Screening for and decolonization of Staphylococcus aureus carriers before total joint replacement is associated with lower S aureus prosthetic joint infection rates.

BACKGROUND: Prosthetic joint infections (PJI) can be devastating postoperative complications after total joint replacement (TJR). The role of decolonization of Staphylococcus aureus carriers prior to surgery still remains unclear, and the most recent guidelines do not state a formal recommendation for such strategy. Our purpose was to seek further evidence supporting preoperative screening and S aureus decolonization in patients undergoing TJR. METHODS: This was a quasiexperimental quality improvement study comparing a 5-year baseline of deep and organ-space PJIs (2005- 2010) to a 1-year intervention period (May 2015 to July 2016). The intervention consisted of nasal and throat screening for S aureus preoperatively and decolonization of carriers over 5 days prior to surgery. RESULTS: Prior to the intervention, we identified 42 deep and/or organ-space PJIs in 8,505 patients undergoing TJR (0.5%). S aureus was the causal microorganism in 28 of 42 (66.6%) cases. During the intervention, 22.5% (424 of 1,883) of patients were S aureus carriers. The PJI rate was similar overall (0.4%, 7 of 1,883; odds ratio, 0.75; 95% confidence interval, 0.34-1.67; P = .58), but there was a significant reduction in S aureus PJI to only 1 case during the intervention (odds ratio, 0.15; 95% confidence interval, 0.004-0.94; P = .039). CONCLUSIONS: Active screening for S aureus and decolonization of carriers prior to TJR was associated with a reduction in PJI due to S aureus, but no changes in overall PJI rates were observed.

Not all total joint replacement patients are created equal: preoperative factors and length of stay in hospital.

BACKGROUND: We conducted a cross-sectional study of primary total joint replacement (TJR) patients to determine predictors for prolonged length of stay (LOS) in hospital to identify patient characteristics that may inform resource allocation, accounting for patient complexity. METHODS: Preoperative demographics, medical comorbidities and acute hospital LOS from a consecutive series of primary TJR patients from an academic arthroplasty centre were abstracted. We categorized patients as LOS of 3 or fewer days, 4 days, or 5 or more days to align results with varying LOS benchmarks. To identify predictors for LOS, we used a generalized logistic regression model fitted on an LOS ternary outcome, using LOS of 3 or fewer days as a reference category. RESULTS: The sample included 1459 patients: 61.7% total knee and 38.3% total hip. Male sex was predictive of an LOS of 3 or fewer days (4 d: odds ratio [OR] 0.48, 95% confidence interval [CI] 0.364-0.631; ≥ 5 d: OR 0.57, 95% CI 0.435-0.758), as was current smoking status (4 d: OR 0.425, 95% CI 0.274-0.659; ≥ 5 d: OR 0.489, 95% CI 0.314-0.762). Strong predictors of prolonged LOS included total hip versus total knee arthroplasty, age 75 years or older, American Society of Anesthesiologists classification of 3 and 4 and number of cardiovascular comorbidities. CONCLUSION: Not all patients undergoing TJR are equal. The goal should be individual patient-focused care rather than a predetermined LOS that is not achievable for all patients. Hospital resource planning must account for patient complexity when planning future bed management.

CONTEXTE: Nous avons réalisé une étude transversale auprès de patients soumis à une chirurgie pour prothèse articulaire totale (PAT) afin de déterminer les facteurs prédictifs d'une durée du séjour hospitalier (DSH) prolongée (en établissement de soins de courte durée) et de dégager les caractéristiques des patients qui permettraient d'orienter l'allocation des ressources en tenant compte de la complexité des cas. MÉTHODES: Nous avons extrait les données démographiques préopératoires, les comorbidités médicales et la DSH pour une série de cas consécutifs de PAT primaire dans un centre d'arthroplastie universitaire. Nous avons classé les patients par catégorie de DSH, soit 3 jours ou moins, 4 jours, ou 5 jours et plus, de manière à répartir les résultats selon les diverses cibles de DSH. Pour dégager les facteurs prédictifs de la DSH, nous avons utilisé un modèle de régression logistique généralisé intégré à un paramètre ternaire de DSH, en utilisant la DSH de 3 jours ou moins comme catégorie de référence. RÉSULTANTS: L'échantillon regroupait 1459 patients : 61,7 % recevant une prothèse totale du genou (PTG) et 38,3 % recevant une prothèse totale de la hanche (PTH). Le fait d'être de sexe masculin était prédictif d'une DSH de 3 jours ou moins (4 j : rapport des cotes [RC] 0,48, intervalle de confiance [IC] à 95 % 0,364­0,631; ≥ 5 j : RC 0,57, IC à 95 % 0,435­0,758), tout comme le statut à l'égard du tabagisme (4 j : RC 0,425, IC à 95 % 0,274­0,659; ≥ 5 j : RC 0,489, IC à 95 % 0,314­0,762). Les facteurs prédictifs fiables d'une DSH prolongée incluaient la PTH c. PTG, l'âge de 75 ans ou plus, une classification de 3 ou 4 selon l'American Society of Anesthesiologists et le nombre de comorbidités cardiovasculaires. CONCLUSION: Les patients soumis à une PAT ne s'équivalent pas tous. L'objectif devrait être d'administrer des soins centrés sur le patient plutôt que sur une DSH prédéterminée qui, dans les faits, ne s'applique pas à tous patients. La planification des ressources hospitalières devra à l'avenir tenir compte de la complexité des cas dans la planification de la gestion des lits.

Staged bilateral total knee arthroplasty: does history dictate the future?

A retrospective cohort study of 668 staged bilateral TKA patients was conducted to determine first-side versus second-side subjective and objective outcomes. Improvement in patient perceived function, measured by one-year Oxford Score (OKS) was defined by a minimal clinically important difference of >5 points in OKS. Results indicate that patients who had a minimal clinically important improvement (MCII) on the first-side have a significantly greater chance of maintaining or improving benefit with second-side TKA (OR 3.2; 95% CI 1.63-6.22; P=0.000). Of those with no clinical improvement (NCI), 71.4% achieved MCII on the second-side, while 28.6% remained NCI (P=0.000). Patients who do not initially benefit from first-side TKA should not be denied second-side staged-TKA as they still have a significant chance of achieving an MCII.

Patient perspective survey of total hip vs total knee arthroplasty surgery.

A 42-item survey was developed and administered to determine patient perception of and satisfaction with total hip arthroplasty (THA) vs total knee arthroplasty (TKA). A total of 153 patients who had both primary THA and TKA for osteoarthritis with 1-year follow-up were identified. Survey response rate was 72%. Patients were more satisfied with THA meeting expectations for improvement in function and quality of life (P < .05), whereas pain relief expectations were equivalent. Most patients (70.9%) reported that TKA required more physiotherapy. One-year Oxford score and improvement in Oxford score from preoperative to 1 year were superior for THAs (P = .000). Despite equivalent pain relief, THAs trend toward higher satisfaction compared with TKAs. THA is more likely to "feel normal" with greater improvement in Oxford score. Recovery from TKA requires more physiotherapy and a longer time to achieve a satisfactory recovery status. Patients should be counseled accordingly.

Antibiotic prophylaxis for total joint replacement surgery: results of a survey of Canadian orthopedic surgeons.

BACKGROUND: The role of perioperative antibiotic prophylaxis in total joint replacement (TJR) surgery is well established. Whereas guidelines have been published in some countries, in Canada controversy persists concerning the best clinical practice for perioperative antibiotic prophylaxis in TJR. METHODS: We conducted a survey of 590 practising orthopedic surgeons performing TJR in Canada to assess current antibiotic prophylaxis practice. The survey included questions pertaining to antibiotic prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision arthroplasty setting, as well as postoperative wound drainage evaluation and management. RESULTS: The response rate after 2 mail-outs was 410 of 590 (69.5%). Current antibiotic prophylaxis regimens varied widely among surgeons, underscoring the controversy that exists regarding what constitutes best clinical practice. CONCLUSION: Opinions regarding use of perioperative antibiotic prophylaxis in TJR vary widely among orthopedic surgeons in Canada, illustrating the controversy as to what constitutes best clinical practice. This survey also points to a lack of consensus about the current management of postoperative wound drainage.