Tranexamic Acid Is Associated With Reduced Periprosthetic Joint Infection After Primary Total Joint Arthroplasty.

BACKGROUND: Previous studies have demonstrated preoperative anemia to be a strong risk factor for periprosthetic joint infection (PJI) in total joint arthroplasty (TJA). Allogeneic blood transfusion can be associated with increased risk of PJI after primary and revision TJA. Tranexamic acid (TXA) is known to reduce blood loss and the need for allogeneic blood transfusion after TJA. The hypothesis of this study is that administration of intravenous TXA would result in a reduction in PJI after TJA. METHODS: An institutional database was utilized to identify 6340 patients undergoing primary TJA between January 1, 2013 and June 31, 2017 with a minimum of 1-year follow-up. Patients were divided into 2 groups based on whether they received intravenous TXA prior to TJA or not. Patients who developed PJI were identified. All PJI patients met the 2018 International Consensus Meeting definition for PJI. A multivariate regression analysis was performed to identify variables independently associated with PJI. RESULTS: Of the patients included, 3683 (58.1%) received TXA and 2657 (41.9%) did not. The overall incidence of preoperative anemia was 16%, postoperative blood transfusion 1.8%, and PJI 2.4%. Bivariate analysis showed that patients who received TXA were significantly at lower odds of infection. After adjusting for all confounding variables, multivariate regression analysis showed that TXA is associated with reduced PJI after primary TJA. CONCLUSION: TXA can help reduce the rate of PJI after primary TJA. This protective effect is likely interlinked to reduction in blood loss, lower need for allogeneic blood transfusion, and issues related to immunomodulation associated with blood transfusion.

Highlighting the Roles of Anemia and Aspirin in Predicting Ninety-Day Readmission Following Aseptic Revision Total Joint Arthroplasty.

BACKGROUND: Revision total joint arthroplasties (TJAs) are associated with an increased rate of complications. To date, it is unclear what drives readmission after aseptic revision arthroplasty and what measures can be taken to possibly avoid them. The purpose of this study is to (1) determine the reasons for readmission after aseptic revision TJA and (2) identify patient-specific or postoperative risk factors through a multivariate analysis. METHODS: A retrospective study examined 1503 cases of aseptic revision TJA between 2009 and 2016 at an urban tertiary care hospital. Eighty-seven cases (5.8%) of readmission within 90 days of index surgery were identified. Bivariate and multivariate analyses were performed to assess independent risk factors for readmission. RESULTS: The reasons for readmission were infection (38%), wound complications (22%), and dislocation/instability of the prosthetic joint (13%). Only preoperative anemia was associated with an increased odds ratio (OR) of readmission (OR 1.82, 95% confidence interval [CI] 1.126-2.970, P = .015), whereas postoperative venous thromboembolism prophylaxis with aspirin (OR 0.58, 90% CI 0.340-0.974, P = .039) and discharge to an inpatient rehab facility (OR 0.22, 95% CI 0.051-0.950, P = .042) were associated with significantly lower odds of readmission. CONCLUSION: Based on this single institutional study, addressing preoperative anemia and considering the implementation of aspirin for venous thromboembolism prophylaxis may be 2 targets to potentially reduce readmission after aseptic revision TJA.

Web-Based, Self-Directed Physical Therapy After Total Hip Arthroplasty Is Safe and Effective for Most, but Not All, Patients.

BACKGROUND: Recent data suggested that unsupervised, self-directed physical therapy (SDPT) is both safe and efficacious for patients undergoing total hip arthroplasty (THA) and that formal outpatient physical therapy (OPPT) may not be routinely required. The purpose of this study was to evaluate the routine use of an SDPT program in a nonselect patient population. METHODS: This is a multi-surgeon, single-institution, retrospective study of 941 consecutive patients discharged home, from January 2016 to December 2016, after primary, unilateral THA and enrolled in a web-based SDPT program. Patients were seen 4 weeks after surgery and OPPT was prescribed for perceived need, patient request, or if unable to use the web-based program. Patient-reported outcomes, medical comorbidities, and assessment of home environment were prospectively recorded. RESULTS: Overall, 646 of 941 patients (68.7%) were not prescribed OPPT (SDPT-only group) while 295 of 941 patients (31.3%) were prescribed OPPT (SDPT + OPPT group). In the SDPT + OPPT group, 88.2% were for perceived need, 10.8% for patient request, and 1.0% due to inability to use the web-based platform. Multivariate analysis identified male sex (odds ratio, 0.64; 0.45-0.90; P = .012) and a higher preoperative Short Form-12 physical component (odds ratio, 0.98; 0.96-0.99; P = .036) as independent variables protective against requiring OPPT. At a minimum 6-month follow-up, the SDPT-only group had statistically higher hip disability and osteoarthritis outcome score junior compared to the SDPT + OPPT cohort (85.0 vs 80.9; P = .012). CONCLUSION: Web-based SDPT is safe and effective for most, but not all, patients eligible for home discharge after THA. It is critical to preserve OPPT services for the one-third of patients who require them. LEVEL OF EVIDENCE: Level III.

Intra-articular Corticosteroid Injection Following Total Knee Arthroplasty: Is It Effective?

BACKGROUND: Total knee arthroplasty (TKA) for the majority of patients with severe knee osteoarthritis provides relief of symptoms and improved function. However, there remains a subset of dissatisfied patients despite an unremarkable workup. A corticosteroid injection (CSI) is a commonly used nonsurgical treatment for painful knee osteoarthritis but its efficacy in a replaced knee remains unknown. METHODS: A retrospective chart review identified primary TKA patients who subsequently received a CSI into a replaced knee from 2015 to 2016 by a single surgeon. Patients receiving a CSI underwent clinical examination, laboratory analysis to rule out infection, and radiographic evaluation before CSI. Patient variables were recorded and a patient satisfaction survey assessed the efficacy of the injection. The survey response rate was 70.1%. RESULTS: Of the 129 responders, 82.9% remembered the injection. The average time from index arthroplasty to injection was median 5.3 months (interquartile range, 2.1-23.4) and 30.8% of patients received more than 1 injection (range, 1-5). Overall, 76.6% reported decreased pain, 57.9% reported increased motion, and 65.4% reported long-term decreased swelling. Improvement lasted greater than 1 month for 56.1% of patients, and overall 84.1% reported improvement (slight to great) in the knee following CSI. No patient developed a periprosthetic joint infection (PJI) within 1 year of injection. CONCLUSION: This study suggests that certain patients following TKA may benefit from a CSI. However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out conditions unlikely to improve long term from a CSI.

Web-Based, Self-Directed Physical Therapy After Total Knee Arthroplasty Is Safe and Effective for Most, but Not All, Patients.

BACKGROUND: Recently, self-directed physical therapy (SDPT) programs have gained popularity following total knee arthroplasty (TKA). This study evaluated the safety and efficacy of the routine use of an SDPT program in a nonselect patient population. METHODS: This is a single-surgeon, retrospective study of 296 consecutive patients from August 2016 to October 2017 discharged home after primary, unilateral TKA and enrolled in a web-based SDPT program. Patients were seen 2 weeks after surgery and outpatient physical therapy (OPPT) was prescribed if flexion was less than 90°, upon patient request, or inability to use the web-based platform. RESULTS: Overall, 195 of 296 (65.9%) patients did not require OPPT (SDPT-only) while 101 of 296 were prescribed OPPT (34.1%, SDPT + OPPT). In SDPT + OPPT, 66.3% were for flexion <90°, 27.7% by patient request, 5.0% received a prescription but did not attend OPPT, and 1.0% due to inability to use the web-based platform. The rate of manipulation under anesthesia was 2.36% overall (SDPT + OPPT, 6.93%; SDPT-only, 0.0%). Multivariate analysis identified elevated Charlson comorbidity index, elevated body mass index, higher preoperative SF12 mental score, and loss of flexion at 2 weeks as independent predictors associated with the need for OPPT. CONCLUSION: Web-based SDPT is safe and effective for most patients eligible for home discharge after TKA. It is difficult to preoperatively predict those patients who will require OPPT; therefore, we recommend close follow-up. It is critical to preserve these services for patients who require them after TKA as up to a third of patients required OPPT.

Positive Blood Cultures Decrease the Treatment Success in Acute Hematogenous Periprosthetic Joint Infection Treated With Debridement, Antibiotics, and Implant Retention.

BACKGROUND: The influence of positive blood cultures on surgical outcome of acute hematogenous periprosthetic joint infection (PJI) treated by debridement, antibiotics, and implant retention (DAIR) remains unknown. This study evaluated the influence of positive blood cultures on the treatment success of DAIR in patients with acute hematogenous PJI. METHODS: A retrospective chart review on 49 patients with blood culture data for acute hematogenous PJI was performed from 2005 to 2016 at a single institution. All patients were treated by DAIR and had a minimum follow-up of 1 year. Treatment success was defined by the Delphi criteria. Multivariate logistic regression analysis was performed to identify variables associated with positive blood culture and treatment success. Kaplan-Meier survivorship curves and log-rank tests were used for analysis. RESULTS: Overall, 44.9% (22/49) of blood cultures obtained yielded positive growth. Elevated Elixhauser comorbidity index was a significant risk factor associated with positive blood (adjusted odds ratio [OR], 1.65; 95% confidence interval [CI], 1.13-2.40; P = .049). A positive blood culture was the only significant factor predicting treatment failure in acute hematogenous PJI (OR, 3.94; 95% CI, 1.18-13.1; P = .026) after adjusting for confounding variables. Kaplan-Meier survivorship for infection-free implant survivorship was 53.1% (95% CI, 38.3%-65.8%) at 1 year for all patients, 66.7% (95% CI, 45.7%-81.1%) for patients with negative blood cultures, and 36.4% (95% CI, 17.2%-55.7%) for patients with positive blood cultures (P = .037). CONCLUSION: The presence of positive blood cultures is associated with decreased treatment success of DAIR for acute hematogenous PJI. Patients with more comorbidities may need to be treated more aggressively for a favorable outcome.

The James A. Rand Young Investigator's Award: Battling the Opioid Epidemic with Prospective Pain Threshold Measurement.

BACKGROUND: Responsible analgesic prescribing is paramount in the opioid epidemic era, yet no standardized protocol exists. We aim to (1) quantify and correlate outpatient opioid need after total knee and hip arthroplasties (TKA and THA) with preoperative objective pain pressure thresholds (PPTs) and subjective pain measures and (2) report incidence of nonsurgical opioid prescriptions 6 weeks postoperatively. METHODS: Prospectively, PPTs were measured using an algometer with a maximum force of 20 pounds in 160 consecutive patients (90 TKA and 70 THA). Two locations were tested: operative joint (medial epicondyle TKA and lateral iliac crest THA) and ipsilateral olecranon for systemic control. Visual Analog Score, Pain Severity Score, Pain Interference Score, and subjective pain threshold were obtained. Six-week outpatient narcotic consumption morphine equivalents recorded and prescriptions crosschecked with the state Controlled Substance Reporting System. Multivariate analysis was performed to evaluate local and/or systemic PPT and subjective measures with narcotic consumption. RESULTS: Average operative site and systemic PPT was 6.91 and 7.72 pounds force, respectively. Subjective averages: Visual Analog Score 7.14, Pain Severity Score 5.05, Pain Interference Score 5.16, and perceived threshold 6.77. Six-week average outpatient narcotic consumption was 314.9 morphine equivalents or 125 five milligram oxycodones. Twenty percent received opioids from outside providers. Linear regression revealed a negative correlation between operative site PPT (-0.26; P = .047) and systemic PPT (-0.31; P = .021). Subjective pain metrics failed to meet significance. CONCLUSION: This novel study demonstrated a statistically significant negative correlation between preoperative pain threshold and outpatient narcotic consumption. Twenty percent of patients received opioid prescriptions outside orthopedic providers in the 6 weeks after surgery highlighting the importance of interdisciplinary communication.

Are All Periprosthetic Joint Infections the Same? Evaluating Major vs Minor Criteria.

BACKGROUND: The diagnosis of periprosthetic joint infection (PJI) can be made when 1 major criterion or 3 of 5 minor criteria are present. However, the outcomes of patients with a major vs minor criteria for diagnosis have not been studied. The objective of this study was to evaluate if a difference in outcome of surgical intervention existed between patients with PJI who were diagnosed with a major criterion or a combination of minor criteria. METHODS: A retrospective chart review identified 277 primary total hip or knee arthroplasty patients who had developed PJI based on the International Consensus Meeting definition. Patients were further stratified into "major" vs "minor" groups. Patient demographics, PJI workup, surgical treatment, microbiological growth, and clinical outcomes were recorded. Treatment success was defined by using the Delphi criteria. Standard statistical analysis was performed. RESULTS: Overall, 34 patients met minor-only criteria (12.2%), whereas 243 met major criteria. Of the minor-only patients, 16 (47%) were culture negative. When controlling for confounding variables, there was no statistically significant difference with regard to treatment success (minor 94.1% vs major 82.3%, P = .085) between groups at final follow-up (mean 110 months, range 2.3-567 months). Only higher Charlson comorbidity index (P = .001) and an initial 2-stage surgical procedure (P = .003) were associated with decreased treatment success. CONCLUSION: PJI patients were similar between both criteria groups, and there was no difference in treatment success as defined by the Delphi criteria between minor-only PJI and major criteria PJI patients.

Positive Blood Cultures in Periprosthetic Joint Infection Decrease Rate of Treatment Success.

BACKGROUND: Blood cultures are often obtained at the time of periprosthetic joint infection (PJI) diagnosis yet they are not considered part of the diagnostic criteria and the effects of a positive result on surgical outcome are unknown. The purposes of this study are to characterize the use of blood cultures when diagnosing PJI and to determine the association of positive blood cultures with PJI treatment success. METHODS: A retrospective chart review on 320 patients surgically treated for primary hip and knee PJIs was performed from 2006-2013 at 2 academic medical centers with minimum 12-month follow-up. Treatment success was defined by the Delphi criteria. Multiple logistic regression analysis was performed to identify variables associated with treatment success. RESULTS: Blood cultures were obtained from 53.1% of PJI patients (170/320) at the time of diagnosis. The same organism was identified 86.0% of the time in blood culture and operative culture. Patients with positive blood cultures at the time of PJI diagnosis had elevated synovial white blood cell count (98,979, P = .012), elevated serum C-reactive protein (24.2 mg/L, P < .001), and decreased treatment success (65.1%) compared with those with a negative blood culture (85.0%) and those without a blood culture (82.7%, P = .013). A positive blood culture remained associated with decreased PJI treatment success using multiple logistic regression analysis. CONCLUSION: The presence of positive blood cultures at the time of PJI diagnosis decreased PJI treatment success. Further prospective studies are needed to help identify the role of blood cultures in the work up of PJI and treatment optimization in these patients.

Intraoperative Dexamethasone Reduces Readmission Rates Without Affecting Risk of Thromboembolic Events or Infection After Total Joint Arthroplasty.

BACKGROUND: The use of perioperative dexamethasone has been proven to reduce pain and shorten recovery for patients undergoing total hip and knee arthroplasty. However, the effect of these medications on 90-day readmissions and the rates of clinically significant venous thromboembolic events (VTE) after total joint arthroplasty (TJA) remains unknown. METHODS: Patients undergoing unilateral, primary total joint arthroplasty between 2009 and 2016 in a single institution were identified. There were 6617 patients who did not receive dexamethasone intraoperatively compared to 1293 patients who received a single, intraoperative, intravenous dose of dexamethasone (8-10 mg). The primary outcomes were the rate of clinically significant VTE and 90-day readmission. Secondary outcomes included wound complications, periprosthetic joint infection, and 90-day mortality. RESULTS: While the overall rate of clinically symptomatic VTE was lower in the dexamethasone group, this did not reach significance in a univariate analysis (0.1% vs 0.2%, P = .353). Only body mass index (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.03-1.24; P = .006) and longer length of stay (OR, 1.16; 95% CI, 1.06-1.28; P = .001) were associated with VTE in the multivariate analysis (OR, 0.31; 95% CI, 0.04-2.36; P = .319). However, the use of intravenous dexamethasone was independently associated with a reduction in 90-day readmission rate (1.6% vs 2.5%; OR, 0.57; 95% CI, 0.36-0.90; P = .016). There was no difference in the rate of periprosthetic joint infection or mortality. CONCLUSION: A single, intraoperative, low dose of dexamethasone is not associated with a reduction in clinically significant VTE but may be a safe and effective adjunct medication to lower 90-day readmission rates. LEVEL OF EVIDENCE: Level III.

Inpatient Consults and Complications During Primary Total Joint Arthroplasty in a Bundled Care Model.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) are implementing changes in hospital reimbursement models for total joint arthroplasty (TJA), moving to value-based bundled payments from the fee-for-service model. The purpose of this study is to identify consults and complications during the perioperative period that increase financial burden. METHODS: We combined CMS payment data for inpatient, professional, and postoperative with retrospective review of patients undergoing primary TJA and developed profiles of patients included in the Comprehensive Care for Joint Replacement bundle undergoing TJA. Statistical comparison of episode inpatient events and payments was conducted. Multiple regression analysis was adjusted for length of stay, disposition, and Charlson-Deyo comorbidity profile. RESULTS: Median total payment was $21,577.36, which exceeded the median bundle target payment of $20,625.00. Adjusted analyses showed that psychiatry consults (increase of $73,123.32; P < .001), internal medicine consults ($5789.38; P ≤ .001), pulmonary embolism ($35,273.68; P < .001), intensive care unit admission ($14,078.37; P < .001), and deep vein thrombosis ($9471.26; P = .019) resulted in increased payments using multivariate analysis adjusted for length of stay, Charlson-Deyo comorbidities, and discharge disposition. CONCLUSION: Patients with inpatient complications such as pulmonary embolism and/or deep vein thrombosis, intensive care unit admission, and medical/psychiatric consultation exceeded the CMS target. Although study results showed typical complication rates, acute inpatient consultation significantly increased utilization beyond the CMS target even when adjusted for length of stay, patient comorbidities, and discharge. Needed medical care should continue to be a priority for inpatients, and allowance for individual outliers should be considered in policy discussions.

Beyond Mirels: Factors Influencing Surgical Outcome of Metastasis to the Extremities in the Modern Era.

Mirels scoring system for determining prophylactic stabilization need of skeletal metastases includes a limited number of variables and does not differentiate between procedure types. This study sought to identify additional variables associated with surgical failure, radiographic disease progression, and patient survival. A retrospective review was performed of patients from January 2004 to 2014 who underwent surgical treatment of skeletal metastases of the extremities, were >18 years of age, and had adequate radiographic surveillance. Eighty-nine metastatic bone lesions in 77 patients were included. Mirels score >8 (p = .015) and tumor origin (p = .008) were associated with surgical failure, which was 16.8%. Male gender (p < .001) and use of bone cement (p = .019) were associated with radiographic progression, 43.8% overall. Antiresorptive medications usage (p = .02) was associated with survival. The study concluded that tumor origin may be highly important when considering surgical treatment for metastatic bone disease and antiresorptive medications should be used postoperatively, given an association with survival. (Journal of Surgical Orthopaedic Advances 27(3):178-186, 2018).

Laminoplasty versus laminectomy with fusion for the treatment of spondylotic cervical myelopathy: short-term follow-up.

BACKGROUND CONTEXT: Laminoplasty and laminectomy with fusion are two common procedures for the treatment of cervical spondylotic myelopathy. Controversy remains regarding the superior surgical treatment. PURPOSE: To compare short-term follow-up of laminoplasty to laminectomy with fusion for the treatment of cervical spondylotic myelopathy. STUDY DESIGN/SETTING: Retrospective review comparing all patients undergoing surgical treatment for cervical spondylotic myelopathy by a single surgeon. PATIENT SAMPLE: All patients undergoing laminoplasty or laminectomy with fusion by a single surgeon over a 5-year period (2007-2011). OUTCOME MEASURES: Cervical alignment and range of motion on pre- and post-operative radiographs and clinical outcome measures including Japanese Orthopaedic Association (JOA) scores, neck disability index (NDI), short form-12 mental (SF-12M) and physical (SF-12P) composite scores and visual analog pain scores for neck (VAS-N) and arm (VAS-A). METHODS: Patients undergoing laminoplasty or laminectomy with fusion by a single surgeon were reviewed. Cohorts of 41 laminoplasty patients and 31 laminectomy with fusion patients were selected based on strict criteria. The cohorts were well matched based on pre-operative clinical scores, radiographic measurements, and demographics. The average follow-up was 19.2 months for laminoplasty and 18.2 months for laminectomy with fusion. Evaluated outcomes included Japanese Orthopaedic Association (JOA) score, neck disability index (NDI), short form-12 (SF-12), visual analog pain scores (VAS), cervical sagittal alignment, cervical range of motion, length of stay, cost and complications. RESULTS: The improvement in JOA, SF-12 and VAS scores was similar in the two cohorts after surgery. There was no significant change in cervical sagittal alignment in either cohort. Range-of-motion decreased in both cohorts, but to a greater degree after laminectomy with fusion. C5 nerve root palsy and infection were the most common complications in both cohorts. Laminectomy with fusion was associated with a higher rate of C5 nerve root palsy and overall complications. The average hospital length of stay and cost were significantly less with laminoplasty. CONCLUSIONS: This study provides evidence that laminoplasty may be superior to laminectomy with fusion in preserving cervical range of motion, reducing hospital stay and minimizing cost. However, the significance of these differences remains unclear, as laminoplasty clinical outcome scores were generally comparable to laminectomy with fusion.

What Should Define Preoperative Anemia in Primary THA?

BACKGROUND: The use of tranexamic acid (TXA) in THA decreases the risk of transfusion after surgery. However, nearly 10% of patients still undergo a transfusion, which has been independently associated with an increased risk of complications. Preoperative anemia has been proven to be a strong predictor of transfusion after THA, but the ideal "cutoff" values in today's population that maximize sensitivity and specificity to predict transfusion have yet to be established. QUESTIONS/PURPOSES: (1) Which preoperative factors are associated with postoperative transfusion in the setting of TXA use? (2) If preoperative hemoglobin (Hgb) remains associated with transfusion, what are the best-supported preoperative Hgb cutoff values associated with increased transfusion after THA? METHODS: A retrospective chart analysis was performed from January 1, 2013, to January 1, 2015, on 558 primary THAs that met prespecified inclusion criteria. A multivariable logistic regression analysis model was used to identify independent factors associated with transfusion. Area under the receiver-operator curve (AUC) was used to determine the best-supported preoperative Hgb cut point across all participants, as well as adjusted by sex and TXA use. Overall, 60 patients with a blood transfusion were included and compared with 498 control subjects (11% risk of transfusion). RESULTS: After controlling for potential confounding variables such as age, sex, American Society of Anesthesiologist score, intravenous TXA (IV TXA) use, and preoperative Hgb, we found that patients with lower preoperative Hgb (g/dL per 1-unit decrease, odds ratio [OR], 2.6; 95% CI, 2.0-3.5; p < 0.001), female sex (vs male, OR, 4.2; 95% CI, 1.7-10.3; p = 0.002), and those unable to receive IV TXA (topical TXA/no TXA, OR, 13.5; 95% CI, 6.3-28.6; p < 0.001) were more likely to receive a transfusion. Of these, preoperative Hgb was found to be the variable most highly associated with transfusion (AUC, 0.876). A preoperative Hgb cutoff value of 12.6 g/dL maximized the AUC (0.876) for predicting transfusion across all patients unadjusted for baseline characteristics (sensitivity = 83, specificity = 84) with values of 12.5 g/dL (sensitivity = 85, specificity = 77) and 13.5 g/dL (sensitivity = 92, specificity = 77) for women and men, respectively. CONCLUSIONS: The 1968 WHO definitions of anemia (preoperative Hgb < 13 g/dL for men and < 12 g/dL for women) used currently may underestimate patients at risk of transfusion after THA today. Further studies are needed to see if blood conservation referral decreases the risk of transfusion with preoperative treatment of anemia. LEVEL OF EVIDENCE: Level III, therapeutic study.

Complications of total hip arthroplasty following solid organ transplantation.

PURPOSE: Solid organ transplants (SOT) continue to increase with recipients living longer than ever before. The lifelong immunosuppression in these patients also may place them at increased risk for postoperative complications. The efficacy of total hip arthroplasty (THA) in this patient population is undisputed but previous studies investigating the complication profiles in these patients often are underpowered to identify rare complications as well as make comparisons between individual organs. The purpose of this study was to use a large database to compare complications of a combined SOT cohort as well as each individual organ to a control population. METHODS: A search of the entire Medicare database from 2005 to 2011 was performed using International Classification of Disease version 9 (ICD-9) codes to identify patients who underwent THA after one or more solid organ transplants. A large cohort of patients served as a control with minimum 2-year follow-up. Post-operative complications at 30-day, 90-day, and overall time points were investigated. RESULTS: Transplant patients carry more medical comorbidities and are prone to increased medical complications, dislocations (OR 1.45, p < 0.001), need for irrigation and debridement (OR 1.90, p < 0.001), and periprosthetic infection (OR 1.69, p < 0.001) compared to patients without SOT. Total hip arthroplasty after renal transplantation has the worst complication profile of the individual organs whereas lung and pancreas transplants were no different than control with regard to overall surgical complications. CONCLUSIONS: The complications of THA after SOT vary by individual organ and these results may aid in patient selection and perioperative patient counseling.

Cervical Myelopathy Doubles the Rate of Dislocation and Fracture After Total Hip Arthroplasty.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a common and underdiagnosed cause of gait dysfunction, rigidity, and falls in the elderly. Given the frequent concurrency of CSM and hip osteoarthritis, this study is designed to evaluate the relative risk of CSM on perioperative and short-term outcomes after total hip arthroplasty (THA). METHODS: The Medicare Standard Analytical Files were searched from 2005 to 2012 to identify all patients undergoing primary THA and the subset of patients with preexisting CSM. Risk ratios with 95% confidence intervals were calculated for 90-day, 1-year, and overall follow-up for common postoperative complications: periprosthetic dislocation, fracture, infection, revision THA, and wound complications. RESULTS: The risk ratios of all surgical complications, including dislocation, periprosthetic fractures, and prosthetic joint infection, were increased approximately 2-fold at all postoperative time points for patients. CONCLUSION: Preexisting CSM is a significant risk factor for primary THA complications including dislocation, periprosthetic fractures, and prosthetic joint infection.

Should We Think Twice About Psychiatric Disease in Total Hip Arthroplasty?

BACKGROUND: Psychiatric disease (PD) is common, and the effect on complications in total hip arthroplasty (THA) is poorly understood. The purpose of this study was to evaluate the medical and surgical postoperative complication profile in patients with PD, and we hypothesize that they will be significantly increased compared with control group. METHODS: A search of the entire Medicare database from 2005 to 2011 was performed using International Classification of Disease version 9 codes to identify 86,976 patients who underwent primary THA with PD including bipolar (5626), depression (82,557), and schizophrenia (3776). A cohort of 590,689 served as a control with minimum 2-year follow-up. Medical and surgical complications at 30-day, 90-day, and overall time points were compared between the 2 cohorts. RESULTS: Patients with PD were more likely to be younger (age < 65 years; odds ratio [OR] = 4.51, P < .001), female (OR = 2.02, P < .001) and more medically complex (significant increase in 28/28 Elixhauser medical comorbidities, P < .001). There was a significant increase (P < .001) in 13/14 (92.8%) recorded postoperative medical complications rates at the 90-day time point. In addition, there was a statistically significant increase in periprosthetic infection (OR = 2.26, P < .001), periprosthetic fracture (OR = 2.09, P < .001), dislocation (OR = 2.30, P < .001), and THA revision (OR = 1.93, P < .001) at overall follow-up. CONCLUSION: Patients with PD who undergo elective primary THA have significantly increased medical and surgical complication rates in the global period and short-term follow-up, and these patients need to be counseled accordingly.

How Do Previous Solid Organ Transplant Recipients Fare After Primary Total Knee Arthroplasty?

INTRODUCTION: Total knee arthroplasty (TKA) has been proven to increase knee outcome scores after solid organ transplantation (SOT), but many authors are concerned about a higher complication rate. The purpose of this study is to evaluate the complication profile of TKA after previous SOT. METHODS: A search of the entire Medicare database from 2005 to 2011 was performed using International Classification of Disease, version 9, codes to identify 3339 patients who underwent TKA after 1 or more solid organ transplants including the kidney (2321), liver (772), lung (129), heart (412), and pancreas (167). A cohort of 1,685,295 patients served as a control with minimum 2-year follow-up. Postoperative complications at 30-day, 90-day, and overall time points were compared between the 2 cohorts. RESULTS: Patients with any SOT were younger (age: <65, odds ratio [OR]: 6.58, P < .001), male (OR: 1.88, P < .001), and medically complex (significant increase in 28 of 29 Elixhauser comorbidities, P < .05). There was a significant increase (P < .05) in 11 of 13 (84.6%) recorded postoperative medical complications rates at 90 days. There was a significant increase overall in periprosthetic infection (OR: 2.11, P < .001), periprosthetic fracture (OR: 1.78, P < .001), and TKA revision (OR: 1.36, P < .001). When analyzed by individual organ, heart and lung transplants carried the fewest medical and surgical complications. CONCLUSION: The results of this study demonstrate that patients with previous SOT who undergo elective primary TKA have more postoperative complications in the global period and at short-term follow-up. Yet, complication profiles by individual organ varied significantly.

Lingering Risk: Bariatric Surgery Before Total Knee Arthroplasty.

BACKGROUND: Obesity continues to increase in the United States with an estimated 35% obesity and 8% bariatric (body mass index >40) rate in adults. Bariatric patients seek advice from arthroplasty surgeons regarding the temporality of bariatric surgery (BS), yet no consensus currently exists in the literature. METHODS: A total of 39,014 patients were identified in a claim-based review of the entire Medicare database with International Classification of Diseases, Ninth Revision codes to identify patients in 3 groups. Patients who underwent BS before total knee arthroplasty (group I: 5914 experimental group) and 2 control groups that did not undergo BS but had either a body mass index >40 (group II: 6480 bariatric control) or <25 (group III: 26,616 normal weight control). International Classification of Diseases, Ninth Revision, Clinical Modification codes identified preoperative demographics or comorbidities and evaluated short-term medical (30 day) and long-term surgical (90 days and 2 years) complications. RESULTS: Group I had the greatest female predominance, youngest age, and highest incidence of: deficiency anemia, cardiovascular disease, pulmonary disease, liver disease, ulcer disease, polysubstance abuse, psychiatric disorders, and smoking. Medical and surgical complication incidences were greatest in group I including: 4.98% deep vein thrombosis; 5.31% pneumonia; 10.09% heart failure; and 2-year infection, revision, and manipulation rates of 5.8%, 7.38%, and 3.13%, respectively. These values were significant elevation compared to III and slightly greater than II. CONCLUSIONS: This study demonstrates that BS before total knee arthroplasty is associated with greater risk compared to both nonobese and obese patients. This is possibly due to a higher incidence of medical or psychiatric comorbidities determined in the Medicare BS patients, wound healing difficulties secondary to gastrointestinal malabsorption, malnourishment from prolonged catabolic state, rapid weight loss before surgery, and/or age.