Outcomes of Total Knee and Hip Arthroplasty in Patients With Perioperative Thrombocytopenia.

BACKGROUND: Thrombocytopenia is an abnormally low level of blood platelets (less than 150,000/mL) resulting in an increased risk for bleeding. Typically, patients with platelet levels below 50,000/mL should delay arthroplasty or be transfused with platelets before surgery. However, existing studies are mixed regarding the effects of more moderate thrombocytopenia in terms of total knee and hip arthroplasty outcomes. METHODS: This level III retrospective chart review examined the effects of different severities of preoperative thrombocytopenia on length of hospitalization, readmission, and transfusion rates in 5,617 primary total knee and hip arthroplasties at one tertiary academic medical center. Preoperative platelet levels were sectioned into clinically relevant groups and compared with clinical outcomes using univariable and multivariable models. RESULTS: On univariate analysis, having platelet levels of <100,000/mL and 100 to 149,000/mL was associated with a longer length of stay. However, after controlling individual demographics, there was no association between platelet levels and length of stay, nor with 30-day readmission. Finally, on univariate analysis, patients with platelet levels of <100,000/mL and 100 to 149,000/mL were more likely to have a blood transfusion, which remained true for those with <100,000/mL after controlling for individual demographics. CONCLUSIONS: Total hip and total knee arthroplasty are safe in patients with varying platelet levels and not associated with increased length of stay or 30-day readmission. However, patients with more severe thrombocytopenia are more likely to receive red blood cell transfusions than patients with milder thrombocytopenia.

Neuropathic (Charcot) Arthropathy of the Knee.

Neuropathic arthropathy of the knee (Charcot knee) is a rare pathology defined by progressive destruction of bone and soft tissue in a patient with underlying peripheral neuropathy. Historically, Charcot knee was associated with neurosyphilis, but it has been increasingly described as a late stage of diabetes. The pathophysiology of the disease is not completely understood, but theories include repetitive microtrauma and an abnormal neurovascular response. Patients present with a warm, swollen, and unstable joint and have rapid bone resorption and characteristic findings on pathology. Nonsurgical options for pain and dysfunction include total contact casting and bracing treatment. Pharmacologic management includes diphosphonates, although this use is considered off-label. Surgical management historically included knee fusion. However, recent case series have suggested that newer prostheses allow for successful arthroplasty in this cohort, although complications are higher when compared with joint arthroplasty in patients with normal neurologic function.

What is the Level of Evidence Substantiating Commercial Payers' Coverage Policies for Total Joint Arthroplasty?

BACKGROUND: The prevalence of total joint arthroplasty (TJA) in the United States has drawn the attention of health care stakeholders. The payers have also used a variety of strategies to regulate the medical necessity of these procedures. The purpose of this study was to examine the level of evidence of the coverage policies being used by commercial payers in the United States. METHODS: The references of the coverage policies of four commercial insurance companies were reviewed for type of document, level of evidence, applicability to a TJA population, and success of nonoperative treatment in patients with severe degenerative joint disease. RESULTS: 282 documents were reviewed. 45.8% were primary journal articles, 14.2% were level I or II, 41.2% were applicable to patients who were candidates for TJA, and 9.9% discussed the success of nonoperative treatment in patients who would be candidates for TJA. CONCLUSION: Most of the references cited by commercial payers are of a lower level of scientific evidence and not applicable to patients considered to be candidates for TJA. This is relatively uniform across the reviewed payers. The dearth of high-quality literature cited by commercial payers reflects the lack of evidence and difficulty in conducting high level studies on the outcomes of nonoperative versus operative treatment for patients with severe, symptomatic osteoarthritis. Patients, surgeons, and payers would all benefit from such studies and we encourage professional societies to strive toward that end through multicenter collaboration.

Management of Periprosthetic Hip and Knee Joint Infections With a Known Sinus Tract-A Single-Center Experience.

BACKGROUND: Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty (TJA). A sinus tract communicating with a prosthetic joint is a major criterion defining PJI. Despite this fact, many patients presenting with a draining sinus tract undergo invasive procedures before initiation of two-stage revision arthroplasty. We hypothesized that many patients undergo nondefinitive procedures to treat the sinus tract, rather than undergoing definitive treatment of infection with two-stage revision. METHODS: A retrospective review of all cases of two-stage revision arthroplasty at Loyola University Medical Center between January 2004 and May 2018 was performed. Patients with infected TJA and periprosthetic sinus tract were included. Records were queried for laboratory values and prior procedures. RESULTS: We identified 160 patients who underwent two-stage revision for infection over the 14-year period. Of the 160 patients, 25 had a documented periprosthetic sinus tract before initiation of definitive revision arthroplasty and were included. Eleven (44.0%) had one or more procedures including interventional radiology drain placement, local wound care, or formal irrigation and debridement before definitive treatment. Forty-five percent of patients that underwent nondefinitive procedures before definitive surgery had either an erythrocyte sedimentation rate or C-reactive protein at normal or near-normal levels. CONCLUSION: Many arthroplasty patients presenting with periprosthetic sinus tracts undergo nondefinitive procedures before definitive treatment. Inherent surgical risks of these procedures can increase the overall morbidity and mortality of these patients. Further effort is needed to educate surgeons regarding management of sinus tracts after TJA.

Minimum twelve-year follow-up of fixed- vs mobile-bearing total knee arthroplasty: Double blinded randomized trial.

BACKGROUND: Total knee arthroplasty (TKA) with fixed-bearing (FB) implants have demonstrated impressive functional results and survival rates. Meanwhile, rotating-platform (RP) constructs have biomechanically shown to reduce polyethylene wear, lower the risk of component loosening, and better replicate anatomic knee motion. There is growing question of the clinical impact these design changes have long-term.Questions/purposes: The aim of this double-blinded prospective randomized trial was to compare function and implant survival in patients who received either FB or RP press-fit condylar Sigma (PFC Sigma, DePuy, Warsaw, IN) total knee replacements at a minimum follow-up of twelve years. PATIENTS AND METHODS: Patient reported outcome measures used included the functional Knee Society Score, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) scores, Medical Outcomes Short Form-36 (SF-36) score, and satisfaction assessment on a four-point Likert scale. The data was collected from times preoperative, two-years, and final encounter (mean 13.95 years). A total of 28 RP and 19 FB knees (58.8%) were analyzed at the final follow-up. RESULTS: Among all patients, KSS and WOMAC scores statistically improved from pre-op to 2-year, while KSS statistically worsened from 2-year to final follow-up. The RP group averaged better follow-up scores in all assessments at the final follow-up with exception of overall satisfaction. There was no statistically significant difference in the functional Knee Society Score, Short Form-36, WOMAC scores, patient satisfaction or implant survival between the two groups at any measured period. CONCLUSIONS: The use of a fixed-bearing or rotating-platform design does not convey significant superiority in terms of function or implant longevity at a minimum twelve years after total knee arthroplasty. LEVEL OF EVIDENCE: Level I, Experimental study, randomized controlled trial (RCT).

Management of Osteoarthritis of the Hip.

The American Academy of Orthopaedic Surgeons, in collaboration with the American Association of Hip and Knee Surgeons, the Hip Society, the American College of Radiology, the American Physical Therapy Association, the Limb-lengthening and Reconstruction Society, and the Pediatric Orthopaedic Society of North America, released Management of Osteoarthritis of the Hip: Evidence-Based Clinical Practice Guideline. The complete guideline is available on OrthoGuidelines (www.orthoguidelines.org). The guideline is intended to assist those taking care of patients with osteoarthritis of the hip in making decisions regarding the most appropriate treatment. A group of experts with knowledge of orthopaedic surgery, physical therapy, and musculoskeletal radiology developed 18 recommendations for nonoperative and operative treatment based on relevant literature. A companion article illustrates the use of these guidelines by discussing specific case examples and evidence-based treatments for osteoarthritis of the hip.

Characterization of Outcomes of 2-Stage Exchange Arthroplasty in the Treatment of Prosthetic Joint Infections.

BACKGROUND: Two-stage revision is the preferred treatment for prosthetic hip and knee infections in the United States. Recent studies have questioned the true success rate of this treatment. The purpose of this study is to investigate outcomes of prosthetic hip and knee infections undergoing resection arthroplasty and spacer insertion at a single institution. METHODS: We identified 103 patients who underwent prosthesis resection and spacer placement for infection over a 10-year period. Twenty-three cases were excluded based on preset exclusion criteria leaving 80 cases (56 knees, 24 hips). A retrospective review was performed to examine the outcomes of these patients. RESULTS: Following spacer placement but before reimplantation, 9 (11.25%) of the 80 joints underwent repeat debridement and spacer exchange for persistent infection. Twenty-four (30.00%) patients had a serious complication during their treatment course. Fourteen (17.50%) patients never underwent reimplantation. Of these, 10 continued with spacer retention, 2 had resection arthroplasty, and 1 each had an amputation and an arthrodesis. Of the 66 patients with successful reimplantation, 48 (72.70%) remained infection free at most recent follow-up. CONCLUSIONS: Two-stage revision does not result in the high rates of cure reported previously, when taking into account the substantial number of patients who never undergo the subsequent reimplantation surgery. Of those who underwent reimplantation in our study, many required additional spacer exchange or had complications. Surgeons and patients should consider these outcomes when discussing the treatment of prosthetic hip and knee infections.

Use of a Tourniquet in Total Knee Arthroplasty Causes a Paradoxical Increase in Total Blood Loss.

BACKGROUND: A tourniquet in total knee arthroplasty has been used in an attempt to decrease perioperative blood loss; however, questions exist regarding safety and efficacy. Tranexamic acid has also been used to decrease blood loss by stabilizing clot formation. Because of these concerns, routine tourniquet use for total knee arthroplasty was discontinued by the senior author and routine tranexamic acid administration was commenced. The purpose of this study was to examine total perioperative blood loss with tourniquet use, with tourniquet use and routine use of tranexamic acid, and with tranexamic acid use alone without tourniquet. METHODS: A retrospective cohort study of 132 patients in 3 groups was performed. The first group underwent total knee arthroplasty with limited tourniquet use only during cementing, the second group had the same protocol but with tranexamic acid administered, and the third group had tranexamic acid but no tourniquet used. Perioperative blood loss was calculated using the Gross formula. RESULTS: The mean calculated blood loss was highest in the tourniquet-only group at 1,591.39 mL (95% confidence interval [CI], 1,064.97 to 2,117.81 mL), decreased in the second group using tranexamic acid and tourniquet at 1,215.34 mL (95% CI, 1,104.93 to 1,325.75 mL), and was lowest in the third group with tranexamic acid and no tourniquet at 1,007.22 mL (95% CI, 878.78 to 1,135.66 mL). CONCLUSIONS: Use of a limited tourniquet protocol during total knee arthroplasty resulted in a paradoxical increase in blood loss. Surgeons should consider omitting routine tourniquet use in total knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of metabolic syndrome in patients undergoing total joint arthroplasty and relevance of biomarkers.

BACKGROUND: Metabolic syndrome (MetS) is a collection of clinical conditions, including central obesity, hypertension, glucose intolerance and dyslipidemia. The long-term inflammatory and metabolic dysfunction associated with MetS may contribute to osteoarthritic processes leading up to total joint arthroplasty (TJA). The purpose of this study was to investigate levels of metabolic biomarkers and the prevalence of MetS in patients undergoing TJA. METHODS: Under IRB approval, citrated plasma samples were collected from 41 patients undergoing total hip and knee arthroplasty (THA/TKA) preoperatively and day 1 postoperatively. Control group consisted of 25 healthy human plasma samples (female and male, 18-35 years old) purchased from George King Biomedical Inc. (Overland Park, KS, USA). Samples were profiled for c-peptide, ferritin, IL-6, insulin, resistin, TNF-α, IL-1a, leptin, and PAI-1 using metabolic biochips purchased from RANDOX Co. (Antrim, Northern Ireland). NCEP/ATP III guidelines were used to evaluate which patients met MetS criteria. RESULTS: Levels of IL-6, resistin, TNF-a, IL-1a, leptin, and PAI-1 were significantly elevated in patients undergoing TJA compared to normal. C-peptide and insulin were both decreased in TJA compared to normal. No significance was found when comparing TJA to normal for ferritin. TNFα was significantly lower in TJA+MetS compared to TJA-MetS, while other biomarkers showed no difference in TJA±MetS populations. Insulin & c-peptide both showed a significant decrease in TJA-MetS compared to normal, but levels in TJA+MetS patients were not significantly different from controls. Resistin showed significant increases in TJA+MetS vs. normal, but not in TJA-MetS vs. normal. CONCLUSIONS: Overall, the differing metabolic profile seen in patients undergoing TJA suggest ongoing metabolic dysfunction. Insulin and c-peptide patterns among the different test groups hint toward a complex and dysfunctional metabolic process involved, with leptin and underlying insulin resistance playing a role. Increased resistin in TJA+MetS, but not in TJA-MetS, compared to normal, suggests that while elevated resistin levels may be associated with the osteoarthritic process, levels are further attenuated by MetS, which is highly prevalent in this population. Increased TNFα in TJA-MetS compared to TJA+MetS may be an artifact of differing sample populations or a true complication of the complex pathophysiology and medical regimen seen in patients with both OA and MetS. The lack of difference seen in the remaining biomarkers suggest that having MetS as a comorbidity does not contribute to the elevated levels seen in patients undergoing TJA.

Wound Hygiene Practices After Total Knee Arthroplasty: Does It Matter?

BACKGROUND: Current literature is limited with regard to standardized postoperative surgical site hygiene after total knee arthroplasty (TKA). With little guidance from the literature, the timing of permissible postoperative cleaning is a decision made by the individual surgeon using anecdotal evidence. A standardized wound care regimen is of particular interest to minimize the risk of infection. METHODS: To examine what species of bacteria recolonize the surgical site postoperatively, a randomized controlled trial was performed of 16 TKA patients who were allowed to shower at 2 days postoperatively and of 16 patients who were asked to wait until 2 weeks postoperatively before showering after TKA. Culture swabs of skin adjacent to the incision were performed preoperatively, just after incision closure, at dressing removal, and at 2 weeks postoperatively. Bacteria were speciated and compared between groups. A swab of the contralateral knee was performed at 2 weeks as a control. A survey of patient's preference regarding early and late showering was also carried out. RESULTS: No difference was found between the groups in rate of colonization or bacterial type, and no patients developed infection. Patients overwhelmingly preferred early showering rather than late (P = .28-.99). CONCLUSION: There is no difference in surgical site bacterial recolonization between early and delayed showering after primary TKA.

Levels of Matrix Metalloproteinases in Arthroplasty Patients and Their Correlation With Inflammatory and Thrombotic Activation Processes.

An imbalance of matrix metalloproteinases (MMPs) and their inhibitors is thought to play a major role in the pathophysiology of joint diseases. The aim of this study is to provide additional insights into the relevance of MMP levels in arthroplasty patients in relation to inflammation and thrombosis. Deidentified plasma samples from 100 patients undergoing total hip arthroplasty or total knee arthroplasty were collected preoperatively, on postoperative day 1, and on postoperative day 3. Tissue inhibitor of MMP 4, tumor necrosis factor α (TNF-α), pro-MMP1, MMP3, MMP9, MMP13, and d-dimer were measured using enzyme-linked immunosorbent assay kits. A biochip array was used to profile interleukin (IL) 2, IL-4, IL-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), interferon gamma, TNF-α, IL-1α, IL-1ß, monocyte chemoattractant protein 1, and endothelial growth factor (EGF) levels. The levels of MMP1, MMP9, MMP13, and TNF-α were elevated preoperatively in arthroplasty patients when compared to healthy individuals. The concentrations of MMP1 and MMP9 increased slightly in postsurgical samples. d-Dimer levels were elevated preoperatively, increased postoperatively, and started decreasing on postoperative day 3. Significant correlations between MMP9 with TNF-α, IL-6, IL-8, VEGF, and EGF were identified. Elevated preoperative MMP1, MMP9, and MMP13 concentrations suggest that they may play a role in the pathogenesis of arthritis. There is also evidence of increased coagulation activity and possible upregulation of several MMPs postsurgically. Correlation analysis indicates that MMP9 levels may potentially be related to inflammation and thrombosis in arthroplasty patients.

Total Knee Arthroplasty in Patients with Blount Disease or Blount-Like Deformity.

Blount disease is associated with complex deformity of the proximal tibia, and some patients will develop knee osteoarthritis. Five patients (eight knees) with Blount disease or Blount-like deformity underwent total knee arthroplasty. Mean proximal tibial metaphyseal-diaphyseal angle was 20.75°. Each patient had substantial posteromedial tibial bony defects and six knees required extensive medial releases. Two knees required increased constraint at index procedure. One patient has undergone bilateral revision surgery with rotating hinge prostheses. Mean WOMAC scores were 13.5 and Knee Society scores were 212.5 at average 75.2 month follow-up. Despite technical challenges, patients with these deformities can have successful outcomes after total knee arthroplasty. Surgeons should be prepared to address posteromedial tibial bony defects and consider constrained arthroplasty at the index procedure.

Perioperative Factors and Their Effect on the Fibrinolytic System in Arthroplasty Patients.

BACKGROUND: Total joint arthroplasty (TJA) patients are mostly of advanced age and with comorbidities such as increased body mass index (BMI) and impaired glucose tolerance. These factors and type of surgery may affect the fibrinolytic system. AIM: To investigate the effect of age, sex, BMI, type of surgery, and tranexamic acid (TXA) treatment on the fibrinolytic system in TJA patients. METHODS: Ninety-nine patients undergoing TJA (32 total hip arthroplasty [THA] and 67 total knee arthroplasty [TKA]) were included in this study. Blood samples were drawn at preoperative clinic appointments and on postoperative day 1. Antigenic levels of d-dimer, plasminogen activator inhibitor 1 (PAI-1), and tissue plasminogen activator (tPA) were measured using a commercially available enzyme-linked immunosorbent assay kit. Antiplasmin activity was measured using functional method. Age, gender, hemoglobin (Hb) levels, and BMI were collected from the records. RESULTS: Preoperative d-dimer and tPA levels were positively correlated with age, whereas preoperative antiplasmin was negatively correlated with age. Body mass index was only associated with preoperative tPA levels. There was no significant difference in postoperative levels of d-dimer, PAI-1, tPA, or antiplasmin between patients treated with TXA or without TXA. Percentage change in d-dimer and tPA showed significantly lower values in patients treated with TXA compared to the nontreated group. Type of surgery did not affect the fibrinolytic markers. CONCLUSION: These results confirm that advanced age and elevated BMI positively contribute to fibrinolytic dysregulation in TJA patients, whereas TXA seems to decrease the fibrinolytic activity.

Fibrinolytic Dysregulation in Total Joint Arthroplasty Patients: Potential Clinical Implications.

BACKGROUND: The alterations of the fibrinolytic components in osteoarthritic joint disease and their postsurgical modulation are not clearly understood. Preexisting hemostatic dysfunction may lead to both thrombotic and bleeding events in these patients. AIM: To profile fibrinolytic parameters in patients undergoing total joint arthroplasty prior to and on postoperative day 1. METHODS: A total of 98 total joint arthroplasty patients were included in this study. Blood samples were drawn preoperatively and on postoperative day 1 status posttotal knee or total hip arthroplasty surgery. d-Dimer, plasminogen activator inhibitor 1 (PAI-1), and tissue plasminogen activator (tPA) were measured using commercially available enzyme-linked immunosorbent assay kits. Antiplasmin activity was measured by using a functional method. RESULTS: Preoperative PAI-1, d-dimer, and tPA levels were significantly higher in arthroplasty patients compared to healthy controls. Preoperative antiplasmin level was lower than controls. Postoperative levels of PAI-1 and d-dimer were increased compared to preoperative values. Postoperative antiplasmin values were lower than preoperative levels. Changes in tPA was not significant. There was no correlation between preoperative PAI-1 and d-dimer levels. Pre- and postoperative percentage changes in each individual were calculated for PAI-1, d-dimer, tPA, and antiplasmin. There was a positive correlation between d-dimer and PAI-1. Negative correlations between antiplasmin and d-dimer and between antiplasmin and PAI-1 were noted. CONCLUSION: These results confirm the perturbation in the fibrinolytic system of patients undergoing total joint arthroplasty surgery. Surgical intervention may also enhance the observed changes. The alterations in the fibrinolytic system may lead to the observed hemostatic complications such as bleeding, hematoma formation, or potential need for blood transfusion.

Revision total hip arthroplasty without bone graft of high-grade acetabular defects.

Mixed results have been reported with bulk and cancellous bone graft to fill defects during acetabular revision arthroplasty. Jumbo cups have been used to maximize host bone contact, and if adequate initial stability can be achieved, this approach may provide a superior long-term outcome. We retrospectively reviewed a consecutive series of 107 acetabular revisions performed using jumbo cups without bone graft. Bone defects were assessed using a validated radiographic classification system that yielded 64 hips with significant bone defects for inclusion. Mean change in American Academy of Orthopaedic Surgeons lower extremity core and pain scores and in Short Form-12 scores showed increases of 22.01, 37.52, and 17.08 points, respectively. Postoperative radiographs consistently demonstrated host bone ingrowth into the jumbo acetabular shells, except for 3 failures. Careful incremental reaming up to a size that optimizes host bone support and contact may eliminate the need for bone graft in most acetabular revision arthroplasties.