Worse Outcomes Are Associated With Proximal Femoral Replacement Following Periprosthetic Joint Infection.

BACKGROUND: Proximal femoral replacements (PFRs) are often used in the setting of severe bone loss. As osteolysis has become less common, PFR may be used to address other causes of bone loss such as infection or periprosthetic fracture. The aim of this study is to investigate the clinical outcomes of PFR for non-neoplastic conditions. METHODS: A retrospective review of 46 patients undergoing PFR at a single institution was performed. The electronic records were reviewed to extract relevant information including the reason for use of PFR, surgical variables, follow-up, and complications. Survivorship curves were generated and differences in survivorship were evaluated using the log-rank test. Radiographic evaluation was also performed. RESULTS: Using revision as an endpoint, the Kaplan-Meier analysis of the entire cohort demonstrated a survival rate of 74% at 1 year and 67% at 5 years. Patients with a preoperative diagnosis of periprosthetic joint infection demonstrated the lowest survivorship with a failure rate of 47%. Furthermore, a high dislocation rate at 17.4% (n = 8) was observed. The use of dual-mobility articulation was effective in reducing dislocation. CONCLUSION: PFR is a valuable reconstructive option for patients with massive proximal femoral bone loss. This study demonstrates that patients with periprosthetic joint infection who undergo PFR reconstruction are at very high risk of subsequent failure, most commonly from reinfection and instability. The use of a dual-mobility articulation in association with PFR appears to help mitigate risk of subsequent dislocation.

Distal Femoral Replacement and Periprosthetic Joint Infection After Non-Oncological Reconstruction: A Retrospective Analysis.

BACKGROUND: Distal femoral replacement (DFR) is commonly used to manage massive bone loss around the knee arising from aseptic loosening, periprosthetic joint infection (PJI), and distal femoral fractures. A number of studies report the outcome of DFR with considerable variation in long-term survivorship. This study investigated the outcome of DFR for patients with aseptic failures, fractures, and PJI. METHODS: A retrospective review of 182 patients who underwent DFR for non-oncological indications between 2002 and 2018 was conducted. Data collected included the following: indication, postoperative complications, reoperation, revision, and follow-up. Implant survivorship with Kaplan-Meier curves along with a log-rank test for different preoperative indications was performed. A Cox regression model was used to evaluate the risk of revision. RESULTS: The overall postoperative complication rate was very high at 36%. The most common complication was PJI (17%). The rate of reoperation for any cause was 29.7%, and the revision rate was 13.7%. The most common cause of re-revision was PJI (7.1%). Revision-free survivorship of the DFR implant was 91.6% at 1 year, 87.9% at 2 years, 82.5% at 5 years, and 73.4% at 10 years. Patients who had a prior-PJI had the lowest survivorship compared to patients undergoing DFR for management of periprosthetic fracture and mechanical loosening. Additionally, the prior-PJI group was at a fourfold increased risk of postoperative PJI compared to the aseptic group. CONCLUSION: DFR is a valuable reconstructive option for patients with massive bone loss around the knee. However, patients undergoing DFR are at high risk of complications, reoperations, and failure.

Substantial Preoperative Work Is Unaccounted for in Total Hip and Knee Arthroplasty.

BACKGROUND: The Centers for Medicare and Medicaid Services has recently designated the codes for total hip and knee arthroplasty as misvalued and has asked the Relative Value Scale Update Committee (RUC) to review the work required to perform these procedures. Although other studies have reported time spent on perioperative and postoperative care, time spent on coordinating and performing preoperative care is not included in current RUC methodology and has yet to be addressed in literature. METHODS: We prospectively tracked a consecutive series of 438 primary total hip arthroplasty and total knee arthroplasty patients by one of the 5 surgeons over a 3-month period. Each clinical staff member tracked the amount of time to perform each preoperative care task from the last clinic visit until day of surgery. Data were analyzed separately between providers and ancillary medical staff. RESULTS: Although the current RUC review includes 40 minutes of preservice time on the day of surgery, surgeons spent an average of an additional 43.2 minutes while physician assistants and nurse practitioners spent an additional 97.9 minutes per patient on preoperative care prior to that time. Ancillary medical staff spent a mean of 110.2 minutes per patient. The most common tasks include preoperative phone calls, templating and surgical planning, and preoperative patient education classes. CONCLUSION: Surgeons and advanced practice providers spend nearly 2 hours per arthroplasty patient on preoperative care not accounted for in current RUC methodology. As readmissions, hospital stay, and complication rates continue to decline, Centers for Medicare and Medicaid Services should consider the substantial work required during the preoperative phase to allow for these improved outcomes.

Quantifying the Perioperative Work Associated With Total Hip and Knee Arthroplasty: The Burden Has Increased With Contemporary Care Pathways.

BACKGROUND: Recently, the Centers for Medicare and Medicaid Services (CMS) has labeled the procedural codes for total hip arthroplasty (THA) and total knee arthroplasty (TKA) as potentially misvalued and has asked the American Medical Association (AMA) and its Relative Value Scale Update Committee (RUC) to review this. To assess the validity of this claim, we aimed to catalog the specific service tasks and duration of time required for each task associated with the perioperative care of the patient who underwent primary THA and TKA. METHODS: We prospectively timed preservice and immediate postservice activities performed outside of the operating room (OR) by 7 arthroplasty surgeons over a four-week period. Specific timing data for preservice activities performed in the OR were obtained retrospectively from our institutional electronic medical record for 500 patients undergoing THA and 500 undergoing TKA. Results were compared with the current approved values reviewed by the RUC in 2013 and converted to work relative value units (wRVUs) based on the intensity coefficients used by the RUC. RESULTS: The average total preservice evaluation time was 42.2 minutes. The average time from the patient entering the OR to incision was 40.8 ± 25.4 minute. Immediate postservice tasks took 30.0 minutes. Compared with the 2013 RUC weighted wRVU value of 1.394 for preservice and 0.560 for immediate postservice activities, we found that surgeons actually perform 1.567 wRVUs of preservice and 0.672 of immediate postservice activities. CONCLUSION: Policymakers should consider these findings when reviewing the time and intensity spent on perioperative care for patients undergoing THA and TKA.

Management of a pelvic mass following a worn uncemented total hip arthroplasty.

Intrapelvic granulomatous masses from polyethylene wear debris can easily be misdiagnosed if orthopaedic etiology is not considered. This article presents the case of a 50 year old woman with history of hip joint trauma and total hip arthroplasty (THA) revisions who presented to her gynecologist with a large intrapelvic cyst. Prolonged use of an indwelling drain and failure to recognize the orthopaedic origin of the mass resulted in articular infection that required an antibiotic spacer and subsequent THA revision. This patient did not have pain or evidence of medial wall defects, but did have a history of trauma, revision arthroplasty and acetabular allograft. In the presence of these findings, wear-induced polyethylene debris should be considered in the differential diagnosis of the pelvic mass.

Blood management in total joint arthroplasty.

Blood loss associated with total joint arthroplasty can be substantial. Various techniques for dealing with such blood loss include allogeneic blood programs, preadmission donation programs, pharmacologic agents, hemodilution, and perioperative blood salvage. This article reviews these techniques as well as the consequences of perioperative anemia. Problems associated with blood transfusions are also outlined.

Simultaneous revision and contralateral primary total knee arthroplasty.

BACKGROUND: There is controversy regarding whether simultaneous or staged bilateral total knee arthroplasty should be performed in patients with bilateral gonarthrosis. In addition, revision total knee arthroplasties have been less successful than primary arthroplasties. The purpose of this study was to evaluate the results of simultaneous revision and contralateral primary total knee arthroplasties performed during the same setting. METHODS: The study cohort included 150 knees in seventy-five patients who had undergone revision arthroplasty because of aseptic failure of a total knee arthroplasty and a contralateral primary arthroplasty for severe gonarthrosis under the same anesthetic. The study group was compared with a control group of sixty patients who had severe arthritis in one knee and had undergone unilateral revision total knee arthroplasty on the contralateral side. The duration of follow-up averaged five years in the group treated with the simultaneous arthroplasties and eight years in the control group. Clinical and radiographic results were evaluated with the Knee Society rating system. RESULTS: In the study group, the average knee score improved by 48 points on the side of the primary arthroplasty and by 37 points on the side of the revision. At the last follow-up visit, most (sixty-five) of the seventy-five patients stated that the knee with the revision felt better than the knee with the simultaneously performed primary arthroplasty. In the control group, the average knee score improved by 30 points on the side of the revision arthroplasty. However, forty-five of the sixty patients had a primary total knee arthroplasty on the contralateral side within two years after the index revision arthroplasty; by four years, all sixty patients had undergone a contralateral primary arthroplasty. CONCLUSIONS: We found a favorable outcome in patients who had undergone simultaneous revision and contralateral primary total knee arthroplasties. Despite a lower mean knee score and less motion, most patients seemed to prefer the knee with the revision arthroplasty to the knee with the primary procedure. These results suggest that this combined procedure is a safe and favorable alternative to a staged procedure consisting of revision and subsequent contralateral primary total knee arthroplasty.

Preoperative use of recombinant human erythropoietin before total joint arthroplasty.

BACKGROUND: Previous reports have suggested that the use of recombinant human erythropoietin is effective for decreasing the need for perioperative allogeneic blood transfusion. The purpose of this study was to evaluate the efficacy of erythropoietin in combination with, and compared with, preoperative autologous donation for reducing allogeneic blood requirements for total joint arthroplasty. METHODS: Two hundred and forty patients undergoing primary and revision total hip or knee arthroplasty were enrolled into three groups with different treatment regimens: (1) erythropoietin and preoperative autologous donation (Group 1), (2) erythropoietin alone (Group 2), and (3) preoperative autologous donation alone (Group 3). Patients were evaluated with regard to requirements for allogeneic transfusion, change from the baseline to the lowest postoperative hemoglobin value, postoperative complications, and adverse reactions. RESULTS: The rate of allogeneic transfusion was 11% in Group 1 (erythropoietin and preoperative autologous donation) compared with 28% in Group 2 (erythropoietin alone) and 33% in Group 3 (preoperative autologous donation alone). Within Group 1, patients who had a unilateral primary arthroplasty had an allogeneic transfusion rate of 4% and those who had a bilateral or revision arthroplasty had an allogeneic transfusion rate of 17%. In Groups 2 and 3, the allogeneic transfusion rates were 14% and 15%, respectively, for the patients who had a unilateral primary arthroplasty and 35% and 47%, respectively, for those who had a bilateral or revision arthroplasty. CONCLUSIONS: Preoperative use of erythropoietin in conjunction with preoperative autologous donation reduces the need for allogeneic blood transfusion associated with total joint arthroplasty more effectively than does either erythropoietin or preoperative autologous donation alone.

Incidence of patellar clunk with a modern posterior-stabilized knee design.

Patellar clunk is an uncommon complication of posterior-stabilized total knee arthroplasty (TKA), though the incidence has been reported to be as high as 7.5% with some posterior-stabilized implants, and the etiology is multifactorial. Femoral component design has been implicated as a major cause of this complication. This series compares the incidence of patellar clunk with 2 different knee prostheses, the Insall-Burstein II (IB) and the NexGen Legacy PS (NG), both manufactured by Zimmer (Warsaw, Ind). One-hundred fifty consecutive posterior-stabilized TKAs were in each group, and the groups were similar in surgical approaches and techniques. Insall-Salvati (IS) ratios and joint-line positions were measured on preoperative and postoperative x-rays. Knee Society Clinical and Functional scores were calculated. Incidence of patellar clunk was reduced from 4% with the IB design to 0% with the NG design. IS ratios, joint-line positions, and clinical outcomes were no different between the groups. It appears that femoral component design may play a substantial role in development of patellar clunk after posterior-stabilized TKA.

A comparison of stemmed and unstemmed components in revision knee arthroplasty.

The purpose of the current study was to compare retrospectively the results of the Insall-Burstein constrained condylar knee implant used with and without intramedullary stems in 207 revision knee arthroplasties with the Insall-Burstein constrained condylar knee implant. One hundred sixty-one knees had either one or two stems placed. One hundred eight femoral stems and 76 tibial stems were placed. Fifty-five knees had no femoral or tibial stem. The average knee scores ranged from 52 preoperatively to 86 postoperatively. The average range of motion postoperatively was 4 degrees (range, 0 degrees -10 degrees ) to 106 degrees (range, 94 degrees -118 degrees ) in this group. The average postoperative knee score was 86 in the unstemmed group and 85 in the stemmed group with no difference in average range of motion. There were four (3%) cases of tibial loosening and two (2%) cases of femoral loosening in the unstemmed group. There were two (2%) cases of tibial loosening and two (2%) cases of femoral loosening at an average followup of 4.2 years (range, 2-6.2 years). Despite the higher constraint inherently designed in an Insall-Burstein constrained condylar knee component, the current study did not show a significantly higher loosening in implants without stems compared with implants used with stems. Therefore, the use of a semiconstrained component does not alone constitute a requirement for the use of an intramedullary stem.

Adoption of information technology by resident physicians.

The Internet represents a technological revolution that is transforming our society. In the healthcare industry, physicians have been typified as slow adopters of information technology. However, young physicians, having been raised in a computer-prevalent society, may be more likely to embrace technology. We attempt to characterize the use and acceptance of the Internet and information technology among resident physicians in a large academic medical center and to assess concerns regarding privacy, security, and credibility of information on the Internet. A 41-question survey was distributed to 150 pediatric, medical, and surgical residents at an urban, academic medical center. One hundred thirty-five residents completed the survey (response rate of 90%). Responses were evaluated and statistical analysis was done. The majority of resident physicians in our survey have adopted the tools of information technology. Ninety-eight percent used the Internet and 96% use e-mail. Two-thirds of the respondents used the Internet for healthcare-related purposes and a similar percentage thought that the Internet has affected their practice of medicine positively. The majority of residents thought that Internet healthcare services such as electronic medical records, peer-support websites, and remote patient monitoring would be beneficial for the healthcare industry. However, they are concerned about the credibility, privacy, and security of health and medical information online. The majority of resident physicians in our institution use Internet and information technology in their practice of medicine. Most think that the Internet will continue to have a beneficial role in the healthcare industry.

Haemophilus influenza infection complicating a total knee arthroplasty.

Haemophilus influenza is rarely a cause of septic arthritis in adults. It has not been reported as a cause of infection in total knee arthroplasties. Haemophilus influenza septic arthritis is a late stage, hematogenous infection. A 43-year-old woman with a history of rheumatoid arthritis was found to have Haemophilus influenza infection 3 years after the index total knee arthroplasty. The patient was treated with debridement and systemic antibiotics. At the 5-year followup, the patient was comfortable and free of clinical signs of infection. This approach was successful at eradicating infection and salvaging the total knee arthroplasty.

Outcomes of total hip arthroplasty are similar for patients with displaced femoral neck fractures and osteoarthritis.

This study attempted to evaluate whether total hip arthroplasty for displaced femoral neck fractures had significantly different outcomes when compared with total hip arthroplasty for osteoarthritis. This is a retrospective study of 60 patients who had total hip arthroplasties between 1997 and 2001. Thirty patients (mean age, 79.7 years) had total hip arthroplasties for displaced femoral neck fractures; 30 patients (mean age, 76.9 years) were treated with total hip arthroplasties for osteoarthritis. The same surgeon used the modified lateral approach for all surgeries. All patients had radiographic assessment, physical examination, and evaluation with the Harris hip score. The mean followup was 38 months. The mean Harris hip score for the 25 patients treated with a total hip arthroplasty for a femoral neck fracture was 81 points; the mean hip score for the 27 patients treated with a total hip arthroplasty for osteoarthritis was 87 points. No statistically significant differences between these groups were observed. Patients who were treated with a total hip arthroplasty for a femoral neck fracture did not have increased perioperative morbidity compared with patients who had a total hip arthroplasty for osteoarthritis. This study suggests that the outcomes for total hip arthroplasties in this consecutive series of patients treated for displaced femoral neck fractures and osteoarthritis are comparable.

A two-stage approach to primary knee arthroplasty in the infected arthritic knee.

Fourteen patients with either septic knee arthritis or osteomyelitis of the knee with marked joint destruction were treated by resection arthroplasty with the introduction of an antibiotic cement spacer block, appropriate antibiotic therapy, and subsequent primary total knee arthroplasty. Most patients with septic arthritis had chronic infection. Eight patients had positive cultures preoperatively; the remaining patients had either a culture negative purulent aspiration or diagnostic radiographic studies. All patients underwent reconstruction with primary total knee arthroplasty on an average of 3.1 months after the initial stage procedure. Knee Society scores progressed from 46 preoperatively to 89 postoperatively, with an average range of motion from 3 degrees to 105 degrees. At latest clinical follow-up (average, 4.5 years), no patients had recurrence of infection. These data suggest that this method is successful in treating chronically infected knees with a 2-staged arthroplasty.