Chronic Anticoagulation is Associated With Increased Risk for Postoperative Complications Following Aseptic Revision Total Hip Arthroplasty.

BACKGROUND: With an aging global population, the incidence of revision total hip arthroplasty (rTHA) is expected to increase markedly. While patients undergoing primary total hip arthroplasty who require chronic anticoagulation (AC) have been associated with increased postoperative complications, less is known about the impact of chronic AC status on postoperative complications in the rTHA setting. This study sought to compare complication rates following aseptic rTHA between patients who were on chronic AC and those who were not. METHODS: A large national database was utilized to retrospectively identify 9,421 patients who underwent aseptic rTHA between 2014 and 2019. Patients were divided into 2 cohorts: 1,790 patients (19.0%) were in the chronic AC cohort (ie, having an AC prescription filled within 6 months prior to and following rTHA), and 7,631 patients (81.0%) were not on chronic AC. Postoperative complications at 90-days and 2-years were compared between cohorts utilizing univariate and multivariate analyses, controlling for sex, age, and comorbidities. RESULTS: At 90-days, chronic AC patients had increased odds of prosthetic joint infections (PJIs) (odds ratio [OR] 3.2, P < .001), surgical site infections (OR 3.6, P < .001), and mechanical prosthetic complications (OR 3.5, P < .001), which included any aseptic loosening, implant dislocation, or broken prosthetic. At 2-years, chronic AC patients had increased odds of PJI (OR 3.3, P < .001) as well as mechanical prosthetic complications (OR 3.2, P < .001). Chronic AC patients were also at increased risk for reoperation within 2 years after initial aseptic rTHA (OR 1.9, P < .001). CONCLUSIONS: Patients on chronic AC have significantly higher odds of 90-day and 2-year complications after aseptic rTHA. This includes increased odds of PJI, surgical site infection, and mechanical prosthetic complications. Patients receiving chronic AC who undergo rTHA should be counseled on the risk-benefit ratio of their chronic AC status in a multidisciplinary setting to optimize their postoperative outcomes.

Does the Primary Surgical Approach Matter When Choosing the Approach for Revision Total Hip Arthroplasty?

BACKGROUND: Multiple surgical approaches are used for primary total hip arthroplasty (pTHA) and revision total hip arthroplasty (rTHA). This study sought to investigate prevalence of discordance of pTHA and rTHA surgical approaches and to evaluate how approach concordance impacts postoperative outcomes. METHODS: A retrospective review of patients who underwent rTHA from 2000 to 2021 was conducted at 3 large urban academic centers. Patients who had minimum 1-year follow-up post-rTHA were included and grouped based on whether they received pTHA via a posterior (PA), direct anterior (DA), or laterally based (DL) approach, and by concordance of index rTHA approach with their pTHA approach. Of the 917 patients studied, 839 (91.5%) were included in the concordant cohort and 78 (8.5%) in the discordant cohort. Patient demographics, operative characteristics, and postoperative outcomes were compared. RESULTS: Discordance was most prevalent in the DA-pTHA subset (29.5%), compared to the DL-pTHA subset (14.7%) or PA-pTHA subset (3.7%). Discordance varied significantly between primary approaches among all revisions, with DA-pTHA patients having the highest discordance rate for patients revised for aseptic loosening (46.3%, P < .001), fracture (22.2%, P < .001), and dislocation (33.3%, P < .001). There were no differences between groups in dislocation rate, re-revision for infection, or re-revision for fracture. CONCLUSION: The results of this multicenter study showed patients who received pTHA via the DA were more likely to receive rTHA via a discordant approach compared to other primary approaches. Since approach concordance did not impact dislocation, infection, or fracture rates after rTHA, surgeons can feel reassured using a separate approach for rTHA. LEVEL III EVIDENCE: Retrospective Cohort Study.

Users' Concerns About Endometriosis on Social Media: Sentiment Analysis and Topic Modeling Study.

BACKGROUND: Endometriosis is a debilitating and difficult-to-diagnose gynecological disease. Owing to limited information and awareness, women often rely on social media platforms as a support system to engage in discussions regarding their disease-related concerns. OBJECTIVE: This study aimed to apply computational techniques to social media posts to identify discussion topics about endometriosis and to identify themes that require more attention from health care professionals and researchers. We also aimed to explore whether, amid the challenging nature of the disease, there are themes within the endometriosis community that gather posts with positive sentiments. METHODS: We retrospectively extracted posts from the subreddits r/Endo and r/endometriosis from January 2011 to April 2022. We analyzed 45,693 Reddit posts using sentiment analysis and topic modeling-based methods in machine learning. RESULTS: Since 2011, the number of posts and comments has increased steadily. The posts were categorized into 11 categories, and the highest number of posts were related to either asking for information (Question); sharing the experiences (Rant/Vent); or diagnosing and treating endometriosis, especially surgery (Surgery related). Sentiment analysis revealed that 92.09% (42,077/45,693) of posts were associated with negative sentiments, only 2.3% (1053/45,693) expressed positive feelings, and there were no categories with more positive than negative posts. Topic modeling revealed 27 major topics, and the most popular topics were Surgery, Questions/Advice, Diagnosis, and Pain. The Survey/Research topic, which brought together most research-related posts, was the last in terms of posts. CONCLUSIONS: Our study shows that posts on social media platforms can provide insights into the concerns of women with endometriosis symptoms. The analysis of the posts confirmed that women with endometriosis have to face negative emotions and pain daily. The large number of posts related to asking questions shows that women do not receive sufficient information from physicians and need community support to cope with the disease. Health care professionals should pay more attention to the symptoms and diagnosis of endometriosis, discuss these topics with patients to reduce their dissatisfaction with doctors, and contribute more to the overall well-being of women with endometriosis. Researchers should also become more involved in social media and share new science-based knowledge regarding endometriosis.

Applications for open access normalized synthesis in metastatic prostate cancer trials.

Recent metastatic castration-resistant prostate cancer (mCRPC) clinical trials have integrated homologous recombination and DNA repair deficiency (HRD/DRD) biomarkers into eligibility criteria and secondary objectives. These trials led to the approval of some PARP inhibitors for mCRPC with HRD/DRD indications. Unfortunately, biomarker-trial outcome data is only discovered by reviewing publications, a process that is error-prone, time-consuming, and laborious. While prostate cancer researchers have written systematic evidence reviews (SERs) on this topic, given the time involved from the last search to publication, an SER is often outdated even before publication. The difficulty in reusing previous review data has resulted in multiple reviews of the same trials. Thus, it will be useful to create a normalized evidence base from recently published/presented biomarker-trial outcome data that one can quickly update. We present a new approach to semi-automating normalized, open-access data tables from published clinical trials of metastatic prostate cancer using a data curation and SER platform. Clinicaltrials.gov and Pubmed.gov were used to collect mCRPC clinical trial publications with HRD/DRD biomarkers. We extracted data from 13 publications covering ten trials that started before 22nd Apr 2021. We extracted 585 hazard ratios, response rates, duration metrics, and 543 adverse events. Across 334 patients, we also extracted 8,180 patient-level survival and biomarker values. Data tables were populated with survival metrics, raw patient data, eligibility criteria, adverse events, and timelines. A repeated strong association between HRD and improved PARP inhibitor response was observed. Several use cases for the extracted data are demonstrated via analyses of trial methods, comparison of treatment hazard ratios, and association of treatments with adverse events. Machine learning models are also built on combined and normalized patient data to demonstrate automated discovery of therapy/biomarker relationships. Overall, we demonstrate the value of systematically extracted and normalized data. We have also made our code open-source with simple instructions on updating the analyses as new data becomes available, which anyone can use even with limited programming knowledge. Finally, while we present a novel method of SER for mCRPC trials, one can also implement such semi-automated methods in other clinical trial domains to advance precision medicine.

Time to Venous Thromboembolism Events Following Total Hip Arthroplasty: A Comparison Between Aspirin and Warfarin.

BACKGROUND: The attitude and approach of orthopedic community for minimizing venous thromboembolism (VTE) has evolved over the last decade with the trend toward use of aspirin (and mechanical modalities) in lieu of aggressive anticoagulation. The optimal length of VTE prophylaxis following total hip arthroplasty (THA) still remains unknown. This study aimed to determine the timing of VTE in patients who received aspirin compared to warfarin, and determine if 30 days of prophylaxis remain adequate. METHODS: This is a retrospective study of 18,003 patients undergoing primary and revision THA at a single institution between January 2008 and August 2020. During this time, our institution underwent a transition from the use of warfarin to aspirin as the main method for VTE prophylaxis. Symptomatic deep vein thrombosis and pulmonary embolism occurring within 90 days of surgery were identified from medical records and phone call logs. Aspirin and warfarin cohorts were matched to account for demographic and comorbidity differences. Timing of pulmonary embolism was determined based on either the date of diagnostic imaging or patient-provider phone calls confirming diagnosis. RESULTS: The cohorts included 46 patients in the warfarin group and 46 in the aspirin group. Time to VTE was significantly shorter in the warfarin group compared to aspirin (P = .021) with a median time to VTE of 3 days (interquartile range 2-14) and 10 days (interquartile range 4-19) respectively. Over 90% of the events occurred within 32 or 30 days of surgery in the warfarin and aspirin groups respectively. CONCLUSION: Based on the findings, a 30-day aspirin prophylaxis remains appropriate for patients undergoing THA.

Impact of Intraoperative Hypothermia on Transfusion Requirements in Patients With Pelvic and Acetabular Trauma.

OBJECTIVES: To explore the association between intraoperative hypothermia and perioperative blood loss and blood transfusion requirements in patients with operative pelvic and acetabular fractures. DESIGN: Retrospective review. SETTING: Single, Level 1 trauma center in Atlanta, Georgia. PATIENTS/PARTICIPANTS: Three hundred seventy-four patients who underwent surgical fixation of an acetabular fracture and/or pelvic ring injury at a single Level 1 trauma center during the years 2013-2017. MAIN OUTCOME MEASURES: Estimated blood loss during surgery (EBL, mL), drain output (mL) on postoperative day 1 (POD1), and rate of postoperative packed red blood cell (pRBC) transfusion (%). RESULTS: A significant association was found between intraoperative hypothermia and postoperative transfusion requirement (P = 0.016). The rate of postoperative blood transfusion was 42% for patients with intraoperative hypothermia compared with 28% for controls. In a subgroup analysis of patients presenting with an admission acidosis, the rate of postoperative transfusion was significantly increased to more than 4 times as likely when intraoperative hypothermia was present, even after controlling for admission hemoglobin, Injury Severity Score, and rate of preoperative transfusion (OR 4.4; P = 0.018). CONCLUSIONS: For patients with pelvic trauma who present with an admission acidosis, intraoperative hypothermia is an independent risk factor for postoperative blood transfusion. This information is clinically important given the modifiable nature of intraoperative patient temperature and the known complications and sequelae associated with increased transfusion rates. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes Following Revision for Mechanically Assisted Crevice Corrosion in a Single Femoral Design.

BACKGROUND: Mechanically assisted crevice corrosion (MACC) is a described complication following metal-on-polyethylene (MoP) total hip arthroplasty (THA). The literature regarding outcomes following revision for MACC suggests that complication rates are high. The purpose of this investigation is to add to this literature with the largest reported series to date. METHODS: This is a retrospective cohort study of 552 consecutive patients who underwent 621 MoP primary THAs. We identified patients who subsequently underwent revision THA for a diagnosis of MACC. All patients were implanted with the same implant combination (Accolade I stem/cobalt-chromium low friction ion treatment femoral head). Patient demographic, surgical, and laboratory data were collected. Follow-up was calculated from the revision surgery and Hip Disability and Osteoarthritis Outcome Score Joint Replacement and hip subjective values (HSV) were examined at final follow-up. Descriptive statistics were performed. RESULTS: The revision rate for MACC was 11.6% and mean time to revision was 6.6 (±2.4) years. Revised patients (n = 69) had a mean preoperative serum cobalt-chromium ratio of 3.5 (±2.4). There were 8 cases of gross trunnion failure. At mean 3.2 (±1.9) years following revision, the overall major complication rate was 11.6% with a 5.8% reoperation rate. At final follow-up, mean Hip Disability and Osteoarthritis Outcome Score Joint Replacement scores were 83.2 (±15.6) and mean hip subjective value was 77.6 (±17.4). Revision resulted in significant increases in both parameters (P < .001). CONCLUSION: The incidence of MACC in MoP THA is likely higher than previously reported, particularly for certain implant combinations. Revision surgery for MACC can achieve good outcomes but a high clinical suspicion with early detection and revision is likely key to success.

Thirty Days of Aspirin for Venous Thromboembolism Prophylaxis Is Adequate Following Total Knee Arthroplasty, Regardless of the Dose Used.

BACKGROUND: The optimal length of aspirin prophylaxis to minimize venous thromboembolism (VTE) following total knee arthroplasty (TKA) remains unknown. This study aimed to determine the timing of VTE after TKA in patients who received low and high dose aspirin, and determine if 30 days of prophylaxis remains adequate. METHODS: We retrospectively reviewed records of 9208 patients undergoing primary TKA between 2010 and 2020 who received either low (81 mg twice daily, n = 4413) or high (325 mg twice daily, n = 4795) dose aspirin for VTE prophylaxis. Symptomatic VTEs occurring within 90 days of surgery were identified from medical records and phone call logs. Major bleeding events (MBE) within the first 30 days were also documented. Time to event was recorded. RESULTS: Overall, 88 patients (1.0%) developed symptomatic VTE, with no significant differences in incidence between the low (n = 40, 0.9%) and high (n = 48, 1.0%) dose groups (P = .669). The median time to VTE was 8 days (interquartile range [IQR] 2-15.5), median time to deep vein thrombosis was 12 days (IQR 5-18), and median time to pulmonary embolism was 5 days (IQR 1.5-15). There was a similar distribution in time to VTE in both the low and high dose groups. Aside from a single DVT occurring at day 44, all VTE occurred within 30 days of surgery. During the prophylactic time period, 41 patients (0.4%) developed MBE, which tended to occur more frequently (0.6% vs 0.3%, P = .018) and earlier in the high dose group. CONCLUSION: Based on the findings, a 30-day low or high dose aspirin regimen remains optimal for prevention of VTE without increasing MBE in TKA patients.

Capsular Management in Direct Anterior Total Hip Arthroplasty: A Randomized, Single-Blind, Controlled Trial.

BACKGROUND: The direct anterior approach (DAA) is a popular approach to total hip arthroplasty (THA). Unlike the posterior approach, the importance of anterior capsular management is unknown. This randomized controlled trial compares capsular repair versus capsulectomy. METHODS: This single-surgeon, single-blinded, parallel-group randomized controlled trial occurred between 2013 and 2016. Patients undergoing unilateral, primary THA for osteoarthritis consented to undergo blinded, simple randomization to anterior capsulotomy with repair or anterior capsulectomy. Primary outcome measures included hip range of motion, hip flexion strength, and pain with seated hip flexion. Secondary outcome measures included surgical time, estimated blood loss, postoperative complications, and hip disability and osteoarthritis outcome score. Data were prospectively collected intraoperatively, six weeks, six months, an average of over 5 years postoperatively. RESULTS: Ninety-eight patients were ultimately enrolled in the trial; 50 received capsulectomy and 48 received capsulotomy. No significant differences were seen in preoperative demographics or in primary or secondary outcomes during this study. No difference was seen in pain at final follow-up at average > 5 years postoperatively. CONCLUSION: This study demonstrates that capsular management in DAA THA does not affect postoperative pain or range of motion. The anterior capsule's role in prosthetic stability after DAA THA remains uncertain, but it does not currently appear that repair provides benefit and may lead to increased surgical time and blood loss. As such, capsular management in DAA THA is at surgeon discretion.

Feasibility of Rapid Development and Deployment of a Telemedicine Program in a Foot and Ankle Orthopedic Practice.

BACKGROUND: A lack of access to care is predictably associated with negative outcomes in foot and ankle surgery. Despite recent advances in telecommunication technologies, the field of orthopedics has been slow to adopt these resources in offsetting barriers to care. The COVID-19 pandemic has forced departments to change their clinical approach, lending unprecedented opportunity to better understand how telehealth may bridge this care gap in foot and ankle practices. The purpose of this study was to assess patient-reported outcomes of telemedicine encounters, including comfort and patient satisfaction. Our hypothesis was that patients would be significantly less satisfied with telemedicine when compared with in-office appointments for all nonemergency visit types. METHODS: Telemedicine satisfaction was assessed via phone survey with a modified 1 to 5 Likert scale. Patients who had completed a telemedicine visit between April 13, 2020, and June 19, 2020, were eligible to participate. Patient demographics were recorded, and data were analyzed using paired and independent t tests for parametric continuous data and Fisher's exact and chi-square tests for noncontinuous data. A total of 216 patients completed the telemedicine questionnaire. RESULTS: The overall mean satisfaction for telemedicine visits (4.7) was significantly lower than that for in-office visits (4.9) (P < .001). However, the majority (90.3%) of patients reported they would use telemedicine again in the future. When compared, patients seeking fracture care had significantly higher telemedicine satisfaction (4.9, n = 38) than those receiving nonfracture care (4.6, n = 178) (P = .001), and those greater than 50 miles from the clinic had higher satisfaction (5.0, n = 14) than patients living within 50 miles of the clinic (4.7, n = 202) (P < .001). CONCLUSION: Patients were more satisfied with their in-office clinic visit than telemedicine, although the vast majority of patients endorsed a willingness to utilize telemedicine in the future. Patients with trauma and greater barriers to foot and ankle care were more satisfied with their telemedicine visits. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department.

Importance: Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed. Objective: To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures. Design, Setting, and Participants: This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019. Main Outcomes and Measures: Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care. Results: Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03). Conclusions and Relevance: The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

Tourniquet Use Does Not Affect Functional Outcomes or Pain After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial.

BACKGROUND: The use of a tourniquet during total knee arthroplasty (TKA) is controversial. Pain and return to function are believed, by some, to be influenced by the use of a tourniquet. The hypothesis of this study was that use of a tourniquet would delay postoperative functional recovery and increase pain as compared with no tourniquet use. METHODS: Two hundred patients were recruited for this prospective, double-blinded, randomized controlled trial. Patients were randomized to undergo TKA either with a tourniquet (100 patients) or without one (100 patients) and blinded to group allocation. Primary outcome measures were functional assessment testing using the Timed Up & Go (TUG) test and visual analog scale (VAS) pain scores. Secondary outcome measures included the stair-climb test, blood loss, surgical field visualization, and range of motion. Outcome measures were completed preoperatively, in the hospital, and postoperatively at a first and a second follow-up. The minimal detectable change, Student t test, Fisher exact test, and nonasymptotic chi-square analysis with an alpha of p < 0.05 were used to determine significance. RESULTS: The no-tourniquet group had more calculated blood loss (1,148.02 mL compared with 966.64 mL; p < 0.001) and more difficulty with surgical field visualization (p < 0.0001). The tourniquet group had greater knee extension at the first follow-up (-7° compared with -9°; p = 0.044). CONCLUSIONS: Tourniquet use during TKA significantly decreases blood loss and does not adversely affect early postoperative outcomes. Tourniquet use during routine TKA is safe and effective, and concerns about deleterious effects on function and pain may not be justified. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Patients With Infected Total Hip Arthroplasty Undergoing 2-Stage Exchange Arthroplasty Experience Massive Blood Loss.

BACKGROUND: Two-stage exchange arthroplasty is the preferred treatment for chronic periprosthetic joint infection following total hip arthroplasty (THA). These patients are at high risk of substantial blood loss and perioperative blood transfusion. Our study aimed at determining risk factors for blood transfusion during a 2-stage exchange for infected THA. METHODS: Medical records of 297 patients with infected THA who underwent 2-stage exchange arthroplasty from 1997 to 2016 were reviewed. Blood loss was calculated using a validated formula. Transfusion data, clinical information, and operative data were gathered to determine predictors of blood loss and risk factors for perioperative allogeneic blood transfusion. RESULTS: Calculated blood loss was significantly higher during reimplantation than resection arthroplasty (5156.0 ± 3402 mL vs 3706.9 ± 2148 mL; P < .0001). Blood transfusion was needed in 81% after resection and 81.1% after reimplantation. Allogeneic blood transfusion averaged 3.6 ± 1.8 units for stage 1 and 4.2 ± 2.9 units for stage 2 (P = .0066). Patient characteristics that increased the likelihood for perioperative blood transfusions were increasing preoperative international normalized ratio, type 2 diabetes, current smoking, age, and transfusion requirement in the first stage. Tranexamic acid usage was associated with decreased blood loss. CONCLUSION: Patients with periprosthetic joint infection following THA have significant blood loss during both stages of exchange arthroplasty, especially reimplantation. Hematological optimization should be considered in all patients requiring a transfusion after the first stage, as these patients are at greater risk of requiring transfusion after the second stage. The use of tranexamic acid dramatically decreases the risk of requiring a transfusion in both stages and should be more ubiquitously incorporated into blood management protocols.

Increased Postoperative Glucose Variability Is Associated with Adverse Outcomes Following Total Joint Arthroplasty.

BACKGROUND: Increased glucose variability during hospitalization has been associated with a longer length of stay in the hospital and a higher mortality rate following non-orthopaedic surgical procedures. Our aim was to investigate the association between glucose variability and postoperative complications following total joint arthroplasty. METHODS: We analyzed data on 21,487 patients who had undergone total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a single center from 2001 to 2017. Patients with a minimum of 2 postoperative glucose values per day or >3 values overall were included in the study. Glucose variability was assessed using a coefficient of variation. Adverse outcomes included an increased length of stay in the hospital, 90-day mortality, reoperations, periprosthetic joint infection, and surgical site infection. Periprosthetic joint infection was defined using the Musculoskeletal Infection Society criteria. RESULTS: The final cohort included 2,360 patients who had undergone THA and 2,698 who had undergone TKA; 1,007 (19.9%) had diabetes. Higher glycemic variability was associated with an increased length of stay, 90-day mortality, periprosthetic joint infection, and surgical site infection. Adjusted analysis indicated that for every 10-percentage-point increase in the coefficient of variation, the length of stay increased by 6.1% (95% confidence interval [CI], 5.1% to 7.2%; p < 0.001), the risk of mortality increased by 26% (odds ratio [OR] = 1.26, 95% CI = 0.98 to 1.61; p = 0.07), and the risks of periprosthetic joint infection and surgical site infection increased by 20% (OR = 1.20, 95% CI = 1.02 to 1.41; p = 0.03) and 14% (OR = 1.14, 95% CI = 1.00 to 1.31; p = 0.06), respectively. These associations were independent of the year of surgery, age, body mass index, Elixhauser comorbidity index, diagnosis of diabetes, in-hospital use of insulin or steroids, and mean glucose values during hospitalization. CONCLUSIONS: Higher glucose variability in the postoperative period is associated with increased rates of surgical site and periprosthetic joint infections and may be a useful predictor of the risk of mortality following THA and TKA. Efforts should be made to control the glucose variability in the early postoperative period, and future studies should examine the role of continuous glucose monitoring in a subset of patients with high glucose fluctuations. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Periarticular Ropivacaine Cocktail Is Equivalent to Liposomal Bupivacaine Cocktail in Bilateral Total Knee Arthroplasty.

BACKGROUND: This study compares the effectiveness of 2 commonly used periarticular injection formulations: liposomal bupivacaine and bupivacaine (EXP) and ropivacaine, epinephrine, ketorolac, and clonidine (ROP) in patients undergoing bilateral total knee arthroplasty or unicompartmental knee arthroplasty. METHODS: Twenty-six total knee arthroplasty patients (52 knees) and 3 unicompartmental knee arthroplasty patients (6 knees) undergoing simultaneous, bilateral arthroplasty were randomized to receive periarticular injections in a blinded fashion. Even birth year patients were selected for PAI of EXP in the right knee and ROP in the left knee. This was reversed for odd birth years. Visual analog scale pain scores for each knee and patient perceived difference in knee functional recovery were recorded during physical therapy, throughout the hospitalization. RESULTS: There was no difference in visual analog scale pain scores between the EXP and ROP injected knees at any time point during the first 2 days after surgery. Postoperative pain scores averaged 41.9 mm (range 0-100 mm) for EXP and 43.1 mm (range 0-100 mm) for ROP. Patients were unable to detect a difference in the functional recovery between their knees on postoperative day 0, 1, or 2. No complications as a result of either periarticular injection occurred. CONCLUSION: Periarticular injections of EXP and ROP are equally effective after knee arthroplasty and patients do not appreciate differences between knees as determined by pain score or perceived functional recovery during the first 2 days after bilateral knee arthroplasty. This study demonstrates that a liposomal bupivacaine injection does not add an incremental benefit for pain control compared to a less expensive injection formulation.