No Difference Between Low- and Regular-dose Aspirin for Venous Thromboembolism Prophylaxis After THA.

BACKGROUND: Aspirin is established as an effective prophylaxis for venous thromboembolism (VTE) after THA; however, there is no consensus as to whether low- or regular-dose aspirin is more effective at preventing VTE. QUESTIONS/PURPOSES: (1) Is there a difference in the incidence of symptomatic VTE within 90 days of elective THA using low-dose aspirin compared with regular-dose aspirin? (2) Is there a difference in the risk of significant bleeding (gastrointestinal and wound bleeding) and mortality between low- and standard-dose aspirin within 90 days after surgery? METHODS: We retrospectively evaluated 7488 patients in our database who underwent THA between September 2012 and December 2016. A total of 3936 (53%) patients received aspirin alone for VTE prophylaxis after THA. During the study period, aspirin was prescribed as a monotherapy for VTE prophylaxis after surgery in low-risk patients (no history of VTE, recent orthopaedic surgery, hypercoagulable state, history of cardiac arrhythmia requiring anticoagulation, or receiving anticoagulation for any other medical conditions before surgery). Patients were excluded if aspirin use was contraindicated because of peptic ulcer disease, intolerance, or other reasons. Patients received aspirin twice daily (BID) for 4 to 6 weeks after surgery and were grouped into two cohorts: a low-dose (81 mg BID) aspirin group (n = 1033) and a standard-dose (325 mg BID) aspirin group (n = 2903). The primary endpoint was symptomatic VTE (deep vein thrombosis [DVT] and pulmonary embolism [PE]). Secondary endpoints included significant bleeding (gastrointestinal [GI] and wound) and mortality. Exploratory univariate analyses were used to compare confounders between the study groups. Multivariate regression was used to control for confounding variables (including age, sex, body mass index, comorbidities, and surgeon) as we compared the study groups with respect to the proportion of patients who developed symptomatic VTE, bleeding (GI or wound), and mortality within 90 days of surgery. RESULTS: The 90-day incidence of symptomatic VTE was 1.0% in the 325-mg group and 0.6% in the 81-mg group (p = 0.35). Symptomatic DVT incidence was 0.8% in the 325-mg group and 0.5% in the 81-mg group (p = 0.49), and the incidence of symptomatic PE was 0.3% in the 325-mg group and 0.2% in the 81-mg group (p = 0.45). Furthermore, bleeding was observed in 0.8% of the 325-mg group and 0.5% of the 81-mg group (p = 0.75), and 90-day mortality was not different (0.1%) between the groups (p = 0.75). After accounting for confounders, regression analyses showed no difference between aspirin doses and the 90-day incidence of symptomatic VTE (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.29-2.85; p = 0.85) or symptomatic DVT (OR, 0.96; 95% CI, 0.26-3.59; p = 0.95). CONCLUSIONS: We found no difference in the incidence of symptomatic VTE after THA with low-dose compared with standard-dose aspirin. In the absence of compelling evidence to the contrary, low-dose aspirin appears to be a reasonable option for VTE prophylaxis in otherwise healthy patients undergoing elective THA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Patients with a History of Treated Septic Arthritis are at High Risk of Periprosthetic Joint Infection after Total Joint Arthroplasty.

BACKGROUND: In patients undergoing total joint arthroplasty (TJA), increasing attention has been directed recently toward identifying specific patient-related risk factors that may predispose patients to periprosthetic joint infection (PJI). Currently, it is unclear whether having a history of a treated native septic arthritis is a risk factor for PJI after TJA in the same joint. Previous studies have reported contradictory evidence and results varied between a substantially higher rates of PJIs to very low or no reported PJIs. QUESTIONS/PURPOSES: (1) What is the risk of PJI in patients who received TJA and had a history of treated same-joint native joint septic arthritis and (2) What are the associated risk factors for these patients developing PJI? METHODS: This was a multicenter retrospective analysis of patients who received primary THA or TKA between January 2000 and December 2016 and who had a history of treated native joint septic arthritis in the same joint. Patients were included in the study only if they were considered to have resolved their joint infection based on a preoperative evaluation that included: (1) the absence of clinical symptoms and signs of active infection or local joint inflammation, (2) recent plain radiographs showing only advanced degenerative changes without evidence of active osteolysis or bone infection, (3) preoperative laboratory investigations for infection, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and total leukocyte counts within normal ranges. Patients were reviewed for the occurrence of postoperative PJI. The final cohort included 62 patients who had a mean followup of 4.4 years (range, 3 months-17 years) from the time of TJA. A total of 21 patients (34%) had less than 2 years of followup, including six (10%) mortalities. In total, eight patients (13%) died during the study period, none of which were due to PJI. Patient characteristics, time interval from treatment of septic arthritis to TJA, and Charlson comorbidity index adjusted for age were collected. We used a Kaplan-Meier analysis to estimate the overall survivorship among all TJAs as well as those who underwent THA versus TKA, and we performed a statistical comparison using the Mantel-Cox log-rank test. We performed a Cox regression hazard ratio (HR) survival analysis to identify risk factors for PJI. The PJI odds ratios (OR) for patients who underwent TJA within 2 years of septic arthritis were calculated as an additional temporal analysis. RESULTS: In patients with a history of treated same-joint native septic arthritis, the proportion of PJI was five of 62 patients (8%). The Kaplan-Meier analysis demonstrated an overall survivorship free from PJI of 92% at 14.5 ± 1.14 years (95% confidence interval [CI] = 12.3-16.8 years). All PJI cases occurred only in patients who underwent TKA, which when analyzed separately, yielded a survivorship of 85% at 10.5 ± 0.9 years (95% CI = 8.7-12.3 years) versus 100% in patients who underwent THA (p = 0.068). Mean time to PJI occurrence was 10 months (range, 2-20 months). After controlling for relevant confounding variables, such as age, sex, affected joint and comorbidities, we found smoking (HR, 8.06; 95% CI, 1.33-48.67; p = 0.023) to be associated with increased risk for PJI development. CONCLUSION: Patients with history of native joint infections are at higher risk of PJI, especially smokers. Despite our limitations, this study suggests careful assessment of several other factors in these patients, including allowing a minimum interval of 2 years from the time of resolving native joint septic arthritis to TJA. Patients who are undergoing TKA seem to be more prone to the PJI risk and may benefit from more aggressive planning. In addition, medical optimization of comorbidities that may confer additional risk, such as diabetes, become exceptionally important in these patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

Arthroscopic irrigation and debridement is associated with favourable short-term outcomes vs. open management: an ACS-NSQIP database analysis.

PURPOSE: Septic arthritis of the knee is an orthopaedic emergency that is associated with marked morbidity and can potentially be life threatening. Surgical debridement can be performed either arthroscopically or via an arthrotomy. The aim of this study was to compare the 30-day complications and adverse outcomes between the two procedures. METHODS: Patients with a diagnosis of septic arthritis of the knee between 2011 and 2015 were identified using the ACS-NSQIP database. The study population included 695 patients, who had knee septic arthritis and underwent either an arthroscopic irrigation or debridement (I&D) (n = 464) or open irrigation and debridement (n = 231). Preoperative data included demographics, independent functional status, and comorbidities. Outcomes of interest included wound complications, infectious complications, cardiovascular events, hospital readmissions, and reoperations, or any of the previous adverse events. RESULTS: Both cohorts were similar in most baseline characteristics. Bleeding requiring transfusion was significantly lower in the arthroscopic (n = 13; 3.6%) compared to the open procedure (n = 31; 13.4%; p = 0.0001). Home discharge was significantly higher in the arthroscopic irrigation and debridement group (n = 310; 67.5%) compared to the open group (n = 126; 55%; p = 0.0013). The overall incidence of adverse events was lower in the arthroscopic group (n = 158; 34%) compared to the open group (n = 112; 49%; p = 0.0002). There was no difference in rates of infectious complications, thromboembolic events, hospital readmission, reoperation, or mortality between the groups. Open irrigation and debridement was associated with higher risk of bleeding requiring transfusion (OR = 3.79; 95% CI: 2.02-7.13; p = 0.0001), higher risk of incidence of adverse events (OR = 1.46; 95% CI: 1.02-2.08; p = 0.039), and lower home discharge (OR = 3.79; 95% CI: 2.02-7.13; p = 0.0001) within 30 days after the procedure. CONCLUSION: Arthroscopic irrigation and debridement demonstrated favourable short-term outcomes. Patients who underwent arthroscopic irrigation and debridement had lower rates of blood transfusions, lower rates of adverse events, and higher home discharge rates compared to open irrigation and debridement. This study is the largest analysis comparing arthroscopic vs. open irrigation and debridement in a national database sample. These findings conclude that arthroscopic debridement can be an alternative first-line option in managing septic arthritis. LEVEL OF EVIDENCE: III.

Emergency Department Visits Within Thirty Days of Discharge After Primary Total Hip Arthroplasty: A Hidden Quality Measure.

BACKGROUND: Thirty-day hospital readmissions following total hip arthroplasty (THA) have received increasing scrutiny by policy makers and hospitals. Emergency department (ED) visits may not necessarily result in an inpatient readmission but can be a measure of performance and can incur costs to the health system. The purpose of this study is to describe the following: (1) the frequency and subsequent disposition; (2) patient characteristics; (3) reasons; and (4) potential risk factors for ED visits that did not result in a readmission within 30 days of discharge after THA. METHODS: All primary THAs performed at a large healthcare system between 2013 and 2015 were identified. Patients who received unplanned hospital services for complications within 30 days following surgery were identified and analyzed. A multiple regression analysis was utilized to identify risk factors predisposing for returning to the ED without readmission. RESULTS: From a total of 6270 primary THAs, 440 patients (7%) had an unplanned return to the hospital within 30 days. Of those, 227 (3.6%) patients presented to the ED and were not readmitted. Higher percentage of African Americans was noted among patients who returned to the ED versus those who did not (20.2% vs 9.8%, P < .01). The most common medical diagnoses were nonspecific medical symptoms (24.8%) followed by minor gastrointestinal problems (10.5%). The most common surgery-related diagnoses were pain and swelling (35%), followed by wound complications (12%) and hip dislocations (7.3%). Nearly 50% of wound complications and 40% of hip dislocations were managed and discharged from the ED without a readmission. Both African Americans (odds ratio 2.28, 95% confidence interval 1.55-3.36) and home discharge (odds ratio 1.90, 95% confidence interval 1.28-2.82) were independent risk factors for return to the ED without readmission. CONCLUSION: ED visits that do not result in hospital readmissions, many of which may be due to serious complications, are more frequent than inpatient readmission. This is extremely relevant to policy makers and quality metrics, especially as comprehensive and bundled payment initiatives become more prevalent.

Effects of a Total Knee Arthroplasty Care Pathway on Cost, Quality, and Patient Experience: Toward Measuring the Triple Aim.

BACKGROUND: Care pathways are increasingly important as the shift toward value-based care continues; however, there is an inconsistent literature regarding their efficacy. The authors hypothesized that a total knee arthroplasty (TKA) care pathway, at a multihospital health system, would decrease cost, length of stay (LOS), discharges to inpatient facilities, postoperative complications at 90 days, and improve patient experience. METHODS: A historical control study with multivariable regression was used to determine the association of an evidence-based care pathway with episode of care cost, LOS, discharge disposition, 90-day postoperative complications, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. RESULTS: In total, 6760 primary TKA surgeries were analyzed. Multivariable regression demonstrated that the full protocol period was associated with a decrease in episode of care costs (-8.501%, 95% confidence interval [CI] -9.639 to -7.350), a decrease in LOS (-26.966%, 95% CI -28.516 to -25.382), and an increase in discharges to home (odds ratio [OR] 3.838, 95% CI 3.318-4.446). The full protocol was not associated with a change in 90-day complications (OR 1.067, 95% CI 0.905-1.258) or patient willingness to recommend (OR 1.06, 95% CI 0.72-1.55). Adjusted episode of care cost savings, normalized to average national Medicare reimbursement, were $2360 per patient. CONCLUSION: TKA care pathways are an effective tool for standardizing care and reducing costs across a large health system. Further investigations are needed to develop interventions to consistently reduce complications. National scale implementation of care pathways in TKA could lead to estimated cost reductions of approximately $1.6 billion annually.

Effect of Antibiotic-Impregnated Bone Cement in Primary Total Knee Arthroplasty.

BACKGROUND: The purpose of this study is to evaluate the effect of commercially available antibiotic-impregnated bone cement (AIBC) on (1) prosthetic joint infections (PJIs) and (2) surgical site infections (SSIs) after primary total knee arthroplasty (TKA). METHODS: A review of primary TKAs between 2014 and 2017 from an institutional database was conducted. This identified 12,541 cases which were separated into AIBC (n = 4337) and non-AIBC (8,164) cohorts. Medical records were reviewed for PJIs and SSIs (mean 2-year postoperative period). Infection rates between the cohorts were compared with univariate analyses followed by subanalysis of high risk patients (defined as having 2 or more of the following characteristics: >65 years, body mass index >40, or Charlson Comorbidity Index score >3). To control for confounders, multivariate analyses were performed with regression models adjusted for age, gender, body mass index, comorbidities, year, operative times, and lengths of stay. RESULTS: On univariate analysis, PJI rates were higher in the AIBC cohort (1.0%) compared to the non-AIBC cohort (0.5%, P < .001). Subanalysis of the high risk patients also showed that PJI rates were higher in the AIBC cohort (1.9% vs 0.6%, P < .01). After adjusting for potential confounders, no significant associations between PJIs and AIBC use were found (odds ratio 1.4, 95% confidence interval 0.9-2.3, P = .133). Similarly, no significant differences in SSI rates were observed between the AIBC (2.9%) and non-AIBC cohorts (2.4%, P = .060) and no significant associations between SSIs and AIBC were found with multivariate analysis (odds ratio 1.0, 95% confidence interval CI 0.8-1.3, P = .948). CONCLUSION: This study found that there was no clinically or statistically significant decrease in infection rates with AIBC in primary TKAs.

Implementation of a Total Hip Arthroplasty Care Pathway at a High-Volume Health System: Effect on Length of Stay, Discharge Disposition, and 90-Day Complications.

BACKGROUND: Standardized care pathways are evidence-based algorithms for optimizing an episode of care. Despite the theoretical promise of care pathways, there is an inconsistent literature demonstrating improvements in patient care. The authors hypothesized that implementing a care pathway, across 11 hospitals, would decrease hospital length of stay (LOS), decrease postoperative complications at 90 days, and increase discharges to home. METHODS: A multidisciplinary team developed an evidence-based care pathway for total hip arthroplasty (THA) perioperative care. All patients receiving THA in 2013 (pre-protocol, historical control), 2014 (transition), and 2015 (full protocol implementation) were included in the analysis. Multivariable regression assessed the relationship of the care pathway to 90-day postoperative complications, LOS, and discharge disposition. Cost savings were estimated using previously published postarthroplasty episode and per diem hospital costs. RESULTS: A total of 6090 primary THAs were conducted during the study period. After adjusting for the covariates, the full protocol implementation was associated with a decrease in LOS (mean ratio, 0.747; 95% confidence interval [CI; 0.727, 0.767]) and an increase in discharges to home (odds ratio, 2.079; 95% CI [1.762, 2.456]). The full protocol implementation was not associated with a change in 90-day complications (odds ratio, 1.023; 95% CI [0.841, 1.245]). Payer-perspective-calculated theoretical cost savings, including both index admission and postdischarge costs, were $2533 per patient. CONCLUSION: The THA care pathway implementation was successful in reducing LOS and increasing discharges to home. The care pathway was not associated with a change in 90-day complications; further targeted interventions in this area are needed. Despite care standardization efforts, high-volume hospitals and surgeons had higher performance. Extrapolation of theoretical cost savings indicates that widespread THA care pathway adoption could lead to national healthcare savings of $1.2 billion annually.

Validation of a Novel Surgical Data Capturing System Following Total Hip Arthroplasty.

BACKGROUND: The OrthoMiDaS (Orthopedic Minimal Data Set) Episode of Care (OME) database was developed in an effort to advance orthopedic outcome measurements on a national scale. This study was designed to evaluate if the OME data capture system would increase the quality of data collected in the context of primary and revision total hip arthroplasty (THA) compared to conventional operative notes. METHODS: This study includes data from the first 100 primary THAs and 100 revision THAs performed by 15 surgeons at a single institution from January through April 2016. Surgeons prospectively entered procedural details into OME following surgery. The OME database and operative notes were compared to evaluate completion rates and agreement. Completion rates were compared using McNemar's test (with continuity correction), while agreement was analyzed using Cohen's kappa (κ) and concordance correlation coefficient. RESULTS: The OME database had significantly higher completion rates for 41% (39/96) of the variables. Proportion of data points that matched between the operative notes and OME data revealed that 54% (52/96) had a proportion agreement >0.90, and 79% (76/96) had a proportion agreement >0.80. In regard to measured agreement, 25% (24/96) of variables had almost perfect agreement, 29% (28/96) had substantial agreement, and 14% (13/96) had moderate agreement. Only 4% (4/96) had fair agreement, 8% (8/96) had slight agreement, and 6% (6/96) had poor agreement. CONCLUSION: The OME data capture system is an efficient tool to document procedural details following THA. The system is user-friendly, comprehensive, and accurate. It has the potential to be a valuable tool for future orthopedic research.

Reduction of Particles in the Operating Room Using Ultraviolet Air Disinfection and Recirculation Units.

BACKGROUND: Airborne bacteria are a major source for wound contamination during total joint arthroplasty. Crystalline ultraviolet C (C-UVC) filter units were designed to disinfect and recirculate air in the operating room (OR). This preliminary study assessed the particle reducing capacity of C-UVC units in a highly controlled OR setting. METHODS: A particle counter was deployed in a positive-pressure OR to measure total and viable particle counts (TPC/VPC). Thirty 23-minute experiments were performed. At 4 designated times a person would walk through the door to mimic OR traffic. Ten experiments were performed as controls, 10 experiments used a C-UVC unit 4 meters (m) from the door, and 10 cases with the C-UVC unit at 8 m. Outcomes included overall, change (Δ), and maximum TPC/VPC. Mann-Whitney U-tests determined statistical differences in TPC/VPC. RESULTS: Compared to controls, the cases with the C-UVC unit at 4 m had significantly lower particle levels. Overall TPC/VPC, changes in TPC/VCP, and maximum TPC/VPC were all significantly lower (P < .05) in the C-UVC unit (4 m) group compared to the controls. The C-UVC at 8 m significantly reduced TPC in all 3 outcomes (P < .05) compared to controls; however, it did not significantly reduce changes in VPC (P = .107) and maximum VPC (P = .052). There were no significant differences in any outcomes between the 4 m and 8 m group. CONCLUSION: C-UVC units have shown to be capable of significantly reducing TPC and VPC in a highly controlled OR setting. Reducing airborne particles using C-UVC units may reduce infection rates following total joint arthroplasty.

High Efficiency Particulate Air Filters Do Not Affect Acute Infection Rates During Primary Total Joint Arthroplasty Using Forced Air Warmers.

BACKGROUND: Studies have suggested that forced-air warmers (FAWs) increase contamination of the surgical site. In response, FAWs with high efficiency particulate air filters (FAW-HEPA) were introduced. This study compared infection rates following primary total joint arthroplasty (TJA) using FAW and FAW-HEPA. METHODS: Primary TJA patients at a single healthcare system were retrospectively reviewed. A total of 5405 THA (n = 2419) and TKA (n = 2986) consecutive cases in 2013 and 2015 were identified. Patients in 2013 (n = 2792) had procedures using FAW, while FAW-HEPA was used in 2015 (n = 2613). The primary outcome was overall infection rate within 90-days. Sub-categorization of infections as periprosthetic joint infection (PJI) or surgical site infection (SSI) was also conducted. PJI was defined as reoperation with arthrotomy or meeting Musculoskeletal Infection Society (MSIS) criteria. SSI was defined as wound complications requiring antibiotics or irrigation/debridement. RESULTS: The FAW and FAW-HEPA groups had similar rates of overall infection (1.65% [n = 46] vs 1.61% [n = 42], P > .99), SSI (1.18% [n = 33] vs 0.84% [n = 22], P = .27), and PJI (0.47% [n = 13] vs 0.77% [n = 20], P = .22). Regression models did not show FAW to be an independent risk factor for increased overall infection (odds ratio [OR] 1.00, 95% confidence interval [CI] 0.65-1.57, P = .97), SSI (OR 1.47, 95% CI 0.83-2.58, P = .18), or PJI (OR 0.53, 95% CI 0.25-1.13, P = .09). CONCLUSION: FAW were not correlated with a higher risk of overall infection, SSI, or PJI during TJA when compared to FAW-HEPA devices.

Diagnostic Utility of Histological Analysis for Detecting Ongoing Infection During Two-Stage Revision Arthroplasty in Patients With Inflammatory Arthritis.

BACKGROUND: Surgeons often rely on intra-operative histology (frozen sections [FS]) to determine the next step in surgical management during the second stage (re-implantation surgery) of 2-stage revision arthroplasty. The purpose of the study is to assess the accuracy of permanent sections (PS) and FS in the diagnosis of persistent infection during re-implantation in patients with an inflammatory arthritis. METHODS: From 2001 to 2016, 47 planned second-stage revision total hip arthroplasty and total knee arthroplasty in patients with inflammatory arthritis were identified. Revisions were classified as having persistent infection if they were Musculoskeletal Infection Society positive at the time of second stage. PS or FS was considered to be positive for infection when at least one of the specimens demonstrated an acute inflammation. Receiver operating characteristic analysis was performed to obtain the diagnostic parameters. RESULTS: There were 9 (19%) persistent infections. Both PS and FS had very high specificity (PS = FS = 94.7%). Sensitivity of PS was higher than FS, although not statistically significant (PS = 88.9%, FS = 55.6%, P = .083). Overall, PS had a better diagnostic utility than FS (area under the curve: PS vs FS = 0.92 vs 0.75, P = .045). Four specimens had discrepancies between PS and FS histology. In all 4 instances, the specimens were read as positive (infected) by PS, but negative by FS. CONCLUSION: Histological analysis is recommended at the time of re-implantation surgery even in patients with inflammatory arthritis. PS had a better diagnostic utility than FS suggesting that areas of acute inflammation may be scattered and may not always be captured in the specimens taken for FS.

Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prophylaxis Following Total Knee Arthroplasty.

BACKGROUND: Aspirin is an effective prophylaxis for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The optimal prophylactic aspirin dose has not been established. The study aims to compare 2 aspirin regimens with regard to the incidence of (1) symptomatic deep venous thrombosis (DVT), (2) pulmonary embolism (PE), (3) bleeding, and (4) mortality within 90 days after TKA. METHODS: We retrospectively identified 5666 patients who received aspirin twice daily for 4 to 6 weeks after TKA. A total of 1327 patients received 81-mg BID and 4339 patients received 325-mg BID aspirin. Postoperative complications collected were VTEs (DVT and PE), bleeding (gastrointestinal or wound bleeding), and mortality. RESULTS: The incidence of VTE was 1.5% in the 325-mg group and 0.7% in the 81-mg group (P = .02). Symptomatic DVT was 1.4% in the 325-mg aspirin compared with 0.3% for the 81-mg aspirin (P = .0009). Regression model showed no correlation between aspirin dose and VTE incidence (odds ratio [OR] = 1.03; 95% confidence interval [95% CI], 0.45-2.36; P = .94) or DVT (OR = 0.50; 95% CI, 0.16-1.55; P = .20). The incidence of PE was 0.2% in the high-aspirin group compared with 0.4% in the low-aspirin group (P = .13). Bleeding was 0.2% in the 325-mg aspirin group and 0.2% in the 81-mg aspirin group (P = .62), and 90-day mortality was similar (0.1%) between the groups (P = .56). CONCLUSION: Low-dose aspirin was not inferior to high-dose aspirin for the prevention of VTE after TKA. Low-dose aspirin can be considered a safe and effective agent in the prevention of VTE after TKA.

Chronic Obstructive Pulmonary Disease Is Associated With Short-Term Complications Following Total Hip Arthroplasty.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Furthermore, COPD patients are at increased risk of complications following surgery. The purpose of this study was to evaluate the postoperative total hip arthroplasty (THA) outcomes of COPD patients. Specifically, we asked the following questions: (1) Is COPD associated with adverse perioperative outcomes and (2) Does COPD increase the risk of short-term complications following THA? METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 64,796 patients who underwent THA between 2008 and 2014. A total of 2426 patients with COPD were identified. COPD and non-COPD cohorts were compared based on the following outcomes: hospital length-of-stay, operative times, discharge disposition, and 30-day postoperative complications. RESULTS: COPD patients were found to have a longer length-of-stay and be discharged to an extended care facility (P < .001). COPD patients were also at significantly (P < .05) increased risk for any complication, such as mortality, myocardial infarction, pneumonia, septic shock, unplanned reintubation, use of a mechanical ventilator >48 hours, deep infection, require a blood transfusion, return to operating room, and a readmission within 30 days postoperatively. CONCLUSIONS: COPD patients are more likely to suffer from postoperative complications following THA when compared to non-COPD patients. Many of these complications are medical, pulmonary evaluation and medical optimization are a critical step in preoperative management for these patients.

Chronic Obstructive Pulmonary Disease Is Associated With Short-Term Complications Following Total Knee Arthroplasty.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major global health issue and a leading cause of morbidity and mortality. Patients with COPD are at increased risk of complications following surgery. The purpose of this study is to evaluate the postoperative total knee arthroplasty (TKA) outcomes in these patients in comparison to a non-COPD matching cohort. Specifically, we asked the following questions: (1) "Is COPD associated with adverse perioperative outcomes?" and (2) "Does COPD increase the risk of short-term complications following TKA?" METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 111,168 patients who underwent TKA between 2008 and 2014. A total of 3975 patients with COPD were identified. Both COPD and non-COPD cohorts were compared in terms of the following outcomes: hospital length of stay, discharge disposition, and 30-day postoperative complications. RESULTS: COPD was a predictor for a prolonged length of stay and a discharge to an extended care facility (P < .001). They were at significantly increased risk of any complication including increased mortality, pneumonia, reintubation, use of a mechanical ventilator for >48 hours, cardiac arrest, progressive renal insufficiency, deep infection, return to operating room, and a readmission within 30 days postoperatively. CONCLUSION: Patients with COPD are more likely to experience postoperative complications following TKA when compared to non-COPD patients. Pulmonary evaluation and optimization are crucial to minimize adverse events from occurring in this difficult-to-treat population.

Cervicothoracic Pedicle Morphometry: Using an Osteological Collection to Characterize Trends in Pedicle Size.

Pedicle screws are a common treatment option for spinal instability. Despite their popularity, pedicle screws carry the risk of transpedicular violation with subsequent neural and vascular damage. This study measured the pedicle dimensions of 500 dry specimens in an osteological collection. The data provide the orthopedic spine surgeon with an accurate measure of pedicle morphometry in light of previously limited and contradictory results. The study demonstrates that pedicle height at the cervicothoracic junction tends to increase with body height, particularly for females. Additionally, T1 pedicle width is smaller for females than males and, for males, tends to decrease with increasing body weight. These results are valuable to the spine surgeon because they suggest that taller patients may afford a larger margin for error in the vertical plane. However, they also demonstrate that heavier patients do not have wider pedicles and thus cannot be assumed to tolerate or require larger-diameter screws. (Journal of Surgical Orthopaedic Advances 27(1):33-38, 2018).

The Learning Curve Associated with the Administration of Intra-Articular Liposomal Bupivacaine for Total Knee Arthroplasty: A Pilot Study.

INTRODUCTION: Liposomal bupivacaine is a long-acting, local, injectable anesthetic that is used to potentially mitigate post-operative pain after total knee arthroplasty (TKA). In addition, it may reduce opioid use in the post-operative period and shorten lengths-of-stay (LOS). There have been mixed results in the literature with regards to its efficacy, which raises questions regarding the injection technique used. Therefore, we evaluated the learning curve associated with injection techniques prior to, and after, formal teaching. Specifically, we compared differences in: 1) opioid use; 2) LOS; 3) pain intensity; and 4) discharge disposition in patients who did not receive liposomal bupivacaine (no infiltration cohort), received liposomal bupivacaine with less optimal technique (subpar infiltration), and received liposomal bupivacaine with appropriate technique (optimal infiltration) during their primary TKA. MATERIALS AND METHODS: A 1:1:1 ratio of 54 consecutive cases of patients who had no liposomal bupivacaine infiltration, those who had subpar infiltration, and those who had optimal infiltration were included. To evaluate opioid use, the dosages were obtained and converted to their respective morphine milliequivalents (mEq). The total mEq usage was obtained for the day of surgery through post-operative day (POD) 3. LOS was recorded in days. Pain scores were calculated using the visual analogue scale (VAS), obtained from the first post-operative physical therapy note. Discharge status was recorded as discharged to home or rehabilitation. We used an ANOVA test for continuous and X2-square test for categorical variables. RESULTS: When compared to patients who had no infiltration, patients who had subpar infiltration had significantly lower opioid use on day 0, while patients who had optimal infiltration had lower opioid use on post-operative day (POD) 0 and 3. When comparing techniques, opioid use was lower on day 3 for patients who had optimal, as compared to subpar technique. However, LOS and VAS were not significantly different among the three groups. The rehab discharge rate was lower for patients who had optimal as compared to subpar technique. CONCLUSION: There is a learning curve associated with liposomal bupivacaine use, and incorporating an appropriate technique can markedly affect post-operative outcomes. This should be taken into account when evaluating the potential benefits of this peri-articular injection. It appears that liposomal bupivacaine may decrease opioid use and pain scores when optimal infiltration techniques are used.

Concomitant Gluteal and Thigh Compartment Syndrome Following Atraumatic Injury.

Gluteal compartment syndrome is a rare diagnosis associated with pelvic trauma and subsequent surgical intervention. Herein, we discuss the case and management of gluteal and thigh compartment syndrome following prolonged immobilization secondary to alcohol. To our knowledge, we present the first case of concomitant gluteal and thigh compartment syndrome following atraumatic injury.

Infrapatellar Fat Pad Resection or Preservation during Total Knee Arthroplasty: A Systematic Review.

Considerations of how to improve postoperative outcomes for total knee arthroplasty (TKA) have included preservation of the infrapatellar fat pad (IPFP). Although the IPFP is commonly resected during TKA procedures, there is controversy regarding whether resection or preservation should be implemented, and how this influences outcomes. Therefore, the purpose of this systematic review was to evaluate how IPFP resection and preservation impacts postoperative flexion, pain, Insall-Salvati Ratio (ISR), Knee Society Score (KSS), patellar tendon length (PTL), and satisfaction in primary TKA. PubMed, EBSCO host, and SCOPUS were queried to retrieve all reports evaluating IPFP resection or preservation during TKA, which resulted into 488 studies. Two reviewers independently reviewed these articles for eligibility based on pre-established inclusion and exclusion criteria. Eleven studies were identified for final analysis, which reported on 11,996 cases. Patient demographics, type of surgical intervention, follow-up duration, and clinical outcome measures were collected and analyzed. Complete resection was implemented in 3,723 cases (31%), partial resection in 5,458 cases (45.5%), and preservation of the IPFP in 2,815 cases (23.5%). Clinical outcome measures included PTL (5 studies), knee flexion (4 studies), pain (6 studies), KSS (3 studies), ISR (3 studies), and patient satisfaction (1 study). No differences were found following IPFP resection for patient satisfaction (p = 0.98), ISR (p > 0.05), and KSS (p > 0.05). There was mixed evidence for PTL, pain, and knee flexion following IPFP resection versus preservation. Studies of shorter follow-up intervals suggested improved pain following resection, while reports of longer follow-up times indicated that resection resulted in increased pain. Given the mixed data available from the current literature, we were unable to conclude that one surgical technique can definitively be considered superior over the other. More extensive research, including randomized controlled trials, is required to better elucidate potential differences between the surgical handling choices. Future studies should focus on patient conditions in which one technique would be best indicated to establish guidelines for best surgical outcomes in those patients.