Return to Cycling After Total Joint Arthroplasty.

BACKGROUND: As total joint arthroplasty (TJA) candidates become younger, patients' expectations continue to expand. We surveyed our patient population to determine rates of return to cycling after TJA so that we could provide more accurate counseling on performance and safety. METHODS: At our single institution, an online survey was generated and sent out to patients who had at least 3 months of follow-up. Patients were split into 4 categories based on surgery type: single total hip arthroplasty (THA), single total knee arthroplasty (TKA), multiple TJA, and revision TJA. RESULTS: A total of 1,029 surveys fit the inclusion criteria. The average age of the patient population was 69 years, with an average of 4.08 years from their time of most recent TJA surgery (maximum follow-up of 18.61 years). Nearly all those who were able to bike prior to surgery were able to return to cycling, with only 6% not being able to do so. There were 41.8% who returned to cycling less than 3 months after surgery. Most cyclists were able to return to their previous level. Patients who had a revision TJA had significantly lower rates of returning to cycling in comparison to single TKA, single THA, and multi-TJA (37.3%, 60.3%, 61.9%, and 60.3%, respectively, P < .005). Patients who never returned to cycling had higher revision rates in comparison to those who were able to get back on a bike (14.4 versus 9.2%, P = .01). CONCLUSIONS: A large proportion of patients who had prior cycling experience were able to return to bike riding within 3 to 6 months after TJA. Individuals who had revision TJA had lower rates of return to cycling in comparison to single TKA, single THA, and multi-TJA. Returning to cycling did not result in higher rates of revision.

Perioperative Sleep Quality Disturbances in Total Joint Arthroplasty is Multifactorial.

BACKGROUND: Sleep quality following arthroplasty procedures is important for patient recovery and satisfaction, but remains poorly understood. The purpose of this study was to report risk factors for sleep disturbances in the perioperative period in patients undergoing primary total joint arthroplasty procedures. METHODS: Sleep surveys were prospectively collected on 751 consecutive patients undergoing total joint arthroplasty at our institution between June 2019 and February 2021 at their preoperative and postoperative visits (2 and 6 weeks). Data were collected on patient demographics, opioid use (preoperatively and postoperatively) as well as tobacco and alcohol use, and specific medical diagnosis that may influence sleep patterns (ie, depression). Statistical analyses were performed using the Student's t-tests and 1-way analysis of variances. RESULTS: For both total hip and total knee patients, worse sleep patterns preoperatively were found in patients who used opioids prior to surgery (P < .001), were current smokers (P < .001), and were aged less than 65 years (P < .001). Postoperative persistent opioid use (more than 3 months) was seen in patients who had worse reported sleep quality preoperatively (P < .001). In comparison to total hip arthroplasty, patients who underwent total knee arthroplasty were more likely to report less sleep in the postoperative period. Patients who were current smokers (compared to nonsmokers or previous smokers) (P = .014) had worse sleep quality at all time points that persisted at 6 weeks, although these differences were seen more in total hip patients than in total knee patients (P = .006 versus P = .059). CONCLUSIONS: Sleep quality disturbances around the time of surgery appear to be multifactorial. LEVEL OF EVIDENCE: Therapeutic Level III.

Patellofemoral Arthroplasty.

Patellofemoral arthroplasty (PFA) as a treatment option for isolated patellofemoral disease continues to evolve. Enhancement in patient selection, surgical technique, implant design, and technology has led to improved short-term and midterm outcomes. Furthermore, in the setting of a younger patient with isolated patellofemoral arthritis, PFA represents an option for improved function with faster recovery times, bone preservation, maintenance of ligamentous proprioception, and the ability to delay total knee arthroplasty (TKA). The most common reason for revising PFA to a TKA is progression of tibiofemoral arthritis. In general, conversion of PFA to TKA leads to successful outcomes with minimal bone loss and the ability to use primary TKA implants and instrumentation. PFA seems to be a cost-effective alternative to TKA in appropriately selected patients with 5-, 10-PFA survivorships of 91.7% and 83.3%, respectively, and an annual revision rate of 2.18%; however, more long-term clinical studies are needed to determine how new designs and technologies affect patient outcomes and implant performance.

Screening and Management of Malnutrition in Total Joint Arthroplasty.

Malnutrition is an increasingly prevalent problem in patients undergoing total joint arthroplasty (TJA). Increased risks associated with TJA in the setting of malnourishment have been well documented. Standardized scoring systems in addition to laboratory parameters such as albumin, prealbumin, transferrin, and total lymphocyte count have been developed to identify and evaluate malnourished patients. Despite an abundance of recent literature, there is no consensus on the best approach for screening TJA patients from a nutritional standpoint. Although there are a variety of treatment options, including nutritional supplements, nonsurgical weight loss therapies, bariatric surgery, and the involvement of dieticians and nutritionists, the effect of these interventions on TJA outcomes has not been well characterized. This overview of the most current literature aims to provide a clinical framework for approaching nutrition status in arthroplasty patients. A comprehensive understanding of the tools available for managing malnourishment will facilitate improved arthroplasty care.

Self-Reported Cannabis Use Is Associated With a Lower Rate of Persistent Opioid Use After Total Joint Arthroplasty.

Background: Legalization of cannabis, along with concern over prescription opiate use, has garnered interest in cannabis for adjuvant pain control. This study examines the relationship between cannabis and opioid consumption after total hip (THA) or knee (TKA) arthroplasty. Methods: Patients undergoing primary THA or TKA with minimum 6-month follow-up who self-reported cannabis use were retrospectively reviewed. A total of 210 patients (128 TKAs and 82 THAs) were matched by age; gender; type of arthroplasty; Charlson Comorbidity Index; and use of nicotine, antidepressants, or benzodiazepines to patients who did not self-report cannabis use. Patients receiving an opioid prescription after 90 days postoperatively were classified as persistent opioid users (POUs). Duration of opioid use (DOU) was calculated for non-POU patients as the time between surgery and their last opioid prescription. Differences in inpatient morphine milligram equivalents (MMEs), outpatient MMEs, POU, and DOU were analyzed. Results: Cannabis users required equivalent inpatient and outpatient MMEs. There was no difference in DOU. There was a significant difference in POU between cannabis users and matched controls (1.4% [n = 3] vs 9.5% [n = 20], P < .001, respectively). Grouping patients by TKA or THA, there remained a difference in POU for TKA (1.5% [n = 2] vs 10.9% [n = 14], P = .002) and THA (1.2% [n = 1] vs 7.3% [n = 6], P = .04). There was no difference in inpatient or outpatient MMEs or DOU for THA and TKA patients. Conclusions: There is a reduced rate of POU in patients who self-report perioperative cannabis use. Prospective studies are needed to clarify the role of cannabis as an adjunct to perioperative pain control.

Evaluation of Low-Dose Versus High-Dose Opioid Pathway in Opioid-Naïve Patients After Total Knee Arthroplasty.

BACKGROUND: Pain control after total knee arthroplasty (TKA) remains challenging. Tramadol is a weak opioid with potentially lower side effects and risk for dependency than stronger opioids. The purpose of this study was to evaluate efficacy and safety of tramadol after TKA in opioid-naïve patients compared with stronger opioids. METHODS: A retrospective review of patients who underwent primary TKA was performed. In September 2018, opioid-naïve patients were prescribed tramadol instead of oxycodone. Patients receiving tramadol (low-opioid group) were matched to patients discharged with oxycodone before this transition (high-opioid group). We compared morphine milligram equivalent (MME) consumption and outcomes up to 3 months postoperatively. RESULTS: Two-hundred and five patients underwent TKA, with 126 receiving tramadol. Fourteen patients were converted to stronger opioid (11.2% conversion rate). Seventy patients from the low-opioid group were matched to 70 patients in the high-opioid group. Average daily inpatient MME consumption was higher in the high-opioid group (40.0 ± 27.4 vs 16.3 ± 10.9, P = .000). Outpatient prescribed MME was significantly higher in the high-opioid group (135.5 ± 71.5 vs 75.3 ± 51.3, P = .000) along with a higher number of refills (0.53 ± 1.1 vs 0.886 ± 0.94, P = .041). Knee range of motion was not statistically different at any timepoint postoperatively. There was higher adverse event rate in the low-opioid group (8.6% vs 5.7%) but not statically significant. CONCLUSIONS: Low opioid regimen following TKA showed lower MME consumption than high opioid regimen with no effect on outcomes up to 3 months. Use of low opioid regimen should be considered for TKA surgery.

Incidence and Risk Factors of Orthostasis After Primary Hip and Knee Arthroplasty.

BACKGROUND: Postoperative orthostatic intolerance can limit mobilization after hip and knee arthroplasty. The literature is lacking on the incidence and risk factors associated with orthostatic intolerance after elective arthroplasty. METHODS: A retrospective case-control study of primary total hip, total knee, and unicompartmental knee arthroplasty patients was conducted. Patients with orthostatic events were identified, and potential demographic and perioperative risk factors were recorded. Orthostatic intolerance was defined as postoperative syncope, lightheadedness, or dizziness, limiting ambulation and/or requiring medical treatment. Statistical analysis was completed using Pearson's chi-square test for categorical data and t-tests for continuous data. Binary logistic regression was performed. RESULTS: A total of 500 consecutive patients were included. The overall incidence of orthostatic intolerance was 18%; 25% in total hip arthroplasty (THA) and 11% in total knee arthroplasty. On univariate analysis, significant risk factors for developing postoperative orthostatic intolerance include older age, female gender, THA surgery, lower American Society of Anesthesiologists class, absence of recreational drug use, lower estimated blood volume, lower preoperative diastolic blood pressure, spinal with monitored anesthesia care (MAC), posterior approach for THA, bupivacaine use in spinal, percent of blood loss, postoperative oxycodone or tramadol use, higher postoperative intravenous fluid volume, and lower postoperative hemoglobin. Multivariate analysis demonstrated persistent significance of female gender, THA surgery, spinal with MAC, bupivacaine use in spinal, and more intravenous fluid administered postoperatively. CONCLUSION: Orthostatic intolerance affects a significant number of arthroplasty patients. Awareness of risk factors and modification of perioperative variables linked to orthostatic intolerance may assist the surgeon in choosing the appropriate surgical setting, educating patients, and improving early postoperative recovery.

Bone Cement Hypersensitivity in Patients With a Painful Total Knee Arthroplasty: A Case Series of Revision Using Custom Cementless Implants.

Little is known about patients with bone cement hypersenstivity after total knee arthroplasty (TKA). We present 7 patients implanted with 8 TKAs with clinical failure and a cement hypersensitivity diagnosis. All demonstrated hypersensitivity to bone cement via skin patch and/or lymphocyte transformation testing. All 7 patients also showed hypersensitivity to metal, most commonly nickel. Patients underwent custom cementless TKA revision. Prerevision and postrevision outcome measures, radiographs, intraoperative findings, and postrevision complications are reported. Functional scores improved after revision except Veterans RAND-12 mental component scores, which declined. Four patients continue to exhibit symptoms postoperatively, while one patient has had 3 additional surgical procedures. Patients presenting with bone cement hypersensitivity after TKA are particularly challenging. Evidence-based guidelines are lacking, and revision surgery may not relieve the presenting symptoms.

Incidence and Predictive Risk Factors of Postoperative Urinary Retention After Primary Total Knee Arthroplasty.

BACKGROUND: Postoperative urinary retention (POUR) after total knee arthroplasty (TKA) may cause urologic injury and delay patient discharge. This study measures the incidence of POUR and identifies predictive risk factors. METHODS: Two-hundred seventy-one consecutive patients undergoing primary unilateral TKA were prospectively enrolled. Bladder scans were performed in the postanesthesia care unit (PACU) and every four hours thereafter. POUR was defined as >400cc with inability to void and was treated with catheterization. Patient demographics, urologic history, operative data, perioperative medications, and bladder scanner volumes were investigated with the univariate and multivariate logistic regression analysis. RESULTS: Fifty-five patients (20%) developed POUR. Compared with non-POUR patients, PACU bladder scan volumes were greater in patients who developed POUR (344cc vs 120cc, P < .001). POUR patients had lower BMI (27.8 vs 29.4, P = .03), longer operative duration (83.9 vs 76.0 minutes, P = .002), and lower ASA scores (2.2 vs 2.4, P = .02). Total intravenous fluid was equivalent between groups (1134cc vs 1185cc, P = .41). POUR patients received less narcotics measured by morphine milligram equivalents (16.1 vs 23.9, P < .001). Fifteen variables including spinal type (bupivacaine and ropivacaine) and paralytic use were not predictive of POUR. Potentially predictive variables included anesthetic types administered (spinal, general, regional, and combination) and perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs), glycopyrrolate, and muscle relaxants. The multivariate analysis showed that NSAIDs (P = .05) and glycopyrrolate (P = .04) were significant predictors. CONCLUSION: A significant percentage of patients develop POUR after TKA. Select patient demographics and PACU bladder scanning may identify those at risk. Appropriate pain control and judicious use of perioperative NSAIDs and glycopyrrolate may help minimize the risk of POUR.

Usefulness of Perioperative Laboratory Tests in Total Hip and Knee Arthroplasty: Are They Necessary for All Patients?

BACKGROUND: Laboratory studies are routinely obtained preoperatively and postoperatively for total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study evaluates the necessity of routine, perioperative laboratory tests and identifies risk factors for laboratory-associated interventions. METHODS: This retrospective review evaluated 967 consecutive patients scheduled for primary, unilateral TKAs (n = 593) or THAs (n = 374) over an 18-month period at a single institution. Preoperative prothrombin time (PT) and International Normalized Ratio (INR), complete blood count (CBC), complete metabolic panel (CMP), and postoperative CBC and basic metabolic panel (BMP) were recorded along with any laboratory-associated intervention. Patient demographics and comorbidities identified risk factors for abnormal or actionable laboratory studies. RESULTS: Preoperatively, the actionable rates for PT/INR, CMP, and CBC were 0.3%, 1.4%, and 0.5%, respectively. Vascular, renal, and immunologic diseases were risk factors for an actionable CBC. Risk factors for an actionable CMP include cardiac arrhythmia and diabetes. There were no risk factors for an actionable PT/INR. Postoperatively, only 1.5% of BMPs and 1.5% of CBCs were actionable. Congestive heart failure, renal disease vascular disease, or history of cancer (P = .030) were risk factors for an actionable CBC. There were no risk factors for an actionable BMP. Patients with an abnormal preoperative lab were 2.4 times more likely to have an actionable postoperative lab. Patients with an actionable preoperative lab were 11.3 times more likely to have an actionable postoperative lab. CONCLUSION: Routine preoperative and postoperative labs may not be necessary on all patients undergoing a TKA or THA. Comorbid risk factors and abnormal or actionable preoperative CMPs and CBCs can help determine the usefulness of postoperative laboratory assessments.

Alpha-Defensin Is Not Superior to Traditional Diagnostic Methods for Detection of Periprosthetic Joint Infection in Total Hip Arthroplasty and Total Knee Arthroplasty Patients.

BACKGROUND: Synovial fluid alpha-defensin (AD) may improve diagnostic accuracy of periprosthetic joint infection (PJI) following total knee (TKA) and hip (THA) arthroplasty but is only available as send-out test. This study evaluated laboratory result accuracy between send-out test vs hospital labs and if AD made a difference in treatment plan. METHODS: A retrospective review was performed of 152 consecutive patients with a TKA or THA joint aspiration for painful or clinically concerning joint. Synovial fluid was sent to our institution (hospital-based labs, HBL) and send-out immunoassay laboratory (Synovasure). Patients were scored with specific criteria from validated scoring system for PJI using HBL and Synovasure results. The score with and without AD test was compared to determine if AD impacted patient management. RESULTS: Overall, there was strong agreement between institutions for PJI diagnosis (Cohen's kappa score 0.96). Twenty-nine patients had PJI diagnosis (score ≥6), of which 28 (97%) had positive AD with 1 false-negative result. Sixty-three patients had inconclusive score (between 2 and 5) and 60 patients had negative PJI diagnosis (score ≤1). Of these patients, 5 underwent surgery for infection. Two patients had surgery for positive AD, 2 for positive culture, and 1 because of elevated HBL results. The AD test changed the PJI diagnosis and influenced decision for surgery in only 1.3% (2/152) of patients. CONCLUSION: Minimal differences were found in laboratory values between institutions. The addition of AD may be useful in cases of equivocal laboratory results but does not appear to be necessary for routine diagnosis of PJI after TKA/THA. LEVEL EVIDENCE: Level III.

The Effect of the COVID-19 Pandemic on Hip and Knee Arthroplasty Patients in the United States: A Multicenter Update to the Previous Survey.

BACKGROUND: In March 2020, elective total hip and knee arthroplasty (THA and TKA) were suspended across the United States in response to the COVID-19 pandemic. We had previously published the results of a survey to the affected patients from 6 institutions. We now present the results of a larger distribution of this survey, through May and June 2020, to electively scheduled patients representing different regions of the United States. METHODS: Fifteen centers identified through the American Association of Hip and Knee Surgeons Research Committee participated in a survey study of THA and TKA patients. Patients scheduled for primary elective THA or TKA but canceled due to the COVID-19 elective surgery stoppage (3/2020-5/2020) were included in the study. Descriptive statistics along with subgroup analysis with Wilcoxon rank were performed. RESULTS: In total, surveys were distributed to 2135 patients and completed by 848 patients (40%) from 15 institutions. Most patients (728/848, 86%) had their surgery postponed or canceled by the surgeon or hospital. Unknown length of surgical delay remained the highest source of anxiety among survey participants. Male patients were more likely to be willing to proceed with surgery in spite of COVID-19. There were minimal regional differences in responses. Only 61 patients (7%) stated they will continue to delay surgery for fear of contracting COVID-19 while in the hospital. CONCLUSION: Similar to the previous study, the most anxiety-provoking thought was the uncertainty, over if and when the canceled joint replacement surgery could be rescheduled. Patients suffering from the daily pain of hip and knee arthritis who have been scheduled for elective arthroplasty remain eager to have their operation as soon as elective surgery is allowed to resume.

Patient Perception Regarding Potential Effectiveness of Cannabis for Pain Management.

BACKGROUND: Self-reported cannabis use has increased since its recent legalization in many states. The primary objective of this study is to describe patients' beliefs regarding the potential effectiveness of cannabis and gauge patient acceptance of these compounds if prescribed by a physician. METHODS: Five hundred fifty-five consecutive new patients in a total joint arthroplasty (TJA) practice completed a questionnaire at their new patient or preoperative encounter. Questions regarding their beliefs about the potential effectiveness of cannabis for pain management were presented to the patient. Each question was scored in accordance to the agreement of the patient. Data were also collected on patient demographics, and current cannabis, tobacco, and/or alcohol use. RESULTS: Current cannabis use was reported in 20.2% (112/555) of respondents. Patients were interested in using cannabis if prescribed by a physician for acute (75.3%, 418/515) and chronic (74.4%, 415/555) pain. Seventy-seven percent (428/555) of patients believe (strongly agree or agree) that cannabis should be legalized for medical use, whereas only 39% (217/555) strongly agree or agree that cannabis should be legalized for recreational use. Patients strongly agree or agree that cannabis can help with sleep or anxiety, 44.9% (249/555) and 49.4% (274/555) respectively. Most patients had never smoked (53%, 294/555) and drink one or less alcoholic beverage per week (52.1%, 299/555). CONCLUSION: Patients believe that cannabis may be helpful for pain management after TJA and are willing to use if prescribed by their orthopedic provider. Further research is warranted to determine if cannabis is a helpful adjunct to pain management in this patient population.

Cutibacterium colonization of the anterior and lateral thigh.

AIMS: Of growing concern in arthroplasty is the emergence of atypical infections, particularly Cutibacterium (formerly Propionibacterium) sp. infections. Currently, the dermal colonization rate of Cutibacterium about the hip is unknown. Therefore, the aim of this study was to investigate colonization rates of Cutibacterium sp. at locations approximating anterior and posterolateral approaches to the hip joint. METHODS: For this non-randomized non-blinded study, 101 adult patients scheduled for hip or knee surgery were recruited. For each, four 3 mm dermal punch biopsies were collected after administration of anaesthesia, but prior to antibiotics. Prebiopsy skin preparation consisted of a standardized preoperative 2% chlorhexidine skin cleansing protocol and an additional 70% isopropyl alcohol mechanical skin scrub immediately prior to biopsy collection. Two skin samples 10 cm apart were collected from a location approximating a standard direct anterior skin incision, and two samples 10 cm apart were collected from a lateral skin incision (suitable for posterior, direct-lateral, or anterolateral approaches). Samples were cultured for two weeks using a protocol optimized for Cutibacterium. RESULTS: A total of 23 out of 404 cultures (collected from 101 patients) were positive for a microorganism, with a total of 22 patients having a positive culture (22%). Overall, 15 of the cultures in 14 patients were positive for Cutibacterium sp. (65%), of which Cutibacterium acnes comprised the majority (n = 13; 87%). Other isolated microorganisms include coagulase-negative Staphylococcus (n = 6), Clostridium (n = 1), and Corynebacterium (n = 1). Of all positive cultures, 15 were obtained from the anterior location (65%), of which seven (60%) were from the most proximal biopsy location. However, these findings were not statistically significant (anterior vs lateral, p = 0.076; proximal vs distal, p =0.238). CONCLUSION: Approximately 14% (14/101) of the patients demonstrated a positive Cutibacterium colonization about the hip, the majority anteriorly. Given the high colonization rate of Cutibacterium, alternative skin preparations for total hip arthroplasty should be considered. Cite this article: Bone Joint J 2020;102-B(7 Supple B):52-56.

The James A. Rand Young Investigator's Award: Traditional Intravenous Fluid vs. Oral Fluid Administration in Primary Total Knee Arthroplasty: A Randomized Trial.

BACKGROUND: Optimal perioperative fluid management has not been established in patients undergoing orthopedic surgical procedures. Our purpose was to investigate the effects of perioperative fluid management (ie, preoperative, intraoperative, and postoperative) on patients undergoing total knee arthroplasty (TKA). METHODS: One hundred thirty patients who met inclusion criteria undergoing primary unilateral TKA were prospectively randomized into traditional (TFG) vs oral (OFG) perioperative fluid management groups. The primary outcome was change in body weight (BW). Secondary outcome measures included knee motion, leg girth, bioelectrical impendence, quadriceps activation, functional outcomes testing, Knee injury and Osteoarthritis Outcome Score JR, VR-12, laboratory values, vital signs, patient satisfaction, pain scores, and adverse events. RESULTS: The TFG had increased BW the evening of surgery (7.0 ± 4.3 vs 3.0 ± 3.9, P < .0001), postoperative day (POD) #1 (9.1 ± 4.3 vs 4.7 ± 3.9, P < .0001), and POD #2 (6.2 ± 5.0 vs 4.4 ± 4.0, P = .032). Bioelectrical impedance showed less limb edema in the OFG (4.2 ± 29.7 vs 17.8 ± 30.3, P < .0001) on POD #1. Urine specific gravity differences were seen preoperatively between groups (OFG, more hydrated, P = .002). Systolic blood pressure decrease from the baseline was greater in the OFG on arrival to the floor (19.4 ± 13.5 vs 10.6 ± 12.8, P < .0001) and 8 (23.4 ± 13.3 vs 17.0 ± 12.9, P = .006) and 16 (25.8 ± 13.8 vs 25.8 ± 13.8, P = .046) hours after floor arrival. The TFG had more urine output on POD #1 (3369 mL ± 1343 mL vs 2435 mL ± 1151 mL, P < .0001). The OFG were more likely to go home on POD #1 than the TFG (63 vs 56, P = .02). CONCLUSION: Oral fluid intake with IVF restriction in the perioperative period after TKA may offer short-term benefits with swelling and BW fluctuations. The authors continue to limit perioperative IVFs and encourage patient initiated fluid intake.

Does the Method of Sterile Glove-Opening Influence Back Table Contamination? A Fluorescent Particle Study.

BACKGROUND: Surgical site infections (SSI) may result from inadvertent intraoperative contamination events. This study investigated the method of opening surgical gloves onto the operative field (OF) and potential contamination rates. METHODS: Twenty surgical glove packets were coated with a commercially available fluorescent particle powder. Two methods of glove openings (10 surgical glove packets in each cohort) were investigated: direct drop (DD) onto the OF vs opening and direct hand-off (DH) to a sterile intermediary (SI). Ultraviolet black light was used to quantify fluorescent particles for dispensed glove packets and the OF in both cohorts. The gloves of the SI were inspected in the DH cohort. A previously used contamination scale for fluorescent particle model contamination was employed: 0: no detectable fluorescent particle specks, 1: 1-5 specks, 2: 5-10 specks, 3: 11-100 specks, 4: >100 specks. RESULTS: The DD cohort had a median OF contamination of 4 (range, 3-4) vs 3 for the DH trials (range, 1-3; P = .001). Likewise, the median glove contamination was higher in the DD cohort, 3 (range, 2-4) vs 1 for DH (range, 0-3; P = .007). Minimal contamination was found on the hands of the SI. Total fluorescent contamination rates, including the gloves of SI in the DH cohort, revealed greater overall contamination in DD (median, 3.5; range, 2-4) vs DH cohort (median, 1; range, 0-3); (P < .001). CONCLUSION: Using a fluorescent particle model, there is a greater burden of potential contamination from dispensed glove packets and OF with DD vs DH. The DH method did not show significant fluorescent particle contamination on the SI gloves. These data support the use of the opening of gloves via DH over the DD method in total joint arthroplasty to decrease the risk of potential contamination.

Cannabis Use Does Not Affect Outcomes After Total Knee Arthroplasty.

BACKGROUND: The self-reported use of cannabis has increased since its recent legalization in several states. The primary purpose of this study is to report total knee arthroplasty (TKA) outcomes in patients using cannabis. METHODS: Seventy-one patients who underwent a primary unilateral TKA with minimum 1-year follow-up, who self-reported cannabis use, were retrospectively reviewed. The study period was from January 2014 to February 2018 at a single institution. Patients with a history of opioid consumption, alcohol abuse, tobacco, or illicit drug use were excluded. A matched control was conducted based on age, body mass index, gender, smoking status, and insurance type (surrogate of socioeconomic status) in patients with a unilateral TKA who did not report cannabis use. Outcome measures included Knee Society Scores (KSS), range of motion, Veterans RAND-12 mental and physical component scores. No preoperative differences were noted with these measures. Postoperative complications were recorded and reported. RESULTS: No difference in length of stay was noted between the users (46.9 hours ± 15.7) and nonusers (49.3 hours ± 20.4) (P = .464). In-hospital total morphine equivalents did not differ between the 2 groups (user = 137 ± 104 mg, nonuser = 146 ± 117 mg, P = .634). Postoperative range of motion did not differ between users (128.4° ± 10.4°) and nonusers (126.9° ± 7.5°) (P = .346). No mean differences in follow-up KSS (user = 180.1 ± 24.9, nonuser = 172.0 ± 33.9, P = .106) or total change (user = 61.7 ± 32.8, nonuser = 62.7 ± 30.7, P = .852) in KSS were noted. Likewise, no significant mean differences in Veterans RAND-12 (mental component scores: user = 54.8 ± 9.3, nonuser = 55.9 ± 8.79, P = .472; physical component scores: user = 48.3 ± 9.9, nonuser = 45.8 ± 10.1, P = .145) scores were demonstrated. There were no differences in readmissions (user = 5, nonuser = 4, P = .730) or reoperations (user = 5, nonuser = 2, P = .238). CONCLUSION: Cannabis use does not appear to influence (adverse or beneficial) short-term outcomes in patients undergoing a primary TKA. Further studies are warranted to determine the efficacy and safety of cannabis as a constituent of multimodal pain management following TKA before endorsements can be made by orthopedic surgeons.

What Is the Value of Component Loosening Assessment of a Preoperatively Obtained Bone Scan Prior to Revision Total Knee Arthroplasty?

BACKGROUND: Bone scintigraphy (BS) is frequently ordered to investigate cause of failure following total knee arthroplasty (TKA). Its correlation of component loosening with intraoperative findings (IFs) at the time of revision TKA (rTKA) has not been well studied. This study investigated correlations between the preoperatively obtained radiologist report (RR) of BS, preoperatively documented surgeon prediction (SP) of component loosening, and operative reports documenting IFs. METHODS: Our institutional database was retrospectively reviewed for all rTKA done after BS and revealed 96 eligible cases. The RR and SP cohorts were subdivided into all potential combinations of component loosening and were then compared with each other as well as IF. In addition to calculating the percentage correct of RR and SP compared with IF, the levels of agreement between RR and SP were compared using the kappa statistic. RESULTS: Of the 96 cases, the RR correctly correlated with IF in 35 cases (37%), whereas the SP was correct in 66 cases (69%), indicating the preoperative interpretation of the surgeon regarding component loosening at rTKA was correct more frequently (P < .001). The kappa statistic between RR and IF was only 0.23 (95% confidence interval [CI] = 0.15-0.32), indicating minimal agreement. The kappa statistic between SP and IF was 0.57 (95% = CI 0.46-0.68), indicating weak agreement. Furthermore, the kappa statistic between RR and SP was 0.36 (95% CI = 0.27-0.45), also indicating minimal agreement. CONCLUSIONS: In rTKA, there is weak agreement regarding component loosening between a radiologist's opinion of a preoperatively obtained bone scan and the surgeon's preoperative interpretation of clinical and radiographic data. While neither reliably accurately predicts what is found at the time of rTKA, the surgeon's preoperative interpretation is more closely correlated with actual IFs of component loosening.

Revisions of Modular Metal-on-metal THA Have a High Risk of Early Complications.

BACKGROUND: The risk of early complications is high after monoblock acetabular metal-on-metal (MoM) THA revisions. However, there is a paucity of evidence regarding clinical complications after isolated head-liner exchange of modular MoM THA. QUESTIONS/PURPOSES: The purposes of this study were (1) to describe the frequency of early complications after an isolated head-liner exchange revision of modular MoM THA; and (2) to determine whether patients who experienced complications or dislocation after head-liner exchanges had higher serum chromium (Cr) or cobalt (Co) ion levels than those who did not. METHODS: A review of our institution's total joint registry retrospectively identified 53 patients who underwent 54 liner exchange revisions of a modular acetabular MoM THA. The study period was from April 2008 to April 2016 at a single tertiary care center. During this period, isolated head-liner exchanges (rather than more extensive revisions) were performed in patients if they did not have evidence of loosening of the acetabular or femoral components. Reasons for revision surgery included pain, mechanical symptoms, radiographic evidence of osteolysis, elevated serum metal ions, and MRI abnormalities with 40 of the 54 hips having pain or mechanical symptoms and 38 of 54 hips having multiple reasons for revision before surgery. Patients were excluded if they did not meet the minimum postrevision followup or had the modular liner exchange secondary to infection. All revisions were from a single manufacturer with one head-liner exchange of a MoM THA from another manufacturer excluded during the study period. The mean time from index MoM THA to modular exchange was 96 (SD ± 36) months. Because the focus of this study was early complications, we had a minimum 90-day followup duration for inclusion. Mean followup after revision was 15 months (SD ± 12); a total of 56% (30 of 54) had followup of at least 12 months' duration. Complications (dislocation, infection) and reoperations were obtained by chart review performed by individuals other than the treating physician(s). Serum metal ion levels were obtained before head-liner exchange. The median serum Cr and Co levels were 6 µg/L (range, 0-76 µg/L) and 12 µg/L (range, 0-163 µg/L), respectively. RESULTS: Of the 54 revision THAs, 15 (28%) developed complications. Nine (17%) occurred within 90 days of the revision surgery and 11 (20%) resulted in reoperation. The most common complication was dislocation (12 of 54 [22%]) with recurrent dislocation noted in eight of these 12 patients. All patients with recurrent dislocation continued to dislocate and underwent repeat revision. Patients with dislocation had higher median serum Cr and Co ion levels than those without dislocation (Cr: 24 [range, 11-76] versus 4 [range, 0-70], p = 0.001 [95% confidence interval {CI}, 10-57]; Co: 41 [range, 6-163] versus 8 [range, 0-133], p = 0.016 [95% CI, 6-141]). Three (6%) of the 54 patients underwent repeat surgery for deep space infection. CONCLUSIONS: Complications and reoperations are common after modular head-liner exchange in the setting of a failed MoM THA. Our study likely underestimates the frequency of complications and revisions because the followup period in this report was relatively short. Dislocation is the most common complication and elevated serum metal ion levels may be a predictor of dislocation. These findings are concerning and surgeons should be aware of the high complication risk associated with this procedure. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Has Self-reported Marijuana Use Changed in Patients Undergoing Total Joint Arthroplasty After the Legalization of Marijuana?

BACKGROUND: Marijuana use has become more accessible since its recent legalization in several states. However, its use in a total joint arthroplasty population to our knowledge has not been reported, and the implications of its use in this setting remain unclear. QUESTIONS/PURPOSES: We report (1) the self-reported use of marijuana in patients undergoing total joint arthroplasty both before and after its legalization; and (2) clinical and demographic factors associated with marijuana use in patients undergoing total joint arthroplasty. METHODS: One thousand records of patients undergoing primary total joint arthroplasty (500 consecutive before and 500 consecutive after the legalization of the commercial sale of marijuana in Colorado) were included for analysis. Preoperative medical history and physicals were retrospectively reviewed for self-reported and reasons (medicinal versus recreational) for use. Additionally, patient records were used to determine insurance type, age, gender, smoking status, history of substance abuse, preoperative narcotic use, alcohol intake, and the type of arthroplasty performed. RESULTS: Self-reported use after legalization dramatically increased from 1% (four of 500) to 11% (55 of 500) (odds ratio [OR], 15.3 [95% confidence interval, 5.5-42.6]; p < 0.001) after legalization. For those reporting use after legalization, 46% (25 of 55) of patients reported recreational use, 26% (14 of 55) medicinal use, 27% (15 of 55) did not report a reason for use, and 2% (one of 55) reported both recreational and medicinal use. Factors associated with use included younger age (with a 10-year mean difference between the groups [p < 0.001]), male gender (36 of 59 users [61%] versus 411 of 941 nonusers [44%]; OR, 2.02; p < 0.01), current smokers (22 of 59 users [37%] versus 54 of 941 [6%] nonusers; OR, 0.09; p < 0.01), a history of substance abuse (eight of 59 users [14%] versus 18 of 941 nonusers [2%]; OR, 8.04; p < 0.001), insurance type (Medicaid only, 28 of 59 [48%] users versus 56 of 941 [6%] nonusers; OR, 20.45; p < 0.01), and preoperative narcotic use (eight of 59 users [14%] versus 17 of 941 nonusers [2%]; OR, 2.4; p < 0.001). We did not find differences with regard to alcohol use, amount of alcohol consumption, or insurance types other than Medicaid. CONCLUSIONS: These results suggest the legalization of marijuana has led to either more users or more patients who are willing to report its use given the lack of legal ramifications. Despite these findings, the evidence to date precludes the use of marijuana postoperatively in patients undergoing total joint arthroplasty. Further investigation, ideally in a prospective randomized manner, should focus on opioid consumption, nausea, sleep patterns, and outcomes in patients using marijuana who are undergoing total joint arthroplasty before recommendations can be made for its use. LEVEL OF EVIDENCE: Level III, therapeutic study.