Comparison of Early Complication Rates After High Tibial Osteotomy Versus Unicompartmental Knee Arthroplasty for Knee Osteoarthritis.

Background: Although both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) can be utilized to treat unicompartmental osteoarthritis (OA) in select patients, the early complication rates between the 2 procedures are not well understood. Understanding of the complication profiles for both procedures would help clinicians counsel patients with unicompartmental knee OA who may be eligible for either treatment option. Purpose: To compare the 30-day complication rates after HTO versus UKA for the treatment of knee OA using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Study Design: Cohort study; Level of evidence, 3. Methods: NSQIP registries between 2006 and 2019 were queried using Current Procedural Terminology codes to identify patients undergoing HTO and UKA for knee OA. Patients >60 years of age were excluded. Patient demographics, preoperative comorbidities, and intraoperative data were collected. Postoperative 30-day complications, including venous thromboembolism (VTE), urinary tract infection (UTI), transfusion, surgical-site infection (SSI), and reoperations were recorded. Complication rates between treatment groups were compared using a multivariate logistic regression model adjusted for sex, age, body mass index, steroid use, respiratory status (smoking/dyspnea/chronic obstructive pulmonary disease), diabetes, and hypertension. Results: A total of 156 patients treated with HTO and 4755 patients treated with UKA for knee OA were identified. Mean patient ages were 46 years for the HTO group and 53.4 years for the UKA group. Operative time was significantly longer in the HTO group versus the UKA group (112 minutes vs 90 minutes; P < .001). Multivariate analyses found no significant differences in VTE (1.3% vs 0.6%), UTI (0.6% vs 0.3%), transfusion (0.6% vs 0.2%), deep SSI (0.6% vs 0.1%), and reoperation (1.3% vs 1%) rates between HTO and UKA groups. The HTO group had a higher rate of superficial SSI compared with the UKA group (2.6% vs 0.6%; P = .006) (adjusted odds ratio, 4.2; 95% CI, 1.4-12.5; P = .01). Conclusion: There were no differences in 30-day VTE, UTI, transfusion, deep SSI, and reoperation rates for HTO versus UKA in the treatment of knee OA. HTO was associated with a higher rate of superficial SSI compared with UKA. These findings serve to guide clinicians in counseling patients regarding the early risks after HTO and UKA.

Repeat High-Dose Dexamethasone May Improve Recovery 48 Hours after Total Hip Arthroplasty.

Objectives: Perioperative dexamethasone is an effective anti-emetic and systemic analgesic in total hip arthroplasty (THA) that may reduce opioid consumption and enhance rapid recovery. However, there is no consensus on the optimal perioperative dosing that is safe and effective for faster rehabilitation and improved pain control while maintaining safe blood glucose levels. Methods: A retrospective review of 101 primary THA patients at a single institution who received perioperative dexamethasone was conducted. Patients were stratified by dexamethasone induction dosage (10 mg as high, <6mg as low) and whether a repeat dose was given 16-24 hours postoperatively. Age, gender, BMI, diabetes status, and ASA were controlled between groups. The pain was evaluated with inpatient morphine milligram equivalents (MME) requirements and visual analog scale (VAS) at 8, 16, and 24 hours postoperatively. Mobility was assessed by inpatient ambulation distance, Boston AM-PAC mobility score, and percentage of gait assistance as determined by a physical therapist. Secondary outcomes included postoperative nausea and vomiting (PONV) limiting therapy sessions, PONV requiring breakthrough anti-emetics, glucose levels, surgical site infection, wound healing complications, and discharge destination. Results: Compared to patients receiving one dose of high or low dexamethasone, patients receiving two dosages of high-dose dexamethasone had significantly further ambulation distance and lower percentage of gait assistance on postoperative day 2. A generalized linear model also predicted that any repeat dexamethasone, regardless of dosage, significantly improved ambulation distance and gait assistance compared to the one-dose cohort. There was no statistically significant difference between VAS scores, MME requirements, PONV, postoperative glucose levels >200, discharge destination, or risk of infection between groups. Conclusion: A repeat high-dose dexamethasone, the morning after surgery, may improve percentage of gait assistance and ambulation endurance on postoperative day two. There was no risk of uncontrolled glucose levels or infections compared to receiving one dose of dexamethasone at induction.

Alkaline Phosphatase is an Independent Risk Factor for Periprosthetic Fractures in Total Joint Arthroplasty.

BACKGROUND: Serum alkaline phosphatase (ALP) is a biomarker for chronic low-grade inflammation along with hepatobiliary and bone disorders. High abnormal ALP levels in blood have been associated with metabolic bone disease and high bone turnover. METHODS: All primary total hip and knee arthroplasties from 2005 to 2019 were queried from the National Surgical Quality Improvement Program database. Patients with available serum ALP levels were included and stratified to low (<44 IU/L), normal (44 to 147 IU/L), and high (>147 IU/L). A risk-adjusted multivariate logistic regression was used to analyze ALP as an independent risk factor of complications. RESULTS: The analysis included 324,592 patients, consisting of 11,427 low ALP, 305,977 normal ALP, and 7,188 high preoperative ALP level patients undergoing total joint arthroplasty. Adjusted multivariate logistic regression analysis showed high ALP level patients had an overall increased risk of readmission within 30 days of surgery compared with the control group (odds ratio [OR], 1.69; P < 0.01). High ALP patients also had an increased risk of postoperative periprosthetic fracture (OR, 1.6), postoperative wound infection (OR, 1.81), pneumonia (OR, 2.24), renal insufficiency (OR, 2.39), cerebrovascular disease (OR, 2.2), postoperative bleeding requiring transfusion (OR, 1.83), sepsis (OR, 2.35), length of stay > 2 days (OR, 1.47), Clostridium difficile infection (OR, 2.07), and discharge to a rehab facility (OR, 1.41) (all P < 0.05). A low ALP level was also associated with increased postoperative bleeding transfusion risk (OR, 1.12; P < 0.01) and developing a deep vein thrombosis (OR, 1.25; P = 0.03). CONCLUSION: Abnormal serum ALP levels in patients undergoing primary total joint arthroplasty are associated with increased postoperative periprosthetic fracture risk and medical complications requiring increased length of stay and discharge to a rehabilitation facility.

Preoperative Malnutrition and Metabolic Markers May Predict Periprosthetic Fractures in Total Hip Arthroplasty.

Background: Periprosthetic fractures are a devastating complication of total hip arthroplasty (THA) and are associated with significantly higher mortality rates in the postoperative period. Given the strain that periprosthetic fractures place on the patient as well as the healthcare system, identifying and optimizing medical comorbidities is essential in reducing complications and improving outcomes. Methods: All THA with primary indications of osteoarthritis from 2007 to 2020 were queried from the National Surgical Quality Improvement Program database. Demographic data, preoperative laboratory values, medical comorbidities, hospital course, and acute complications were collected and compared between patients with and without readmission for a periprosthetic fracture. A multivariate logistic regression analysis was performed to determine associated independent risk factors for periprosthetic fractures after index THA. Results: The analysis included 275,107 patients, of which 2539 patients were readmitted for periprosthetic fractures. Patients with postoperative fractures were more likely to be older (>65 years), females, BMI >40, and increased medical comorbidities. Preoperative hypoalbuminemia, hyponatremia, and abnormal estimated glomerular filtration rates were independent risk factors for sustaining a periprosthetic fracture and readmission within 30 days. Modifiable patient-related factors of concurrent smoking and chronic steroid use at the time of index THA were also independent risk factors for periprosthetic fractures. Inpatient metrics of longer length of stay, operative time, and discharge to rehab predicted postarthroplasty fracture risk. Readmitted fracture patients subsequently had increased risks of developing a surgical site infection, urinary tract infection, and requiring blood transfusions. Conclusions: Patients with hypoalbuminemia, hyponatremia, and abnormal estimated glomerular filtration rate are at increased risk for sustaining periprosthetic fractures after THA. Preoperative optimization with close monitoring of metabolic markers and modifiable risk factors may help not only prevent acute periprosthetic fractures but also associated infection and bleeding risk with fracture readmission.

Kinematic Alignment May Reduce Opioid Consumption and Length of Stay Compared to Mechanically Aligned Total Knee Arthroplasty.

OBJECTIVE: Previous studies have sought to determine the effects of total knee arthroplasty (TKA) using kinematic alignment (KA) versus mechanical alignment (MA) to reproduce the native knee alignment and soft tissue envelope for improved patient satisfaction. There are limited studies that compare acute perioperative outcomes between KA and MA patients as it pertains to pain-related opioid consumption and hospital length of stay (LOS). This study aims to compare early KA and MA in restoring function and rehabilitation after surgery to reduce hospitalization and opioid consumption. METHODS: A retrospective review of 42 KA and 58 MA primary TKA patients performed by a single surgeon between 2020-2021 was conducted. Demographics were controlled between groups and radiographic measurements and functional outcomes were compared. Pain was evaluated with inpatient/outpatient morphine milligram equivalents (MME) and visual analogue scale (VAS) scores. Mobility was assessed using multiple measures by a physical therapist. Mean preoperative and 3-month postoperative flexion range of motion (ROM) were analyzed, and overall complications, LOS, and non-home discharge between groups compared. Continuous variables were compared using the Wilcoxon rank-sum test, and categorical variables were compared using the chi-square or Fisher exact test. Statistical significance was set at P < 0.05. RESULTS: KA patients had shorter LOS (1.8 vs 3.1 days) and less cumulative opioid requirements compared to MA patients (578 vs 1253 MME). On postoperative day 0, KA patients ambulated on average twice the distance of MA patients (20 vs 6.5 feet). KA patients had residual tibia component in varus (1.4° vs -0.3°), femoral component in valgus (-1.9° vs 0.2°), and valgus joint line obliquity compared with MA (-1.5° vs 0.2°). There were no significant differences between 3-month postoperative flexion arc motion, discharge destination, KOOS or SF-12 outcomes, and surgical complication rates between groups. CONCLUSIONS: By restoring the native joint line obliquity and minimizing the frequency of ligament releases, KA for TKA may improve pain relief, early mobility, and decreased length of stay compared with traditional methods of establishing neutral limb axis by MA.

Prior Diagnosis of COVID Has No Increased Complications in Total Joint Arthroplasty.

Introduction Although a substantial portion of the United States population has been infected with and recovered from Coronavirus Disease-19 (COVID-19), many patients may have persistent symptoms and complications from disease-driven respiratory disease, arrhythmias, and venous thromboembolism (VTE). With institutions resuming elective total joint arthroplasties (TJA), it is unclear whether a prior resolved diagnosis of COVID has any implications on postoperative outcomes. Methods All elective TJA performed in 2021 at our institution were retrospectively reviewed and a history of prior COVID+ result recorded. Baseline demographics, days from prior COVID+ result to surgery date, preoperative methicillin-resistant Staphylococcus aureus (MRSA) nares colonization, and laboratory markers were obtained to determine baseline characteristics. Postoperative estimated blood loss (EBL), length of stay (LOS), rate of revision surgery, and discharge destination were compared between groups. Perioperative and postoperative rates of VTE, urinary tract infection (UTI), pneumonia, postoperative oxygen supplementation, cardiac arrhythmia, renal disease, sepsis, and periprosthetic joint infections within six months of surgery were recorded. Results Of the 155 elective TJA performed in 2021, 24 patients had a prior COVID+ diagnosis with a mean of 253 days from positive result to surgery date. There were no significant differences in baseline demographics, comorbidities, and preoperative lab markers between groups. Surgeries on patients with a prior COVID+ had a significantly higher EBL (260 vs 175cc), but postoperative outcomes of VTE, UTI, pneumonia, oxygen supplementation requirement, nares MRSA+, cardiac disease, and infection rates between groups were similar. Bivariate logistic regression revealed increased days from COVID+ diagnosis (>6 months) to surgery date were associated with a shorter LOS. Conclusion Although a prior COVID+ diagnosis had increased intraoperative blood loss, there were no significant differences in respiratory, infectious, cardiac, and thromboembolic complications up to six months after elective TJA. This study suggests that asymptomatic C+ patients receiving elective TJA do not require more aggressive prophylactic anticoagulation or antibiotic regimens to prevent VTE or perioperative infections. As institutions around the nation resume pre-COVID rates of arthroplasty surgeries, a prior diagnosis of COVID appears to have no effects on postoperative complications.

Cryoneurolysis Is a Safe, Effective Modality to Improve Rehabilitation after Total Knee Arthroplasty.

Although long term pain and mobility outcomes in total knee arthroplasties (TKA) are successful, many patients experience significant amount of debilitating pain during the immediate post-operative period that necessitates narcotic use. Percutaneous cryoneurolysis to the infrapatellar saphenous and anterior femoral cutaneous nerves may help to better restore function and rehabilitation after surgery while limiting narcotic consumption. A retrospective chart review of primary TKA patients receiving pre-operative cryoneurolysis from 2019 to 2020 was performed to assess total opioid morphine milligram equivalents (MME) consumed inpatient and at interval follow-up. Demographics and medical comorbidities were compared between cryoneurolysis and age-matched control patients to assess baseline characteristics. Functional rehabilitation outcomes, including knee range of motion (ROM), ambulation distance, and Boston AM-PAC scores, as well as patient reported outcomes using the KOOS JR and SF-12 scores were analyzed using STATA 17 Software. The analysis included 29 cryoneurolysis and 28 age-matched control TKA patients. Baseline demographics and operative technique were not significant between groups. Although not statistically significant, cryoneurolysis patients had a shorter length of stay (2.5 vs. 3.5 days) and overall less inpatient and outpatient MME requirements. Cryoneurolysis patients had statistically significant improved 6-week ROM and 1-year follow-up KOOS JR and SF-12 mental scores compared to the control. There were no differences in complication rates. Cryoneurolysis is a safe, effective treatment modality to improve active functional recovery and patient satisfaction after TKA by reducing MME requirements. Patients who underwent cryoneurolysis had on average fewer MME prescribed during the perioperative period, improved active ROM, and improved patient-reported outcomes with no associated increased risk of infections, deep vein thrombosis, or neurologic complications.

Chlorhexidine gluconate lavage during total joint arthroplasty may improve wound healing compared to dilute betadine.

PURPOSE: Intraoperative wound irrigation prior to closure during total joint arthroplasty (TJA) is an essential component of preventing infections and limiting health care system costs. While studies have shown the efficacy of dilute betadine in reducing infection risk, there remains concerns over its safety profile and theoretical inactivation by blood and serum. This study aims to compare infection and wound complications between chlorhexidine gluconate (CHG) and betadine lavage during TJA. METHODS: All primary TJA between 2019-2021 were analyzed at a single institution, and periprosthetic joint infection (PJI), wound drainage, 30 and 90-day emergency room (ER) readmission due to wound complications, aseptic loosening, and revision surgery rate were compared between patients undergoing intraoperative CHG versus betadine lavage prior to closure. Baseline demographics were controlled, and multivariate logistic regression was performed to compare complication rates. RESULTS: A total of 410 TJA, including 160 hip and 250 knee arthroplasties were included. Compared to the dilute betadine cohort, all TJA patients undergoing CHG lavage had a statistically significant lower 30 and 90-day emergency room readmission rate due to wound complications. Both hip and knee arthroplasty patients with CHG had a statistically significant lower rate of postoperative superficial drainage and dressing saturation at clinic follow-up, but only knee arthroplasty patients had significant decreased readmission rate for incisional wound vacuum placement and close inpatient monitoring of wound healing. Among all TJA, there was no significant association in the rate of PJI requiring return to the OR between groups. CONCLUSIONS: Although betadine is cost-effective and has been shown to reduce PJI rates, there remains concerns in the literature over soft tissue toxicity and wound healing. This study suggests CHG may be as efficacious as dilute betadine in preventing PJI while also decreasing the risk of superficial drainage and wound complications needing unplanned ER visits during the acute postoperative period.

Type 2 diabetes impacts colorectal adenoma detection in screening colonoscopy.

BACKGROUND: Diabetes is associated with an increased risk of colorectal cancer (CRC). We conducted a retrospective analysis of adenoma detection rates (ADR) in initial screening colonoscopies to further investigate the role of diabetes in adenoma detection. METHODS: A chart review was performed on initial average risk screening colonoscopies (ages 45-75) during 2012-2015. Data collected included basic demographics, insurance, BMI, family history of CRC, smoking, diabetes, and aspirin use. Multivariable generalized linear mixed models for binary outcomes were used to examine the relationship between diabetes and variables associated with CRC risk and ADR. RESULTS: Of 2865 screening colonoscopies, 282 were performed on patients with type 2 diabetes (T2DM). Multivariable analysis suggested that T2DM (OR = 1.49, 95% CI:1.13-1.97, p = 0.0047) was associated with an increased ADR, as well as smoking, older age, higher BMI and male sex (all p < 0.05). For patients with T2DM, those not taking diabetes medications were more likely to have an adenoma than those taking medication (OR = 2.38, 95% CI:1.09-5.2, p = 0.03). CONCLUSION: T2DM has an effect on ADR after controlling for multiple confounding variables. Early interventions for prevention of T2DM and prescribing anti-diabetes medications may reduce development of colonic adenomas and may contribute to CRC prevention.

Risk factors for venous thromboembolism in total shoulder arthroplasty.

BACKGROUND: Although venous thromboembolism (VTE) has been studied in lower-extremity arthroplasty, there are few guidelines regarding established risk factors for VTE in total shoulder arthroplasty (TSA). With literature suggesting the VTE rate may be as high as 13%, VTE prevention and risk factors should be considered in preoperative planning. METHODS: All TSAs from 2011 through 2016 were queried from the National Surgical Quality Improvement Program database. Age, sex, body mass index, American Society of Anesthesiologists class, ethnicity, functional status, comorbidities, discharge destination, surgical indication, length of stay, and operative time were compared between patients with and without 30-day postoperative VTE. Pearson χ2 and t tests were used to assess baseline categorical and continuous variables, respectively. Multivariate logistic regression analysis was conducted to determine associated independent risk factors for VTE. RESULTS: The analysis included 13,299 patients; VTE developed in 83 patients (0.62%). Patients with VTE were older (72 years vs. 69 years) and had a longer hospital stay (3.5 days vs. 1.9 days). Compared with patients with no VTE, patients with VTE were more likely to undergo TSA for proximal humeral fractures, to be discharged to a rehabilitative center, to have a preoperative albumin level lower than 3.5 g/dL, to undergo non-elective surgery, to have an American Society of Anesthesiologists class of 3 or greater, to have a surgical-site infection develop, and ultimately to need a shoulder reoperation (all P < .05). Multivariate logistic regression analysis revealed that hypoalbuminemia (albumin level < 3.5 g/dL), an increased length of stay, and African American ethnicity were independent risk factors for VTE development. CONCLUSION: Patients with hypoalbuminemia, an increased length of stay, and African American ethnicity are at an increased risk of VTE after shoulder arthroplasty. A high index of suspicion is warranted for elderly patients with fractures who may need preoperative medical optimization.

Confounders in Adenoma Detection at Initial Screening Colonoscopy: A Factor in the Assessment of Racial Disparities as a Risk for Colon Cancer.

BACKGROUND AND AIMS: The incidence and mortality of colorectal cancer is persistently highest in Black/African-Americans in the United States. While access to care, barriers to screening, and poverty might explain these findings, there is increased interest in examining biological factors that impact the colonic environment. Our group is examining biologic factors that contribute to disparities in development of adenomas prospectively. In preparation for this and to characterize a potential patient population, we conducted a retrospective review of initial screening colonoscopies in a cohort of patients. METHODS: A retrospective review was performed on initial average risk screening colonoscopies on patients (age 45-75 years) during 2012 at three institutions. Descriptive statistics and multivariable logistic regression models were used to examine the relationship between potential risk factors and the detection of adenomas. RESULTS: Of the 2225 initial screening colonoscopies 1495 (67.2%) were performed on Black/African-Americans and 566 (25.4%) on Caucasians. Multivariable logistic regression revealed that older age, male sex, current smoking and teaching gastroenterologists were associated with higher detection of adenomas and these were less prevalent among Black/African-Americas except for age. Neither race, ethnicity, BMI, diabetes mellitus, HIV nor insurance were associated with adenoma detection. CONCLUSION: In this sample, there was no association between race and adenoma detection. While this may be due to a lower prevalence of risk factors for adenomas in this sample, our findings were confounded by a lower detection rate by consultant gastroenterologists at one institution. The study allowed us to rectify the problem and characterize patients for future trials.

Early postoperative complications and discharge time in diabetic patients undergoing total shoulder arthroplasty.

PURPOSE: With the increasing elderly population and obesity epidemic, diabetes is an important factor in arthroplasty planning. Although research suggests diabetes is associated with increased postoperative morbidity after hip and knee replacement, the effect of diabetes and varying management with insulin versus non-insulin agents on total shoulder arthroplasty (TSA) is not established. METHODS: All TSAs from 2015 to 2016 were queried from the American College of Surgeons National Surgical Quality Improvement Program database. Age, gender, BMI, steroid, ASA, operative time, and smoking status were compared between all diabetics, diabetics on insulin, diabetics on non-insulin agents, and non-diabetics to account for confounding variables. Thirty-day postoperative complications, readmission rate, surgical site infection (SSI), and non-routine discharge to rehabilitation were compared using bivariate and multivariate binary logistic regression. Postoperative time to discharge between diabetic groups was analyzed using univariate ANOVA with Tukey's test. RESULTS: The analysis included 7246 patients (insulin in 5% (n = 380), non-insulin in 13% (n = 922), and non-diabetics in 82% (n = 5944)). Diabetics were more likely to have an ASA ≥ 3 compared to non-diabetics (89.5% vs 50.1%; p < 0.001). Bivariate logistic regression showed statistical significance in readmission and non-routine discharge between all diabetics and non-diabetics (OR 1.7, 1.4; p = 0.001, 0.001), but there was no significance between SSI rate (0.3% vs 0.4%; p = 0.924). Multivariate logistic regression between groups showed significance in readmission between non-insulin diabetics vs non-diabetics (OR 1.5; p = 0.027), readmission and non-routine discharge in insulin vs non-diabetics (OR 2.1, 1.7; p = 0.003, < 0.001), and no significance between insulin and non-insulin diabetics. Postoperative days to discharge were 2.4, 2.0, and 1.8 days in insulin, non-insulin, and non-diabetics respectively. Mean differences were significant between all groups. CONCLUSIONS: Diabetic patients are at a higher risk for readmission and non-routine discharge compared to non-diabetics. Despite no increased risk in SSI, longer postoperative discharge time in diabetics should be considered in TSA planning. TRIAL REGISTRATION: Not applicable LEVEL OF EVIDENCE: Level III, case-control study.