Vancomycin Powder and Dilute Povidone-Iodine Lavage for Infection Prophylaxis in High-Risk Total Joint Arthroplasty.

BACKGROUND: Dilute povidone-iodine lavage has been shown to be safe and effective in decreasing acute periprosthetic joint infection (PJI) following total joint arthroplasty (TJA). Vancomycin powder is reported to be effective in preventing infection in spine surgery. We hypothesize that a "vanco-povidone protocol" (VIP) for TJA patients at high risk for infection is safe and will decrease the rate of PJI. METHODS: High-risk TJA patients (body mass index >40, active smokers, American Society of Anesthesiologists ≥3, immunosuppression/diabetes, methicillin-resistant Staphylococcus aureus colonization, revision surgery) utilizing VIP were compared to a high-risk historical cohort not treated with VIP, at a single institution. VIP consisted of dilute povidone-iodine lavage followed by application of vancomycin powder prior to wound closure. Primary endpoint was PJI within 3 months postoperatively. RESULTS: The historical, high-risk control cohort consisted of 3251 patients with a PJI incidence of 1.8%. A total of 1413 subjects received the VIP protocol with a PJI incidence of 1.3%. There was a 27.8% risk reduction when compared to the control group of high-risk subjects not treated with the VIP. There were no medical complications secondary to the use of VIP, no increase in vancomycin-resistant enterococcus or vancomycin-resistant Staph aureus, and no cases of acute renal impairment secondary to application of the local vancomycin. CONCLUSIONS: PJI remains a common complication of TJA, especially in high-risk populations. This study indicates that a protocol of dilute povidone-iodine lavage combined with topical vancomycin powder is safe and may reduce PJI incidence in high-risk TJA patients. Due to low, current PJI rates, a multi-institutional randomized controlled trial is necessary to assess interventions that minimize the risk of PJI. LEVEL OF EVIDENCE: Retrospective Observational Cohort.

Up to 18-Year Follow-Up Wear Analysis of a First-Generation Highly Cross-Linked Polyethylene in Primary Total Hip Arthroplasty.

BACKGROUND: The advent of highly cross-linked polyethylene (HCLPE) has significantly improved total hip arthroplasty survivorship. HCLPE has been shown to improve wear properties in midterm outcomes when compared to traditional polyethylene liners; however, there is a paucity of studies evaluating long-term outcomes. In addition, there is concern that wear rates may accelerate as the implant ages. Thus, the aims of this study are to report on the longest-to-date follow-up of a specific first-generation HCLPE liner and to determine whether there is a change in the annual wear rate over time. METHODS: Forty hips in 38 patients which were previously reported on in a midterm study were included in this long-term follow-up study. Patients in this cohort all received total hip arthroplasty between March 1999 and August 2004 using the Crossfire HCLPE liner. Annual wear rates (mm/y) were calculated for this cohort. Patients were contacted and asked about complications or revision procedures they may have had since the index procedure. RESULTS: Clinical follow-up averaged 12.9 years with a range of 7-18 years. The average follow-up duration was 12.5 years with a range of 10-17 years. Linear wear was found to be 0.056 ± 0.036 mm/y. Osteolysis was not observed in any of the patients with greater than 10-year radiographic follow-up. Furthermore, only 1 patient required revision surgery following a mechanical fall. CONCLUSION: Our study demonstrates the long-term wear rates associated with HCLPE liners continue to match rates published in midterm studies. Previously, we have reported that this cohort had an average annual wear rate of 0.05 mm/y over 10 years. This most recent report demonstrates a similar wear rate with up to 18-year follow-up.

Irrigation and Debridement for Early Periprosthetic Knee Infection: Is It Effective?

BACKGROUND: Irrigation and debridement (I&D) is performed for early management of periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). Symptom reporting is a subjective measure and may miss direct management of PJI. Utilizing an objective time interval from index procedure to I&D may better inform treatment decisions. METHODS: From 2009 to 2017, retrospective review was performed of 55 knee PJI cases at our institution. All patients underwent polyethylene liner exchange and I&D for PJI. Patients were stratified by time from index procedure to I&D (≤2 weeks, >2 weeks). Success was defined as eradication of infection and resolution of presenting symptoms. Failed cases required subsequent procedures due to infection. RESULTS: Average follow-up time after index TKA was 2.5 years. Among patients with I&D within 2 weeks of index TXA, 14 patients (82%) were successfully treated while 3 (18%) had infection recurrence. These outcomes were significantly improved compared to patients with I&D after 2 weeks: 19 (50%) successes and 19 (50%) failures (P = .024). Staphylococcal species were the most frequent pathogen in patients treated before and after 2 weeks of index TKA (39% and 50%, respectively). Outcomes were pathogen-independent in PJIs treated before or after 2 weeks of index TKA (P = .206 and .594, respectively). CONCLUSION: Our results demonstrate that patients with early PJI managed with I&D and liner exchange within 2 weeks of index TKA had higher rates of treatment success when compared to those with I&D beyond 2 weeks. These findings suggest that time from index TKA to I&D is an objective and reliable indicator of treatment success when considering I&D in acute onset knee PJI.

Oral health implications in total hip and knee arthroplasty patients: A review.

Over the past two decades, oral health has emerged as a health care priority. Historically, patients greater than 65 years of age, the economically disadvantaged, members of racial or ethnic minority groups, or the disabled or home bound have experienced significant barriers to routine dental care. The connection between oral health care and periprosthetic joint infections (PJI) continues to be of importance to the orthopedic surgeon, as such infections are significantly morbid and costly. This review aims to introduce the importance of oral health as a small but crucial portion of an arthroplasty patient's overall perioperative management.

Manipulation under Anesthesia: Does Polyethylene Thickness Matter?

Total knee arthroplasty (TKA) has been established as the most effective treatment for end-stage, symptomatic osteoarthritis of the knee. However, improper polyethylene size selection has been proposed to predispose patients to postoperative stiffness following TKA. The aim of this study is to evaluate if there is a correlation between the use of the thinnest tibial implant thickness and implant manufacturer with the likelihood of undergoing manipulation under anesthesia (MUA). A retrospective review of unilateral TKAs performed between January 2012 and November 2015 was performed. Each knee implant system was normalized by total tibial component thickness for each individual implant system (metal back plus polyethylene) and reaggregated to assess the difference in MUA rates when comparing the thinnest tibial component thickness against the next two sizes. Subset analysis was performed comparing the thinnest tibial component thickness for each individual implant system versus (1) all other tibial component sizes and (2) tibial components one and two sizes larger. A total of 2,728 patients were retrospectively evaluated, of which 71 (2.60%) underwent MUA. Combined tibial component thickness ranged from 8 to 21 mm. When aggregated together to compare the MUA rate between the thinnest liner and the next two sizes, no statistically significant difference was observed (p = 1). Subset analysis demonstrated inconsistent significant differences in MUA rates. Our results suggest that the polyethylene liner thickness alone is not a predictor of postoperative knee stiffness necessitating MUA. When selecting a polyethylene liner, a proper fit maximizing flexion/extension stability is the most crucial factor.

Osteolysis Complicating Total Knee Arthroplasty.

Osteolysis is a process mounted by the host immune system that relies on several variables, including patient-related factors, type of insert material, modes of wear, and implant design. Imaging techniques such as radiography, computed tomography (CT) scans, magnetic resonance imaging (MRI), and tomosynthesis aid in diagnosing osteolysis. Surgical options for the treatment of osteolysis include the insertion of bone grafts, bone cement, and prosthetic augmentation. Although no approved pharmacological therapies for the specific treatment of osteolysis exist, the use of bisphosphonates and statins decreases the risk of osteolysis.

Economics of All-Polyethylene Versus Metal-Backed Tibial Prosthesis Designs.

With the large number of total knee arthroplasties being performed and expectations that these numbers will be on the rise over the coming decades, efforts to provide cost-efficient care are of greater interest. The preferred design of knee arthroplasty implants has changed over time, with the original all-polyethylene tibial (APT) design being replaced by metal-backed tibial (MBT) components, as well as more recent considerations of newer APT designs. Modern APT components have been shown to have similar or superior outcomes than MBT components. Despite their limitations, APT components can be used to reduce the economic burden to the provider, medical institution, and health care system as a whole. There is a paucity of evidence-based literature directly comparing the cost associated with APT and MBT components. The purpose of this report is to review the literature to assess the available data regarding direct and indirect costs of both designs so that orthopedic surgeons can account for economic differences in everyday practice. [Orthopedics. 2016; 39(3):S61-S66.].