Modifiable Analgesia-/Anesthesia-Related Factors and Risk of Severe Gastrointestinal Complications After Lower Extremity Total Joint Arthroplasty: A Nationwide Analysis.

BACKGROUND: Severe gastrointestinal (GI) complications after elective hip and knee arthroplasty (THA/TKA) are rare. Some of them can be life-threatening and/or require emergency abdominal surgery. We studied the epidemiology of severe GI complications after THA/TKA and associations with anesthesia- and/or analgesia-related factors. METHODS: We included 591,865 THA and 1,139,616 TKA cases (Premier Healthcare claims database; 2006-2016). Main outcomes were GI complications and related emergency surgeries within 30 days after THA/TKA. Anesthesia- and analgesia-related factors were anesthesia type (neuraxial, general), use of peripheral nerve block, patient-controlled analgesia, nonopioid analgesics (acetaminophen, gabapentin/pregabalin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, ketamine), and opioids (in oral morphine equivalents, categorized into low, medium, and high use based on the interquartile range). Mixed-effects models measured associations between anesthesia- and analgesia-related factors and outcomes, which were reported using odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Among THA patients, GI complications were observed in 1.03% (n = 6103), with 0.08% (n = 450) requiring emergency surgery; this was 0.79% (n = 8971) and 0.05% (n = 540), respectively, for TKA patients. After adjustment for relevant covariates (including opioid use), almost all anesthesia-/analgesia-related factors were associated with significantly decreased odds of GI complications, specifically use of cyclooxygenase-2 inhibitors (OR 0.72 CI 0.67-0.76/OR 0.82 CI 0.78-0.86), nonsteroidal anti-inflammatory drugs (OR 0.81 CI 0.77-0.85/OR 0.90 CI 0.86-0.94), and peripheral nerve blocks (OR 0.77 CI 0.69-0.87/OR 0.91 CI 0.85-0.97); all for THA and TKA, respectively (all P < .01). CONCLUSION: Rare, but devastating, acute GI complications (requiring surgery) after THA/TKA may be positively impacted by a variety of modifiable anesthesia-/analgesia-related interventions.

Acetabular positioning is more consistent with the use of a novel miniature computer-assisted device.

INTRODUCTION: Computer-assisted surgery (CAS) relying on registration of the anterior pelvic plane (APP) allows precise acetabular component placement. We determined the variability of cup placement in patients who underwent THA with and without the use of CAS that does not rely on the registration of APP. METHODS: Fifty-one patients who underwent staged-bilateral THAs, one without CAS (control), and a subsequent one with CAS (study group), were included. Acetabular inclination and anteversion were measured on standardized post-operative radiographs. Variance in cup position and Lewinnek's zone proportionality were compared between the groups. Multiple regressions were performed to identify factors affecting variability in acetabular component placement. RESULTS: The mean inclination for the control and study group was 42.7° (SD 4.5) and 42.5° (SD 2.9), respectively. The inclination variance was 20.5° and 8.2° respectively (p = < 0.001). Cup inclination was more consistent in the study than in the control group (deviation from the mean: 2.3° vs. 3.8°, p < 0.001). The mean anteversion for the control and the study group was 25.5° (SD 7.4) and 26.8° (SD 4.3), respectively. The anteversion variance was 54.2° and 18.2° respectively (p = <0.001). Consistency in cup anteversion was significantly improved with CAS (deviation from the mean: 3.4° vs. 5.8°; p = 0.002). Lewinnek's zone proportionality was not affected by the use of  CAS. In the linear regression analysis, CAS significantly increased consistency in cup inclination (p = 0.01). Patient's factors including BMI and laterality affected consistency of cup placement. CONCLUSION: CAS without referencing the APP allows a more consistent orientation of the acetabular component when compared to freehand placement.

Topical Tranexamic Acid in Revision Total Knee Arthroplasty Reduces Transfusion Rates and May Be Associated With Earlier Recovery.

BACKGROUND: The use of tranexamic acid (TXA) has been proved to be effective in reducing blood loss and transfusion requirements after primary total knee arthroplasty (TKA). However, the evidence for its use in revision surgery is scant. We assessed the safety and efficacy of topical TXA in revision TKA. METHODS: We retrospectively compared 76 revision TKA patients who received topical TXA (3 g before tourniquet deflation) "study group" with a historic control group of 205 revision TKA patients in which TXA was not used. Each group was further stratified into subgroups according to the type of revision. All patients were followed for a minimum of 6 weeks. Blood loss, transfusion requirements, changes in hemoglobin-hematocrit levels, Knee Society Score, and complications were recorded. RESULTS: The mean estimated blood loss, hemoglobin drop, and transfusion rate were significantly lower in the study group than in the control group (P = .008, P < .001, P < .001, respectively). Hidden blood loss was similar between the 2 groups (P = .12). Six weeks postoperatively, the improvement in the knee-specific Knee Society Score was significantly higher in the study group than in the control group (P < .001). No significant differences were found in thromboembolic complications between the 2 groups (P = .92). In the subgroup analysis, when both components (femur and tibia) were revised, the relative risk of transfusion was significantly lower with the use of TXA (relative risk 0.227, confidence interval 0.0593-0.860, P = .004). CONCLUSION: Topical TXA in revision TKA is safe and effective in reducing blood loss and transfusions. This effect is enhanced when both components are revised. Additionally, the use of TXA may improve early outcomes.

Pelvic pitch and roll during total hip arthroplasty performed through a posterolateral approach. A potential source of error in free-hand cup positioning.

PURPOSE: Intraoperative pelvic motion can alter the perceived cup inclination and version during non-navigated THA. We quantified pelvic motion during different phases of primary THA performed in the lateral decubitus through a posterolateral approach. METHODS: Pelvic roll (rotation of the coronal plane) and pitch angles (rotation parallel to the coronal plane) were studied in 75 patients undergoing THA for osteoarthritis by four arthroplasty surgeons. Ten steps of surgery were defined. Angular motion was recorded with a miniature surgical device that utilizes inertial sensors. RESULTS: The mean absolute roll ranged from 0.03° detected at the end of surgery to 4.13° detected during acetabular exposure. The mean absolute pitch ranged from 0.05° detected at the end of surgery to 2.54° detected during hip dislocation. The maximum pelvic roll and pitch detected during surgery averaged 17.62° (SD: 5.08) and 9.3° (SD: 3.39) respectively. Absolute roll and pitch angles were not affected by patient's BMI, sex, pre-operative hip motion, or surgeon. Before cup insertion, the greatest mean change in roll was observed during acetabular exposure (10.02° anteriorly), and for pitch was observed during dislocation (1.88° caudally). CONCLUSION: During THA performed through a posterolateral approach, there is a progressive anterior pelvic roll that peaks before cup insertion. This can lead to underestimation of cup anteversion during non-navigated THA. The anterior roll does not completely correct, even when all retractors and external forces acting on the pelvis are removed. Pelvic pitch that could affect the perceived cup inclination occurs to a lesser extent than pelvic roll.

Return to the operating room after patellofemoral arthroplasty versus total knee arthroplasty for isolated patellofemoral arthritis-a systematic review.

PURPOSE: Patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA) are accepted treatments for end-stage isolated patellofemoral osteoarthritis (PFOA). However, complications and re-operations have historically differed between the two procedures. We performed a systematic review to report on the re-operation rates between TKA and modern PFA for isolated PFOA. METHODS: Systematically identified publications reporting on patients that underwent either TKA or modern PFA for isolated PFOA were reviewed. Meta-analysis software was used to screen potential articles with at least one year follow-up that detailed reasons for re-operation. Data was extracted and analyzed for all re-operations. Survival of the implant was used as the primary outcome; return to the operating room (OR) for any reason was used as a secondary outcome. RESULTS: The weighted rate of either conversion or revision arthroplasty in the PFA group and the TKA group was 6.34 and 0.11, respectively. The weighted rate of return to the OR for bony and soft tissue procedures was 1.06 and 0.79, respectively. The weighted rate of manipulation under anaesthesia (MUA) was 0.32 and 1.23, respectively. CONCLUSION: Patients who undergo PFA may be more likely to return to the operating room for conversion to TKA and/or revision surgery than those who undergo TKA.

The Role of the Tourniquet and Patella Position on the Compartmental Loads During Sensor-Assisted Total Knee Arthroplasty.

BACKGROUND: An inflated tourniquet may diminish the natural excursion of the extensor mechanism and alter compartmental loads, affecting the surgeon's ability to accurately assess ligament balance during total knee arthroplasty (TKA). In addition, patella position (reduced, lateralized, or everted) has also been known to affect compartmental loads. This study used intraoperative sensing to assess how a combination of tourniquet inflation and patella position may affect medial and lateral compartmental loads during sensor-assisted TKA. METHODS: Fifty-six patients (13 men) with a mean age of 66 years (standard deviation, 8.66) and mean BMI of 31 kg/m2 (standard deviation, 6.66) undergoing primary cemented TKA for primary osteoarthritis were enrolled. After final prosthetic implantation, with the tourniquet inflated, medial and lateral compartment loads were obtained in the 10°, 45°, and 90° of flexion with the patella in reduced, lateralized, or everted positions. The tourniquet was deflated and this process repeated. Surgeons were blinded to the values as to not influence medial and lateral stressing of the knee. Linear regression was used to evaluate absolute loads. RESULTS: Tourniquet inflation did not significantly alter compartmental loads regardless of knee flexion or patella position. Lateral compartment loads significantly increased as the patella moved from the reduced, to the lateralized, to the everted position with the tourniquet inflated or deflated. CONCLUSION: Tourniquet inflation did not significantly alter compartmental loads during sensor-assisted TKA. However, irrespective of tourniquet use, a lateralized or everted patellar position significantly increased lateral compartment loads.

The Impact of Varying Femoral Head Length on Hip External Rotation During Posterior-approach Total Hip Arthroplasty.

Background: Prior investigations of total hip arthroplasty (THA) have studied the effects of prosthetic femoral head size and stem offset on hip range of motion (ROM), impingement risk, and overall hip stability to optimize the return to activities of daily living. However, the relationship between femoral head length and hip ROM, specifically external rotation (ER), has not been evaluated. The aim of our study was to intraoperatively assess how femoral head length affects hip ROM during a posterior approach THA. Methods: Thirty-two patients undergoing a primary elective THA through a posterior approach were prospectively included. After final femoral stem insertion, femoral head trials were performed using the targeted head length, followed by the shorter (-3.0 to -3.5 mm) and longer (+3.0 to +4.0 mm) head length configurations. At each length, hip ER was measured using an intraoperative goniometer from an imageless navigation system. ER values across the three head lengths were compared using a repeated-measures analysis of variance and paired t-tests. Results: Varying femoral head lengths demonstrated a statically significant and reproducible effect on intraoperative ER range (analysis of variance; P < .001) in each patient. An increased femoral head length (mean 3.4 mm) significantly decreased (P < .001) ER range by 10.8 ± 3.3° while a shortened femoral head length (mean 3.5 mm) significantly increased (P < .001) the ER ROM by 6.0 ± 3.8°. Conclusions: The results of this study demonstrate the sensitivity of hip ROM to incremental changes in femoral head length. As ER is important for activities of daily living, inadvertent lengthening should be avoided.

Use of Topical Tranexamic Acid Reduces Direct and Indirect Blood Loss and Transfusion Rates in Revision Total Hip Arthroplasty.

BACKGROUND: In primary total hip arthroplasty (THA), evidence supports the use of tranexamic acid (TXA) as an effective strategy for reducing blood loss, but scant evidence supports its use in revision THA. QUESTIONS/PURPOSES: We aimed to evaluate whether the use of topical TXA in revision THA is associated with less blood loss and lower transfusion rates and to assess its safety, specifically as it relates to thromboembolic complications. METHODS: In this retrospective comparative study, two groups who underwent revision THA between 2005 and 2017 were defined: 98 patients who received 3 g of topical TXA (study group) and 475 patients who did not receive TXA (control group). Subjects were divided into subgroups according to the type of revision. Hemoglobin and hematocrit levels, blood loss, and transfusions were recorded. The follow-up period was 6 weeks. RESULTS: Median estimated blood loss, hidden blood loss, hemoglobin drop, and transfusion rates were significantly lower in the study group. The rates of post-operative thromboembolism were similar in the two groups. According to subgroup analysis, patients with revision of the femoral component, both components, and staged exchange revisions showed significantly lower rates of transfusion. CONCLUSION: Topical TXA administration during revision THA effectively reduced direct and indirect blood loss, including hidden losses, without increasing the rates of thromboembolic events. This effect appeared to be enhanced when the femoral component was revised.

Multimodal prophylaxis in patients with a history of venous thromboembolism undergoing primary elective hip arthroplasty.

AIMS: We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk of VTE. METHODS: Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. RESULTS: Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. CONCLUSION: Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71-77.

Characterization of Re-admission and Emergency Department Visits Within 90 Days Following Lower-Extremity Arthroplasty.

BACKGROUND: Acute care events including emergency department (ED) visits and unscheduled inpatient re-admissions following lower-extremity arthroplasty are not fully understood. QUESTION/PURPOSES: The purpose of this study was to characterize acute care events occurring after discharge in patients who received a lower-extremity arthroplasty: the incidence, timing, and risk factors of inpatient admission and ED visits within 90 days of discharge. METHODS: The New York State Inpatient and Emergency Department Databases were used to identify patients who underwent elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) from 2009 to 2013 (124,234 and 76,411 patients, respectively). Multivariate logistic regression analysis was used to determine the predictors of and the most frequent reasons for unscheduled acute care within 90 days of discharge. RESULTS: Unscheduled acute care was needed in 13.79% of patients (8.81% of inpatient re-admissions and 4.98% of ED visits), most often in the first week after discharge (61.05% of all inpatient re-admissions and 20.46% of all ED visits). Most of these visits were for musculoskeletal pain, peri-prosthetic joint or wound infection, cardiac complications, blood transfusion, psychiatric events, mechanical complications, and deep vein thrombosis. Predictors for the need for acute care after TKA included African American and Hispanic race or ethnicity, Medicaid coverage, and neuraxial anesthesia. Predictors for the need for acute care after THA included older age (over 85 years), African American race, and Medicaid coverage. CONCLUSION: We identified demographic and procedure-related variables associated with an increased risk of ED visits and inpatient re-admissions after TKA or THA. Understanding these variables will contribute to improved care quality.