Phase 1 study of the pharmacokinetics and clinical proof-of-concept activity of a biofilm-disrupting human monoclonal antibody in patients with chronic prosthetic joint infection of the knee or hip.

We report the results of a first-in-human phase 1 clinical study to evaluate TRL1068, a native human monoclonal antibody that disrupts bacterial biofilms with broad-spectrum activity against both Gram-positive and Gram-negative species. The study population consisted of patients with chronic periprosthetic joint infections (PJIs) of the knee or hip, including both monomicrobial and polymicrobial infections, that are highly resistant to antibiotics due to biofilm formation. TRL1068 was administered via a single pre-surgical intravenous infusion in three sequentially ascending dose groups (6, 15, and 30 mg/kg). Concomitant perioperative antibiotics were pathogen-targeted as prescribed by the treating physician. In this double-blinded study, 4 patients were randomized to receive placebo and 11 patients to receive TRL1068 on day 1, as well as targeted antibiotics for 7 days prior to the scheduled removal of the infected implant and placement of an antibiotic-eluting spacer as the first stage of the standard of care two-stage exchange arthroplasty. No adverse events attributable to TRL1068 were reported. TRL1068 serum half-life was 15-18 days. At day 8, the concentration in synovial fluid was approximately 60% of the blood level and thus at least 15-fold above the threshold for biofilm-disrupting activity in vitro. Explanted prostheses were sonicated to release adherent bacteria for culture, with elimination of the implant bacteria observed in 3 of the 11 patients who received TRL1068, which compares favorably to prior PJI treatments. None of the patients who received TRL1068 had a relapse of the original infection by the end of the study (day 169). CLINICAL TRIALS: This study is registered with ClinicalTrials.gov as NCT04763759.

Alignment in Total Knee Arthroplasty: Avoid Crossing Over From Varus to Valgus.

BACKGROUND: Ideal target limb alignment remains a debated topic in total knee arthroplasty (TKA). We aimed to determine the effect of limb alignment correction on patient-reported outcomes and knee range of motion (ROM) following TKA. METHODS: In this retrospective analysis, patients (N = 409) undergoing primary TKA at a single institution were studied. Using full leg-length radiographs, limb alignment was measured preoperatively and postoperatively. Patients were categorized by preoperative (Preop) alignment (varus > 0°; valgus < 0°). Preop varus patients were then divided as follows based on postoperative alignment: neutral (VAR-NEUT, 0°± 2), remaining in varus (VAR-rVAR, ≥3°), and cross-over to valgus (VAR-CO, ≤-3°). Similarly, Preop valgus patients were divided as follows for postoperative alignment: neutral (VAL-NEUT, 0°± 2), remaining in valgus (VAL-rVAL, ≤-3°), and cross-over to varus (VAL-CO, ≥3°). The Knee Injury and Osteoarthritis Outcome Score for Joint Replacement survey scores were collected at preoperatively as well as at 6 weeks, 3, 6, and 12 months postoperatively. Knee ROM was collected at 2 weeks, 6 to 12 weeks, and >6 months postoperatively. An analysis of variance repeated on time followed by a Bonferroni post hoc test was used to compare outcomes for the postoperative alignment subgroups. RESULTS: Preop Varus patients: Those in the VAR-CO group (overcorrected to -4.03° ± 1.95valgus) were observed to have lower Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores at 3, 6, and 12 months postoperatively compared to those in the NEUT group (P < .05). This finding was paired with reduced ROM at 6 to 12 weeks postoperatively in the VAR-CO group compared to VAR-NEUT and VAR-rVAR (P < .05). Preop Valgus patients: Those in the VAL-rVal group (left in -4.39° ± 1.39valgus) were observed to have reduced knee flexion at 6 to 12 weeks postoperatively compared to VAL-NEUT and VAL-CO. CONCLUSIONS: These findings indicate that postoperative valgus alignment via either crossing over to valgus (VAR-CO) or remaining in valgus (VAL-rVAL) alignment may result in less preferable outcomes than correction to neutral or slightly varus alignment.

The Chitranjan S. Ranawat Award: Manipulation Under Anesthesia to Treat Postoperative Stiffness After Total Knee Arthroplasty: A Multicenter Randomized Clinical Trial.

BACKGROUND: Manipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy on range of motion (ROM) and outcomes. METHODS: There were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and physical therapy, while the treatment group also received one dose of pre-MUA intravenous dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov. RESULTS: The ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < .001). The ROM was similar between the treatment and control groups at 6 weeks following MUA (101 versus 99°, respectively; P = .35) and at one year following MUA (108 versus 108°, respectively; P = .98). Clinical outcomes were similar at both end points. CONCLUSIONS: In this multicenter randomized clinical trial, the addition of intravenous dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatory medications remains warranted. LEVEL OF EVIDENCE: Level 1, RCT.

Clinical and Radiographic Outcomes of a Monoblock Fluted Titanium-Tapered Stem for Paprosky IIIa, IIIb, and IV Femoral Bone Defects.

BACKGROUND: Modern fluted titanium-tapered stems (FTTS) have been increasingly utilized to achieve primary stability in conversion and revision total hip arthroplasty with major femoral bone loss. This study sought to determine the radiographic and clinical outcomes of a monoblock FTTS in patients who had major femoral bone loss. METHODS: A multicenter retrospective observational study of all total hip arthroplasty patients who received a monoblock FTTS who had up to 5-year radiographic follow-up was conducted. Only patients with femoral Paprosky classifications of IIIa, IIIb, and IV were included. Eighty-one monoblock FTTS were examined. Median clinical follow-up was 29 months (range, 18 to 58). Stem subsidence and loosening were assessed on most recent radiographs. All-cause revisions and stem survivals were assessed. RESULTS: Median subsidence was 1.4 millimeters (mm) (range, 0 to 15.0). Sixteen (23.9%) and 3 (4.5%) stems had subsidence greater than 5 and 10 mm, respectively. All stems not acutely revised appeared stable, without evidence of loosening, at latest follow-up. Ten hips (12.3%) required reoperations. Of these, only 5 (6.2%) stems were removed; 4 due to periprosthetic joint infection and 1 for surgical exposure during acetabular revision. Kaplan-Meier analyses yielded an all-cause stem survivorship of 95.1% at 2-years and 87.1% at 4-years. Stem survivorships excluding septic causes was 98.8% at both 2 and 4 years. CONCLUSION: Monoblock FTTS in complex femoral reconstruction cases showed encouraging clinical and radiographic results in patients who had severe femoral bone loss at median 29 months follow-up.

Otto Aufranc Award: Intraosseous Vancomycin in Total Hip Arthroplasty - Superior Tissue Concentrations and Improved Efficiency.

BACKGROUND: Literature shows that intraosseous (IO) infusions are capable of providing increased local concentrations compared to those administered via intravenous (IV) access. Successes while using the technique for antibiotic prophylaxis administration in total knee arthroplasty (TKA) prompted consideration for use in total hip arthroplasty (THA) however; no study exists for the use of IO vancomycin in THA. METHODS: This single-blinded randomized control trial was performed from December 2020 to May 2022. Twenty patients were randomized into 1 of 2 groups: IV vancomycin (15 mg/kg) given routinely, or IO vancomycin (500 mg/100cc of NS) injected into the greater trochanter during incision. Serum vancomycin levels were collected at incision and closure. Soft tissue vancomycin levels were taken from the gluteus maximus (at start and end of case), and acetabular pulvinar tissue. Bone vancomycin levels were taken from the femoral head, acetabular reamings, and intramedullary bone. Adverse local/systemic reactions, 30-day complications, and 90-day complications were also tracked. RESULTS: A statistically significant reduction in serum vancomycin levels was seen when comparing IO to IV vancomycin at both the start and at the end of the procedure. All local tissue samples had higher concentrations of vancomycin in the IO group. Statistically significant increases were present within the acetabular bone reamings, and approached significance in intramedullary femoral bone. CONCLUSION: This study demonstrates the utility of IO vancomycin in primary THA with increased local tissue and decreased systemic concentrations. With positive findings in an area without tourniquet use, IO may be considered for antibiotic delivery for alternative procedures.

Intraosseous Morphine Decreases Postoperative Pain and Pain Medication Use in Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial.

BACKGROUND: Intraosseous (IO) infusion of medication is a novel technique for total knee arthroplasty (TKA) antibiotic prophylaxis. To decrease postoperative pain in TKA patients, we investigated addition of morphine to a standard IO antibiotic injection. METHODS: A double-blind, randomized controlled trial was performed on 48 (24 each) consecutive patients undergoing primary TKA. The control group received an IO injection of antibiotics as per the standard protocol. The experimental group received an IO antibiotic injection with 10 mg of morphine. Pain, nausea, and opioid use were assessed up to 14 days postoperatively. Morphine and interleukin-6 serum levels were obtained 10 hours postoperatively in a subgroup of 20 patients. RESULTS: The experimental group had lower Visual Analog Scale pain score at 1, 2, 3, and 5 hours postoperatively (P = .0032, P = .005, P = .020, P = .010). This trend continued for postoperative day 1, 2, 8, and 9 (40% reduction, P = .001; 49% reduction, P = .036; 38% reduction, P = .025; 33% reduction, P = .041). The experimental group had lower opioid consumption than the control group for the first 48 hours and second week postsurgery (P < .05). Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores for the experimental group showed significant improvement at 2 and 8 weeks postsurgery (P < .05). Serum morphine levels in the experimental group were significantly less than the control group 10 hours after IO injection (P = .049). CONCLUSION: IO morphine combined with a standard antibiotic solution demonstrates superior postoperative pain relief immediately and up to 2 weeks. IO morphine is a safe and effective method to lessen postoperative pain in TKA patients. LEVEL OF EVIDENCE: Therapeutic, Level 1.

Clinical Outcomes for Open Hip Abductor Repair Using Tenodesis and Bone Trough Repair Techniques.

BACKGROUND: Hip abductor complex tears remain an injury without a clear consensus on management. Surgical treatment has been recommended after unsuccessful nonoperative management. This study evaluates both tenodesis and bone trough techniques, with treatment choices guided by previously described tear classification. METHODS: This is a retrospective cohort study of 45 hips in 44 patients who underwent surgical treatment for symptomatic, chronic hip abductor tear unresponsive to nonoperative treatment. Demographics and preoperative and postoperative values (including visual analog scale pain scores, gait assessment, and muscle strength) were evaluated. Type I tears were treated using tendon tenodesis. Type II tears were treated through a bone trough repair. RESULTS: Forty-five hips (44 patients) were operated on with a minimum of 6-month follow-up. There were 27 type I and 18 type II tears. Eighty-seven percent of patients were female. Twenty-eight percent of type II patients (5/18) had a preexisting arthroplasty in place. Significant improvements in pain (P < .001), gait (P < .001), and muscle strength (P < .001) were achieved in both the tear types. Type I repairs showed superior results to type II repairs. However, both showed significant improvements. Postoperative magnetic resonance imaging at 6 months showed healed tenodesis in 81% (17/21) of type I tears and 50% (5/10) of type II tears. CONCLUSION: Our study shows improvement in pain and function after surgical repair of hip abductor tendon injuries in both simple and complex tears. This improvement is seen even during ongoing surgical site healing. Magnetic resonance imaging findings may remain abnormal for more than 1 year after surgery and do not clearly denote repair failure.

Impact of Valgus vs Varus Mechanical Axis Correction During Primary Total Knee Arthroplasty on Postoperative Periarticular Bone Mineral Density.

BACKGROUND: Knee periarticular bone mineral density (BMD) is influenced by limb malalignment. The purpose of this study is to determine if the nature and magnitude of alignment correction (ΔAlign°) performed during primary total knee arthroplasty (TKA) had an impact on BMD at the metaphysis of the distal femur (DFmr) and proximal tibia (PTb). METHODS: Seventy-one patients (male = 37 |female = 34; age: 65 ± 2 years) underwent full-length standing X-rays and knee-specific BMD measurements using dual-energy X-ray absorptiometry before and 3 and 6 months following TKA. A t-test was used to compare baseline demographics and knee-specific BMD measures (medial/lateral DFmr/PTb) between patients with preoperative valgus (VAL, N = 18) and varus (VAR, N = 53) malalignment. Pearson correlation analysis was used to determine if ΔAlign° correlated with site-specific knee BMD changes. A 2 (varus/valgus) by 3 (time) analysis of variance was used to compare site-specific BMD (%ΔBMD) changes following TKA. Type I error was set at α = 0.05 for all analyses. RESULTS: VAR patients had higher preoperative BMD for medial measurement at both the DFmr (VAR: 1.17 ± 0.06 g/cm2; VAL: 1.00 ± 0.09 g/cm2) and PTb (VAR: 1.41 ± 0.07 g/cm2; VAL: 1.29 ± 0.14 g/cm2) (P < .05). ΔAlign° and %ΔBMD were correlated on the medial side of the DFmr (r = 0.393, P < .05) and lateral/medial BMD ratio at the PTb (r = -0.670, P < .01) in VAL patients. Only VAL patients had significant %ΔBMD changes at 6 months postoperative with increases on the medial side only for the DFmr and PTb (+4%-8%, P < .05). CONCLUSION: Valgus patients exhibited reduced medial BMD at DFmr and PTb and showed sustained improvements 6 months postsurgery. Mechanical axis correction may be clinically impactful to bone remodeling when correcting valgus malalignment. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Hypothermia in Total Joint Arthroplasty: A Wake-Up Call.

BACKGROUND: Total joint patients are particularly vulnerable to perioperative hypothermia (PH) (combined effects of anesthesia, radiation, and convective heat loss from exposed skin surfaces and cool temperatures in the operating room). There are limited studies on PH in these patients. METHODS: In a retrospective review of 204 patients undergoing primary hip and 179 undergoing primary knee replacement surgeries, time and temperature parameters were collected from the electronic health records from preoperative and postoperative recovery room nursing assessments, intraoperative anesthesia records, and floor nursing notes. Basic patient demographic data was recorded. Chi-squared and paired t-tests were used to compare between hypothermic and normothermic groups. RESULTS: At the time of incision, 60 of 179 (34%) total knee arthroplasty (TKA) patients and 80 of 204 (39%) total hip arthroplasty (THA) patients were hypothermic. In THA patients, 65% remained hypothermic for the duration of anesthesia compared to 33% of TKA patients. The largest drop in core body temperature in both THA and TKA patients occurred between preoperative holding and induction of anesthesia. In THA patients, spinal anesthesia had a significantly higher occurrence of PH. No significant patient factor was found to increase risk. CONCLUSION: Emphasis on preoperative holding protocols, decreasing time from operating room entry to incision, and increasing ambient room temperature could reduce risk of hypothermia in total joint replacement patients.

Will New Metal Heads Restore Mechanical Integrity of Corroded Trunnions?

BACKGROUND: Metal wear and corrosion from modular junctions in total hip arthroplasty can lead to further unwanted surgery. Trunnion tribocorrosion is recognized as an important contributor to failure. This study was performed to determine if new metal heads restore mechanical integrity of the original modular junction after impaction on corroded trunnions, and assess which variables affect stability of the new interface created at revision total hip arthroplasty. METHODS: Twenty-two trunnions, cobalt-chromium (CoCr) and titanium alloy (TiAIV), (CoCr, n = 12; TiAIV, n = 10) and new metal heads were used, 10 trunnions in pristine condition and 12 with corrosion damage. Test states were performed using an MTS Machine and included the following: 1, Assembly; 2, Disassembly; 3, Assembly; 4, Toggling; and 5, Disassembly. During loading, three-dimensional motion of the head-trunnion junction was measured using a custom jig. RESULTS: There were no statistical differences in the tested mechanical properties between corroded and pristine trunnions implanted with a new metal femoral head. Average micromotion of the head versus trunnion interface was greatest at the start of loading, stabilizing after approximately 50 loading cycles at an average of 30.6 ± 3.2 µm. CONCLUSION: Corrosion at the trunnion does not disrupt mechanical integrity of the junction when a CoCr head is replaced with a CoCr trunnion. However, increased interface motion of a new metal head on a corroded titanium trunnion requires additional study. The evaluation of ball head size on mechanical integrity of trunnions would also be a potential subject of future investigation, as increasing the ball head size at the time of revision is not uncommon in revisions today.

Quantifying and Predicting Surgeon Work Effort for Primary and Revision Total Knee Arthroplasty.

BACKGROUND: The objectives of this study were to quantify increased utilization of resources in revision total knee arthroplasty (TKA) compared with primary TKA, determine preoperative factors that predict outcome measures, and compare Medicare reimbursement for each procedure. METHODS: Seventy-eight revision TKA patients were compared with 80 primary TKA patients. Outcomes measured were surgical time, estimated blood loss, length of stay, and complications. RESULTS: Revision TKA showed 49% increased surgical time compared with primary TKA. Estimated blood loss was increased 91%. Tibial and femoral bone loss was associated with increased surgical time as was use of longer stemmed tibial components. Average Medicare hospital payment increased 29% ($13,464 for primary, $17,331 for revision). Average physician reimbursement represented a 36% increase. Relative value units were increased to 31%. CONCLUSION: There was substantial increase in work effort not commensurate with current Medicare reimbursement, which may limit patient access to revision TKA.

Quantifying and Predicting Surgeon Work Input in Primary vs Revision Total Hip Arthroplasty.

BACKGROUND: Primary total hip arthroplasties (THAs) performed annually are projected to increase 174% by 2030, causing a parallel increase for revision THA. Increased surgical effort and readmission rates associated with revision THA may discourage surgeons from performing them. Although revision THA Medicare reimbursement is greater, it may be disproportionate to time and effort. We examined work input between primary and revision THA, assessing predictive factors. We also compared surgeon work input to current reimbursement. METHODS: A total of 156 patients were identified, 80 primary and 76 revision THA. Demographic, clinical, and radiographic data were collected. Radiographic data were collected from the most recent preoperative radiographs taken before primary or revision THA. Multiple linear and logistic regression models were used to identify patient factors contributing to select outcome variables by a stepwise method, with a probability value for entry (P = .05) and removal (P = .10). Residual analysis was performed, confirming validity of these models. RESULTS: Average age, body mass index, and percentage of female patients were similar between cohorts. There was no statistically significant difference between the demographic variables, although data revealed patient variables contributing to statistically significant increases in surgical time, length of stay, blood loss, and complications with revision THA. CONCLUSION: Despite a 66% increase in "percent effort" and 3-fold higher readmission rate, revision THA requires at least a 2-fold increase because of nonquantifiable factors. Revision THA demonstrates a substantial increase in work effort not commensurate with current Medicare reimbursement, which may force surgeons to limit or eliminate revision arthroplasties performed reducing access to patient care.

Tibial Stems in Revision Total Knee Arthroplasty: Is There an Anatomic Conflict?

Tibial stems are frequently used in revision total knee arthroplasty (TKA). We investigated the effect of tibial stems on final component alignment and tray position. Thirty 3D reconstructed cadaveric tibial models were classified according to canal bow angle. After virtual implantation of 120 mm and 200 mm stemmed tibial components, deviation from native mechanical axis was measured. Tibial alignment valgus malposition of up to three degrees occurred and most pronounced with 120 mm stems. Canal alignment using 200 mm stems deviated tray position medially and posteriorly. Mild to moderate valgus bowing of the tibial canal is not uncommon (57% in our series) possibly leading to valgus malalignment. Anatomic conflict between the tibial mechanical axis and intramedullary canal can exist, with alignment and tray placement implications.

Anteroposterior Knee Stability During Stair Descent.

This study examined the influence of tibio-femoral conformity on anteroposterior (AP) knee stability during stair descent, particularly with a dished cruciate sacrificing (CS) design. A joint simulator simulated stair descent of cadaveric knees. Tibio-femoral displacement was measured. Knees were tested in intact, ACL-deficient, and TKA with cruciate-retaining (CR), CS and posterior-stabilizing (PS) inserts. Loading during stair descent simulation caused femur displacement anteriorly prior to quadriceps contraction. Quadriceps contraction reestablished the initial femoral AP position. During simulated stair descent, AP stability was restored using PS, CR or CS inserts with an intact PCL. The CS design without the PCL did not provide AP stability. Increasing quadriceps force to restore AP stability may explain the clinical findings of pain and fatigue experienced by some patients after TKA.

Maximizing tibial coverage is detrimental to proper rotational alignment.

BACKGROUND: Traditionally, the placement of the tibial component in total knee arthroplasty (TKA) has focused on maximizing coverage of the tibial surface. However, the degree to which maximal coverage affects correct rotational placement of symmetric and asymmetric tibial components has not been well defined and might represent an implant design issue worthy of further inquiry. QUESTIONS/PURPOSES: Using four commercially available tibial components (two symmetric, two asymmetric), we sought to determine (1) the overall amount of malrotation that would occur if components were placed for maximal tibial coverage; and (2) whether the asymmetric designs would result in less malrotation than the symmetric designs when placed for maximal coverage in a computer model using CT reconstructions. METHODS: CT reconstructions of 30 tibial specimens were used to generate three-dimensional tibia reconstructions with attention to the tibial anatomic axis, the tibial tubercle, and the resected tibial surface. Using strict criteria, four commercially available tibial designs (two symmetric, two asymmetric) were placed on the resected tibial surface. The resulting component rotation was examined. RESULTS: Among all four designs, 70% of all tibial components placed in orientation maximizing fit to resection surface were internally malrotated (average 9°). The asymmetric designs had fewer cases of malrotation (28% and 52% for the two asymmetric designs, 100% and 96% for the two symmetric designs; p < 0.001) and less malrotation on average (2° and 5° for the asymmetric designs, 14° for both symmetric designs; p < 0.001). CONCLUSIONS: Maximizing tibial coverage resulted in implant malrotation in a large percentage of cases. Given similar amounts of tibial coverage, correct rotational positioning was more likely to occur with the asymmetric designs. CLINICAL RELEVANCE: Malrotation of components is an important cause of failure in TKA. Priority should be given to correct tibial rotational positioning. This study suggested that it is easier to balance rotation and coverage with asymmetric tibial baseplates; clinical research will need to determine whether the observed difference affects patellar tracking, loosening rates, or the likelihood of revisions after TKA.

Intraosseous Administration of Medications in Total Knee Arthroplasty: An Opportunity for Improved Outcomes and Superior Compliance.

Background: Vancomycin is a prophylactic antibiotic with bactericidal activity against methicillin-resistant Staphylococcus aureus that is commonly used in total joint replacement surgery1. In total knee arthroplasty (TKA), intraosseous infusions administered following tourniquet inflation have demonstrated improved local vancomycin concentrations with decreased systemic absorption1-3. This administration method results in no adverse reactions locally, as well as equivalent or lower systemic complications compared with other vancomycin administration methods4. Intraosseous infusion of prophylactic surgical antibiotics has been shown to be more effective than intravenous administration, with the potential for reduction in surgical site infections5. Description: After the operative extremity has been prepared and draped in the usual sterile fashion, the limb is elevated and the tourniquet is inflated to 250 mm Hg. Prior to incision, an intraosseous vascular access system (Arrow EZ IO; Teleflex) is inserted with a power driver into the tibial tubercle region. The desired volume of the medication is injected into the tibia. The device is removed and then inserted into the anterior distal femur, centrally, just proximal to the patella. Following this, the desired volume of the medication is injected into the femur. The device is then removed, and the TKA proceeds according to the surgeon's standard technique. Alternatives: Alternative administration methods for vancomycin include other invasive methods and noninvasive delivery. Intravenous delivery is the most traditional form of medication delivery1,2. Additional alternatives include noninvasive placement of antibiotic powder into the wound and localized soft-tissue injections of desired medications1-3. Rationale: Opting to administer antibiotics and other medications intraosseously (rather than intravenously) has shown improved compliance with the golden-hour rule of preoperative antibiotics (especially for vancomycin)4, lower incidences of acute kidney injury or adverse systemic effects4, and improved local tissue concentrations of all medications delivered1-3. Expected Outcomes: Expected outcomes include improved local tissue concentrations with decreased systemic concentrations of vancomycin and with no reported local or systemic adverse reactions, as well as the potential for improved infection prevention1-5. Literature regarding the use of intraosseous infusion during TKA has been thorough and very well received. A prospective, randomized study by Young et al. evaluated local and systemic concentrations of vancomycin following intraosseous versus intravenous administration. The authors found that low-dose intraosseous vancomycin resulted in tissue concentrations equal to or superior to those of systemic administration, also noting that the administration route reduced the infiltration time of the vancomycin without systemic complications1. Local concentrations at the knee were found to be 5 to 9 times greater with intraosseous infusion in patients with a body mass index of >35 kg/m2 as compared with the use of intravenous administration, with no adverse reactions systemically. Local concentrations in this patient population were also found to be comparable to those observed in patients with a lower body mass index2. A recent study assessing the use of intraosseous vancomycin showed that local concentrations of vancomycin were maintained even if the procedure continued beyond the point of tourniquet deflation, with mean concentrations being 5 times higher locally at the end of the procedure in the intraosseous versus the intravenous group3. A separate study showed no adverse systemic reactions and no incidents of acute kidney injury among patients receiving intraosseous vancomycin. An additional study showed that intraosseous administration of vancomycin decreased the incidence of postoperative joint infections compared with traditional intravenous administration5. Newer studies assessing the use of intraosseous infiltration have begun to focus on the delivery of other medications, not just antibiotics. At our institution, we have examined the benefits of intraosseously administrated morphine, which has shown a significant decrease in pain and opioid consumption up to 2 weeks postoperatively. Important Tips: You may run into issues with the medication delivery due to the amount of resistance you encounter. If resistance is too great, you may first attempt to readjust the intraosseous needle depth to improve flow. If resistance is still high, you may consider downsizing to a 30-cc syringe in order to better infiltrate the medication.Note that if you downsize your syringe, you will require more time to infiltrate the desired amount of fluid. An additional way to save time is to open multiple syringes and have them prefilled with your desired medication so that they may be handed off once completed rather than needing to be refilled.A hemostat or pickup may be applied underneath the cuff of the intraosseous needle in order to help remove the needle from the bone. This step is sometimes required because the intraosseous handpieces do not have multidirectional trigger capabilities, and removing the needle can require an upward force to be applied.The use of midline locations allows the small incisions you make for intraosseous infusion to be incorporated into your larger knee incision, with no additional morbidity to the patient.Consider utilizing the medial and/or lateral femoral condyles as landmark locations for infusion if your patient is large. Alternatively, recent literature has shown nearly equivalent results with just the tibial infusion, so you may consider discontinuing the femoral intraosseous infusion if there are consistent issues with successfully initiating the medication delivery. Acronyms and Abbreviations: IO = intraosseousMRSA = methicillin-resistant Staphylococcus aureusRCT = randomized controlled trialsIV = intravenousBMI = body mass indexOR = operating room.

Health Status of Total Hip Versus Total Knee Arthroplasty Patients and Possible Effects on Decisions Regarding Surgical Location, Cost, and Access to Care.

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are no longer considered inpatient-only procedures. Qualifying for inpatient status reimbursement requires additional, unreimbursed administrative effort, and may limit care to these patients. Purpose: We sought to evaluate and compare the overall health status of patients receiving THA and TKA. Methods: We conducted a retrospective review evaluating 2207 patients undergoing primary THA and TKA from 2015 to 2018 at a single institution. Clinical parameters, surgical procedure, medical history, laboratory values, length of stay (LOS), and discharge location were recorded and compared between the 2 groups. Results: In 2202 patients, we observed differences for body mass index (THA = 29.4 ± 0.4, TKA = 32.1 ± 0.3), low-density lipoprotein cholesterol levels (THA = 105.8 ± 13.5 mg/dL; TKA = 128.6 ± 13.7 mg/dL), and blood glucose levels (THA = 98.2 ± 1.7 mg/dL; TKA = 101.4 ± 1.3 mg/dL), indicating that TKA patients were more likely than THA patients to be classified as obese, hypercholesterolemic, and hyperglycemic. We observed longer LOS in THA patients (51.25 hours, 95% CI ± 3.87 hours) than in TKA patients (36.93 hours, 95% CI ± 1.17 hours). A greater proportion of TKA patients were discharged home (81.97%, N = 1155) rather than to additional care facilities compared with THA patients (71.84%, N = 539). Conclusion: In this retrospective study, we observed that TKA patients had higher rates of comorbidities than did THA patients, but TKA patients spent less time in the hospital and were more likely to be discharged home. Future studies should evaluate reasons for poor clinical outcomes for patients undergoing total joint arthroplasty with an outpatient designation.

Patient Perceptions of Same-Day Discharge Versus Overnight Stay After Total Joint Arthroplasty: Results of a Survey.

Background: In the COVID-19 era, there has been increasing interest in same-day discharge (SDD) after total joint arthroplasty (TJA). However, patient perception of SDD is not well reported. Purpose: We sought to understand patients' perceptions and preferences of postoperative care by surveying patients who have completed both an overnight stay (ONS) and an SDD after TJA. Methods: We emailed survey links to 67 patients who previously underwent either 2 total hip arthroplasties (THAs) or 2 total knee arthroplasties (TKAs). Results: Fifty-two patients (78%) responded to the survey. Thirty-four (65%) patients underwent staged, bilateral TKAs, and 18 (35%) patients underwent staged, bilateral THAs. Overall, 63% of patients preferred their SDD, 12% had no preference, and 25% preferred their ONS, with no difference in preference between TKA and THA groups. Those who preferred their SDD reported being more comfortable at home. Those who preferred their ONS felt their pain and concerns were better addressed. No differences were found in comfort, sleep quality, appetite, burden on family, return to function, feelings of being discharged too soon, overall experience, 30-day emergency department (ED) visits, or readmissions within 30 days between patients' SDD and ONS. There was a small statistically significant difference between patients' perception of safety between SDD and ONS. Conclusion: Our survey found that most patients reported a preference for SDD after TJA over ONS. Although there was a small difference in patient perception of safety, there were no differences in return to the ED or readmissions after SDD and ONS.