Higher Annual Total Hip Arthroplasty Volume Decreases the Risk of Intraoperative Periprosthetic Femur Fractures.

BACKGROUND: Periprosthetic femur fracture (PFF) is a complication of total hip arthroplasty (THA). These occur intraoperatively or postoperatively, and documented risk factors of PFFs include women, age greater than 65 years, cementless stems, and inflammatory arthropathies. The aim of this retrospective cohort study was to assess the relationship of years of surgical experience and surgeon annual THA volume on intraoperative and postoperative PFFs. METHODS: Data were collected from a database query, and PFFs were identified as either intraoperative or postoperative. Intraoperative and postoperative PFFs were both compared to a control group of non-PFF patients. Years of surgical experience at the time of surgery and annual THA volume for the primary surgeon were calculated for all cases. Logistic regression analyses were used to calculate odds ratios for each of the surgeon variables when adjusted for patient demographics. RESULTS: Thirty-seven intraoperative and 108 postoperative PFFs were identified and compared to 7,629 controls. From regression analyses, high-volume surgeons (≥50 THA/year) had lower odds of intraoperative PFF (adjusted odds ratio (aOR) = 0.40, P = .020) but not postoperative PFF (aOR = 1.02, P = .921). Surgeon experience (≥15 years since board certification at the time of surgery), was not significantly related to either PFF outcomes. For patient factors, age ≥65 years (aOR = 2.30, P < .001) and women (aOR = 2.69, P < .001) were both significant predictors of postoperative PFFs only. CONCLUSION: Surgeons who performed 50 or more THAs per year had significantly fewer intraoperative PFFs than surgeons who did less than 50 THAs per year. Surgeon experience was not significantly related to PFFs.

The AAHKS Clinical Research Award: Oral Dexamethasone Following Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial.

BACKGROUND: Intravenous dexamethasone has been shown to reduce pain in total joint arthroplasty. This double-blind, randomized, placebo-controlled trial investigated the postoperative effects and safety of oral dexamethasone as a potential augment to multimodal pain management in outpatient knee arthroplasty. METHODS: The authors prospectively randomized 109 consecutive patients undergoing primary total knee arthroplasty. Patients assigned to Group A (57 patients) received 4 mg of dexamethasone by mouth twice per day starting postoperative day (POD) 1 for 4 days and those assigned to Group B received placebo capsules. All healthcare professionals and patients were blinded to group allocation. The primary outcome was defined as postoperative pain scores. Secondary outcomes included 90-day postoperative complications, nausea and vomiting, daily opioid usage, assistance for ambulation, difficulty sleeping, and early patient reported outcomes. Demographics were similar between groups. RESULTS: The patients who received dexamethasone had a statistically significant decrease in VAS scores when averaging POD 1 to 4 (P = .01). The average VAS scores among individual days were significantly lower with dexamethasone on POD 2, 3, and 4. While taking dexamethasone, morning and mid-day VAS scores were significantly lower. There was no difference between the groups with opioid use, nausea or vomiting, 90-day complications, ability to walk with/without assistance, difficulty sleeping, and early patient reported outcomes. CONCLUSION: This double-blind, randomized, placebo-controlled trial demonstrated that oral dexamethasone following primary total knee arthroplasty can reduce postoperative pain. This may be a beneficial option in ambulatory surgery where intravenous limitations exist, but larger series are needed to further evaluate the safety profile in this population.

Multiple Venous Thromboembolism Pharmacologic Agents Are Associated with an Increased Risk for Early Postoperative Complications following a Total Joint Arthroplasty.

The purpose of this study was to determine the effect that concurrent venous thromboembolism (VTE) medications had on early outcomes following primary total joint arthroplasty (TJA). 2653 total knee and hip arthroplasties were reviewed at a tertiary medical center. The study performed a multivariable comparison of outcomes in patients on 2 or more VTE medications, as well as a logistic regression on outcomes following each addition of a VTE medication postoperatively (number of VTE medications was 1-4). Controlling for gender, age, body mass index, and preoperative American Society of Anesthesiologists score throughout the analysis, patients who received 2 or more VTE prophylaxis medications had increased LOS (p < 0.001), transfusions (p < 0.001), emergency department visits (p=0.001), readmissions (p < 0.001), 90dPOE (p < 0.001), and PE (p < 0.001). Every additional postoperative VTE medication incrementally increased the risk for longer LOS (p < 0.001), transfusions (p < 0.001), 90dPOE (p < 0.001), deep vein thrombosis (p=0.049), PE (p < 0.001), emergency department visits (p=0.005), and readmission (p=0.010). Patients on multiple VTE medications following TJA demonstrate significantly poorer outcomes. The current study's findings caution the use of multiple VTE medications whenever possible immediately following a TJA.

Indwelling Urinary Catheter for Total Joint Arthroplasty Using Epidural Anesthesia.

BACKGROUND: The objective of this study was to evaluate if not placing an indwelling urinary catheter leads to a higher potential for adverse genitourinary (GU) issues after total joint arthroplasty (TJA) under epidural anesthesia. METHODS: Three hundred thirty-five consecutive patients who underwent primary TJA using epidural anesthesia were retrospectively reviewed. The initial 103 patients received a preoperative urinary catheter, which was maintained until the morning of postoperative day 1. The subsequent 232 patients did not receive a preoperative urinary catheter. Demographics, medical complications, GU complications, and length of stay were compared between groups. RESULTS: Compared between catheter and noncatheter groups, there were no differences in demographics including age, gender, or laterality of surgery. There was a difference in type of surgery (total knee arthroplasty vs total hip arthroplasty) (P = .008). There was no difference in American Society of Anesthesiologists score, but with a difference in body mass index (P = .01). There were no differences in GU complications among patients with benign prostatic hyperplasia or prostate cancer. However, among patients with a history of prostate disorders (benign prostatic hyperplasia or prostate cancer), urinary tract infection rate was higher in catheter group (P = .023). Postoperative GU complications were associated with increased median age in years and increased average length of stay in days. CONCLUSION: Patients undergoing TJA under epidural anesthesia demonstrate no increased risk of postoperative urological complications without the placement of preoperative indwelling urinary catheter. The routine use of preoperative catheters can be reconsidered for this mode of anesthesia. LEVEL OF EVIDENCE: Level II, retrospective comparative study.

Emergency Department Visit Within One Year Prior to Elective Total Joint Arthroplasty Is Predictive of Postoperative Return to Emergency Department Within 90 Days.

BACKGROUND: The Comprehensive Care for Joint Replacement Model, developed by Centers for Medicare and Medicaid Services, aims to improve the quality of joint replacement. Metrics including emergency room visit rates after primary total knee and total hip arthroplasty (TKA and THA) are of particular interest. The purpose of this study is to determine if preoperative emergency department (ED) visits are predictive of postoperative ED visits among patients undergoing elective THA or TKA. METHODS: In a retrospective analysis of 6996 patients who underwent elective primary arthroplasty (2453 hips, 4543 knees), we identified all patients who had an ED visit from up to 1 year prior to their surgical date to 90 days after. We assessed if preoperative visit frequency or temporality is predictive of a return to the ED visit within 90 days. RESULTS: TKA and THA patients with a single preoperative ED visit had an odds ratio of 1.9 and 2.0, respectively, of returning to the emergency room postoperatively (P < .001). Increasing preoperative visit frequency correlated with increasing odds ratios (1.9-16.7, P < .001). The proximity of the most recent preoperative visit prior to surgery had a positive trend toward a larger effect, but did not clearly demonstrate a dose-dependent effect. CONCLUSION: Presentation to the ED is common prior to total joint arthroplasty and is predictive of a postoperative visit within 90 days. Increasing preoperative visit frequency further increases a patient's risk of a postoperative visit within 90 days.

Topical vs Intravenous Tranexamic Acid in Primary Total Hip Arthroplasty: A Double-Blind, Randomized Controlled Trial.

BACKGROUND: Tranexamic acid (TXA) reduces perioperative blood loss in total hip arthroplasty (THA). METHODS: In our randomized control trial, 139 patients were enrolled and received 2 g of either topical or intravenous (IV) TXA. Preoperative and postoperative protocols were standardized. RESULTS: Calculated blood and Hgb loss were lower in the IV group (1195.0 ± 485.9 mL, 1442.7 ± 562.7 mL; P = .006), (160.3 [g] ± 63.8, 188.4 [g] ± 68.5; P = .014). There was a trend toward significance in transfusion reduction (11% [IV] vs 18% [topical]; P = .3). Both groups effectively reduced the transfusion rate. There was significant financial incentive for the use of TXA in THA with a savings of $314 per patient. CONCLUSIONS: IV and topical TXA are effective tools to reduce blood loss and transfusion costs in THA, and we recommend the IV form for ease of use.