Perioperative management of acetabular and pelvic fractures: evidence-based recommendations.

PURPOSE: The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF. METHODS: A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis. RESULTS: A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic. CONCLUSION: The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Impact of Preoperative Opioid Use on Patient-Reported Outcomes after Revision Total Knee Arthroplasty: A Propensity Matched Analysis.

This is a retrospective study. Prior studies have characterized the deleterious effects of narcotic use in patients undergoing primary total knee arthroplasty (TKA). While there is an increasing revision arthroplasty burden, data on the effect of narcotic use in the revision surgery setting remain limited. Our aim was to characterize the effect of active narcotic use at the time of revision TKA on patient-reported outcome measures (PROMs). A total of 330 consecutive patients who underwent revision TKA and completed both pre- and postoperative PROMs was identified. Due to differences in baseline characteristics, 99 opioid users were matched to 198 nonusers using the nearest-neighbor propensity score matching. Pre- and postoperative knee disability and osteoarthritis outcome score physical function (KOOS-PS), patient reported outcomes measurement information system short form (PROMIS SF) physical, PROMIS SF mental, and physical SF 10A scores were evaluated. Opioid use was identified by the medication reconciliation on the day of surgery. Propensity score-matched opioid users had significantly lower preoperative PROMs than the nonuser for KOOS-PS (45.2 vs. 53.8, p < 0.01), PROMIS SF physical (37.2 vs. 42.5, p < 0.01), PROMIS SF mental (44.2 vs. 51.3, p < 0.01), and physical SF 10A (34.1 vs. 36.8, p < 0.01). Postoperatively, opioid-users demonstrated significantly lower scores across all PROMs: KOOS-PS (59.2 vs. 67.2, p < 0.001), PROMIS SF physical (43.2 vs. 52.4, p < 0.001), PROMIS SF mental (47.5 vs. 58.9, p < 0.001), and physical SF 10A (40.5 vs. 49.4, p < 0.001). Propensity score-matched opioid-users demonstrated a significantly smaller absolute increase in scores for PROMIS SF Physical (p = 0.03) and Physical SF 10A (p < 0.01), as well as an increased hospital length of stay (p = 0.04). Patients who are actively taking opioids at the time of revision TKA report significantly lower preoperative and postoperative outcome scores. These patients are more likely to have longer hospital stays. The apparent negative effect on patient reported outcomes after revision TKA provides clinically useful data for surgeons in engaging patients in a preoperative counseling regarding narcotic use prior to revision TKA to optimize outcomes.

The Performance of Diagnostic Tests for Identifying Periprosthetic Joint Infection After Failed Partial Knee Arthroplasty.

BACKGROUND: Indications for unicompartmental knee arthroplasty (UKA) and patello-femoral arthroplasty are expanding. Despite the lower published infection rates for UKA and patello-femoral arthroplasty than total knee arthroplasty, periprosthetic joint infection (PJI) remains a devastating complication and diagnostic thresholds for commonly utilized tests have not been investigated recently. Thus, this study evaluated if diagnostic thresholds for PJI in patients who had a failed partial knee arthroplasty (PKA) align more closely with previously reported thresholds specific to UKA or the 2018 International Consensus Meeting on Musculoskeletal Infection. METHODS: We identified 109 knees in 100 patients that underwent PKA with eventual conversion to total knee arthroplasty within a single healthcare system from 2000 to 2021. Synovial fluid nucleated cell count and synovial polymorphonuclear percentage in addition to preoperative serum erythrocyte sedimentation rate, serum C-reactive protein, and serum white blood cell count were compared with Student's t-tests between septic and aseptic cases. Receiver operating characteristic curves and Youden's index were used to assess diagnostic performance and the optimal cutoff point of each test. RESULTS: Synovial nucleated cell count, synovial polymorphonuclear percentage, and serum C-reactive protein demonstrated excellent discrimination for diagnosing PJI with an area under the curve of 0.97 and lower cutoff values than the previously determined UKA specific criteria. Serum erythrocyte sedimentation rateESR demonstrated good ability with an area under the curve of 0.89. CONCLUSION: Serum and synovial fluid diagnostic thresholds for PJI in PKAs align more closely with the thresholds established by the 2018 International Consensus Meeting as compared to previously proposed thresholds specific to UKA. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

The Significance of Race/Ethnicity and Income in Predicting Preoperative Patient-Reported Outcome Measures in Primary Total Joint Arthroplasty.

BACKGROUND: Utilization of total joint arthroplasty (TJA) by minorities is disproportionately low compared to Whites. Contributing factors include poorer outcomes, lower expectations, and decreased access to care. This study aimed to evaluate if race and income were predictive of preoperative patient-reported outcome measures (PROMs) and the likelihood of achieving the minimal clinically important difference (MCID) following TJA. METHODS: We retrospectively reviewed 1,371 patients who underwent primary TJA between January 2018 and March 2021 in a single healthcare system. Preoperative and postoperative PROM scores were collected for Patient-Reported Outcomes Measurement Information System (PROMIS) Mental Health, PROMIS Physical Function (PF10a), and either Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS). Demographic and comorbidity data were included as explanatory variables. Multivariable regression was used to analyze the association between predictive variables and PROM scores. RESULTS: Mean preoperative PROM scores were lower for non-Whites compared to Whites. Increased median household income was associated with higher preoperative PROM scores. Non-White race was associated with lower PROMIS Mental Health and KOOS, but not PF10a or HOOS scores. Only non-White race was associated with a decreased likelihood of achieving MCID for PF10a. Neither race nor income was predictive of achieving MCID for KOOS and HOOS. CONCLUSION: Non-White race/ethnicity and lower income were associated with lower preoperative PROMs prior to primary TJA. Continued research is necessary to identify the causes of this discrepancy and correct this disparity.

Treatment of Severe Acetabular Bone Loss Using a Tantalum Acetabular Shell and a Cemented Monoblock Dual Mobility Acetabular Cup.

As the number of revision total hip arthroplasty increases, innovative solutions to complex problems are needed to address challenges posed by these complex cases. Severe acetabular bone loss, including cases of pelvic discontinuity, is a notable challenge with few solutions. Hip instability after revision arthroplasty remains one of the leading causes of revision and patient morbidity. The use of pelvic distraction and a press-fit tantalum shell for chronic discontinuity and posterior column open reduction and internal fixation with acetabular revision for acute pelvic discontinuity have previously been described. Similarly, dual mobility articulations have demonstrated long-term success in minimizing instability after revision total hip arthroplasty with good long-term survivorship. Here, the authors present a surgical technique in the management of Paprosky types 2 and 3 acetabular defects often with pelvic discontinuity using a tantalum shell in combination with cemented dual mobility liner to increase the stability of the joint. Custom screw placement is facilitated with the use of a metal cutting burr, both on the back table and in situ. The dual mobility liner is cemented, thus allowing for independent positioning of the acetabular implant and bearing surface. This technique has been successfully used in 19 patients with encouraging short-term results.

Regional Implicit Bias Does Not Account for Racial Disparity in Total Joint Arthroplasty Utilization.

BACKGROUND: Racial disparities surrounding the utilization of total hip and total knee arthroplasty (THA, TKA) are well documented. The Implicit Association Test (IAT) is a validated tool used to measure implicit and explicit bias. The purpose of this study is to evaluate if variations in IAT scores by geographical region in the United States (US) correspond with regional variations in THA and TKA utilization by blacks compared to whites. METHODS: Data from the US Census and National Inpatient Sample from 2012 to 2014 were used to calculate THA and TKA utilization rates among Medicare-aged blacks and whites. Data were aggregated by US Census Bureau Division. Regional implicit bias was assessed by calculating a weighted average of IAT scores for each division. RESULTS: Across all geographic regions and years, the surveyed population demonstrated an implicit bias favoring whites over blacks. The population adjusted ratio of white-to-black utilization of THA and TKA by geographic division varied between 0.86-1.85 and 0.87-2.01, respectively. The difference in utilization between geographic divisions reached statistical significance (P < .001). No correlation was found between the IAT scores and race-specific utilization ratios among geographic divisions. CONCLUSION: Implicit bias as measured by regional IAT did not reflect THA and TKA utilization disparities. The racial disparity in utilization of THA and TKA significantly varied between divisions. The observed disparity was greater in divisions with a relatively higher proportion of blacks. To the authors' knowledge, this is the first study to evaluate the impact of implicit bias on utilization of THA and TKA.

Comparison of Patient Demographics and Utilization Trends of Robotic-Assisted and Non-Robotic-Assisted Unicompartmental Knee Arthroplasty.

Robotic-assisted unicompartmental knee arthroplasty (RAUKA) is an emerging area of interest. The purpose of this study was to compare (1) different patient demographic profiles; (2) annual primary and revision utilization rates; (3) risk factors for revision procedures; and (4) survivorship between RAUKA and manual UKA (MUKA). Using the PearlDiver database, patients who underwent RAUKA or MUKA between 2005 and 2014 within the Medicare database were identified, yielding a total of 35,061 patients (RAUKA = 13,617; manual = 21,444). Patient demographics (age, gender, comorbidities, Charlson-Comorbidity Index, and geographic region) were compared between cohorts. Annual primary and revision utilization rates as well as risk factors for revision procedures were also compared. Kaplan-Meier survivorship was also calculated. The Pearson χ2 test was used to test for significance in patient demographics, whereas the Welch t-test was used to compare the incidence of revisions as well as the revision burden (proportion of revisions to total sum of primary and revision procedures). Multivariate binomial logistic regression analysis was performed to compare risk factors for revision procedures. There were statistically significant differences in RAUKA versus MUKA patients with respect to age (p < 0.001), gender (p < 0.001), and region (p < 0.001). RAUKA procedures performed increased over 12-fold compared with manual, which increased only 4.5-fold. RAUKA procedures had significantly lower revision incidence (0.99 vs. 4.24%, p = 0.003) and revision burden (0.91 vs. 4.23%, p = 0.005) compared with manuals. For patients undergoing RAUKA, normal (19-24 kg/m2) and obese (30-39 kg/m2) body mass index (p < 0.05), congestive heart failure (p = 0.004), hypothyroidism (p < 0.001), opioid dependency (p = 0.002), and rheumatoid arthritis (p < 0.001) were risk factors for a revision procedure. Kaplan-Meier survival curve 3 years following the index procedure to all-cause revisions demonstrated that RAUKA patients maintained nearly 100% survivorship compared with manual patients who had 97.5% survivorship. The data demonstrate increased utilization of RAUKA in the United States. The current data indicated that RAUKA has significantly lower revision rates and improved survivorship compared with patients undergoing non-RAUKA within Medicare patients.

The Effects of Patient Occupation, Hobbies, and Body Mass Index on Kneeling after Total Knee Arthroplasty.

A common patient concern after total knee arthroplasty (TKA) is the ability to kneel. Kneeling may have a substantial impact on the patients' ability to perform many activities of daily living, occupations, and hobbies. The purpose of this study was to quantify the percentage of patients able to kneel after TKA after 2 years and to evaluate preoperative patient characteristics that influence the patient's perceived ability to kneel after TKA such as obesity, occupation, and hobbies. We retrospectively assessed a cohort of 404 patients who underwent primary TKA with patellar resurfacing. We assessed the impact of patient hobbies, occupation, employment status, and body mass index (BMI) on the kneeling capacity and patient-reported satisfaction. Univariate analysis was performed using Fisher's exact test, and multivariate analysis was performed using logistic regression with multiple imputations. A total of 404 patients were included. Sixty percent of patients were unable to kneel after TKA. Males (p < 0.001) and patients with occupations or hobbies requiring kneeling (p < 0.05) were more likely to kneel after surgery. We identified an inverse relationship between BMI and the ability to kneel. No correlation was found between duration and frequency of kneeling relative to patient-reported ease or difficulty with kneeling. Patient-reported factors that prevented patients from kneeling were pain, physical inability, and fear of damaging the prosthesis. Patient education may be helpful in improving patient expectations about kneeling after surgery. A small but significant difference in subjective patient satisfaction was observed when comparing patients able to kneel with those unable to kneel.

Tranexamic acid with a pre-operative suspension of anticoagulation decreases operative time and blood transfusion in the treatment of pelvic and acetabulum fractures.

PURPOSE: The purpose was to evaluate the impact of intra-operative administration of tranexamic acid (TXA) and pre-operative discontinuation of prophylactic chemoprophylaxis in patients undergoing internal fixation of pelvic or acetabular fractures on the need for subsequent blood transfusion. Operative time and the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) were also assessed. METHODS: Data from a single level one trauma centre was retrospectively reviewed from January 2014 to December 2017 to identify pelvic ring or acetabular fractures managed operatively. Patients who did not receive their scheduled dose of chemoprophylaxis prior to surgery but who did receive intra-operative TXA were identified as the treatment group. Due to the interaction of VTE prophylaxis and TXA, the variables were analyzed using an interaction effect to account for administration of both individually and concomitantly. RESULTS: One hundred fifty-nine patients were included. The treatment group experienced a 20.7% reduction in blood product transfusion (regression coefficient (RC): - 0.207, p = 0.047, 95%CI: - 0.412 to - 0.003) and an average of 36 minutes (RC): - 36.90, p = 0.045, 95%CI: - 72.943 to - 0.841) reduction in surgical time as compared to controls. The treatment group did not experience differential rates of PE or DVT (RC: 1.302, p = 0.749, 95%CI: 0.259-6.546) or PE (RC: 1.024, p = 0.983, 95%CI: 0.114-9.208). CONCLUSIONS: In the study population, the combination of holding pre-operative chemoprophylaxis and administering intra-operative TXA is a safe and effective combination in reducing operative time and blood product transfusions.

MRI Evaluation of Posterior Capsular Dehiscence After Posterior Approach Total Hip Arthroplasty.

INTRODUCTION: To our knowledge, no previous study has evaluated the use of MRI to diagnose posterior capsule dehiscence after posterior approach total hip arthroplasty (THA) with capsular repair and its association with postoperative posterior hip dislocation. METHODS: A retrospective chart review of patients who underwent posterior approach THA with capsulotomy repair was performed. Patients were identified who subsequently underwent MRI, and these studies were evaluated for signs of posterior capsular disruption. Each chart was then evaluated for episodes of postoperative hip dislocation. RESULTS: Six hundred seventy-five patients were included in the retrospective review. Thirty-two patients (17 women [aged 37 to 78 years] and 15 men [aged 34 to 80 years]) met the inclusion criteria. Fifteen patients of 32 (48.4%) developed posterior capsule dehiscence after repair (group 1). Seventeen patients of 32 (51.6%) did not have MRI evidence of posterior capsule dehiscence (group 2). In group 1, 2 patients of 15 (13.3%) experienced a posterior hip dislocation. No group 2 patients experienced a posterior hip dislocation. Overall, only 2 patients of 32 (6.3%) developed posterior hip dislocations. In group 1, 12 patients of 15 (80%) developed dehiscence at the lateral capsule margin at the greater trochanter suture repair site. The two patients in group 1 with posterior hip dislocations displayed MRI evidence of capsular dehiscence in this region. Two patients of 15 (13.3%) in group 1 demonstrated dehiscence at the central third of the posterior capsule, whereas 1 patient of 15 (6.6%) in group 1 demonstrated dehiscence at the medial/acetabular margin. No significant difference was found between the dislocation rates between groups 1 and 2 (P = 0.212). The distribution of capsular dehiscence (lateral, middle, and medial capsule) in group 1 was significant (P = 0.0006). DISCUSSION: MRI can effectively diagnose capsular dehiscence in patients who have undergone posterior THA. Most repaired capsules failed in the lateral repair region. MRI offers the potential to identify patients with a higher risk of implant dislocation. LEVEL OF EVIDENCE: Therapeutic level III.

Opioid Disorders Are Associated With Thromboemboli Following Primary Total Knee Arthroplasty.

BACKGROUND: Opioid use disorder (OUD) is defined as a problematic pattern of opioid abuse and dependency leading to problems or distress. The purpose of this study is to investigate whether OUD patients undergoing primary total knee arthroplasty (TKA) have higher rates of venous thromboembolisms (VTEs), readmissions, and costs of care. METHODS: Patients undergoing TKA with OUD were identified and matched to controls in a 1:4 ratio according to age, gender, comorbidity index, and comorbidities within the Medicare database. Ninety-day VTEs, 90-day readmissions, and costs of care were compared. A P-value less than .01 was considered statistically significant. RESULTS: The study yielded 54,480 patients with (n = 10,929) and without (n = 43,551) OUD undergoing primary TKA. Matching was successful as there were no significant differences in baseline characteristics. OUD patients were found to have greater odds of VTEs (odds ratio 2.27, P < .0001) 90 days following primary TKA. OUD patients were found to have greater odds of 90-day readmissions (odds ratio 1.39, P < .0001) in addition to incurring higher day of surgery ($13,360.73 vs $11,911.94, P < .0001) and 90-day costs ($18,380.89 vs $15,565.57, P < .0001) compared to controls. CONCLUSION: After adjusting for confounders, this analysis of 54,480 patients identified that patients with OUD have higher rates of VTEs, readmissions, and costs following primary TKA. In addition to using these data to help educate and counsel patients, the study should be used to help further regulate and control opioid prescriptions written by healthcare professionals.

Prophylactic inferior vena cava filters for operative pelvic fractures: a twelve year experience.

INTRODUCTION: Conflicting evidence exists regarding the role of inferior vena cava filters (IVCFs) in the prevention of pulmonary embolism. The aim of this study was to review an institutional policy of prophylactic IVCF placement in all operative pelvic and acetabular fractures as a means of preventing PE by comparing it to a historical prepolicy period of significantly less aggressive IVCF placement. METHODS: The trauma registry of a single level 1 trauma center was retrospectively queried for all pelvic or acetabular fractures for the prepolicy and intervention periods as defined as January 2003-December 2008 and January 2009-December 2014, respectively-yielding 231 patients for analysis. The primary and secondary outcomes measured were the incidence of PE and deep vein thrombosis. RESULTS: The rate of prophylactic IVCF insertion significantly increased during the study period (p < 0.001). The incidence of pulmonary embolism (1.8% vs. 5.1%, p = 0.351) and DVT (19.3% vs. 10.3%, p = 0.231) were not significantly different when comparing the prepolicy and intervention cohorts. In patients with operative fractures, a nonsignificant trend of increasing incidence of DVTs was appreciated in patients with a prophylactic IVCF versus those without prophylactic IVCF (13 vs. 2, p = 0.222). DISCUSSION: A policy of increased use of prophylactic IVCFs in patients with operative pelvic and acetabular fractures failed to reduce the incidence of PE or DVT. In contrast, several case reports and institutional series have published several risks associated with IVCF placement including failure to retrieve temporary IVCF. CONCLUSION: The benefit of prophylactic IVCF in this patient population is unclear.

Perioperative Complications in Patients with Rheumatoid Arthritis Following Primary Total Knee Arthroplasty: An Analysis of 102,898 Patients.

There are conflicting results regarding the impact of rheumatoid arthritis (RA) on total knee arthroplasty (TKA) outcomes. Therefore, the purpose of this study was to compare outcomes of patients with and without RA undergoing primary TKA. Specifically, we assessed (1) 90-day medical complications, (2) 90-day readmission rates, (3) short-term implant-related complications, (4) 1-year mortality, and (5) total global 90-day episode-of-care costs. The authors of the study hypothesize that RA would increase the rate of medical- and implant-related complications, readmission rates, and costs. A retrospective level of evidence III study was conducted using the Medicare standard analytical files from the PearlDiver database. Patients were queried using the International Classification of Disease, ninth revision codes. Patients with RA were randomly matched 1:1 to controls according to age, gender, and Charlson's comorbidity index. Two mutually exclusive cohorts were formed. Medical- and implant-related complications, readmission rates, and costs were analyzed and compared between the cohorts. Statistical analysis using logistic regression was performed calculating odds ratios (OR), 95% confidence intervals (95% CI), and their respective p-values. The query returned 102,898 patients with (n = 51,449) and without (n = 51,449) RA undergoing primary TKA within the Medicare database from 2005 to 2014. Patients with RA had greater odds of medical complications (OR: 2.08, 95% CI: 1.98-2.20, p < 0.001), implant complications (OR: 1.30, 95% CI: 1.24-1.36, p < 0.001), 1-year mortality (OR: 1.35, 95% CI: 0.68-2.70, p = 0.39), total 90-day episode-of-care costs ($16,605 vs. 15,716.53; p < 0.001), and 90-day readmission rates were similar between cohorts (OR: 1.08, 95% CI: 1.05-1.12, p < 0.001). RA increases postoperative complications and costs following primary TKA within Medicare patients. Comprehensive preoperative optimization for patients with a diagnosis of RA may mitigate perioperative complications, thus improving patient outcomes, and ultimately reducing episode-of-care costs.

Surgical and Medical Costs for Fibromyalgia Patients Undergoing Total Knee Arthroplasty.

The potential added costs of managing fibromyalgia patients after total knee arthroplasty (TKA) have not been assessed. Therefore, the purpose of this study was to perform a cost analysis of fibromyalgia versus nonfibromyalgia patients who underwent TKA. Specifically, we evaluated the following episodes of care: (1) readmission rates, (2) total costs, (3) total reimbursements, and (4) net losses for surgical and medical complications. Patients who underwent TKAs between 2005 and 2014 from the Medicare Standard Analytical Files of the PearlDiver supercomputer were propensity score matched by patients with and without fibromyalgia in a 1:1 ratio based on age, sex, and the Charlson Comorbidity Index, yielding a total of 305,510 patients distributed equally between the cohorts for analysis. Odds ratios (ORs), 95% confidence intervals (CIs), and p-values were calculated. Mean costs, total costs, and total reimbursements were assessed as along with total net losses, which were defined as total costs minus total reimbursements. Fibromyalgia patients had similar 90-day readmission rates compared with nonfibromyalgia patients (OR: 1.03; 95% CI: 1.00-1.06; p = 0.06) but incurred lower readmission costs (US$2,318,384,295 vs. US$2,534,482,404; p < 0.001). Although fibromyalgia patients had higher total reimbursements for medical complications ($27,758,057 vs. US$18,780,610; p < 0.001), the increased management costs (US$106,049,870 vs. US$66,080,469; p < 0.001) led to greater net losses (US$78,291,813 vs. US$47,299,859; p < 0.001). Similarly, although fibromyalgia patients had higher total reimbursements for surgical complications (US$94,192,334 vs. US$73,969,026; p < 0.001), the increased surgical costs (US$382,122,613 vs. US$306,359,910; p < 0.001) led to greater net losses (US$287,930,279 vs. US$232,390,884; p < 0.001). This study highlights some of the potential financial discrepancies of managing patients with fibromyalgia. Our findings suggest medical and surgical complication costs to be greater than reimbursement, resulting in overall net financial losses. These findings need to be considered in the light of health care reform and cost structuring.

Sleep Apnea Increases Ninety-Day Complications and Cost Following Primary Total Joint Arthroplasty.

BACKGROUND: Sleep apnea (SA) negatively affects bone mineralization, cognition, and immunity. There is paucity in the literature regarding the impact of SA on total joint arthroplasty (TJA). The purpose of this study is to compare complications in patients with and without SA undergoing either total knee (TKA) or total hip arthroplasty (THA). METHODS: A retrospective review from 2005 to 2014 was conducted using the Medicare Standard Analytical Files. Patients with and without SA on the day of the primary TJA were queried using the International Classification of Diseases, ninth revision codes. Patients were matched by age, gender, Charlson Comorbidity Index), and body mass index. Patients were followed for 2 years after their surgery. Ninety-day medical complications, complications related to implant, readmission rates, length of stay, and 1-year mortality were quantified and compared. Logistic regression was used to calculate odds ratios (OR) with their respective 95% confidence interval and P values. RESULTS: After the random matching process there were 529,240 patients (female = 271,656, male = 252,106, unknown = 5478) with (TKA = 189,968, THA = 74,652) and without (TKA = 189,968, THA = 74,652) SA who underwent primary TJA between 2005 and 2014. Patients with SA had greater odds of developing medical complications following TKA (OR 3.71) or THA (OR 2.48). CONCLUSION: The study illustrates an increased risk of developing postoperative complications in patients with SA following primary TJA. Surgeons should educate patients on these adverse effects and encourage the use of continuous positive airway pressure which has been shown to mitigate many postoperative complications.

Significance of incidental intra-articular and peri-articular FDG avid foci on PET/CT.

BACKGROUND: Positron emission tomography/computed tomography (PET/CT) is a useful imaging adjunct in patients with sarcoma. Intra-articular and peri-articular 18F-fluoro-2-deoxy-D-glucose (FDG) avid lesions are often discovered incidentally. PURPOSE: To describe the etiology, appearance, and standardized uptake values (SUV) of incidentally detected FDG avid intra-articular and peri-articular foci in patients with sarcoma. MATERIAL AND METHODS: The institutional sarcoma database between November 2011 and November 2016 was retrospectively reviewed. Patients were included if a PET/CT scan was performed and an FDG avid intra-articular or peri-articular focus was found that was distinct from the primary sarcoma. RESULTS: The majority of FDG avid foci represented benign, non-physiologic conditions such as osteoarthritis, enthesopathy, bursitis, and post-surgical changes. Six patients each had radiographic features consistent with tenosynovial giant cell tumor (TSGCT) and metastatic disease, respectively. Lower SUV, bilateral findings, and the absence of metastatic disease elsewhere were associated with benign etiologies. There was a statistically significant difference between the mean SUV measured in patients with TSGCT and those with benign, non-physiologic conditions ( P < 0.001). The difference between the benign, non-physiologic cohort and the cohort with widespread metastatic disease did not reach statistical significance ( P = 0.07). CONCLUSIONS: In patients with soft-tissue or osseous sarcomas, isolated FDG avid intra-articular or peri-articular foci without additional metastatic lesions likely represent benign processes. Isolated intra-articular or peri-articular foci with significantly elevated SUV measurements were favored to represent TSGCT in this series.

The effect of surgically implanted metallic bullet fragments on the intervertebral disc using a canine model☆.

PURPOSE: To characterize the gross, histologic, and systemic changes caused by implantation of metal fragments commonly used in commercial bullets into the intervertebral disc. BACKGROUND CONTEXT: Long-term complications of retained bullet fragments in the spine have been documented in the literature; however, the impact of different metal projectiles on the intervertebral disc has not been described. This study was performed to assess the local effects of the metallic bullet fragments on the intervertebral disc and their systemic effects regarding metal ion concentrations in serum and solid organs. STUDY DESIGN: Animal Model Study. METHODS: Funding for this project was provided by the Cervical Spine Research Society in the amount of $10,000. Copper, lead, and aluminum alloys from commercially available bullets were surgically implanted into sequential intervertebral discs in the lumbar spine of six canines. Kirschner wire implantation and a sham operation were performed as controls. Radiographs were performed to confirm the location of the bullets. Animals were sacrificed at 4, 6, and 9 months postimplantation. Whole blood, plasma, cerebrospinal fluid, kidney tissue, and liver tissue samples were analyzed for copper and lead concentrations. Histologic and gross samples were examined at the time of sacrifice. RESULTS: Significant tissue reactions were noted in the discs exposed to copper and lead. Copper resulted in significantly more severe disc degeneration than either the lead or aluminum alloy. In the short interval follow-up of this study, no statistically significant trend was observed in whole blood, plasma, cerebrospinal fluid, and tissue levels. CONCLUSION: This study demonstrates that the canine intervertebral disc is differentially susceptible to metallic fragments depending on the composition. Trends were noted for increasing levels of lead and copper in liver tissue samples although statistical significance could not be reached due to short time interval and small sample size. The metallic composition of retained fragments can be a determining factor in deciding on surgical intervention.