Traumatic brain injuries in paediatric patients: individual vs. team sports-related hospitalizations.

Paediatric sport participation continues to increase in the United States, with a corresponding increase in sports-related concussions or traumatic brain injuries (TBIs). It is important to recognize which sports are at elevated risk and identify risk factors for hospital admission and length of stay (LOS). Paediatric patients (ages 5-18) from 2008 to 2014 were identified from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). Eight hundred and ninety-four patients included those who were hospitalized with a TBI resulting from participation in an individual (451 patients) or team (443 patients) sport. We evaluated the differences in LOS and total charges between individual and team sports and found that compared to team sports, TBI patients in individual sports had significantly longer hospital stays compared to team sports (1.75 days versus 1.34 days, p < 0.001) and costlier ($27,333 versus $19,069, p < 0.001) hospital stays. This may be due to reduced awareness and reduced compliance with return-to-play protocols in individual sports. Safety education information at a young age, increased awareness of TBIs, and additional medical support for individual sports as well as team sports may help mitigate these findings.

Nerve Compression Syndromes of the Shoulder.

Nerve compression syndromes of the shoulder contribute to pain, paresthesia, and weakness of the upper extremity. This review examines the recent literature regarding thoracic outlet syndrome, suprascapular neuropathy, long thoracic nerve palsy, and quadrilateral space syndrome. Overlapping features are common among shoulder pathologies, and thus, key anatomical features, pathophysiology, clinical manifestations, diagnostic techniques, and treatments are highlighted for all aforementioned conditions.

Abnormal Coagulation as a Risk Factor for Postoperative Complications After Primary and Revision Total Hip and Total Knee Arthroplasty.

BACKGROUND: Patients undergoing total joint arthroplasty (TJA) have an increased likelihood of having an abnormal coagulation profile compared with the general population. Coagulation abnormalities are often screened for before surgery and considered during perioperative planning. This study assesses a preoperative abnormal coagulation profile as a risk factor for postoperative complications after total hip arthroplasty (THA), revision THA (rTHA), total knee arthroplasty (TKA), and revision TKA (rTKA) and then examines specific coagulopathies to determine their influence on complication rates. METHODS: Patients who underwent THA, rTHA, TKA, or rTKA from 2011 to 2017 were identified in the American College of Surgeons National Surgical Quality Improvement Program database and then assessed for preoperative abnormal coagulation profiles. Various postoperative complications were analyzed for each cohort, and two separate multivariate regression analyses were used to assess the relationship between abnormal coagulation and postoperative complications. RESULTS: 403,566 THA, rTHA, TKA, or rTKA cases were identified, and 40,466 (10.0%) of patients were found to have an abnormal coagulation profile. Patients with preoperative coagulation abnormalities had higher likelihoods of postoperative complications after primary TJA than in revision TJA. An international normalized ratio>1.2 was associated with the most types of postoperative complications, followed by a bleeding disorder diagnosis. A partial thromboplastin time>35 seconds was associated with only one type of postoperative complication, while a platelet count <150,000 per µL was associated with postoperative complications only after TKA. CONCLUSION: TJA in patients with abnormal coagulation profiles may result in adverse outcomes. These patients may benefit from preoperative intervention. Prophylactic care needs to be personalized to the specific coagulation abnormalities present.

A novel method for predicting superior gluteal nerve safe zones in the lateral approach to the hip.

INTRODUCTION: The superior gluteal nerve (SGN) is at risk for laceration during lateral approach total hip arthroplasty (THA). The purpose of this study is to assess the accuracy of the trochanter-to-iliac crest distance (TCD) and the nerve-to-trochanter distance (NTD) ratio in determining a reproducible safe zone around the SGN independent of height. MATERIALS AND METHODS: Eighteen hemipelvises were dissected and the SGNs were exposed. The distance (NTD) from greater trochanter (GT) to the most inferior branch of the SGN encountered in each of the three approaches (Bauer et al., 1979) was measured. A reference distance (TCD) was measured from the GT to the highest point on the iliac crest. The NTD was divided by the TCD to generate standardized ratios. Coefficient of variation CV = (SD/mean) × 100 was calculated for each distance and ratio to measure relative variability. RESULTS: The standardized ratios (and CV) were determined for the nerve branches in three different surgical approaches: Hardinge 0.464 (0.9%), Bauer 0.406 (1.7%), and Frndak 0.338 (4.1%). There was a strong correlation of the individual NTDs with the TCD: NTD for Hardinge (r = 0.996, p < .001), NTD for Bauer (r = 0.984, p < .001), and NTD for Frndak (r = 0.932, p < .001). CONCLUSION: By measuring the TCD preoperatively and using the respective standardized ratios, surgeons can accurately predict the NTD and how proximal to the GT each SGN branch can be expected to be encountered during lateral approach to the hip. This will allow surgeons to work with a more precise safe zone around the SGN and minimize the possibility for a nerve injury.

Evaluation of rotator cuff abduction moment arms for superior capsular reconstruction and reverse total shoulder arthroplasty.

PURPOSE: The rotator cuff (RC) muscles contribute to dynamic stability and rotational actions of the glenohumeral joint. Moment arm can be used to demonstrate the potential work a muscle contributes to a musculoskeletal joint rotation. This study aimed to understand the moment arm contributions of the RC muscles and explore changes following a complete supraspinatus tear treated with either superior capsular reconstruction (SCR) or reverse total shoulder arthroplasty (rTSA). METHODS: Five fresh-frozen cadaveric specimens were prepared and mounted in an apparatus where each intact RC muscle was held in tension with a line of action toward its origin on the scapula. Mean moment arms for each muscle were determined experimentally based on Optotrak data collected during cadaveric shoulder arm abduction. RESULTS: Using ANOVA testing, our analysis demonstrated significant differences (p < 0.001) in infraspinatus and teres minor moment arms after rTSA compared to the intact shoulder model. After SCR, significant differences (p < 0.001) were seen in teres minor, with these differences being statistically similar to the changes seen in teres minor after rTSA. Subscapularis showed no significant difference in moment arm values between the models (p = 0.148). CONCLUSION: Our results illustrate that mean moment arms were preserved in the RC muscles after complete supraspinatus tear. This study also shows evidence that subscapularis function may be maintained after SCR or rTSA. After SCR, infraspinatus may maintain similar abduction ability compared to the anatomical shoulder, while teres minor ability may increase. Infraspinatus may have decreased abduction ability after rTSA while teres minor may have increased ability.

Histological Assessment of Wallerian Degeneration of the Rat Tibial Nerve Following Crush and Transection Injuries.

BACKGROUND: Wallerian degeneration (WD) following peripheral nerve injury (PNI) is an area of growing focus for pharmacological developments. Clinically, WD presents challenges in achieving full functional recovery following PNI, as prolonged denervation of distal tissues for an extended period of time can irreversibly destabilize sensory and motor targets with secondary tissue atrophy. Our objective is to improve upon histological assessments of WD. METHODS: Conventional methods utilize a qualitative system simply describing the presence or absence of WD in nerve fibers. We propose a three-category assessment that allows more quantification: A fibers appear normal, B fibers have moderate WD (altered axoplasm), and C fibers have extensive WD (myelin figures). Analysis was by light microscopy (LM) on semithin sections stained with toluidine blue in three rat tibial nerve lesion models (crush, partial transection, and complete transection) at 5 days postop and 5 mm distal to the injury site. The LM criteria were verified at the ultrastructural level. This early outcome measure was compared with the loss of extensor postural thrust and the absence of muscle atrophy. RESULTS: The results showed good to excellent internal consistency among counters, demonstrating a significant difference between the crush and transection lesion models. A significant decrease in fiber density in the injured nerves due to inflammation/edema was observed. The growth cones of regenerating axons were evident in the crush lesion group. CONCLUSION: The ABC method of histological assessment is a consistent and reliable method that will be useful to quantify the effects of different interventions on the WD process.

Readability Level of English and Spanish Orthopaedic Patient Education Materials English and Spanish Patient Education.

There are 16 million Hispanic people in the United States who rely on Spanish as their only effective method of communication. However, there is a scarcity of literature evaluating if patient education resources in Spanish meet the average American reading level or National Institute of Health (NIH) and American Medical Association (AMA) grade-level recommendations, especially in the field of orthopaedics. Representative orthopaedic search terms were input into Google and ten articles pertaining to patient education were selected. Videos, scientific journals, and surgical technique guides were excluded. Articles were then digitally analyzed and compared. Mean United States grade level equivalent was 11.26 ± 2.23 for English articles and 10.55 ± 1.45 for Spanish articles. English orthopaedic materials featured a significantly more difficult grade level (p < 0.01) than equivalent Spanish works. Spanish orthopaedic materials generated in the United States featured significantly lower (p < 0.01) readability scores than those written outside the United States. Our study demonstrated both English and Spanish materials were written at a high school level. Spanish materials were written at more appropriate grade-levels than their English counterparts. (Journal of Surgical Orthopaedic Advances 30(2):096-100, 2021).

Does Virtual Reality Improve Procedural Completion and Accuracy in an Intramedullary Tibial Nail Procedure? A Randomized Control Trial.

BACKGROUND: Artificial reality technologies are currently being explored as potential options to improve surgical education. Previous studies have primarily examined the efficacy of artificial reality in laparoscopic procedures, but to our knowledge, none have been performed in orthopaedically relevant procedures such as intramedullary tibial nailing, which calls for more versatile large-scale movements. QUESTIONS/PURPOSES: Does a virtual reality simulator with or without a standard technique guide result in (1) a higher proportion of participants who completed the insertion of an intramedullary tibial nail in a synthetic bones model and (2) greater procedural accuracy than does training with a technique guide alone? METHODS: Twenty-five first- and second-year medical students without prior exposure to intramedullary tibial nail insertion were recruited. Participants were randomly assigned to the technique guide control group (n = 8), the virtual reality group (n = 8), or the virtual reality and technique guide group (n = 9). The technique guide was adapted from a commercially available technique guide, which participants in the assigned groups could use to prepare as much as desired. The virtual reality simulation was based on the same procedure, and we used a commercially available virtual reality simulator that we purchased for this task. Participants in the virtual reality experimental groups completed the simulation on three separate sessions, at a set interval of 3 to 4 days apart. After 10 to 14 days of preparation, all participants attempted to insert an intramedullary nail into an intact, compact bone-model tibia that lacked surrounding soft tissue. Participants were given written hints if requested, but no other assistance was given. A procedure was considered complete if the nail and screw were properly placed. Procedural accuracy was defined as the number of incorrect steps normalized out of the 16 possible performed. After the procedure, one orthopaedic surgeon assessed a blinded video of the participant performing it so the assessor could not recognize the individual or that individual's gender. Additionally, the assessor was unaware of which group each participant had been randomized to during the evaluation. RESULTS: A higher proportion of participants in the virtual reality group (6 of 8) and the virtual reality and technique guide group (7 of 9) completed the intramedullary nail than did participants in the technique guide group (2 of 8; p = 0.01). There was no difference in completion between the virtual reality groups (p = 0.89). Participants in the virtual reality and virtual reality and technique guide had fewer normalized incorrect steps than did participants in the technique guide group (3.2 ± 0.1 of 16 and 3.1 ± 0.1 of 16 versus 5.7 ± 0.2 of 16, respectively; p = 0.02 for comparisons of virtual reality groups to technique guide, p = 0.63 between the virtual reality group). CONCLUSIONS: Virtual reality increased both procedural accuracy and the completion proportion compared with a technique guide in medical students. Based on our findings, virtual reality may help residents learn the procedural workflow and movements required to perform surgical procedures. Future studies should examine how and when exactly the technology can be applied to residencies and its impact on residents. LEVEL OF EVIDENCE: Level I, therapeutic study.

Risk factors for suicide among older adults with cancer.

OBJECTIVE: To determine whether the increased risk of suicide for individuals with cancer may be explained by functional limitations, lack of social support, or other factors. METHOD: In this population-based case-control study, interviews of primary informants for suicides in the state of North Carolina were compared to interviews with participants in the Piedmont Health Study of the Elderly to estimate adjusted odds ratios for suicide and self-reported, physician diagnosed cancer, heart attack, stroke, and hip fracture. RESULTS: Adjusting for all other factors, there was a statistically significant association of suicide and cancer (odds ratio [OR] 2.62, 95% confidence interval [CI] CI 1.84-3.73), but not heart attack, hip fracture, or stroke. The risk of suicide was also elevated for men vs. women (OR 17.15, CI 10.88-27.02), whites vs. blacks (OR 9.70, CI 6.07-15.50), and individuals with stressful life events (OR 2.75, CI 1.97-3.86) or limitations of instrumental (OR 2.93, CI 2.03-4.22) but not physical activities of daily living. Suicide cases were not more likely to be short of breath or poor sleep quality. Suicide was statistically significantly less likely for study participants who were married with spouse living vs. other (OR 0.61, CI 0.43-0.88) or who had one or more indicators of social support (OR 0.27, CI 0.19-0.39). CONCLUSION: After adjustment for other risk factors, suicide was strongly associated with cancer but not with other disabling, potentially fatal conditions.

Do Intra-articular Corticosteroid Injections Prior to Total Knee Arthroplasty Increase Postoperative Complication Rates: A Retrospective Review.

There is conflicting literature suggesting that intra-articular corticosteroid injections before total knee arthroplasty (TKA) may lead to an increase in the rate of postoperative complications, specifically periprosthetic joint infection (PJI). Thus, this retrospective review of all TKAs performed at a large, urban hospital will add valuable evidence to help guide future patient care. After exclusion criteria, we retrospectively reviewed 417 patients who received a TKA from a group of fellowship-trained orthopaedic surgeons between 2009 and 2016 at a single academic medical center. Minimum follow-up time was 1 year. Patients were separated into two groups: those who received a preoperative intra-articular corticosteroid injection and those who did not receive an injection. Subgroups were created based on the timing of their most recent preoperative injection: 0 to 3 months, 3 to 6 months, 6 to 12 months, 12+ months, and an unknown time period. Postoperative outcomes for PJI, revision TKA, and manipulation under anesthesia (MUA) were analyzed via a Chi-square test. No statistically significant postoperative differences were observed between groups: PJI (p = 0.904), revision TKA (p = 0.206), and MUA (p = 0.163). The temporal subgroups also failed to demonstrate a statistically significant result: PJI (p = 0.348), revision TKA (p = 0.701), and MUA (p = 0.512). This study revealed no absolute or temporal association between preoperative, intra-articular corticosteroid injections, and complications after TKA. Because these injections are a commonly used treatment modality prior to TKA, further studies should be conducted on a nationwide basis to draw more concrete conclusions.

The Interaction of Diabetic Peripheral Neuropathy and Carpal Tunnel Syndrome.

BACKGROUND: Diabetes mellitus (DM) increases the risk for carpal tunnel syndrome (CTS) and is associated with its own neuropathic complications. Diabetic peripheral neuropathy (DPN) is a common complication seen in diabetic patients. In this study, we examine the relationship between the severity of DPN and CTS. METHODS: Type 2 diabetic and control patients (n = 292) were recruited at a clinic visit. The Michigan Neuropathy Screening Instrument (MNSI) questionnaire was used to collect data related to peripheral neuropathy. The MNSI scores were compared for patients with CTS with and without DM in univariable and multivariable analyses. χ2 analyses were performed to quantitatively measure the associations between peripheral neuropathy and the presence of CTS. RESULTS: Of the 292 patients, 41 had CTS, and 19 of these had both CTS and DM. Of the 138 diabetic patients, 85 had peripheral neuropathy. There was no association between a diagnosis of CTS and an MNSI score indicative of peripheral neuropathy. In the diabetic population, CTS was inversely associated with DPN (P = .017). The MNSI scores between diabetic and control patients with CTS were comparable. CONCLUSION: The severity of peripheral neuropathy in diabetic patients with and without CTS is comparable. Diabetic patients without peripheral neuropathy have an association with higher incidence of CTS in this study, suggesting that there are disparate mechanisms causing DPN and CTS. Nevertheless, diabetes and CTS are risk factors for developing the other, and future studies should further explore how DPN and CTS differ to tailor patient interventions based on their comorbidities.

Fourth-Generation Ceramic Head Fracture in Dual Mobility Total Hip Arthroplasty: A Case Report.

Introduction: Rare cases of Biolox® delta ceramic head fractures in ceramic-on-polyethylene bearings have been reported in the literature. Virtually none of these catastrophic injuries have been documented in dual mobility constructs. Case Report: We report a case of fourth-generation delta ceramic head fracture 4.5 years after implantation in a dual mobility total hip replacement constructs as a result of a ground-level fall. The patient underwent revision arthroplasty with another delta ceramic dual mobility construct and was able to return to work in custodial services 2 weeks after the revision procedure. Conclusion: In summary, we presented an extremely uncommon case of a fractured fourth generation, Biolox® delta ceramic head in a dual mobility total hip arthroplasty (THA), as a result of a ground-level fall. The patient underwent successful revision surgery to another dual mobility delta ceramic THA. Despite substantial advances in ceramic materials, catastrophic failure of 4th generation ceramic head components can still occur even in dual mobility constructs and require revision arthroplasty surgery.

Long-Term Postoperative Total Knee Arthroplasty Flexion Scores in Relation to Body Mass Index.

Knee range of motion (ROM) is an important postoperative measure of total knee arthroplasty (TKA). There is conflicting literature whether patients who are obese have worse absolute ROM outcomes than patients who are not obese. This study analyzed whether preoperative body mass index (BMI) influences knee ROM after patients' primary TKA. A retrospective investigation was performed on patients, who underwent primary TKA at an academic institution, by one of three fellowship-trained adult reconstruction surgeons. Patients were stratified according to their preoperative BMI into nonobese (BMI < 30.0 kg/m2) and obese (BMI ≥ 30.0 kg/m2) classifications. Passive ROM was assessed preoperatively as well as postoperatively at patients' most recent follow-up visit that was greater than 2 years. Mann-Whitney U tests were performed to determine statistical significance at p-value <0.05 for ROM outcomes. No statistically significant differences were observed when ROM in the nonobese group was compared with ROM in the obese group both preoperatively (105.73 ± 11.58 vs. 104.14 ± 13.58 degrees, p-value = 0.417) and postoperatively (105.83 ± 14.19 vs. 104.49 ± 13.52 degrees, p-value = 0.777). Mean follow-up time for all patients was 4.49 ± 1.92 years. In conclusion, long-term postoperative ROM outcomes were similar between patients who were nonobese and patients who were obese.

Preventing Tommy John Surgery: The Identification of Trends in Pitch Selection, Velocity, and Spin Rate Before Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction is a common surgery among Major League Baseball (MLB) pitchers that results in a significant number of missed games. Little has been reported regarding game-by-game trends that can identify those on the verge of becoming injured. PURPOSE: To determine if there is a patterned change in MLB pitchers' pitch selection, velocity, or spin rate in games leading up to Tommy John surgery that may predict subsequent UCL surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of MLB pitchers who underwent primary UCL reconstruction between 2009 and 2019 was performed. Pitch characteristics were evaluated on a game-by-game basis for the 15 games leading up to surgery. A Mann-Kendall trend test was used to identify trends in pitch selection, velocity, and spin rate for multiple pitch types. A Kendall τb correlation coefficient was identified, with values closer to 1 or -1 signifying a stronger monotonic trend. RESULTS: A total of 223 MLB pitchers underwent UCL reconstruction in the time period. In the 15 games leading up to surgery, decreases in pitch velocity for 4-seam fastballs (τb = -0.657; P < .001), 2-seam fastballs (τb = -0.429; P = .029), and sliders (τb = -0.524; P = .008) were significantly associated with game number closer to injury. There was a significant positive association in the spin rate for cutters (τb = 0.410; P = .038) and a significant negative association in spin rate for 4-seam fastballs over the course of these 15 games (τb = -0.581; P = .003). In addition, there was a significant positive association in the percentage of curveballs thrown (τb = 0.486; P = .013). CONCLUSION: The study results suggest that there is a patterned change in certain pitch statistics in MLB pitchers in the games leading up to Tommy John surgery. Although the absolute change from game to game may be small, it may be possible for these trends to be monitored before a player becomes injured, thus reducing the significant burden Tommy John surgery places on these athletes.

The use of a triflange salvage system for catastrophic pelvic osteolysis after failed total hip arthroplasty.

INTRODUCTION: The custom triflange acetabular implant (CTAI) has been described to address catastrophic pelvic osteolysis, but long-term outcome data is scarce. METHODS: Revision-free survivorship after revision THA with a CTAI was retrospectively reviewed in seven patients. RESULTS: Mean and median follow-up time were 7.39 (1.61-16.8) years and 7.50 years, respectively. Revision-free survivorship was 85.7% (6/7). One patient underwent revision for recurrent dislocations. All patients were able to ambulate at recent follow-up- 2/7 without assistance. CONCLUSIONS: The CTAI is a viable option for patients with catastrophic pelvic osteolysis. There is a high complication rate, but the incidence of revision is low.

Chronic Corticosteroid Use as a Risk Factor for Perioperative Complications in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Osteoarthritis may be caused by or concurrent with diseases such as rheumatoid arthritis or systemic lupus erythematosus, which rely on chronic corticosteroids regimens for treatment. If a total knee or hip arthroplasty is needed, this chronic treatment method has been associated with poorer surgical outcomes. METHODS: A retrospective analysis of data collected by the American College of Surgeons National Surgical Quality Improvement Program was conducted. The Current Procedural Terminology codes were used to identify 403,566 total knee arthroplasty and total hip arthroplasty patients who were then stratified by the use of chronic corticosteroids for univariate analysis. RESULTS: Forteen thousand seven hundred seventy-four of the patients identified were prescribed chronic corticosteroid regimens. A statistically significant difference was observed in perioperative complications for patients prescribed with corticosteroids, including higher rates of surgical site infection (P = 0.0001), occurrence of deep incisional surgical site infection (P < 0.0001), occurrences of organ space surgical site infection (P < 0.0001), wound dehiscence (P < 0.0001), general would infection (P < 0.0001), pneumonia (P < 0.0001), occurrences of unplanned intubation (P = 0.0002), urinary tract infection (P < 0.0001), and readmission (P < 0.0001). No statistically significant difference was observed in the 30-day mortality between the 2 groups (0.63), venous thromboembolic event (0.42), cerebrovascular accident (0.12), myocardial infarction (0.49), cardiac arrest (0.098), deep vein thrombosis (0.17), or sepsis (0.52). CONCLUSION: Many of the notable differences in complications may be directly attributed to the immunosuppressive nature of corticosteroids. With increased knowledge of which perioperative complications to monitor, surgeons can tailor treatment strategies to this population that reduce morbidity and improve outcomes.

Surgical Duration Implicated in Major Postoperative Complications in Total Hip and Total Knee Arthroplasty: A Retrospective Cohort Study.

INTRODUCTION: Total hip and knee arthroplasties are two of the most commonly performed orthopaedic surgeries and are expected to increase in incidence in the coming decades. We sought to examine whether the duration of these procedures is related to various postoperative complications using data from 2010 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing total hip and knee arthroplasty by their respective Current Procedural Terminology codes. Operation time was stratified into four quartiles with equal sample sizes in each quartile for total hip and knee arthroplasty separately. The first quartile of surgical times was used as the control to which the other three quartiles were compared. Multivariate logistic regression analysis was performed on all samples that accounted for possible covariates, totaling 119,076 patients for total hip and 189,297 for total knee arthroplasty. RESULTS: The third and fourth quartiles of total hip and total knee arthroplasty were markedly associated with higher incidences of wound complications, particularly infection and dehiscence. In addition, prolonged total hip arthroplasty was associated with a markedly higher rate of urinary tract infections for the third and fourth quartiles, and deep vein thrombosis in the fourth quartile. CONCLUSIONS: The surgical duration of total hip and knee arthroplasties is an independent risk factor for wound complications and several other important postoperative complications. Therefore, extensive preoperative planning and postoperative prophylactic measures should be performed to minimize patient morbidity and reduce hospital costs.

Enterobacter cloacae Periprosthetic Joint Infection After Bariatric Surgical Anastomotic Leak.

Four weeks after a bilateral total knee arthroplasty (TKA), an immunocompetent, 61-year-old, Caucasian man presented with a periprosthetic joint infection (PJI) of the left knee by Enterobacter cloacae (an enteric bacteria). The most likely source of his infection was due to an anastomotic leak after a bariatric surgery done 6 months before TKA. There is a growing focus on stratifying the risk of PJI after TKA. Hematogenous seeding of enteric bacteria leading to PJI is an unexplored risk that will become more prevalent as bariatric procedures before TKA continue to increase in frequency. We present a patient who demonstrates this PJI risk with a rare microbe (E cloacae).