in S aureus PJI to only 1 case during the intervention (odds ratio, 0.15; 95% confidence interval, 0.004-0.94; P = .039). CONCLUSIONS: Active screening for S aureus and decolonization of carriers prior to TJR was associated with a reduction in PJI due to S aureus, but no changes in overall PJI rates were observed.

Nuisance Symptoms in Total Joint Arthroplasty: Prevalence and Impact on Patient Satisfaction.

BACKGROUND: While hip and knee total joint arthroplasty (TJA) patients experience marked improvement in pain relief and function, many patients experience nuisance symptoms, which may cause discomfort and dissatisfaction. METHODS: A prospective survey study to determine type and prevalence of hip/knee TJA nuisance symptoms and impact on patient satisfaction at 1 year postoperative was conducted. The survey determined occurrence of common nuisance symptoms (eg, localized pain, swelling, instability, stiffness) and impact on overall satisfaction rated on a 10-point visual analog scale (VAS). Survey responses were analyzed using descriptive statistics. RESULTS: The sample comprised 545 TJA patients who completed the survey: 335 knees (61%) and 210 hips (39%). Among knees, the most commonly reported nuisance symptoms and associated impact on satisfaction included difficulty kneeling (78.2%; VAS, 4.3; SD, 3.3), limited ability to run/jump (71.6%; VAS, 3.3; SD, 3.3), and numbness around incision (46.3%; VAS, 3.8; SD, 3.3). Overall, 94% of knee patients experienced at least 1 nuisance symptom at 1 year, reporting mean satisfaction of 9/10 (SD, 1.7). Among hips, the most commonly reported nuisance symptoms and associated impact on satisfaction were limited ability to run/jump (68.6%; VAS, 3.4; SD, 3.4), thigh muscle pain (44.8%; VAS, 3; SD, 2.7), and limp when walking (37.6%; VAS, 4.1; SD, 3.2). Overall, 88% of hip patients experienced at least 1 self-reported nuisance symptom at 1 year, reporting mean satisfaction of 8.9/10 (SD, 1.7). CONCLUSION: Nuisance symptoms after hip/knee TJA are very common. Despite the high prevalence, impact on overall satisfaction is minimal and patient satisfaction remains high. Careful preoperative counseling regarding prevalence is prudent and will help establish realistic expectations following TJA.

Rationale and design of the HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) Trial: a protocol for an international randomised controlled trial evaluating early surgery for hip fracture patients.

INTRODUCTION: Annually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%-10% at 30 days and 10%-20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial-HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications. METHODS AND ANALYSIS: HIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients. ETHICS AND DISSEMINATION: All centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources. TRIAL REGISTRATION NUMBER: NCT02027896; Pre-results.

Profound Trunnion Wear Resulting in Femoral Head-Neck Dissociation in Total Hip Arthroplasty.

We describe a case of aseptic failure with profound femoral stem trunnion wear and femoral head dissociation nine years after initial primary total hip arthroplasty (THA) with the Stryker Accolade total hip arthroplasty system. Current guidelines for postoperative care and follow-up after THAs as potential intervention points for early detection of prosthetic joint failure are also reviewed.

Lower Extremity Arterial Calcification on Preoperative Knee Radiographs as a Predictor of Postoperative Cardiovascular Events After Primary Total Knee Arthroplasty.

BACKGROUND: A cross-sectional study of total knee arthroplasty (TKA) patients was conducted to determine the association of lower-extremity arterial calcification (LEAC) with acute perioperative cardiovascular events (CVEs). METHODS: Regression modeling was used to examine the association of radiographic presence of LEAC and acute myocardial infarction (MI), perioperative CVE, 30-day CVE readmit, and 30-day and 1-year mortality. RESULTS: Of 900 TKA patients, LEAC was identified in 21.1%. Of LEAC cases, 1.6% had an acute MI vs 0.1% of non-LEAC cases (P = .031). Perioperative CVE rate was 5.8% for LEAC vs 1.5% for non-LEAC (P = .002). Having LEAC was identified as a significant risk factor for a perioperative CVE (odds ratio [OR] 2.83; 95% confidence interval [CI] 1.09-7.35). Because of limited number of acute MI events, absence of 30-day CVE readmit, 30-day mortality, and few 1-year mortality events, computing OR for these was not possible. Likewise, because of small number of events (n = 3), estimates for the odds of LEAC cases having an acute MI are less reliable, yielding extremely large random errors (OR 11.37; 95% CI 0.09-597.93) and must be interpreted with caution. The OR for 1-year mortality was 1.88 (95% CI 0.17-13.20), but again with large random errors. CONCLUSION: Our study shows that LEAC around the knee is associated with an increased risk of having a perioperative CVE. Crude radiographic detection of LEAC around the knee has the potential to improve risk stratification for TKA patients by informing the surgeon of the need for further preoperative cardiac workup.

Bleeding impacting mortality after noncardiac surgery: a protocol to establish diagnostic criteria, estimate prognostic importance, and develop and validate a prediction guide in an international prospective cohort study.

INTRODUCTION: Various definitions of bleeding have been used in perioperative studies without systematic assessment of the diagnostic criteria for their independent association with outcomes important to patients. Our proposed definition of bleeding impacting mortality after noncardiac surgery (BIMS) is bleeding that is independently associated with death during or within 30 days after noncardiac surgery. We describe our analysis plan to sequentially 1) establish the diagnostic criteria for BIMS, 2) estimate the independent contribution of BIMS to 30-day mortality and 3) develop and internally validate a clinical prediction guide to estimate patient-specific risk of BIMS. METHODS: In the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) study, we prospectively collected bleeding data for 16 079 patients aged 45 years or more who had noncardiac inpatient surgery between 2007 and 2011 at 12 centres in 8 countries across 5 continents. We will include bleeding features independently associated with 30-day mortality in the diagnostic criteria for BIMS. Candidate features will include the need for reoperation due to bleeding, the number of units of erythrocytes transfused, the lowest postoperative hemoglobin concentration, and the absolute and relative decrements in hemoglobin concentration from the preoperative value. We will then estimate the incidence of BIMS and its independent association with 30-day mortality. Last, we will construct and internally validate a clinical prediction guide for BIMS. INTERPRETATION: This study will address an important gap in our knowledge about perioperative bleeding, with implications for the 200 million patients who undergo noncardiac surgery globally every year. Trial registration: ClinicalTrials.gov, no NCT00512109.

Preoperative Predictors of Pain Catastrophizing, Anxiety, and Depression in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: The relationship between pain catastrophizing and emotional disorders including anxiety and depression in osteoarthritic patients undergoing total joint arthroplasty (TJA) is an emerging area of study. The purpose of this study was to examine the association of these factors with preoperative patient characteristics. METHODS: A prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale (PCS) and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Preoperative measures included visual analog pain scale (VAS), Harris Hip and Knee Society scores, Oxford Score, and Kellgren-Lawrence grade. Logistic and quantile regression were used to assess the relationship between preoperative characteristics and PCS or HADS, adjusting for covariate effects. RESULTS: We recruited 463 TJA patients. VAS pain (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.04-1.45) and Oxford (OR 1.13; 95% CI 1.07-1.20) were significant predictors for PCS and its subdomains excluding rumination. Oxford was the only significant predictor for abnormal HADS-A (OR 1.10; 95% CI 1.04-1.17). VAS pain (OR 1.27; 95% CI 1.02-1.52) and Oxford (OR 1.09; 95% CI 1.01-1.17) were significant predictors for abnormal HADS-D. The quantile regression showed similar patterns of association, with female gender, younger age, and higher ASA also associated with HADS-A. CONCLUSION: The most important predictor of catastrophizing, anxiety and/or depression in TJA patients is preoperative pain and poor subjective function. At-risk patients include those with increased pain and generally good clinical function, as well as younger women with significant comorbidities. Such patients should be identified and targeted psychological therapy implemented preoperatively to optimize coping strategies and adaptive behavior to mitigate potential for inferior TJA outcomes including pain and patient dissatisfaction.

Outcomes After Hip Fracture Surgery Compared With Elective Total Hip Replacement.

IMPORTANCE: Patients undergoing surgery for a hip fracture have a higher risk of mortality and major complications compared with patients undergoing an elective total hip replacement (THR) operation. The effect of older age and comorbidities associated with hip fracture on this increased perioperative risk is unknown. OBJECTIVE: To determine if there was a difference in hospital mortality among patients who underwent hip fracture surgery relative to an elective THR, after adjustment for age, sex, and preoperative comorbidities. DESIGN, SETTING, AND PARTICIPANTS: Using the French National Hospital Discharge Database from January 2010 to December 2013, patients older than 45 years undergoing hip surgery at French hospitals were included. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), codes were used to determine patients' comorbidities and complications after surgery. A population matched for age, sex, and preoperative comorbidities of patients who underwent elective THR or hip fracture surgery was created using a multivariable logistic model and a greedy matching algorithm with a 1:1 ratio. EXPOSURE: Hip fracture. MAIN OUTCOMES AND MEASURES: Postoperative in-hospital mortality. RESULTS: A total of 690,995 eligible patients were included from 864 centers in France. Patients undergoing elective THR surgery (n = 371,191) were younger, more commonly men, and had less comorbidity compared with patients undergoing hip fracture surgery. Following hip fracture surgery (n = 319,804), 10,931 patients (3.42%) died before hospital discharge and 669 patients (0.18%) died after elective THR. Multivariable analysis of the matched populations (n = 234,314) demonstrated a higher risk of mortality (1.82% for hip fracture surgery vs 0.31% for elective THR; absolute risk increase, 1.51% [95% CI, 1.46%-1.55%]; relative risk [RR], 5.88 [95% CI, 5.26-6.58]; P < .001) and of major postoperative complications (5.88% for hip fracture surgery vs 2.34% for elective THR; absolute risk increase, 3.54% [95% CI, 3.50%-3.59%]; RR, 2.50 [95% CI, 2.40-2.62]; P < .001) among patients undergoing hip fracture surgery. CONCLUSIONS AND RELEVANCE: In a large cohort of French patients, hip fracture surgery compared with elective THR was associated with a higher risk of in-hospital mortality after adjustment for age, sex, and measured comorbidities. Further studies are needed to define the causes for these differences.

Not all total joint replacement patients are created equal: preoperative factors and length of stay in hospital.

BACKGROUND: We conducted a cross-sectional study of primary total joint replacement (TJR) patients to determine predictors for prolonged length of stay (LOS) in hospital to identify patient characteristics that may inform resource allocation, accounting for patient complexity. METHODS: Preoperative demographics, medical comorbidities and acute hospital LOS from a consecutive series of primary TJR patients from an academic arthroplasty centre were abstracted. We categorized patients as LOS of 3 or fewer days, 4 days, or 5 or more days to align results with varying LOS benchmarks. To identify predictors for LOS, we used a generalized logistic regression model fitted on an LOS ternary outcome, using LOS of 3 or fewer days as a reference category. RESULTS: The sample included 1459 patients: 61.7% total knee and 38.3% total hip. Male sex was predictive of an LOS of 3 or fewer days (4 d: odds ratio [OR] 0.48, 95% confidence interval [CI] 0.364-0.631; ≥ 5 d: OR 0.57, 95% CI 0.435-0.758), as was current smoking status (4 d: OR 0.425, 95% CI 0.274-0.659; ≥ 5 d: OR 0.489, 95% CI 0.314-0.762). Strong predictors of prolonged LOS included total hip versus total knee arthroplasty, age 75 years or older, American Society of Anesthesiologists classification of 3 and 4 and number of cardiovascular comorbidities. CONCLUSION: Not all patients undergoing TJR are equal. The goal should be individual patient-focused care rather than a predetermined LOS that is not achievable for all patients. Hospital resource planning must account for patient complexity when planning future bed management.

CONTEXTE: Nous avons réalisé une étude transversale auprès de patients soumis à une chirurgie pour prothèse articulaire totale (PAT) afin de déterminer les facteurs prédictifs d'une durée du séjour hospitalier (DSH) prolongée (en établissement de soins de courte durée) et de dégager les caractéristiques des patients qui permettraient d'orienter l'allocation des ressources en tenant compte de la complexité des cas. MÉTHODES: Nous avons extrait les données démographiques préopératoires, les comorbidités médicales et la DSH pour une série de cas consécutifs de PAT primaire dans un centre d'arthroplastie universitaire. Nous avons classé les patients par catégorie de DSH, soit 3 jours ou moins, 4 jours, ou 5 jours et plus, de manière à répartir les résultats selon les diverses cibles de DSH. Pour dégager les facteurs prédictifs de la DSH, nous avons utilisé un modèle de régression logistique généralisé intégré à un paramètre ternaire de DSH, en utilisant la DSH de 3 jours ou moins comme catégorie de référence. RÉSULTANTS: L'échantillon regroupait 1459 patients : 61,7 % recevant une prothèse totale du genou (PTG) et 38,3 % recevant une prothèse totale de la hanche (PTH). Le fait d'être de sexe masculin était prédictif d'une DSH de 3 jours ou moins (4 j : rapport des cotes [RC] 0,48, intervalle de confiance [IC] à 95 % 0,364­0,631; ≥ 5 j : RC 0,57, IC à 95 % 0,435­0,758), tout comme le statut à l'égard du tabagisme (4 j : RC 0,425, IC à 95 % 0,274­0,659; ≥ 5 j : RC 0,489, IC à 95 % 0,314­0,762). Les facteurs prédictifs fiables d'une DSH prolongée incluaient la PTH c. PTG, l'âge de 75 ans ou plus, une classification de 3 ou 4 selon l'American Society of Anesthesiologists et le nombre de comorbidités cardiovasculaires. CONCLUSION: Les patients soumis à une PAT ne s'équivalent pas tous. L'objectif devrait être d'administrer des soins centrés sur le patient plutôt que sur une DSH prédéterminée qui, dans les faits, ne s'applique pas à tous patients. La planification des ressources hospitalières devra à l'avenir tenir compte de la complexité des cas dans la planification de la gestion des lits.

Antibiotic prophylaxis for dental procedures at risk of causing bacteremia among post-total joint arthroplasty patients: a survey of Canadian orthopaedic surgeons and dental surgeons.

To elicit current practice and attitudes toward use of antibiotic-prophylaxis among TJA patients prior to dental procedures, a cross-sectional survey of practicing Canadian orthopaedic (OS) and dental surgeons (DS) was undertaken. Of respondents, 77% of OS and 71% of DS routinely prescribe antibiotic-prophylaxis, but while 63% of OS advocate lifelong use, only 22% of DS choose to do so (P<0.0001). Both groups nonetheless recognize the importance of treatment within 2-years post-TJA as per AAOS/ADA guidelines. However, greater duration of practice pointed to potential inadequacy of these guidelines based on reported experience with late-hematogenous infection post-TJA. While discrepancies in attitude toward antibiotic-prophylaxis between surgeon groups remain, both groups agreed that the evidence to support decision making regarding antibiotic-prophylaxis for TJA patients undergoing dental procedures remains inadequate.

Total joint arthroplasty readmission rates and reasons for 30-day hospital readmission.

Given institutional pressures to reduce hospital length of stay (LOS) we hypothesized that "failure to cope" would be a significant factor for readmission following total joint arthroplasty (TJA). A retrospective review of 4288 TJA patients was conducted to determine readmission rates and reasons for readmit within 30 days of discharge. Ninety-five patients (2.2%; 95% CI: 1.8%-2.7%) were readmitted. Leading diagnoses were surgical site infection (23.2%) and cardiovascular event (16.8%). Of readmits 5.3% (5/95) were readmitted for failure to cope, representing 0.1% of the sample. In multivariate analysis, increased age was a significant predictor of readmission (OR = 0.974, 95% CI 0.952-0.997). Contrary to our hypothesis failure to cope was not a leading diagnosis for readmission; concerns remain that early discharge may however correlate with increased readmit rates.