Major complications after total hip arthroplasty with the direct anterior approach at a high-volume Ontario tertiary care centre.

BACKGROUND: The rate of major surgical complications for high-volume orthopedic surgeons using the direct anterior approach (DAA) in Ontario, Canada, is not known. The purpose of this study was to investigate the rate of major surgical complications after total hip arthroplasty (THA) using DAA performed by experienced orthopedic surgeons at a high-volume tertiary care centre in Ontario. METHODS: We conducted a retrospective cohort review of primary THA through DAA performed by 2 experienced fellowship-trained surgeons at an academic hospital in London, Ontario, between Jan. 1, 2012, and May 1, 2019. We excluded the first 100 cases to allow for surgeon learning curves. We recorded major surgical complications (intraoperative events, postoperative periprosthetic fractures, dislocation requiring closed or open reduction, implant failure [aseptic loosening or subsidence], early (< 6 wk) deep wound infection requiring irrigation and débridement, late (≥ 6 wk) deep wound infection requiring irrigation and débridement, and wound complications [wound dehiscence, stitch abscess, erythema, hematoma or seroma]) within 1 year of THA. RESULTS: A total of 875 primary DAA THA procedures were included. The rates of surgical complications were 0.9% for intraoperative events, 1.5% for postoperative periprosthetic fractures, 0.8% for implant failure, 0.7% for early deep wound infection, 0.1% for late deep wound infection and 3.2% for wound complications; there were no cases of dislocation. The rate of revision for implant failure within 1 year was 0.1%. Male sex was associated with a greater risk of implant failure (p = 0.01), and having a higher body mass index was associated with both increased rates of infection (p < 0.01) and having a wound complication (p < 0.01). CONCLUSION: Intraoperative events, postoperative periprosthetic fractures, implant failure, deep wound infection and wound complications accounted for the major surgical complications within 1 year of THA through DAA. The low revision rate suggests that DAA is a safe approach for THA.

The value of corneoscleral rim cultures in keratoplasty: a systematic review and cost-effectiveness analysis.

PURPOSE: This study evaluated the performance of donor corneoscleral rim cultures for predicting infection after corneal transplantation, and determines if there is a correlation between positive corneoscleral rim cultures and postkeratoplasty infection. DESIGN AND DATA SOURCES: This was a systematic review, prognostic accuracy analysis, and cost-effectiveness analysis. Databases searched were: Medline (Ovid), Embase (Ovid), CINAHL, Cochrane Library, Web of Science, and BioSis Previews. Grey literature was also explored. MATERIALS AND METHODS: A systematic review was conducted to locate published and unpublished studies. All studies examining corneal button contamination and its association with endophthalmitis and keratitis posttransplantation were included. Extracted data were used to calculate sensitivity, specificity, positive predictive value, and negative predictive value. Cost data from the London Laboratory Services Group in London, ON were used to calculate the cost-effectiveness of culturing donor rim cultures. RESULTS: Of 7,870 grafts, 954 had a positive rim culture (12.1%), with 12 patients going on to develop keratitis or endophthalmitis (1.3%). The prevalence of keratitis and endophthalmitis in this study was 0.15%, and the positive predictive value 1.5%. Of the 12 infections, nine were fungal and three bacterial. The estimated cost of a positive and negative test result was CAD$45.99 and $14.15, respectively. The cost to run all 7,870 tests was estimated to be $141,735.86, with an incremental cost-effectiveness ratio of $40,215.70. CONCLUSION: There was a significant divergence between bacterial and fungal rim-culture results. Bacterial cultures predicted clinical infection poorly, did not change management, and were expensive. Fungal cultures predicted clinical infection in over 10% of patients, had the potential to change management, and were 40% less expensive than full rim culturing (bacterial and fungal tests). Fungal rim cultures may be considered in areas where fungal infection rates are high.