Cefazolin vs Second-line Antibiotics for Surgical Site Infection Prevention After Total Joint Arthroplasty Among Patients With a Beta-lactam Allergy.

Background: Cefazolin is a first-line agent for prevention of surgical site infections (SSIs) after total joint arthroplasty. Patients labeled allergic to beta-lactam antibiotics frequently receive clindamycin or vancomycin perioperatively due to the perceived risk of a hypersensitivity reaction after exposure to cefazolin. Methods: This single-system retrospective review included patients labeled allergic to penicillin or cephalosporin antibiotics who underwent a primary total hip and/or knee arthroplasty between January 2020 and July 2021. A detailed chart review was performed to compare the frequency of SSI within 90 days of surgery and interoperative hypersensitivity reactions (HSRs) between patients receiving cefazolin and patients receiving clindamycin and/or vancomycin. Results: A total of 1128 hip and/or knee arthroplasties from 1047 patients were included in the analysis (cefazolin n = 809, clindamycin/vancomycin n = 319). More patients in the clindamycin and/or vancomycin group had a history of cephalosporin allergy and allergic reactions with immediate symptoms. There were fewer SSIs in the cefazolin group compared with the clindamycin and/or vancomycin group (0.9% vs 3.8%; P < .001) including fewer prosthetic joint infections (0.1% vs 1.9%). The frequency of interoperative HSRs was not different between groups (cefazolin = 0.2% vs clindamycin/vancomycin = 1.3%; P = .06). Conclusions: The use of cefazolin as a perioperative antibiotic for infection prophylaxis in total joint arthroplasty in patients labeled beta-lactam allergic is associated with decreased postoperative SSI without an increase in interoperative HSR.

Neuromuscular electrical stimulation preserves muscle strength early after total knee arthroplasty: Effects on muscle fiber size.

Loss of quadriceps strength after total knee arthroplasty (TKA) is most pronounced acutely but persists long-term, negatively impacting physical function in daily activities. Neuromuscular electrical stimulation (NMES) early after surgery is an effective adjuvant to standard of care rehabilitation (SOC) for attenuating strength loss following TKA, but the mechanisms whereby NMES maintains strength are unclear. This work aimed to determine the effects of early NMES on quadriceps strength and skeletal muscle fiber size 2 weeks after TKA compared to SOC. Patients scheduled for primary, unilateral TKA were enrolled and randomized into SOC (n = 9) or NMES plus SOC (n = 10) groups. NMES was started within 48 h of TKA, with 45-min sessions twice a day for 2 weeks. Isometric quadriceps strength was assessed preoperatively and 2 weeks following TKA. Vastus lateralis muscle biopsies of the involved leg were performed at the same time points and immunohistochemistry conducted to assess muscle fiber cross-sectional area and distinguish fiber types. Groups did not differ in age, body mass index, sex distribution, or preoperative strength. Both groups got weaker postoperatively, but the NMES group had higher normalized strength. After 2 weeks, the group receiving NMES and SOC had significantly greater MHC IIA and MHC IIA/IIX fiber size compared to SOC alone, with no group differences in MHC I fiber size. These results suggest that NMES mitigates early muscle weakness following TKA, in part, via effects on fast-twitch, type II muscle fiber size. This investigation advances our understanding of how adjuvant, early postoperative NMES aids muscle strength recovery.

Benefits of direct patient discharge to outpatient physical therapy after total knee arthroplasty.

Purpose: To investigate the effectiveness of home health physical therapy followed by outpatient physical therapy as compared to patients discharged directly to outpatient physical therapy in improving functional performance, strength/activation and residual knee pain outcomes among patients who received a total knee arthroplasty.Materials and methods: A secondary analysis of longitudinal data in which patients with total knee arthroplasty underwent home health physical therapy or were discharged directly to outpatient physical therapy. Main outcome measures included the stair climb test, timed up and go, 6-min walk test, quadriceps and hamstring strength, quadriceps activation and residual knee pain.Results: Patients referred to home health physical therapy prior to outpatient physical therapy demonstrated significantly greater declines in stair climb test (10.3; 95% CI [6.5, 14.1]; t = 5.41; p < 0.0001), timed up and go (2.0; 95% CI [1.0, 3.0]; t = 4.10; p < 0.0001), 6-min walk (53.8; 95% CI [29.4, 78.2]; t = 4.35; p < 0.0001), quadriceps strength (21.7%; 95% CI [19.3%, 24.9%]; t = 2.53; p = 0.01), hamstring strength (44.7%; 95% CI [43.4%, 45.7%], t = 3.17; p = 0.002) and higher residual knee pain (0.53; 95% CI [0.04, 1.03]; t = 2.17; p = 0.03) 1 month after total knee arthroplasty compared to those referred directly to outpatient physical therapy.Conclusions: These findings suggest that patients discharged directly to outpatient physical therapy had a more rapid recovery 1 month after total knee arthroplasty. Additional research is needed to investigate the potential causal relation between care pathways and clinical outcomes following total knee arthroplasty.Implications for rehabilitationTotal knee arthroplasty, typically performed to alleviate end-stage knee osteoarthritis, is the most commonly performed elective surgery in the United States.Despite improvement in pain, objective measurements of functional performance and strength often remain at preoperative levels one year after total knee arthroplasty.Patients discharged directly to higher intensity outpatient physical therapy have a more rapid recovery after total knee arthroplasty compared with those patients who received two weeks of home health prior to undergoing outpatient physical therapy.

Metal-on-metal total hip arthroplasty adverse local tissue reaction with intermittent unilateral vascular claudication.

Osteolysis and adverse local soft-tissue reactions are well-documented complications of metal-on-metal prosthetic implants. This case report describes a 68-year-old man who presented to the clinic 10 years after staged bilateral metal-on-metal total hip arthroplasty revisions with the primary complaint of groin pain, intermittent right leg pain, swelling, and muscle cramping while ambulating that resolved with rest. A complete workup was negative for deep venous thrombosis and infection. His symptoms were found to be secondary to an iliopsoas bursal mass externally compressing the femoral vasculature resulting in vascular claudication. He was treated with revision arthroplasty and drainage of the fluid within the iliopsoas bursal effusion with symptomatic resolution.

The Role of Complete Posterior Cruciate Ligament Release in Flexion Gap Balancing for Total Knee Arthroplasty.

BACKGROUND: The sequence of posterior cruciate ligament (PCL) release in posterior-substituting designs, when performing gap balancing in total knee arthroplasty (TKA), is variable. We hypothesize that early complete PCL release during knee exposure will change the flexion balance to result in a uniform medial-lateral flexion gap symmetry at the time of implant placement. METHODS: Ten cadaveric knees were prepared for TKA using standard medial parapatellar approach. Medial and lateral flexion gaps were measured in the conditions of intact, partial (50%) resection, and full resection of PCL. Measurements were performed with both surgical navigation and a caliper. Flexion gap distances were reported for medial and lateral compartments in the 3 PCL conditions. RESULTS: Medial flexion gap increased after only complete release of the PCL (mean 3.94-5.05 mm). The lateral flexion gap increased as well (mean 4.17-4.67 mm). Complete PCL release resulted in a statistically significant increase in medial flexion gap compared to intact (P = .013) and partially released (P = .012) specimens. No significant differences were noted in lateral flexion gap change. Notable change in medial versus lateral gap (flexion gap symmetry) relationship occurred after just partial PCL release (P = .018). CONCLUSION: Among the 3 PCL states, changes in flexion gap distance were most conspicuous in the medial compartment. This suggests gap balancing performed with incomplete PCL release will not accurately reflect gap distance after eventual PCL removal, thus supporting the hypothesis. It is recommended that the PCL should be released to the fullest extent possible before ligament tensioning for femoral component rotation in posterior-stabilized TKA.

Correction to: The relationship of pelvic incidence to post-operative total hip arthroplasty dislocation in patients with lumbar fusion.

The original publication of this paper contain an error. The author name "Alan S. McGee Jr" is incorrect for it should have been "Alan W. McGee Jr".

The relationship of pelvic incidence to post-operative total hip arthroplasty dislocation in patients with lumbar fusion.

PURPOSE: To determine if lumbar fusion increases the risk of dislocation following total hip arthroplasty (THA) via a posterior approach and to investigate anatomic variables associated with this increased risk. METHODS: Five-year retrospective review of THAs performed through a posterior approach identifying cases of post-operative dislocation. Patients were grouped into those with or without previous lumbar spine fusion. Lumbar fusion patients were then further analyzed in terms of cup position, pelvic incidence, sacral slope, and pelvic tilt to determine if there were specific variables associated with the increased risk of dislocation. RESULTS: Five hundred nine primary THAs in 460 patients (non-simultaneous bilateral THAs in 41 patients) met inclusion criteria with a dislocation rate of 5.5%. Thirty-one patients were identified as having prior lumbar fusions. The dislocation rate was significantly higher in fusion patients (29 vs 4%; p = 0.009) yielding a relative risk (RR) of dislocation of 4.77 (p = < 0.0001). Additionally, cup anteversion was significantly different between groups (26.8 vs 21.42; p = 0.009). Dislocators in the fusion group were also at greater risk of requiring subsequent revision (RR = 3.24; p = 0.003). Subgroup analysis of fusion patients revealed that dislocators had lower pelvic incidence and sacral slope compared to non-dislocators (45.2 vs 58.6 [p = 0.0029] and 26.3 vs 35.6 [p = 0.0384] respectively). CONCLUSIONS: Patients with lumbar fusion are at increased risk for post-operative dislocations requiring revision. Together, lower pelvic incidence and decreased sacral slope are associated with increased risk of dislocation in these patients.

Safety and efficacy of resistive polymer versus forced air warming in total joint surgery.

BACKGROUND: Forced-air warming is used as a mechanism to prevent hypothermia and adverse outcomes associated with hypothermia among patients undergoing surgery. Patient safety in healthcare includes the use of devices and technology that minimize potential adverse events to patients. The present study sought to compare the capabilities of patient warming between two different devices that use different mechanisms of warming: forced-air warming and non-air warming. METHODS: One hundred twenty patients undergoing total hip or total knee arthroplasty received patient warming via a forced warming device or non-air warming fabric conductive material. The project was part of a quality improvement initiative to identify warming devices effective in maintaining normothermic patient core temperatures during orthopedic surgery. RESULTS: Forced-air warming and non-air warming achieved similar results in maintaining the core temperature of patients undergoing total knee or hip arthroplasty. No adverse events were reported in either group. Operating room staff observed that the non-air warming device was less noisy and appreciated the disposable covers that could be changed after each surgical case. CONCLUSIONS: These findings demonstrate that hypothermia is achieved by both forced-air and non-forced air warming devices among total knee and hip arthroplasty patients. The potential for airflow disruption is present with the forced-air warming device and does not exist with the non-forced air device. The disruption of laminar airflow may be associated with surgical site infections. The disposable covers used to protect the device and patient have potential implications for surgical site infection. Quality improvement efforts aimed to enhance patient safety should include the implementation of healthcare equipment with the least known or suspected risk.

Centers for Medicare & Medicaid Services' Comprehensive Care for Joint Replacement: The Present and Future for Orthopedic Surgeons.

The primary aim of this article is to describe the structure and challenges of Medicare and Medicaid reimbursement for a total hip or knee arthroplasty within the context of the Comprehensive Care for Joint Replacement model. The secondary aims are to identify potential challenges for reimbursement and solutions to overcome challenges for the orthopedic surgeon, and to describe and compare the current and projected reimbursement structures for total arthroplasty procedures. Final decisions on reimbursement for total arthroplasty as outlined by the Centers for Medicare & Medicaid Services are reviewed. The impact of these decisions and the effect of the Centers for Medicare & Medicaid Services' payment structure on reimbursement for surgeons and organizations and the effect on patient care are highlighted. [Orthopedics. 2017; 40(2):77-80.].

Perioperative blood loss in total hip and knee arthroplasty: Outcomes associated with intravenous tranexamic acid use in an academic medical center.

OBJECTIVES: Clinical trials have reported decreased blood loss with the use of tranexamic acid during joint reconstruction. The purpose of this study was to assess the individual practice implications of tranexamic acid use in joint replacement surgery. METHODS: Health records of adults undergoing total knee arthroplasty and total hip arthroplasty over a 12-month period were retrospectively reviewed. The treatment group comprised patients who received intravenous tranexamic acid perioperatively. The control group comprised patients who did not receive tranexamic acid. RESULTS: Patients in the treatment group (n = 64) and the control group (n = 99) were well matched for demographics, orthopedic diagnosis, and comorbidities. In-hospital postsurgical mean decreases in hemoglobin concentrations were -4.05 g/dL and -4.94 g/dL in the treatment and control groups, respectively (p < 0.001). Postsurgical mean decreases in hematocrit levels were -11.2% and -14.2% in the treatment and control groups, respectively (p < 0.001). Three patients in the treatment group (5%) and 21 patients in the control group (21%) received red blood cell transfusions (p = 0.006). As compared to control, the relative risk of transfusion in the treatment group was 0.23 (95% confidence interval = 0.07-0.76) and the number needed to treat to avoid one transfusion was 7.0 (95% confidence interval = 3.8-14.4). No evidence of thromboembolism or other serious complications were observed in either group. CONCLUSIONS: In patients undergoing joint replacement surgery, perioperative administration of tranexamic acid was associated with diminished blood loss and lesser resource utilization.

Performance-Based Versus Self-Reported Outcomes Using the Hip Disability and Osteoarthritis Outcome Score After Total Hip Arthroplasty.

OBJECTIVE: The purpose of this study was to explore the relationship between patients' self-reported and performance-based function after total hip arthroplasty (THA). DESIGN: Twenty-three patients (age, 61.4 ± 8.3 yrs) undergoing primary THA for hip osteoarthritis participated. Self-reported function and recovery was measured using the Hip Disability and Osteoarthritis Outcome Score activities of daily living and pain subscales. Performance-based functional measures included the timed up and go test, the stair climbing test, and the 6-minute walk test. Outcome measures were assessed preoperatively and postoperatively at 1 and 6 mos. RESULTS: One month after THA, performance-based function declined compared with baseline as follows: timed up and go test, -22.1% ± 25.4%; stair climbing test, -58.5% ± 63.6%; and 6-minute walk test, -22.6% ± 31.7%. In contrast, self-reported function on the Hip Disability and Osteoarthritis Outcome Score Activities of Daily Living significantly improved 1 mo after THA compared with baseline: 40.8% ± 33.3%. One to 6 mos after THA, there were significant improvements in timed up and go test, stair climbing test, and 6-minute walk test, which paralleled improvements on the Hip Disability and Osteoarthritis Outcome Score subscales, although changes were not significantly correlated. CONCLUSION: The disparity between changes in Hip Disability and Osteoarthritis Outcome Scores and functional performance postoperatively suggests that patients may overestimate their functional capacity early after THA, likely in response to pain improvements over the same time period. Therefore, outcomes assessment after THA should include both self-report and performance-based functional measures.