Development of a portable abdominal normothermic regional perfusion (A-NRP) program in the United States.

In situ abdominal normothermic regional perfusion (A-NRP) has been used for liver transplantation (LT) with donation after circulatory death (DCD) liver grafts in Europe with excellent results; however, adoption of A-NRP in the United States has been lacking. The current report describes the implementation and results of a portable, self-reliant A-NRP program in the United States. Isolated abdominal in situ perfusion with an extracorporeal circuit was achieved through cannulation in the abdomen or femoral vessels and inflation of a supraceliac aortic balloon and cross-clamp. The Quantum Transport System by Spectrum was used. The decision to use livers for LT was made through an assessment of perfusate lactate (q15min). From May to November 2022, 14 A-NRP donation after circulatory death procurements were performed by our abdominal transplant team (N = 11 LT, N = 20 kidney transplants, and 1 kidney-pancreas transplant). The median A-NRP run time was 68 minutes. None of the LT recipients had post-reperfusion syndrome, nor were there any cases of primary nonfunction. All livers were functioning well at the time of maximal follow-up with zero cases of ischemic cholangiopathy. The current report describes the feasibility of a portable A-NRP program that can be used in the United States. Excellent short-term post-transplant results were achieved with both livers and kidneys procured from A-NRP.

Trends in Hospital and Surgeon Charges and Reimbursements for Revision Total Knee Arthroplasty.

BACKGROUND: The relationship between surgeon and hospital charges and reimbursements for revision total knee arthroplasty (TKA) has not been well examined. The objective of this study is to report trends and variations in hospital charges and payments compared to surgeons for stage 1 (S1) vs stage 2 (S2) septic revision TKA and aseptic revision (AR) TKA. METHODS: The 5% Medicare sample was used to capture hospital and surgeon data for revision TKA from 2005 to 2014. The charge multiplier (CM) and ratio of hospital to surgeon charges, and the payment multiplier (PM) and ratio of hospital to surgeon payments were calculated. Year-to-year variation and regional trends in-patient demographics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated. RESULTS: In total, 4570 AR, 1323 S1, and 863 S2 TKA patients were included. CM increased for all cohorts: 8.1-13.8 for AR (P < .001), 21.0-22.5 (P = .07) for S1, and 11.8-22.0 (P < .001) for S2. PM followed a similar trend, increasing 8.1-13.8 (P < .001) for AR, 19.8-27.3 (P = .005) for S1, and 14.7-30.7 (P < .001) for S2. Surgeon reimbursement decreased for all cohorts. LOS decreased for AR (3.8-2.8 days), S1 (12.8-6.9 days), and S2 (4.5-3.9 days). Charlson Comorbidity Index remained stable for AR patients but increased significantly for S1 and S2 cohorts. CONCLUSION: Hospital charges and payments relative to the surgeons have significantly increased for revision TKA in the setting of stable or increasing patient complexity and decreasing LOS.

Intraoperative management of a hybrid extracorporeal membrane oxygenation circuit for lung transplantation.

BACKGROUND: The use of extracorporeal circulation (ECC) for intraoperative cardiopulmonary support during lung transplantation has been increasing in the recent years. Our group previously described a novel hybrid extracorporeal membrane oxygenation (ECMO) circuit for use in lung transplantation. TECHNIQUE: Our approach for intraoperative management of our novel hybrid ECMO circuit for lung transplantation is driven by two main goals: The first is to deliver management that ensures an appropriate balance between the native and ECMO cardiac outputs in order to provide a stable environment that promotes attenuation of ischemic-reperfusion injury during implantation. The second is to provide a stable hemodynamic environment that results in an appropriate global perfusion guided by multiple monitors and an organ systems-based approach during implantation. COMMENTS: Our novel technique for intraoperative management of this circuit during lung transplantation is described.

Risk of Prosthetic Joint Infection Increases Following Early Aseptic Revision Surgery of Total Hip and Knee Arthroplasty.

BACKGROUND: It is important to identify risk factors for periprosthetic joint infection (PJI) following total joint arthroplasty in order to mitigate the substantial social and economic burden. The objective of this study is to evaluate early aseptic revision surgery as a potential risk factor for PJI following total hip (THA) and total knee arthroplasty (TKA). METHODS: Patients who underwent primary THA or TKA with early aseptic revision were identified in 2 national insurance databases. Control groups of patients who did not undergo revision were identified and matched 10:1 to study patients. Rates of PJI at 1 and 2 years postoperatively following revision surgery were calculated and compared to controls using a logistic regression analysis. RESULTS: In total, 328 Medicare and 222 Humana patients undergoing aseptic revision THA within 1 year of index THA were found to have significantly increased risk of PJI at 1 year (5.49% vs 0.91%, odds ratio [OR] 5.61, P < .001 for Medicare; 7.21% vs 0.68%, OR 11.34, P < .001 for Humana) and 2 years (5.79% vs 1.10%, OR 4.79, P < .001 for Medicare; 8.11% vs 1.04%, OR 9.05, P < .001 for Humana). Similarly for TKA, 190 Medicare and 226 Humana patients who underwent aseptic revision TKA within 1 year were found to have significantly higher rates of PJI at 1 year (6.48% vs 1.16%, OR 7.69, P < .001 for Medicare; 6.19% vs 1.28%, OR 4.89, P < .001 for Humana) and 2 years (8.42% vs 1.58%, OR 6.57, P < .001 for Medicare; 7.08% vs 1.50%, OR 4.50, P < .001 for Humana). CONCLUSION: Early aseptic revision surgery following THA and TKA is associated with significantly increased risks of subsequent PJI within 2 years.

Transfusion rates are increasing following total hip arthroplasty: risk factors and outcomes.

Despite attempts to minimize exposure to allogeneic blood, there are little data on recent nationwide trends in transfusion following total hip arthroplasty (THA) and no consensus on indications. The purpose of this study was to examine the rate, predictors, and inpatient outcomes associated with transfusion after primary THA. This retrospective cohort study analyzed the data collected from US Nationwide Inpatient Sample (NIS) for each year during the period 2005-2008 to assess the trends in transfusion in patients who underwent elective primary THA. Logistic regression models were used to evaluate the predictive risk factors for blood transfusion. The University Hospital Consortium (UHC) database was also queried to examine the variability in rates of transfusion at different academic medical centers. A total of 129,901 patients were identified in the NIS database. The transfusion rates following THA consistently increased from 18.12% in 2005 to 21.21% in 2008 (P<0.0001). Hospitals in the Northeast and Midwest region had the highest and lowest rates of transfusion, respectively. Significant risk factors for blood transfusion were female gender (odds ratio, OR 2.1), age above 85 (OR 2.9), African-American race (OR 1.7), Medicare payor status (OR 1.6), being at a hospital in the Northeast Region (OR 1.4), the presence of preoperative anemia (OR 1.6), having at least one comorbidity (OR 1.3), and a high Charlson Index score (OR 2.2). Patients receiving blood transfusions had increased in-hospital mortality, longer lengths of stay, and higher total charges compared to non-transfused patients (P<0.001). The UHC database demonstrated that transfusion rates vary widely across different institutions from <5% to >80%. The incidence of blood transfusion has recently increased following total hip arthroplasty and there is great variability in practice. We identified several patient risk factors along with the morbidity and mortality independently associated with transfusion following THA. Further work is needed to standardize the approach to blood conservation and minimize exposure to allogenic blood.

Management of total femoral bone loss using a hybrid cement spacer surgical technique.

Standard treatment for an infected total hip arthroplasty is 2-stage revision. Bone loss in infected total hip arthroplasty presents specific challenges during the first stage. This is especially the case when there is massive or complete loss of the femoral bone stock. We describe a technique successfully used in the setting of total femoral bone loss using a hybrid cement spacer. We describe 2 cases illustrating the technique and perioperative course. This technique is a potential solution for total femoral bone loss that allows the individual to maintain mobility before definitive surgery.

Initial experience and outcomes with a hybrid extracorporeal membrane oxygenation and cardiopulmonary bypass circuit for lung transplantation.

Background: The utilization of extracorporeal life support (ECLS) for intraoperative support during lung transplantation has increased over the past decade. Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has recently emerged as the preferred modality over cardiopulmonary bypass (CPB), many centers continue to use both forms of ECLS during lung transplantation. Our novel hybrid VA-ECMO/CPB circuit allows for seamless transition from VA-ECMO to CPB at a significant cost savings compared to a standalone VA-ECMO circuit. This study describes our initial experience and outcomes in the first 100 bilateral lung transplantations using this novel hybrid VA-ECMO/CPB circuit. Methods: Medical records from September 2017 to May 2021 of the first 100 consecutive patients undergoing bilateral lung transplantation with intraoperative hybrid VA-ECMO support were examined retrospectively. We excluded patients with single lung transplants, retransplantations, preoperative ECLS bridging, and veno-venous (VV) ECMO and those supported with CPB only. Perioperative recipient, anesthetic, perfusion variables, and outcomes were assessed. Results: Of the 100 patients supported with VA-ECMO, 19 were converted intraoperatively to CPB. Right ventricular dysfunction was seen in 37% of patients, and the median mean pulmonary artery pressure was 28 mm Hg. No oxygenator clotting was observed with a median heparin dose of 13,000 units in the VA-ECMO group. Primary graft dysfunction grade 3 at 72 hours was observed in 10.1% of all patients and observed 1-year mortality was 4%. Conclusions: The use of a hybrid VA-ECMO/CPB circuit in our institution allows for rapid conversion to CPB with acceptable outcomes across a diverse recipient group at a significantly reduced cost compared to standalone VA-ECMO circuits.

Improved Executive Function in Adults Diagnosed With Attention-Deficit/ Hyperactivity Disorder as Measured by the Brown Attention-Deficit Disorder Scale Following Treatment With SHP465 Mixed Amphetamine Salts Extended-Release: Post Hoc Analyses From 2 Randomized, Placebo-Controlled Studies.

OBJECTIVE: Assess executive function (EF) improvement with SHP465 mixed amphetamine salts (MAS) extended-release in adults with attention-deficit/hyperactivity disorder (ADHD) using responder analyses of the Brown Attention-Deficit Disorder Scale (BADDS). METHODS: Post hoc analyses examined data from placebo-controlled SHP465 MAS dose-optimization (12.5-75 mg) and fixed-dose (25-75 mg) studies. Treatment response was assessed using two definitions (BADDS total score at endpoint <50 [no EF impairment] vs. ≥50 [impaired]; BADDS total score at endpoint relative to the in-treatment 90% CI range for baseline total score [below the range = improved]). RESULTS: Response rates (SHP465 MAS vs. placebo) favored SHP465 MAS (all nominal p < .0001) in the dose-optimization (BADDS <50: 41.9% vs. 19.2%; below 90% CI range: 57.4% vs. 29.6%) and fixed-dose (BADDS <50: 51.9% vs. 16.7%; below 90% CI range: 70.6% vs. 32.3%) studies. CONCLUSION: Improvement in EF measured by BADDS response rates was approximately 2-fold greater with SHP465 MAS than placebo.

Relationships Between Executive Function Improvement and ADHD Symptom Improvement With Lisdexamfetamine Dimesylate in Adults With ADHD and Executive Function Deficits: A Post Hoc Analysis.

OBJECTIVE: Executive function (EF) deficits are not generally considered synonymous with attention-deficit/hyperactivity disorder (ADHD). Evidence suggests stimulants improve ADHD symptoms and EF deficits in adults with ADHD, but the relationships between improvements in these domains have not been studied. METHODS: These post hoc analyses used data from a 10-week double-blind, placebo-controlled study of adults with ADHD and EF deficits treated with lisdexamfetamine dimesylate (30-70 mg) or placebo conducted from May 2010 to November 2010. Efficacy endpoints included change from baseline at week 10/early termination (ET) in self-report Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) Global Executive Composite (GEC) T-score and ADHD-Rating Scale with Adult Prompts total score (ADHD-RS-AP-TS). Relationships between ADHD symptom and EF changes were examined using recursive path analyses. RESULTS: Mediation proportions were 0.62 (indirect and total treatment effect coefficients [95% CI]: -6.85 [-9.83 to -3.86] and -11.12 [-14.88 to -7.37]) for self-report BRIEF-A GEC T-score change from baseline at week 10/ET on ADHD-RS-AP-TS change from baseline at week 10/ET and 0.93 (indirect and total treatment effect coefficients [95% CI]: -10.34 [-14.11 to -6.57] and -11.18 [-15.80 to -6.55]) for ADHD-RS-AP-TS change from baseline at week 10/ET on self-report BRIEF-A GEC T-score change from baseline at week 10/ET. CONCLUSIONS: Although these data suggest ADHD symptom and EF deficit improvement following lisdexamfetamine are interdependent, it is advantageous to use measures like the BRIEF-A to assess stimulant effects on the wide range of EF deficits associated with ADHD that are not captured by the ADHD-RS-AP alone. TRIAL REGISTRATION: Data used in this secondary analysis came from ClinicalTrials.gov identifier: NCT01101022.

Executive function after risk-reducing salpingo-oophorectomy in BRCA1 and BRCA2 mutation carriers: does current mood and early life adversity matter?

OBJECTIVE: Despite the fact that negative mood and executive dysfunction are common after risk-reducing salpingo-oophorectomy (RRSO), occurring in up to a third of women, little is known about risk factors predicting these negative outcomes. Adverse childhood experiences (ACE) predict poorer health in adulthood and may be a risk factor for negative outcomes after RRSO. Given the complex relationship between early life stress, affective disorders, and cognitive dysfunction, we hypothesized that ACE would be associated with poorer executive function and that mood symptoms would partially mediate this relationship. METHODS: Women who had undergone RRSO were included in the study (N = 552; age 30-73 y). We measured executive function (continuous performance task, letter n-back task, and Brown Attention Deficit Disorder Scale Score), exposure to early life stress (ACE questionnaire), and mood symptoms (Hospital Anxiety and Depression Scale). Generalized estimating equations were used to evaluate the association between ACE and executive dysfunction and the role of mood symptoms as a mediator in this relationship. RESULTS: ACE was associated with greater severity of subjective executive dysfunction (adjusted mean difference [aMD] = 7.1, P = 0.0005) and worse performance on both cognitive tasks (continuous performance task: aMD = -0.1, P = 0.03; n-back: aMD = -0.17, P = 0.007). Mood symptoms partially mediated ACE associations with sustained attention (21.3% mediated; 95% CI: 9.3%-100%) and subjective report of executive dysfunction (62.8% mediated; 95% CI: 42.3%-100%). CONCLUSIONS: The relationship between childhood adversity and executive dysfunction is partially mediated by mood symptoms. These data indicate that assessing history of childhood adversity and current anxiety and depression symptoms may play a role in treating women who report cognitive complaints after RRSO. : Video Summary:http://links.lww.com/MENO/A571.

Video Summary:http://links.lww.com/MENO/A571.

Lung Transplantation Using a Hybrid Extracorporeal Membrane Oxygenation Circuit.

Extracorporeal circulation (ECC) support using intraoperative extracorporeal membrane oxygenation (ECMO) during lung transplantation (LTx) is now a routine practice for many high volume centers. Circuits that are dedicated to ECMO alone can be expensive and do not allow full cardiopulmonary bypass (CPB) to be performed. We describe our technique of instituting venoarterial ECMO during LTx using a less-expensive hybrid circuit that facilitates easy and immediate conversion to full CPB if needed, without interruption of ECC.

Once-daily atomoxetine for adult attention-deficit/hyperactivity disorder: a 6-month, double-blind trial.

This randomized, double-blind, placebo-controlled, 6-month trial examined the efficacy and safety of once-daily morning-dosed atomoxetine in adult patients with attention-deficit/hyperactivity disorder (ADHD) and the efficacy of atomoxetine in ameliorating symptoms through the evening hours. Patients received once-daily atomoxetine (n = 250) or placebo (n = 251) in the morning for approximately 6 months. The efficacy measures included the Adult ADHD Investigator Symptom Rating Scale (AISRS), Conners' Adult ADHD Rating Scale-Investigator Rated: Screening Version, Clinical Global Impressions-ADHD-Severity of Illness, and Adult ADHD Quality of Life Scale. Overall, 94 patients randomized to atomoxetine and 112 patients randomized to placebo completed the study. On the AISRS total score, Conners' Adult ADHD Rating Scale-Investigator Rated: Screening Version evening index total score, Clinical Global Impressions-ADHD-Severity of Illness score, and Adult ADHD Quality of Life Scale total score, atomoxetine was statistically superior to placebo at the 10-week and 6-month time points. From the visitwise analysis, the mean (SD) AISRS total scores for atomoxetine decreased from 38.2 (7.5) at baseline to 21.4 (12.3) at the 6-month end point compared with 38.6 (7.0) to 25.8 (13.2) for placebo (P = 0.035). Nausea, dry mouth, fatigue, decreased appetite, urinary hesitation, and erectile dysfunction were the treatment-emergent adverse events reported significantly more often with atomoxetine. Discontinuations due to adverse events were 17.2% and 5.6% for atomoxetine and placebo, respectively (P < 0.001). Once-daily morning-dosed atomoxetine is efficacious for treating ADHD in adults when measured 10 weeks and 6 months after initiating treatment. Atomoxetine demonstrated significant efficacy that continued into the evening. Adverse events were similar to previous trials.

Resistant organisms in infected total knee arthroplasty: occurrence, prevention, and treatment regimens.

Infection of a primary joint arthroplasty can be a life-changing event for a patient. When the infecting organism demonstrates antibiotic resistance, treatment can be prolonged, and the chances for a successful outcome may be decreased. Antibiotic resistance has been an evolutionary process since the introduction of pharmacologic treatment and until recently has been more problematic with nosocomial types of infections. Methicillin-resistant Staphylococcus aureus skin infections within the community among school or sports teams has been a recent cause for concern. Hospitals have implemented screening and/or isolation procedures to reduce the risk of spreading these resistant organisms and identify patients colonized with resistant organisms. These measures have been successful in patients undergoing total joint arthroplasty. It is important for the orthopaedic surgeon to be knowledgeable about the emergence of resistant bacteria, preoperative and intraoperative screening guidelines, and postoperative considerations to prevent resistant organism infections in total joint arthroplasty patients.

Executive function impairments in high IQ adults with ADHD.

OBJECTIVES: To demonstrate that high IQ adults diagnosed with ADHD suffer from executive function (EF) impairments that: a) can be identified with a combination of standardized measures and self-report data; and b) occur more commonly in this group than in the general population. METHOD: 157 ADHD adults with IQ >/= 120 were assessed with 8 normed measures of EF- 3 index scores from standardized tests of memory and cognitive abilities, and 5 subscales of a normed self-report measure of EF impairments in daily life. RESULTS: 73% of subjects were significantly impaired on >/= 5 of these 8 EF markers. On all 8 measures, incidence of these impairments was significantly greater than in the general population. CONCLUSION: High IQ adults with ADHD tend to suffer EF impairments that can be assessed with these measures; incidence of such impairments in this group is significantly higher than in the general population.

Comparison of Two Measures of Working Memory Impairments in 220 Adolescents and Adults With ADHD.

Objective: This study tests the hypotheses that (a) adolescents and adults with ADHD score lower on two normed measures of verbal working memory, relative to their overall verbal abilities, than the general population and (b) a specific story memory test is a more sensitive and relevant measure of working memory impairment than a numerically based test. Method: Scores on normed story memory and numerical memory tests of 220 adolescents and adults with ADHD were corrected for the individual's verbal abilities and compared with each other and national norms. Results: Participants with ADHD scored significantly below their verbal ability measure on both verbal and numerically based memory tests in comparison with national norms. Scores on verbal memory test were lower than scores for numerically based memory tests. Conclusion: This story memory test is a more sensitive measure of working memory impairments in adolescents and adults with ADHD than measures based on recall of numerical data.

The Patient Perspective: Unmet Treatment Needs in Adults With Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: To characterize impairments in daily life experienced by pharmacologically treated adults with attention-deficit/hyperactivity disorder (ADHD) versus adults without ADHD and to identify unmet needs in ADHD treatment from the perspective of adults with ADHD. METHODS: Adults with ADHD taking prescription medication for ≥ 6 months and adults without ADHD agreed to participate in a cross-sectional online survey during December 2016. Participants with ADHD were stratified by their current ADHD medication: long-acting (LA) once daily, short-acting (SA) ≤ 2 times/d, and augmenters (AU; LA > 1 time/d, SA > 2 times/d, or LA plus SA). RESULTS: A total of 616 adults with ADHD (SA: n = 166, LA: n = 201, AU: n = 249) and 200 adults without ADHD completed the survey. Even with treatment, adults with ADHD reported substantial impairments in their everyday life, particularly at home, at school/work, and in their social life and relationships. Participants with ADHD experienced impairments throughout the day, especially in the afternoon and evening. Signs or symptoms were reported when the ADHD medication was wearing off, resulting in negative effects (including school work, homework, work responsibilities, household responsibilities, emotional responses, mood, and relationships) on the daily life of adults with ADHD. CONCLUSIONS: Adults with ADHD, despite receiving medication, experienced impairments and challenges in many aspects of their daily life. Adults with ADHD described various unmet needs, especially those relating to the duration of treatment effect. When optimizing treatment for adults with ADHD, it is important that the treatment regimen is sufficient to meet the needs of the patient throughout the day.

Availability of emergency contraception after its deregulation from prescription-only status: a survey of Ontario pharmacies.

In 2005 the emergency contraception formulation of levonorgestrel (Plan B) became available in Ontario pharmacies without a prescription. We surveyed 239 pharmacies 1 month before the regulatory change and 14-17 months after the change to determine whether availability of the drug increased. The response rates were 79% and 70% before and after the change in status. The proportion of pharmacies that had an in-stock supply of Plan B increased from 78% to 92% (p < 0.001). After the regulatory change, 87% of the surveyed pharmacies (95% confidence interval 82%-92%) reported that they had the drug in stock and were willing to dispense it behind the counter. Availability was similar for urban and rural pharmacies, but rural pharmacies had more restricted hours (e.g., 15% closed on weekends). Thus, as a result of the regulatory change, emergency contraception is more widely available, but access in rural areas is still limited by restricted pharmacy hours.

ADD/ADHD and Impaired Executive Function in Clinical Practice.

The disorder currently known as attention-deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD) is now recognized by most clinicians as a legitimate and widely prevalent disorder among children and adults. Yet there is still widespread misunderstanding as to the disorder's nature. Many clinicians mistakenly continue to think of this as a behavior disorder characterized by hyperactivity in children and excessive restlessness or impulsivity in adults. In fact, ADD/ADHD is essentially a cognitive disorder, a developmental impairment of executive functions (EFs), the self-management system of the brain. Although EFs are complex, their impairment constitutes a syndrome that can be recognized readily in clinical practice; impaired EF involves a pattern of chronic difficulties in executing a wide variety of daily tasks. Once recognized, this disorder can be effectively treated in most cases. In this article, I describe the nature of EF impairments in ADD/ADHD and how the syndrome can be recognized and effectively treated in clinical practice. (Note: The term ADHD is used in the balance of this article to refer to both inattentive and combined subtypes.).

Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders.

Many adults with a diagnosed psychiatric disorder also have attention-deficit/hyperactivity disorder (ADHD). In many cases, comorbid ADHD is unrecognized and/or undertreated. Differential diagnosis of adult ADHD can be challenging because ADHD symptoms may overlap with other psychiatric disorders and patients may lack insight into their ADHD-related symptoms. Current ADHD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision may prevent appropriate diagnosis of many patients with significant ADHD symptoms. Adults may not be able to provide a history of onset of symptoms during childhood, and it may be difficult to confirm that ADHD symptoms are not better accounted for by other comorbid psychiatric conditions. Comorbid ADHD is most prevalent among patients with mood, anxiety, substance use, and impulse-control disorders. ADHD can negatively affect outcomes of other comorbid psychiatric disorders, and ADHD symptoms may compromise compliance with treatment regimens. Furthermore, unrecognized ADHD symptoms may be mistaken for poor treatment response in these comorbid disorders. In these individuals, ADHD pharmacotherapy seems to be as effective in reducing core ADHD symptoms, as it is in patients who have no comorbidity. Limited evidence further suggests that ADHD therapy may help to improve symptoms of certain psychiatric comorbidities, such as depression. Therefore, management of ADHD may help to stabilize daily functioning and facilitate a fuller recovery.

Infection in primary total knee arthroplasty: contributing factors.

Infection after a total knee arthroplasty is an infrequent but serious complication that can have devastating consequences. Infection carries a risk of significant morbidity, and the cost of treatment can be a substantial burden to the health care system. Eradication of infection can be very difficult. Prevention of infection remains the ultimate goal. Identification of host risk factors, careful patient selection, and optimization of the wound environment and the operating room remain some of the core fundamental steps that help minimize the overall incidence of infection. Although the exact role of each of these risk factors in a clinical setting can be debatable, a multidisciplinary approach incorporating all known and established methods of infection control can help to minimize the incidence of infection following total knee arthroplasty.