Variation in Inflammatory Biomarkers Among Demographic Groups Significantly Affects Their Accuracy in Diagnosing Periprosthetic Joint Infection.

BACKGROUND: Diagnosis of periprosthetic joint infection (PJI) is a multistep process that involves performing various tests including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The latter two tests, despite being used at all times for PJI diagnosis, are known to be nonspecific and substantially affected by demographic characteristics, including age, gender, race, and body mass index. It is unknown how these variations affect the diagnostic utility of serological markers for PJI. METHODS: Institutional databases were queried to identify patients undergoing revision arthroplasty between 2010 and 2018, in whom preoperative serum ESR and CRP was performed. Patient demographics were collected, and patients were cross-referenced with an internal database to determine their infection status. Analyses were performed to determine how ESR and CRP varied with respect to demographic factors, including age, gender, race, and infection status. Given that patient infection status was known at the time of revision, conclusions were drawn about the effect of these variations in inflammatory markers on the diagnostic utility of ESR and CRP. RESULTS: The value of ESR increased by age was higher in females and African American race. No significant differences were observed in the value of CRP among the demographic factors, although a slight positive trend was observed with respect to age. The variation in inflammatory markers significantly affected the sensitivity, specificity, and accuracy of ESR and CRP for PJI diagnosis. CONCLUSION: Understanding how the accuracy of diagnostic tests varies with respect to demographic factors can help physicians avoid subjecting patients to unnecessary additional testing and reach more accurate diagnoses of PJI.

Tranexamic Acid Reduces the Rate of Periprosthetic Joint Infection After Aseptic Revision Arthroplasty.

BACKGROUND: Revision total joint arthroplasty (TJA) has a higher rate of periprosthetic joint infection (PJI) compared with primary TJA, possibly as the result of increased allogeneic blood transfusion. Tranexamic acid (TXA) is gaining popularity in revision TJA to minimize blood loss and the need for transfusion; however, its effect on PJI reduction has yet to be investigated. The hypothesis of this study was that the administration of TXA during revision arthroplasty is protective against subsequent PJI. METHODS: A prospectively maintained institutional database was used to identify patients who underwent revision TJA for aseptic failure from 2009 to 2018 and had a minimum follow-up of 90 days. Patients who developed PJI following revision arthroplasty were identified. All patients with PJI met Musculoskeletal Infection Society (MSIS) criteria. A multivariate analysis was performed to identify variables independently associated with PJI after aseptic revision TJA. RESULTS: Overall, 1,731 patients who underwent aseptic revision were identified; of these patients, 83 (4.8%) developed PJI. Patients who received TXA had significantly lower rates (p = 0.029) of PJI postoperatively at 3.30% compared with those who did not receive TXA at 5.73%. After controlling for relevant confounding variables, TXA remained a significant independent factor that protected against PJI (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.23 to 0.90]; p = 0.030). Female sex was also identified as a significant independent factor that protected against PJI (OR, 0.52 [95% CI, 0.30 to 0.88]; p = 0.016). However, preoperative anemia was independently associated with an increased risk of subsequent PJI (OR, 2.37 [95% CI, 1.34 to 4.16]; p = 0.003). CONCLUSIONS: Based on this study conducted at a single institution, the use of TXA during aseptic revision arthroplasty was independently associated with a reduced risk of subsequent acute PJI after adjusting for multiple patient characteristics and surgical factors. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment Outcomes in Patients Undergoing Surgical Treatment for Arthritis of the Distal Radioulnar Joint.

Objective Surgical treatment options for distal radioulnar joint (DRUJ) arthritis include distal ulnar resection (DUR), DRUJ arthrodesis, and ulnar head replacement. Ulnar convergence leading to persistent pain and clicking is a relatively common complication of complete DUR and DRUJ arthrodesis with distal ulnar segment resection (DRUJA). This led to the development of the distal ulna hemiresection (DUHR) and distal ulnar stump stabilization techniques to reduce the risk of this complication. Patients may experience incomplete relief of pain and limited range of motion (ROM) with these procedures. We hypothesized that there would be no differences in outcomes between the treatment groups, but patients undergoing DUHR, tendon interposition, or distal ulnar stump stabilization would be at lower risk of complications. Methods Records were retrospectively reviewed for 121 patients undergoing DRUJ procedures between 2000 and 2018 at a single institution to collect patient demographics, surgical details, preoperative diagnosis, and outcomes including complications, revision procedures, ROM, pain, and swelling. Patients were grouped for analysis by procedure type: DUR (Darrach procedure), DUHR (Bowers procedure), and DRUJA (Sauve-Kapandji procedure). Continuous variables were compared using an analysis of variance test and categorical variables using the Freeman-Halton extension of the Fisher's exact test. A multivariate logistic regression analysis was performed to identify significant predictors of outcomes. Results Seventy-three patients underwent a DUR procedure, while 33 patients underwent a DUHR procedure and 11 underwent a DRUJA procedure. Mean follow-up was 70.6 months. Patients undergoing DRUJA were significantly younger than those undergoing DUR or DUHR procedure (42.4 vs. 60.0 vs. 62.1, p < 0.001). No significant differences between groups were demonstrated in measured outcomes. Posttraumatic arthritis was the most common preoperative diagnosis (43.4%). Persistent pain was the most common negative outcome (25.6%) followed by limited ROM (19.7%). Five patients (4.3%) suffered postoperative complications, most common being rupture of extensor tendons. Five patients (4.3%) underwent revision procedures. Body mass index (BMI) was a significant predictor of persistent pain (odds ratio = 1.09, p = 0.031). Conclusion The results of our study suggest that outcomes are equivalent between the three distinct treatment groups. Despite the potential benefits, hemiresection, tendon interposition, and distal stump stabilization had no significant effect on outcomes in this study. More than a quarter (25.6%) of patients undergoing DRUJ procedures experience persistent pain postoperatively, while one-fifth (19.7%) experienced limited ROM. Patients with higher BMI are at a significantly greater risk of experiencing persistent postoperative pain. Level of Evidence This is a Level III, retrospective comparative study.

BMI Does Not Affect Complications or Patient Reported Outcomes After Lumbar Decompression Surgery.

STUDY DESIGN: This is a retrospective comparative review. OBJECTIVE: The objective of this study was to identify the influence of body mass index (BMI) on postsurgical complications and patient reported outcomes measures (PROMs) following lumbar decompression surgery. SUMMARY OF BACKGROUND DATA: Current literature does not accurately identify the impact of BMI on postsurgical complications or outcomes. MATERIALS AND METHODS: Records from a single-center, academic hospital were used to identify patients undergoing 1 to 3-level lumbar decompression surgery. Patients under 18 years of age, those undergoing surgery for infection, trauma, tumor, or revision, and those with <1-year follow-up were excluded. Patients were split into groups based on preoperative BMI: class I: BMI <25.0 kg/m; class II: BMI 25.0-29.9 kg/m; class III: BMI 30.0-34.9 kg/m; and class IV: BMI >35.0 kg/m. Absolute PROM scores, the recovery ratio and the percent of patients achieving minimum clinically important difference between groups were compared and a multiple linear regression analysis was performed. RESULTS: A total of 195 patients were included with 34 (17.4%) patients in group I, 80 (41.0%) in group II, 49 (25.1%) in group III, and 32 (16.5%) in group IV. Average age was 60.0 (58.0, 62.0) years and average follow-up was 13.0 (12.6, 13.4) months. All patients improved significantly within each group, except for class III and class IV patients, who did not demonstrate significant improvements in terms of Mental Component Score (MCS-12) scores (P=0.546 and 0.702, respectively). There were no significant differences between BMI groups for baseline or postoperative PROM values, recovery ratio, or the percent of patients reaching minimum clinically important difference. Multiple linear regression analysis revealed that BMI was not a significant predictor for change in outcomes for any measure. The 30-day readmission rate was 6.2% and overall revision rate at final follow-up was 5.1%, with no significant differences between groups. CONCLUSION: This study's results suggest that BMI may not significantly affect complications or patient outcomes at 1-year in those undergoing lumbar decompression surgery. LEVEL OF EVIDENCE: Level III.