Reasons and Risk Factors for Failed Same-Day Discharge After Total Joint Arthroplasty.

BACKGROUND: A shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution's most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD. METHODS: A retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression. RESULTS: Overall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older. CONCLUSIONS: The SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates. LEVEL OF EVIDENCE: III.

Perioperative Blood Management in Total Joint Arthroplasty.

Preoperative anemia is an established risk factor for complications following total joint arthroplasty. Postoperative anemia can be managed with allogeneic blood transfusion, but this has inherent risks. A thorough preoperative workup can help to diagnose anemia and optimize these patients for surgery to minimize the need for postoperative transfusion. Perioperatively, the amount of blood loss can be minimized by using hypotensive anesthetic techniques and administering antifibrinolytic agents. Last, in the event that allogeneic blood transfusion is still required, strict transfusion guidelines should be followed. Evidence-based interventions for preoperative, perioperative, and postoperative blood management in total joint arthroplasty will be reviewed.

2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty.

OBJECTIVE: To develop updated American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA). METHODS: We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process. RESULTS: This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids. CONCLUSION: This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.

Benefits and Adverse Events Associated With Extended Antibiotic Use in Total Knee Arthroplasty Periprosthetic Joint Infection.

BACKGROUND: Total knee arthroplasty (TKA) periprosthetic joint infection (PJI) can be managed with debridement, antibiotic therapy, and implant retention (DAIR). Oral antibiotics can be used after DAIR for an extended time period to improve outcomes. The objective of this study was to compare DAIR failure rates and adverse events between an initial course of intravenous antibiotic therapy and the addition of extended treatment with oral antibiotics. METHODS: A multicenter observational study of patients diagnosed with a TKA PJI who underwent DAIR was performed. The primary outcome of interest was the failure rate derived from the survival time between the DAIR procedure and future treatment failure. RESULTS: One hundred eight patients met inclusion criteria; 47% (n = 51) received an extended course of oral antibiotics. These patients had a statistically significant lower failure rate compared to those who received only intravenous antibiotics (hazard ratio, 2.47; P = .009). Multivariable analysis demonstrated that extended antibiotics independently predicted treatment success, controlling for other variables. There was no significant difference in failure rates between an extended course of oral antibiotics less or more than 12 months (P = .23). No significant difference in the rates of adverse events was observed between patients who received an initial course of antibiotics alone and those who received a combination of initial and extended antibiotic therapy (P = .59). CONCLUSIONS: Extending therapy with oral antibiotics had superior infection-free survival for TKA PJI managed with DAIR. There was no increase in adverse events, demonstrating safety. After 1 year, there appears to be no significant benefit associated with continued antibiotic therapy.

Musculoskeletal Infection Society (MSIS) Update on Infection in Arthroplasty.

Periprosthetic joint infection (PJI) continues to be a devastating problem in the field of total joint arthroplasty, and recent literature can be used to make the preoperative diagnosis of PJI, guide nonsurgical and surgical treatment, and provide postoperative antimicrobial management of PJI patients. The diagnosis of PJI relies on traditional serum and synovial fluid tests, with newer biomarkers and molecular tests. Surgical treatment depends on the duration of infection, host qualities, and surgeon factors, and procedures include débridement, antibiotics, and implant retention, one-stage exchange arthroplasty, two-stage exchange arthroplasty, resection arthroplasty, fusion, or amputation. Appropriate management of PJI involves coordination with infectious disease consultants, internal medicine physicians, and orthopaedic surgeons. Antimicrobial management is guided by the organisms involved, whether it is a new or persistent infection, and antibiotic suppression should be administered on an individual case basis. The goals of this instructional course lecture are to review the most relevant recent literature and provide treating physicians and surgeons with the most up-to-date armamentarium to reduce the recurrence of PJI.

Administration of Tranexamic Acid Improves Long-Term Outcomes in Total Knee Arthroplasty.

BACKGROUND: Blood transfusion in total knee arthroplasty (TKA) is associated with increased morbidity, including periprosthetic joint infection (PJI). Tranexamic acid (TXA) reduces blood transfusion rates, but there is limited evidence demonstrating improved outcomes in TKA resulting from TXA administration. The objectives of this study are determining whether TXA is associated with decreased rate of PJI, decreased rate of outcomes associated with PJI, and whether there are differences in rates of adverse events. METHODS: A multicenter cohort study comprising 23,421 TKA compared 4423 patients receiving TXA to 18,998 patients not receiving TXA. Primary outcome was PJI within 2 years of TKA. Secondary outcomes included revision surgery, irrigation and debridement, transfusion, and length of stay. Adverse events included readmission, deep vein thrombosis, pulmonary emboli, myocardial infarction, or stroke. Adjusted odds ratios were determined using linear mixed models controlling for age, sex, thromboembolic prophylaxis, Charlson comorbidity index, year of TKA, and surgeon. RESULTS: TXA administration reduced incidence of PJI by approximately 50% (odds ratio [OR], 0.55; P = .03). Additionally, there was decreased incidence of revision surgery at 2 years (OR, 0.66; P = .02). Patients receiving TXA had reductions in transfusion rate (OR, 0.15; P < .0001) and length of stay (P < .0001). There was no difference in the rate of pulmonary emboli (OR, 1.20; P = .39), myocardial infarction (OR, 0.78; P = .55), or stroke (OR, 1.17; P = .77). CONCLUSION: Administration of TXA in TKA resulted in reduced rate of PJI and overall revision surgery. No difference in thromboembolic events were observed. The use of TXA is safe and improves outcomes in TKA. LEVEL OF EVIDENCE: Level III, Observational Cohort Study.

Do Culture Negative Periprosthetic Joint Infections Remain Culture Negative?

BACKGROUND: Diagnosis and treatment of culture negative total knee arthroplasty (TKA) periprosthetic joint infection (PJI) is challenging. There is debate over whether culture negative PJI confers increased risk of failure and which organisms are responsible. It is also unclear as to what factors predict conversion from culture negative to culture positivity. To address these issues, we performed an observational study to detect factors associated with transition from culture negative to culture positive TKA PJI in those patients that failed irrigation and debridement (I&D), determine the incidence of this transition, and identify those organisms that were associated with treatment failure. METHODS: A multicenter observational cohort study was performed on patients with TKA PJI as defined by Musculoskeletal Infection Society criteria without cultured organisms and treated with I&D. Primary outcome was failure defined as any subsequent surgical procedure. Secondary outcome included cultured organism within 2 years of initial I&D. RESULTS: Two hundred sixteen TKA I&D procedures were performed for PJI, and 36 met inclusion criteria. The observed treatment failure rate for culture negative PJI treated with I&D was 41.67%. Of those culture negative I&Ds that failed, 53.33% became culture positive after failure. Of those that converted to culture positive, 62.5% were Staphylococcus species. The odds ratio associated with becoming culture positive following culture negative treatment failure in the setting of antibiotic administration prior to the initial I&D procedure was 0.69 (95% confidence interval 0.14-3.47, P = .65). CONCLUSION: Many cases of culture negative TKA PJI treated with I&D eventually fail and become culture positive. Staphylococci are common organisms identified after culture negative PJI.

Are Sonication Cultures of Antibiotic Cement Spacers Useful During Second-stage Reimplantation Surgery for Prosthetic Joint Infection?

BACKGROUND: Organisms may persist on polymethylmethacrylate (PMMA) spacer surfaces, and subclinical infection is postulated to be a source of infection recurrence. Several small patient series have shown a high proportion of positive sonication cultures on PMMA spacers at the second stage of a two-stage revision. However, the association between a positive sonication culture and the risk for recurrence of infection after two-stage exchange is not fully elucidated. QUESTIONS/PURPOSES: Are cultures derived from sonication of antibiotic spacers associated with infection control or recurrence after two-stage revision for prosthetic joint infection (PJI)? METHODS: Between September 2013 and April 2016, we treated 67 patients with PJI with two-stage revisions. At the second stage, all cement spacers were explanted and sonicated. A total of`10 (15%) patients were lost to followup or failed to reach 1-year followup during the study period, and another 16 (24%) were excluded for prespecified reasons, leaving 41 patients for analysis in this study. Of the 41 patients included in this study, there were 25 TKAs, 15 THAs, and one distal femoral replacement. All patients met the Musculoskeletal Infection Society criteria for PJI at Stage 1 of the two-stage revision. The most common infecting organisms prompting two-stage revision were methicillin-sensitive Staphylococcus aureus and coagulase-negative staphylococci. PMMA spacers were most frequently loaded with gentamicin or gentamicin/vancomycin. Standard 6-week intravenous antibiotic courses were used for index infections and postreimplantation suppression was used for 3 months in all patients as determined by cultures and sensitivities. Patients were assessed for recurrence of infection at postoperative clinic visits completed at standard intervals. The average length of followup was 1.9 years with a range of 1 to 3.3 years. RESULTS: Sonication cultures that reached a threshold of 5 colony-forming units for positive culture had poor screening utility for subclinical persistent infection (sensitivity: 0%; confidence interval [CI], 0%-60%), but reasonable use for ruling in successful two-stage revision (specificity: 95%; 95% CI, 82%-99%). Positive sonication culture results in the two of 41 (4.9%) explanted spacers yielded coagulase-negative staphylococci, different from primary prosthesis cultures in both patients (Corynebacterium and Proteus mirabilis), and did not alter antibiotic choice. Neither of the patients has developed a reinfection at followup of 1.2 and 1.9 years. Of the 39 two-stage revisions with negative spacer sonication cultures, four developed reinfections. CONCLUSIONS: Positive sonication fluid culture of PMMA spacers during reimplantation surgery was not associated with persistent or recurrent infection at minimum followup of 1 year. We do not recommend routine sonication of explanted PMMA spacers in the absence of clinical evidence suggesting persistent infection. Multicenter, prospective studies with long-term followup are needed to determine if sonication of PMMA spacers can predict persistent or recurrent infection. LEVEL OF EVIDENCE: Level III, diagnostic study.

Revision total knee arthroplasty with porous-coated metaphyseal sleeves provides radiographic ingrowth and stable fixation.

PURPOSE: Porous-coated metaphyseal sleeves are designed to fill bone defects and facilitate osseointegration when bone loss in encountered during revision total knee arthroplasty (TKA). The purpose of this study is to evaluate short-term results of porous-coated metaphyseal sleeves with regards to implant fixation and clinical outcomes. METHODS: A retrospective review was conducted on 50 patients (79 sleeves-49 tibial and 30 femoral) who had a press-fit metaphyseal sleeve with revision TKA. Tibial and femoral bone loss was classified according to the Anderson Orthopaedic Research Institute (AORI) bone defect classification. Post-operative complications of infection, revision surgery, and dislocation were assessed. Follow-up radiographs were evaluated for signs of loosening using the criteria developed by the Knee Society. The median follow-up was 58.8 months (range 25.8-93.0 months). RESULTS: The bone loss classifications were 1 type 1, 30 type 2a, 2 type 2b, and 17 type 3, and with regards to the femur, 5 were type 1, 8 type 2a, 31 type 2b, and 6 type 3. At final follow-up, 41/45 (91.1%) tibial and 28/29 (96.6%) femoral sleeves showed radiographic evidence of ingrowth. Of these 69 patients, all showed radiographic evidence of bony ingrowth. Three sleeves were revised for infection and two for loosening. The re-operation rate for loosening was 5/74 (6.8%) and for any reason was 14/74 (18.9%). CONCLUSIONS: Modular porous-coated press fit metaphyseal sleeves fill defects and provide evidence of radiographic ingrowth. Short-term stable fixation can be achieved with sleeves, which is helpful as more patients undergo revision total knee arthroplasty with greater bone loss. Longer duration studies are needed to ascertain the survival rate of these implants. LEVEL OF EVIDENCE: IV.

Sonication of Arthroplasty Implants Improves Accuracy of Periprosthetic Joint Infection Cultures.

BACKGROUND: There is evidence that sonication of explanted prosthetic hip and knee arthroplasty components with culture of the sonication fluid may enhance diagnostic sensitivity. Previous studies on the use of implant sonicate cultures have evaluated diagnostic thresholds but did not elaborate on the clinical importance of positive implant sonicate cultures in the setting of presumed aseptic revisions and did not utilize consensus statements on periprosthetic joint infection (PJI) diagnosis when defining their gold standard for infection. QUESTIONS/PURPOSES: (1) How do implant sonicate cultures compare with preoperative synovial fluid cultures and intraoperative tissue cultures in the diagnosis of PJI in both THA and TKA when compared against Musculoskeletal Infection Society (MSIS) criteria for PJI? (2) Utilizing implant sonicate cultures, what is the relative prevalence of bacterial species identified in PJIs? (3) What is the incidence of positive implant sonicate cultures in the setting of presumed aseptic revision hip and knee arthroplasty procedures, and what treatments did they receive? METHODS: Between 2012 and 2016 we performed implant sonicate fluid cultures on surgically removed implants from 565 revision THAs and TKAs. Exclusion criteria including insufficient data to determine Musculoskeletal Infection Society (MSIS) classification, fungal-only cultures, and absence of reported colony-forming units decreased the number of procedures to 503. Procedures represented each instance of revision surgery (sometimes multiple in the same patient). Of those, a definitive diagnosis of infection was made using the MSIS criteria in 178 of 503 (35%), whereas the others (325 of 503 [65%]) were diagnosed as without infection. A total of 53 of 325 (16%) were considered without infection based on MSIS criteria but had a positive implant sonicate culture. Twenty-five of 53 (47%) of these patients were followed for at least 2 years. The diagnosis of PJI was determined using the MSIS criteria. RESULTS: Sensitivity of implant sonicate culture was greater than synovial fluid culture and tissue culture (97% [89%-99%] versus 57% [44%-69%], p < 0.001; 97% [89%-99%] versus 70% [58%-80%], p < 0.001, respectively). The specificity of implant sonicate culture was not different from synovial fluid culture or tissue culture with the numbers available (90% [72%-97%] versus 100% [86%-100%], p = 0.833; 90% [72%-97%] versus 97% [81%-100%], p = 0.317, respectively). Coagulase-negative Staphylococcus was the most prevalent organism for both procedure types. In PJIs, the five most frequent bacteria identified by synovial fluid, tissue, and/or implant sonicate cultures were coagulase-negative Staphylococcus (26% [89 of 267]), methicillin-susceptible Staphylococcus aureus (19% [65 of 267]), methicillin-resistant S. aureus (12% [43 of 267]), α-hemolytic Streptococci (5% [19 of 267]), and Enterococcus faecalis (5% [19 of 267]). Fifty-three of 325 (16%) presumed aseptic revisions had a positive sonication culture. Thirty-four percent (18 of 53) of culture-positive aseptic revision patients received antibiotic treatment for infection and 8% (4 of 53) underwent a secondary revision. CONCLUSIONS: The routine use of implant sonicate cultures in arthroplasty revisions improves the diagnostic sensitivity for detecting the presence of bacteria in both clinical and occult infections. Future studies will need to refine colony-forming unit thresholds for determining clinical infection and indications for treatment. LEVEL OF EVIDENCE: Level III, diagnostic study.

Cartilage regeneration.

Cartilage damaged by trauma has a limited capacity to regenerate. Current methods of managing small chondral defects include palliative treatment with arthroscopic débridement and lavage, reparative treatment with marrow-stimulation techniques (eg, microfracture), and restorative treatment, including osteochondral grafting and autologous chondrocyte implantation. Larger defects are managed with osteochondral allograft or total joint arthroplasty. However, the future of managing cartilage defects lies in providing biologic solutions through cartilage regeneration. Laboratory and clinical studies have examined the management of larger lesions using tissue-engineered cartilage. Regenerated cartilage can be derived from various cell types, including chondrocytes, pluripotent stem cells, and mesenchymal stem cells. Common scaffolding materials include proteins, carbohydrates, synthetic materials, and composite polymers. Scaffolds may be woven, spun into nanofibers, or configured as hydrogels. Chondrogenesis may be enhanced with the application of chondroinductive growth factors. Bioreactors are being developed to enhance nutrient delivery and provide mechanical stimulation to tissue-engineered cartilage ex vivo. The multidisciplinary approaches currently being developed to produce cartilage promise to bring to fruition the desire for cartilage regeneration in clinical use.

No infection reduction using chlorhexidine wipes in total joint arthroplasty.

BACKGROUND: Surgical site infection (SSI) after total joint arthroplasty (TJA) is a rare but devastating complication. Various skin antiseptic applications are used preoperatively to prevent SSI. Recent literature suggests 2% chlorhexidine gluconate (CHG) wipes reduce microbial content at surgical sites, but it is unclear whether they reduce rates of SSI. QUESTIONS/PURPOSES: We compared the SSI rates between TJAs with and without CHG wipe use (1) with all TJAs in one group and (2) stratified by surgical subgroup (THA, TKA). METHODS: We retrospectively reviewed all 3715 patients who underwent primary TJA from 2007 to 2009. CHG wipes were introduced at our facility on April 21, 2008. We compared SSI of patients before (n=1824) and after (n=1891) the introduction of CHG wipes. The wipes were applied 1 hour before surgery. There were 1660 patients with THA (845 CHG, 815 no CHG) and 2055 patients with TKA (1046 CHG, 1009 no CHG). Infections were diagnosed based on the Musculoskeletal Infection Society Guidelines for periprosthetic joint infection. All patients were tracked for 1 year. RESULTS: SSI incidences were similar in patients receiving (1.0%, 18 of 1891) and not receiving (1.3%, 24 of 1824) CHG wipes. In patients with THA, there was no difference in SSI between those receiving (1.2%, 10 of 845) and not receiving (1.5%, 12 of 815) CHG wipes. In patients with TKA, there also was no difference in SSI between those receiving (0.8%, eight of 1046) and not receiving (1.2%, 12 of 1009) CHG wipes. CONCLUSIONS: Introduction of CHG-impregnated wipes in the presurgical setting was not associated with a reduced SSI incidence. Our analysis suggests CHG wipes in TJA are unnecessary as an adjunct skin antiseptic, as suggested in previous smaller studies. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Preoperative decolonization effective at reducing staphylococcal colonization in total joint arthroplasty patients.

Staphylococcus decolonization prior to surgery is used to prevent surgical site infections (SSIs) after total joint arthroplasty (TJA). To determine if current treatment protocols result in successful decolonization of methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA), 106 consecutive patients were screened for nasal MSSA/MRSA colonization pre-operatively and on the day of surgery. Colonized patients used intranasal mupirocin twice a day and chlorhexidine showers daily 5 days prior to surgery. Pre-operatively, 24 joints (22.0%) were positive for MSSA colonization and 5 joints (4.6%) were positive for MRSA colonization. On the day of surgery, 3 joints (2.8%) who underwent decolonization were positive for MSSA colonization and 0 joints were positive for MRSA colonization. The reduction in MSSA colonization was significant (P<0.001), while the eradication of MRSA colonization approached statistical significance (P=0.063). Current decolonization protocols using intranasal mupirocin and chlorhexidine washes are effective for reducing MRSA/MSSA colonization.

Solid organ transplant patients experience high rates of infection and other complications after total knee arthroplasty.

Survival after solid organ transplants in the United States is increasing, and there is a need to understand the complications in knee arthroplasty patients who underwent organ transplantation. A retrospective study was conducted from 1993-2008 on 19 patients (23 knee arthroplasties) with previous successful solid organ transplants. Eleven knee arthroplasties were performed after renal transplantation, and 12 after nonrenal solid organ transplant (seven liver, four heart, one lung). Complications occurred in 9/23 patients (39.1%) and infections occurred in 4/23 patients (17.3%). Of the infected knees, two had MRSA, one had MSSA, and one Escherichia coli. Noninfectious complications (5/24, 21.7%) include aseptic loosening, quadriceps rupture, femoral fracture, hemarthrosis, and arthrofibrosis. All patients with complications were on immunosuppressant medications at the time of arthroplasty. There was a significantly higher rate of infection in the renal group compared to the non-renal group (P = 0.022). There was also a higher overall complication rate in the renal group however this did not reach significance.

The Role of Inhalation Aromatherapy, Lavender and Peppermint in the Management of Perioperative Pain and Opioid Consumption Following Primary Unilateral Total Hip Arthroplasty: A Prospective, Randomized and Placebo-Controlled Study.

Introduction: Aromatherapy is claimed to be effective for the treatment of psychosocial disorders, but objective evidence of its effectiveness is still lacking. Psychosocial disorders have been demonstrated to increase postoperative pain and opioid consumption by up to 50%. This study was designed to assess the effectiveness of Aromatherapy in controlling postoperative pain and opioid in anxious patients. Methods: This prospective, randomized, placebo-controlled study was conducted on anxious patients who underwent primary unilateral total hip arthroplasty. After obtaining signed informed consent, each patient was asked to complete a PROMIS (Patient-Reported Outcomes Measurement Information System) anxiety survey. Patients whose T score were >57.2 were randomized to either an active treatment (Lavender Peppermint Elequil® aromatab®) or a placebo Elequil®-aromatab® treatment. Demographics, pain, opioid consumption, PONV, and psychosocial surveys were collected on Postoperative Day POD1, POD2, POD7 and POD30. At the time of discharge and on POD30, each patient was asked to complete a satisfaction questionnaire, and they were asked to complete an SF12 survey on POD30. Difference between means was assessed using absolute standardized mean differences. Results: Sixty patients were included in the intend-to-treat analysis. Use of lavender and peppermint was associated with a decrease of 26% in pain (POD7; 0.46), 33% in opioid consumption (POD2; 0.42), and 48% in acetaminophen consumption (POD7; 0.54) and a 78% decrease in PONV (POD2; 0.44). Psychosocial scores decreased following surgery (p=0.001). Overall satisfaction ratings at discharge were similar, as were functional recovery scores. Discussion: Our data provides evidence that in patients with preoperative anxiety, lavender and peppermint aromas decreases postoperative pain and opioid requirement compared to placebo. Additional research is required to conform our data. Conclusion: This randomized placebo control study provides evidence of the usefulness of inhalation of lavender and peppermint aromas in patients undergoing primary unilateral total hip arthroplasty.