Delta hemoglobin cutoffs do not predict readmission in patients undergoing primary simultaneous bilateral total hip or knee arthroplasty: A retrospective cohort study.

Background/aims: Primary simultaneous bilateral total joint arthroplasty (simBTJA) can cause postoperative anemia. Clinicians might hesitate to discharge patients who have large changes in hemoglobin [Hgb], despite Hgb levels remaining above transfusion thresholds. This study was conducted to evaluate if delta Hgb or perioperative blood loss correspond with readmission in primary simBTJA patients not transfused perioperatively. Methods: From 2015 - 2020, a retrospective chart review of primary simultaneous bilateral total hip/knee arthroplasty cases was conducted. Preoperative and postoperative Hgb levels were obtained from our database or chart review. Exclusion criteria comprised patients who had a preoperative transfusion or transfusion postoperatively during their surgical admission, and patients not discharged home. Outcomes included whether delta Hgb or perioperative blood loss were predictive of 90-day readmission postoperatively, postoperative anemia, and transfusion during readmission. Results: The 510 individuals undergoing primary simBTJA possessed an average preoperative Hgb of 14.1 g/dL, starting blood volume of 5012 mL, postoperative Hgb of 10.0 g/dL, delta Hgb of 3.90 g/dL, and perioperative blood loss of 1403 mL. 19 patients (3.73 %) were readmitted, with none requiring transfusion. When constructing receiver operating characteristic (ROC) curves predicting readmission from delta Hgb, a threshold of 4.1 g/dL had an area under the curve (AUC) of 0.454, a sensitivity of 0.473, and a specificity of 0.56. For ROC curves predicting readmission from perioperative blood loss, a threshold of 1144 mL had an AUC of 0.453, a sensitivity of 0.842, and a specificity of 0.297. Similar AUCs, sensitivities, and specificities were obtained when adjusting ROC curves for preoperative Hgb or starting blood volume. Conclusions: Delta Hgb and perioperative blood loss do not predict 90-day readmission after primary simBTJA in patients not transfused perioperatively. Patients with a large delta Hgb but stay higher than a 7 g/dL restrictive transfusion threshold may have a strong capacity to overcome postoperative anemia.

Patients Requiring Both Total Hip Arthroplasty and Lumbar Spinal Fusion Have Lower Hip Functional Outcome Scores: A Matched Case-Control Study.

BACKGROUND: While patients who undergo both lumbar spinal fusion (LSF) and total hip arthroplasty (THA) have increased complication rates compared to patients who have not undergone LSF, there is a paucity of literature evaluating THA functional outcomes in patients with a history of LSF. This study was conducted to determine whether patients undergoing THA with a history of LSF have inferior functional outcomes compared to patients having no history of LSF. METHODS: A retrospective matched case-control study was conducted at an academic center. Patients who underwent both THA and LSF (cases) were matched with controls who underwent THA without LSF. Inclusion criteria required a minimum of 1-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement [HOOS-JR]. Following propensity matching for age, sex, race, body mass index, and comorbidities, 291 cases and 1,164 controls were included, with no demographic differences. RESULTS: Patients who underwent both THA and LSF had a significantly lower preoperative HOOS-JR (47 versus 50; P < .001), postoperative HOOS-JR (77 versus 85; P < .001), a significant lower rate of achieving the patient acceptable symptom state (55 versus 67%; P < .001), with no significant difference in delta HOOS-JR (34 versus 34; P = .834). When comparing patients undergoing THA before LSF or LSF before THA, no differences existed for preoperative HOOS-JR (50 versus 47; P = .304), but patients undergoing THA before LSF had lower postoperative HOOS-JR scores (74 versus 81; P = .034), a lower-delta HOOS-JR (27 versus 35; P = .022), and a lower rate of reaching the HOOS-JR minimal clinically important difference (62 versus 76%; P = .031). CONCLUSIONS: Patients who have a history of LSF experience a similar improvement in hip function when undergoing THA compared to patients who do not have a history of LSF. However, due to lower preoperative function, they may have a lower postoperative functional outcome ceiling. Additionally, patients undergoing THA before LSF have worse hip functional outcomes than patients undergoing LSF before THA.

Revision Total Hip Arthroplasty in Octogenarians Compared with Septuagenarians: Is There a Real Difference?

BACKGROUND: The increasing frequency of total hip arthroplasty (THA) as well as an aging population indicate that the need for revision THA will continue to grow, especially in older and potentially medically complex patients. The purpose of this study was to compare THA revision indications, perioperative complications, and readmissions between octogenarian and septuagenarian patients. We hypothesized that patients aged 80 to 89 years would have similar outcomes to patients aged 70 to 79 years undergoing revision THA. METHODS: Between 2008 and 2019, 572 revision THAs were performed at a single tertiary care hospital. Patients were stratified by age group: 70 to 79 years (n = 407) and 80 to 89 years (n = 165). Indication for revision, perioperative medical complications, and 90-day readmission were identified for each patient. Chi-square tests and t-tests were used to compare the groups. Logistic regression was used to assess medical complications and readmissions. RESULTS: Aseptic loosening was a more common indication for revision in patients aged 70 to 79 years (33.4% versus 26.7%; p < 0.001), while periprosthetic fracture was a more common indication for revision in those aged 80 to 89 years (30.9% versus 13.0%). Perioperative medical complications occurred more often in octogenarians (10.9% versus 3.0%; p = 0.001), with arrythmia being the most common type. Patients aged 80 to 89 years were at increased risk for medical complications (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.5 to 7.3; p = 0.004) and readmission (OR, 3.2; 95% CI, 1.7 to 6.3; p < 0.001) when adjusting for body mass index (BMI) and indication for revision. Octogenarians had a higher rate of reoperation following first-time revision than septuagenarians (10.3% versus 4.2%, p = 0.009). CONCLUSIONS: Octogenarians more commonly underwent revision THA for periprosthetic fracture and had higher rates of perioperative medical complications, 90-day readmissions, and reoperations than septuagenarians. Such findings should be considered when counseling patients on both primary and revision THAs. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Does the Use of Tranexamic Acid in Patients Who Have Preoperative Coagulopathy Undergoing Total Joint Arthroplasty Normalize Their Risk of Complications? A Matched Equivalence Analysis.

BACKGROUND: While patients who have a preoperative coagulopathy have an increased risk of perioperative blood loss, tranexamic acid (TXA) has been shown to decrease the risk of complications in this subset. However, a direct comparison of the use of TXA in coagulopathic and noncoagulopathic patients has not been performed. In addition to comparing differences in decreases in hemoglobin, transfusions, and complications, this study examined whether the use of TXA in coagulopathic patients normalized the risk of blood loss relative to matched noncoagulopathic patients. METHODS: We performed a retrospective review of 230 patients who had a preoperative coagulopathy and underwent primary total joint arthroplasty (127 hips, 103 knees) from 2012 to 2019 and received TXA. Coagulopathy was defined as international normalized ratio >1.2, partial thromboplastin time >35 seconds, or platelet count <150,000/mL (mL). A matched comparison group of 689 patients who did not have a coagulopathy and received TXA was identified. A 2 1-sided test (TOST) analysis was performed to test for equivalence. Assuming a clinically relevant difference of 1 g/dL in postoperative decrease in hemoglobin, the equivalence margin was set as ±1 g/dL between the groups. RESULTS: When comparing coagulopathic and noncoagulopathic patients, total hip arthroplasty (THA) patients had no differences in hemoglobin, but had an increased reported estimated blood loss (243 versus 207 mL, P = .040) as well as an increased percent of patients requiring blood transfusions (11.8 versus 5.32%, P = .022). Total knee arthroplasty (TKA) patients had no differences in hemoglobin, estimated blood loss, or percent of patients requiring transfusion. There were no differences in medical or surgical complications for both groups for THA and TKA patients. Equivalence testing for both groups revealed statistical significance that THA and TKA coagulopathic patients receiving TXA had an equivalent risk of blood loss compared to noncoagulopathic patients receiving TXA. CONCLUSION: Coagulopathic patients receiving TXA and undergoing THA had an increased risk of receiving a transfusion; however, there were no differences in complications for both TKA and THA, as well as a normalized risk of blood loss when compared to noncoagulopathic patients. LEVEL OF EVIDENCE: III.

Creation of a Risk Calculator for Predicting New-Onset Cardiac Arrhythmias in Patients Undergoing Lumbar Fusion.

INTRODUCTION: As an increasing number of lumbar fusion procedures are being conducted at specialty hospitals and surgery centers, appropriate patient selection and risk stratification is critical to minimizing patient transfers. Postoperative cardiac arrhythmia has been linked to worse patient outcomes and is a common cause of patient transfer. Therefore, we created a risk calculator to predict a patient's likelihood of developing a new-onset postoperative cardiac arrhythmia after lumbar spinal fusion, which may improve preoperative facility selection. METHODS: A retrospective review was conducted of patients who undergoing lumbar fusion from 2017 to 2021 at a single academic center. Patients were excluded if they had any medical history of a cardiac arrhythmia. Multivariable regression was conducted to determine independent predictors of inpatient arrhythmias. The final regression was applied to a bootstrap to validate an arrhythmia prediction model. A risk calculator was created to determine a patient's risk of new-onset cardiac arrhythmia. RESULTS: A total of 1,622 patients were included, with 45 patients developing a new-onset postoperative arrhythmia. Age (OR = 1.05; 95% CI, 1.02 to 1.09; P = 0.003), history of beta-blocker use (OR = 2.01; 95% CI, 1.08 to 3.72; P = 0.027), and levels fused (OR = 1.59; 95% CI, 1.20 to 2.00; P = 0.001) were all independent predictors of having a new-onset inpatient arrhythmia. This multivariable regression produced an area under the curve of 0.742. The final regression was applied to a bootstrap prediction modeling technique to create a risk calculator including the male sex, age, body mass index, beta-blocker use, and levels fused (OR = 1.04, [CI = 1.03 to 1.06]) that produced an area under the curve of 0.733. CONCLUSION: A patient's likelihood of developing postoperative cardiac arrhythmias may be predicted by comorbid conditions and demographic factors including age, sex, body mass index, and beta-blocker use. Knowledge of these risk factors may improve appropriate selection of an outpatient surgical center or orthopaedic specialty hospital versus an inpatient hospital for lumbar fusions.

Patients Who Have Had Three or More Levels Fused During Lumbar Spinal Fusion Have Worse Functional Outcomes After Total Hip Arthroplasty.

BACKGROUND: Lumbar spinal fusion (LSF) and total hip arthroplasty (THA) are commonly performed in patients who have concomitant spine and hip pathology. While patients who have three or more levels fused during LSF have increased postoperative opioid consumption after undergoing THA, it is unknown whether the number of levels fused during LSF affects THA functional outcomes. METHODS: A retrospective study was conducted at a tertiary academic center for patients who underwent LSF first and then had a primary THA performed with a minimum of one-year follow-up for the Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS-JR). Operative notes were reviewed to determine the number of levels fused during LSF. There were 105 patients who underwent one-level LSF, 55 patients underwent two-level LSF, and 48 patients underwent three-or-more-level LSF. No significant differences existed in age, race, body mass index, and comorbidities between the cohorts. RESULTS: While preoperative HOOS-JR was similar among the three cohorts, patients who had three-or-more-level LSF had significantly lower HOOS-JR scores than patients who had two-level or one-level LSF (71.4 versus 82.4 versus 78.2; P = .010) and a lower delta HOOS-JR (27.2 versus 39.4 versus 35.9; P = .014). Patients who had three-or-more-level LSF had a significantly lower rate of achieving minimal clinically important difference (61.7% versus 87.2% versus 78.7%; P = .011) and the patient acceptable symptom state (37.5% versus 69.1% versus 59.0%; P = .004) for the HOOS-JR, compared to patients who had two-level or one-level LSF, respectively. CONCLUSIONS: Surgeons should counsel patients who have had three-or-more-level LSF that they may have a lower rate of hip function improvement and symptom acceptability after THA, compared to patients who have had a less number of levels fused during LSF.

Participation in Sports and Physical Activities After Total Joint Arthroplasty.

BACKGROUND: Quality data on physical activity participation following total joint arthroplasty (TJA) are limited. The purpose of this study was to explore patient participation, outcomes, and limitations in sports/physical activities following TJA. METHODS: Patients who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA) at a single institution from 2015 to 2020 were surveyed on sports/physical activity participation before and after TJA. Data were correlated with perioperative demographic and outcome scores. In total, 2,366 patients were surveyed: 788 (33.3%) underwent THA, 1,175 (49.7%) underwent TKA, and 403 (17.0%) underwent both THA/TKA. RESULTS: Participation rates were 69.2, 61.5, and 61.3% at one year prior and 86.8, 81.5, and 81.6% at five years prior to THA, TKA, and THA/TKA, respectively. Participation rates were 73.1, 72.0, and 60.8% at mean 4.0 years postoperatively. Weekly time spent (P < .05) and exertion levels (P < .001) increased postoperatively for all three cohorts. For all three cohorts, the most common sports/activities were recreational walking, cycling, swimming, and golf, while intermediate- and high-impact activity participation decreased postoperatively. Independent predictors of postoperative sports/physical activity participation were younger age [THA (P < .001); TKA (P = .010)], lower body mass index [THA (P < .001); TKA (P < .001)], fewer comorbidities [THA (P < .001)], and higher postoperative Hip Injury and Osteoarthritis Outcome Score Junior[THA (P = .012)], Knee Injury and Osteoarthritis Outcome Score Junior[TKA (P = .004)], 12-Item Short Form Physical Component Score[THA (P < .001); TKA (P < .001); THA/TKA (P = .004)], and 12-Item Short Form Mental Component Score[TKA (P = .004)] scores. Activity restrictions were reported among 17.5, 20.9, and 25.1% of THA, TKA, and THA/TKA patients, respectively, and were more commonly self-imposed than surgeon-directed for all cohorts. CONCLUSION: Though sports/physical activity participation may improve following TJA compared to one year preoperatively, participation is decreased compared to five years preoperatively, transitions to low-impact activities, and varies among subsets of patients.

Patients From Distressed Communities Who Undergo Surgery for Hip Fragility Fractures Are Less Likely to Have Advanced Care Planning Documents in Their Electronic Medical Record.

BACKGROUND: Advanced care planning documents provide a patient's healthcare team and loved ones with guidance on patients' treatment preferences when they are unable to advocate for themselves. A substantial proportion of patients will die within a few months of experiencing a hip fracture, but despite the importance of such documents, patients undergoing surgery for hip fracture seldom have discussions documented in the medical records regarding end-of-life care during their surgical admission. To the best of our knowledge, the proportion of patients older than 65 years treated with surgery for hip fractures who have advanced care planning documents in their electronic medical record (EMR) has not been explored, neither has the association between socioeconomic status and the presence of those documents in the EMR. Determining this information can help to identify opportunities to promote advanced care planning. QUESTIONS/PURPOSES: (1) What percentage of patients older than 65 years who undergo hip fracture surgery have completed advanced care planning documents uploaded in the EMR before or during their surgical hospitalization, or at any timepoint (before admission, during admission, and after admission)? (2) Are patients from distressed communities less likely to have advanced care planning documents in the EMR than patients from wealthier communities, after controlling for economic well-being as measured by the Distressed Communities Index? (3) What percentage of patients older than 65 years with hip fractures who died during their hospitalization for hip fracture surgery had advanced care planning documents uploaded in the EMR? METHODS: This was a retrospective, comparative study conducted at two geographically distinct hospitals: one urban Level I trauma center and one suburban Level II trauma center. Between 2017 and 2021, these two centers treated 850 patients for hip fractures. Among those patients, we included patients older than 65 years who were treated with open reduction and internal fixation, intramedullary nailing, hemiarthroplasty, or THA for a fragility fracture of the proximal femur. Based on that, 83% (709 of 850) of patients were eligible; a further 6% (52 of 850) were excluded because they had codes other than ICD-9 820 or ICD-10 S72.0, and another 2% (17 of 850) had incomplete datasets, leaving 75% (640 of 850) for analysis here. Most patients with incomplete datasets were in the prosperous Distressed Communities Index category. Among patients included in this study, the average age was 82 years, 70% (448 of 640) were women, and regarding the Distressed Communities Index, 32% (203 of 640) were in the prosperous category, 25% (159 of 640) were in the comfortable category, 15% (99 of 640) were in the mid-tier category, 5% (31 of 640) were in the at-risk category, and 23% (145 of 640) were in the distressed category. The primary outcome included the presence of advanced care planning documents (advanced directives, healthcare power of attorney, or physician orders for life-sustaining treatment) in the EMR before surgery, during the surgical admission, or at any time. The Distressed Communities Index was used to indicate economic well-being, and patients were identified as being in one of five Distressed Communities Index categories (prosperous, comfortable, mid-tier, at-risk, and distressed) based on ZIP Code. An exploratory analysis was conducted to determine variables associated with the presence of advanced care planning documents in the EMR. A multivariate regression was then performed for patients who did or did not have advanced care planning documents in their medical record at any time. The results are presented as ORs with the associated 95% confidence interval (CI). RESULTS: Nine percent (55 of 640) of patients had advanced care planning documents in the EMR preoperatively or during their surgical admission, and 22% (142 of 640) of patients had them in the EMR at any time. After controlling for potential confounding variables such as age, laterality (left or right hip), hospital type, and American Society of Anesthesiologists (ASA) classification, we found that patients in Distressed Communities Index categories other than prosperous had ORs lower than 0.7, with patients in the distressed category (OR 0.4 [95% CI 0.2 to 0.7]; p < 0.01) and comfortable category (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.01) having a substantially lower odds of having advanced care planning documents in their EMR. Patients aged 86 to 95 years (OR 1.9 [95% CI 1.1 to 3.4]), those 96 years and older (OR 4.0 [95% CI 1.7 to 9.5]), and those with a higher ASA classification (OR 1.6 [95% CI 1.1 to 2.3]) had a higher odds of having advanced care planning documents in the EMR at any time. Among 14 patients who experienced in-hospital mortality, two had advanced care planning documents uploaded into their EMR, whereas 12 of 14 who died in the hospital did not have advanced care planning documents uploaded into their EMR. CONCLUSION: Orthopaedic surgeons should counsel patients regarding the risk for postoperative complications after fragility hip fracture surgery and engage in shared decision-making regarding advanced care planning documents with patients or, if the patients are unable, with their families. Additionally, implementing virtual education about advanced care planning documents and using easy-to-read forms may facilitate the completion of advanced care planning documents by patients older than 65 years, especially patients with low economic well-being. Limitations of this study include having a restricted number of patients in the at-risk and mid-tier Distressed Communities Index categories and a restricted number of patients identifying as non-White races/ethnicities. Future research should evaluate the effect of advanced care document presence in the EMR on end-of-life care intensity in patients treated for fragility hip fractures. LEVEL OF EVIDENCE: Level III, therapeutic study.

Preoperative epidural steroid injections do not increase the risk of postoperative infection in patients undergoing lumbar decompression or fusion: a systematic review and meta-analysis.

PURPOSE: Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery. METHODS: We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle-Ottawa Scale. RESULTS: Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses. CONCLUSION: Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates. LEVEL OF EVIDENCE: II.

Risk of Noise-Induced Hearing Loss for Orthopaedic Surgeons.

BACKGROUND: Noise-induced hearing loss (NIHL) affects the ability of an individual to communicate and can negatively impact quality of life. The risk to orthopaedic surgeons of developing NIHL as a result of occupational exposures in the operating room (OR) is currently unknown. Hearing protection is recommended for levels of >85 decibels (dB), irrespective of length of exposure. The primary goal of the present study was to determine whether orthopaedic surgeons are exposed to harmful noise levels in the OR that puts them at risk for developing NIHL. METHODS: A prospective review was conducted with use of intraoperative audio recordings across 6 orthopaedic subspecialties. Recordings were made in ORs prior to the surgical start time to serve as baseline controls. Decibel levels were reported as the maximum dB level (MDL), defined as the highest sound pressure level during the measurement period, and as the time-weighted average (TWA), defined as the average dB level projected over an 8-hour time period. Noise doses were reported as the percentage of maximum allowable daily noise (dose) and as the measured dose projected forward over 8 hours (projected dose). RESULTS: Three hundred audio recordings were made and analyzed. The average MDL ranged from 96.9 to 102.0 dB, with noise levels for all subspeciality procedures being significantly greater compared with the control recordings (p < 0.001). Overall, MDLs were >85 dB in 84% of cases and >100 dB in 35.0% of cases. The procedure with the highest noise dose was a microdiscectomy, which reached 11.3% of the maximum allowable daily noise and a projected dose of 104.1%. Among subspecialties, adult reconstruction had the highest dose and projected dose per case among subspecialties. CONCLUSIONS: The present results showed that orthopaedic surgeons are regularly exposed to damaging noise levels (i.e., >85 dB), putting them at risk for permanent hearing loss. Further investigation into measures to mitigate noise exposure in the OR and prevent hearing loss in orthopaedic surgeons should be undertaken. CLINICAL RELEVANCE: Orthopaedic surgeons are at risk for NIHL as a result of occupational exposures in the OR.

The Usefulness of Closed Incision Negative Pressure Wound Therapy After Spinal Fusion: A Systematic Review and Meta-Analysis.

OBJECTIVE: To determine if closed incision negative pressure wound therapy (ciNPWT) decreases surgical site infection (SSI) or wound dehiscence after spinal fusion. METHODS: Following PRISMA guidelines, a systematic review and meta-analysis were conducted to identify studies using ciNPWT after spinal fusion. Funnel plots and quality scores of the articles were performed to determine if the articles were at risk of bias. Forest plots were conducted to identify the treatment effect of ciNPWT after spinal fusion. RESULTS: A total of 8 studies comprising 1061 patients who received ciNPWT or a standard postoperative dressing after spinal fusion were included. The rate of SSI (ciNPWT, 4.49% [95% confidence interval (CI), 2.48-8.00] vs. control, 11.32% [95% CI, 7.51-16.70]; P = 0.0103) was significantly lower for patients treated with ciNPWT. A fixed-effects model showed no significant difference between patients who received ciNWPT or a standard postoperative dressing with respect to requiring reoperations for wound debridement (odds ratio, 1.25; 95% CI, 0.64-2.41). In addition, wound dehiscence was not significantly different between the 2 groups, although it was nonsignificantly lower in ciNWPT-treated patients (ciNPWT, 4.59% [95% CI, 2.49-8.31] vs. control: 7.48% [95% CI, 4.38-12.47]; P = 0.23). CONCLUSIONS: ciNPWT may reduce the rates of SSI after spinal fusion. The use of ciNWPT may also significantly reduce the burden associated with postoperative wound complications, but the meta-analysis was insufficiently powered to make this association. Additional studies may identify a subset of patients who benefit from ciNPWT for other wound-related complications.

Low-Dose Aspirin for Venous Thromboembolism Prophylaxis is Associated With Lower Rates of Periprosthetic Joint Infection After Total Joint Arthroplasty.

BACKGROUND: Aspirin as a venous thromboembolism (VTE) prophylactic agent has been shown to have antistaphylococcal and antibiofilm roles. Optimal acetylsalicylic acid (ASA) dosage would facilitate antimicrobial effects while avoiding over-aggressive inhibition of platelet antimicrobial function. Our purpose was to determine the periprosthetic joint infection (PJI) rate after total joint arthroplasty in patients receiving low-dose ASA (81 mg twice a day), in comparison to high-dose ASA (325 mg twice a day). METHODS: We conducted a retrospective cohort study between 2008 and 2020. Eligible patients were older than 18 years, underwent primary total joint arthroplasty, both total knee arthroplasty and total hip arthroplasty, had a minimum 30-day follow-up, and received a full course ASA as VTE prophylaxis. Patients' records were reviewed for PJI, according to Musculoskeletal Infection Society criteria. Patients were excluded if they underwent revision arthroplasty, had a history of coagulopathy, or had an ASA regimen that was not completed. In total 15,825 patients were identified, 8,761 patients received low-dose ASA and 7,064 received high-dose ASA. RESULTS: The high-dose cohort had a higher PJI rate (0.35 versus 0.10%, P = .001). This relationship was maintained when comparing subgroups comprising total knee arthroplasty (0.32 versus 0.06%, P = .019) or total hip arthroplasty (0.38 versus 0.14%, P = .035) and accounting for potentially confounding demographic and surgical variables (odds ratio = 2.59, 95% CI = 1.15-6.40, P = .028). CONCLUSION: Comparing low-dose to high-dose ASA as a VTE prophylactic agent, low-dose ASA had a lower PJI rate. This may be attributable to a balance of anti-infective properties of ASA and antiplatelet effects.

Serum Glucose Variability Increases the Risk of Complications Following Aseptic Revision Hip and Knee Arthroplasty.

BACKGROUND: Increased serum glucose variability has been proposed as a risk factor for perioperative morbidity and mortality. Given the greater surgical complexity and complication risk of revision total joint arthroplasty (TJA), previous findings may not be generalizable to the revision population. The purpose of this study was to investigate the association between glucose variability and postoperative complications following aseptic revision TJA. METHODS: We identified 1,983 patients who underwent an aseptic revision TJA (636 total knee arthroplasties [TKAs] and 1,347 total hip arthroplasties [THAs]) from 2001 to 2019. Patients with ≥2 postoperative glucose values per day or ≥3 values during hospitalization were included in this study. Glucose variability was assessed using the coefficient of variation (COV). Outcomes included length of hospital stay, 90-day complications, mortality, and periprosthetic joint infection (PJI) as defined by the 2018 International Consensus Meeting criteria. Multivariate regression was used to determine the association between glucose variability and each end point, using COV as continuous and categorical variables (that is, COV tertiles). RESULTS: Patients with high glycemic variability were at 1.7 times greater risk for 90-day complications (odds ratio [OR], 1.664 [95% confidence interval (CI), 1.266 to 2.188]; p < 0.001) and 2 times greater risk for PJI at a minimum 1-year follow-up (OR, 1.984 [95% CI, 1.270 to 3.100]; p = 0.003). The risk of 90-day complications increased by 2.2% (OR, 1.022 [95% CI, 1.012 to 1.032]; p < 0.001) and the risk of PJI increased by 1.8% (OR, 1.018 [95% CI, 1.003 to 1.034]; p = 0.013) for every percentage-point increase in COV. Patients with higher glucose variability also had a longer length of stay (beta, 1.028 days [95% CI, 0.590 to 1.466 days]; p < 0.001). These associations were independent of age, sex, body mass index, Charlson Comorbidity Index, involved joint, operative time, history of diabetes, and mean glucose levels. CONCLUSIONS: Higher glucose variability was associated with an increased risk of medical complications and PJI following aseptic revision TJA. Patients undergoing these complex procedures should have glucose levels monitored closely in the perioperative period. Future studies should evaluate the utility of continuous glucose monitoring in this high-risk population. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Does Body Mass Index Influence the Outcomes and Survivorship of Modern Cementless Total Knee Arthroplasty?

BACKGROUND: Higher body mass index (BMI) has been associated with higher rates of aseptic loosening following cemented total knee arthroplasty (TKA). However, there is a paucity of evidence on the effect of BMI on the durability of modern cementless TKA. We aimed to assess the association between BMI and clinical outcomes following cementless TKA and to determine if there was a BMI threshold beyond which the risk of revision significantly increased. METHODS: We identified 1,408 cementless TKAs of a modern design from an institutional registry. Patients were classified into BMI categories: normal (n = 136), overweight (n = 476), obese class I (n = 423), II (n = 258), and III (n = 115). The Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and 12-item Short Form Health Survey scores were collected preoperatively and 2 years postoperatively. Survivorship was recorded at minimum 2 years (range, 24 to 88 months). BMI was analyzed as a continuous and categorical variable. RESULTS: The improvement in patient-reported outcomes was similar across the groups. Thirty four knees (2.4%) were revised and 14 (1.0%) were for aseptic failure. Mean time-to-revision was 1.2 ± 1.3 years and did not differ across BMI categories (P = .455). Survivorship free from all-cause and aseptic revision was 97.1% and 99.0% at mean 4 years, respectively. Using Cox regression to control for demographics and bilateral procedures, BMI had no association with all-cause revision (P = .612) or aseptic revision (P = .186). Receiver operating characteristic curve analysis found no relationship between BMI and revision risk (c-statistic = 0.51). CONCLUSION: BMI did not influence functional outcomes and survivorship of modern cementless TKA, possibly due to improved biological fixation at the bone-implant interface. Longer follow-up is necessary to confirm these findings.

Acute Postoperative Anemia After Unilateral Primary Total Joint Arthroplasty: Restrictive Transfusion Thresholds are Safe for Discharge Regardless of Delta Hemoglobin.

BACKGROUND: Primary unilateral total joint arthroplasty (TJA) is associated with acute postoperative anemia that may require blood transfusion. Clinicians may worry about discharging patients after surgery who experience substantial decreases in hemoglobin (Hgb), even if their Hgb is above restrictive transfusion thresholds. The purpose of this study was to determine whether differences between preoperative and postoperative Hgb values (Delta) correlate with 90-day readmission in patients who did not receive perioperative transfusions. METHODS: A retrospective review of patients undergoing primary unilateral TJA between 2015 and 2020 was performed. The primary outcome was whether a specific cutoff delta Hgb was predictive of readmission within 90 days due to anemia-related causes. Secondary outcomes included the presence of acute postoperative anemia and transfusion during readmission. RESULTS: Six thousand seven hundred and ninety one patients had a median delta Hgb of 2.80. In total, 268 patients (3.95%) were readmitted within 90 days postoperatively, with two patients requiring transfusion during readmission. A significantly higher rate of readmission was found in patients with cardiovascular disease (5.16% versus 3.68%; P = .020). When constructing receiver operating characteristic curves, a cutoff value of 3.20 resulted in an area under curve of 0.595 (0.486-0.704). In patients with cardiovascular disease, a cutoff value of 3.10 resulted in an area under curve of 0.626 (0.466-0.787). CONCLUSION: The magnitude of Hgb change was not predictive of anemia-related readmission within 90 days in patients who did not receive a perioperative transfusion. Patients experiencing higher delta Hgb values but remaining above the transfusion threshold may have a greater physiologic reserve.

Breaking the myths of competition: a cross-sectional analysis of injuries among CrossFit trained participants.

OBJECTIVES: The purpose of this study was to examine the injury rates of individuals engaged in CrossFit training and examine the risk of injury associated with competition. STUDY DESIGN: Cross-sectional analysis. METHODS: Descriptive statistics, including injury incidence and rates, were examined for individuals reporting participation in a CrossFit sanctioned competition between 2013 and 2017. To examine the odds of being injured, we considered logistic regression models, where the primary independent measure was participation length-individual measures of interest included age, sex, body mass index, CrossFit affiliation and competition status. RESULTS: 3049 individuals completed the survey (60% completion rate). All competitors, regardless of competition level, had similar incidence of injury (χ2=1.1, p=0.571). For those who reported competing, our calculated injury rate was 0.21-0.54 injuries per 1000 training hours, while for those not competing, the injury rate was calculated as 0.39-1.30 injuries per 1000 training hours. Logistic regression demonstrated short length of participation in CrossFit training as the main factor associated with the odds of being injured (OR=1.82; 95% CI: 1.15 to 2.92). Additionally, training at an official CrossFit affiliate appeared to have a protective effect from injury (OR=0.85; 95% CI: 0.65, 1.10). CONCLUSION: Our findings provide evidence of the low risk of injury related to these events. Moreover, these findings support the notion that musculoskeletal injuries may be the result of poor progression plans, which may be minimised by participating in an official CrossFit affiliate.