Outcomes of Unicompartmental Knee Arthroplasty in Patients Receiving Long-Term Anticoagulation Therapy: A Propensity-Matched Cohort Study.

BACKGROUND: Although total knee arthroplasty has been considered the gold-standard treatment for severe osteoarthritis of the knee, unicompartmental knee arthroplasty (UKA) has become an increasingly favorable alternative for single-compartment osteoarthritis of the knee. Few studies have examined potential high-risk populations undergoing this procedure. The purpose of this study was to investigate the outcomes of UKA in patients receiving long-term anticoagulation therapy. METHODS: In this study, a large administrative database was queried to identify patients undergoing UKA between 2009 and 2019, who were then divided into a cohort receiving long-term anticoagulation and a control cohort. Propensity scores were utilized to match these patients. Multivariable logistic regression was utilized to compare 90-day and 2-year complication rates between cohorts. RESULTS: Patients who were on long-term anticoagulation had significantly increased odds of extended length of stay, surgical site infection, wound complication, transfusion, deep vein thrombosis, pulmonary embolism, and readmission at 90-day follow-up. The long-term anticoagulation cohort also experienced significantly higher odds of periprosthetic joint infection and mechanical complications at 2-year follow-up; however, odds of conversion to total knee arthroplasty were not increased. CONCLUSIONS: This study demonstrated that long-term anticoagulation use was associated with poorer medical and surgical outcomes at both 90 days and 2 years postoperatively in patients undergoing UKA, even after rigorous adjustment for confounders.

Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty.

BACKGROUND: Prior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis. METHODS: In total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA. RESULTS: Rates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71). CONCLUSIONS: All patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA. LEVEL OF EVIDENCE: III, Retrospective review.

Trends in Costs and Professional Reimbursements for Revision Total Hip and Knee Arthroplasty.

BACKGROUND: With increasing numbers of revision total hip and total knee arthroplasties (rTHAs and rTKAs), understanding trends in related out-of-pocket (OOP) costs, overall costs, and provider reimbursements is critical to improve patient access to care. METHODS: A large database was used to identify 92,116 patients who underwent rTHA or rTKA between 2009 and 2018. The OOP costs associated with the surgery and related inpatient care were calculated as the sum of copayment, coinsurance, and deductible payments. Professional reimbursement was calculated as total payments to the principal physician. All monetary data were adjusted to 2018 dollars. Multivariate regressions evaluated the associations between costs and procedure type, insurance type, and region of service. RESULTS: From 2009 to 2018, overall costs for rTHA significantly increased by 35.0% and overall costs for rTKA significantly increased by 32.3%. The OOP costs for rTHA had no significant changes, while OOP costs for rTKA increased by 20.1%, with patients on Medicare plans having the lowest OOP costs. Professional reimbursements, when measured as a percentage of overall costs, decreased significantly by 4.4% for rTHA and 4.0% for rTKA, with the lowest reimbursements from Medicare plans. CONCLUSION: From 2009 to 2018, total costs related to rTHA and rTKA significantly increased. The OOP costs significantly increased for rTKA, and professional reimbursements for both rTHA and rTKA decreased relative to total costs. Overall, these trends may combine to create greater financial burden to patients and the healthcare system, as well as further limit patients' access to revision arthroplasty care.

Complications Rates Among Revision Total Knee Arthroplasty Patients Diagnosed With COVID-19 Postoperatively.

BACKGROUND: The COVID-19 pandemic introduced a new set of challenges for the arthroplasty community, including the management of patients diagnosed with COVID-19 following revision total knee arthroplasty (rTKA) and its potential impact on postoperative recovery. This study sought to characterize the risks of postoperative COVID-19 infection among rTKA patients. METHODS: A large national database was utilized to query 8,022 total patients who underwent rTKA between 2018 and 2021, of which 60 had a COVID diagnosis within 90 days after surgery (rTKA/COVID positive). These patients were 1:10 propensity-score matched to 600 rTKA patients who did not have a 90-day postoperative COVID diagnosis (rTKA/COVID negative) and 600 COVID positive patients who did not undergo rTKA. Controlling for potential confounders, multivariate logistic regressions were utilized to compare 90-day postoperative complications between groups. RESULTS: Compared to rTKA/COVID negativepatients, the rTKA/COVID positive cohort had significantly higher rates of pneumonia (odds ratio [OR] = 6.1, P < .001), pulmonary embolism (PE) (OR = 32.4, P < .001), deep venous thrombosis (DVT) (OR = 32.4, P < .001), and 90-day readmissions (OR = 2.1, P = .02). Similarly, the rTKA/COVID positive cohort had significantly higher rates of pneumonia (OR = 4.3, P = .001), PE (OR = 36.8, P < .001), and DVT (OR = 36.8, P < .001) compared to COVID positive patients who did not undergo rTKA. CONCLUSIONS: Revision total knee arthroplasty patients diagnosed with COVID-19 postoperatively had increased rates of thromboembolic events, pneumoniae, and 90-day readmissions. Risk mitigation efforts would suggest extending the prophylactic anticoagulation period for rTKA patients diagnosed with postoperative COVID-19.

Periprosthetic Joint Infection Risk After Primary Total Knee Arthroplasty: Are All Preoperative Corticosteroid Injections the Same?

BACKGROUND: Previous evidence has demonstrated an increased risk of periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) in patients receiving corticosteroid injection (CSI) within 3 months of surgery. The study aimed to determine if PJI risk after TKA varied among different corticosteroid agents. METHODS: A total of 85,073 patients undergoing primary TKA from 2009 to 2019 were identified from a large national database. Of these, 1,092 (1.3%) received an ipsilateral, intra-articular CSI within 90 days of TKA. These patients were compared to those not receiving CSI using multivariate logistic regressions following 1:4 propensity score matching, with PJI development as the primary outcome. RESULTS: Patients given an injection of any corticosteroid within 90 days of TKA had significantly higher PJI rates compared to controls (1.6 versus 0.41%; P < .001). This finding was driven by patients receiving methylprednisolone acetate (n = 543) or betamethasone (n = 153), with prevalence rates of 1.7 and 2.6%, respectively (P = .003 and P = .01, respectively). No significant increase in the rate of PJI was observed for patients receiving triamcinolone (1.2%; P = .08; n = 342) or dexamethasone (0.0%; P = 1; n = 54) within 90 days preceding TKA. PJI risk for all agents, administered more than 90 days preoperatively normalized to control levels (0.51 versus 0.34%). CONCLUSIONS: These results suggest that PJI risk varies with CSI type. In this large database study, only patients given methylprednisolone acetate or betamethasone injections within 90 days of surgery had significantly higher PJI rates compared to controls.

Distal Femoral Replacement versus Operative Fixation for Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis.

BACKGROUND: Open reduction and internal fixation (ORIF) and distal femoral replacement (DFR) have been utilized in the management of periprosthetic distal femur fractures. At present, much of the literature has been limited to small retrospective series. The purpose of the current investigation was to present the results of pooled data to determine the complication rates associated with ORIF and DFR. METHODS: Publications from 2010 to 2020 describing 10 or more periprosthetic distal femur fractures treated with ORIF (ie, single plate, intramedullary nail, and dual fixation) or DFR were included, resulting in 32 publications and 1,258 fractures (977 ORIF and 281 DFR). Occurrence of surgical complications, reoperations, and medical complications were evaluated and compared. RESULTS: The rate of surgical complications (ORIF versus DFR, 20.5 versus 14.9%, P = 1.0) and reoperations (12.9 versus 12.5%, P = 1.0) following DFR were similar. However, pooled analyses demonstrated that patients treated with DFR had a higher medical complication rate (ORIF versus DFR, 8.5 versus 23.1%, P = .0006). CONCLUSION: ORIF and DFR for the treatment of periprosthetic distal femur fractures have similar surgical complication and reoperation profiles. While this review found an increased rate of medical complication following DFR, there are limitations in quality reporting in the literature, which should be considered when interpreting the study's findings. Failed ORIF can be salvaged with DFR, but the difficulty of this reoperation is dependent on the ORIF technique that was used. With future prospective studies, this review can help guide management of these fractures.

Hepatitis C Is Associated With Higher Short-Term Complication Rates After Initial Aseptic and Septic Revision Total Hip Arthroplasty: A Matched Cohort Study.

BACKGROUND: It is unclear if hepatitis C virus (HCV) negatively impacts outcomes of revision total hip arthroplasty (rTHA). The purpose of this study is to trend recent rTHA utilization in patients who have HCV and compare postoperative complication rates versus a matched cohort. METHODS: All patients who underwent rTHA were retrospectively identified in a national database. Patients who had HCV (n = 1,746) were matched 1:3 with a matching group (n = 5,238) for age, gender, and several comorbidities. Cochran-Armitage tests were used to analyze trends in the annual proportion of rTHA performed in patients who had HCV from 2010 to 2019. Rates of 90-day medical and prosthesis-related complications within 2 years postoperatively were compared with multivariable logistic regressions. RESULTS: The annual proportion of rTHA performed in patients who had HCV significantly increased from 2010 to 2019 (P < .001). Patients who had HCV exhibited significantly higher rates of acute kidney injuries (7.6% versus 4.4%; odds ratio [OR] 1.50), transfusions (20.6% versus 14.6%; OR 1.38), and re-revisions for prosthetic joint infection (10.9% versus 6.5%; OR 1.73). In subgroup analyses, rates of re-revision for prosthetic joint infection after initial aseptic rTHA (7.1% versus 3.8%; OR 1.82) and periprosthetic fracture after initial septic rTHA (4.5% versus 1.6%; OR 2.77) were significantly higher in the HCV cohort. CONCLUSION: Similar to primary THA, patients who have HCV exhibit significantly increased complication rates after rTHA. With growing utilization in recent years, these data suggest that this population will comprise an increasingly larger proportion of rTHA procedures performed in the coming years.

The Impact of Hepatitis C on Complication Rates After Revision Total Knee Arthroplasty: A Matched Cohort Study.

Background: It is unclear if hepatitis C (HCV) negatively impacts outcomes of revision total knee arthroplasty (rTKA). The purpose of this study was to compare complication rates after rTKA for patients with HCV vs matched controls. Methods: A retrospective cohort study was conducted using the PearlDiver database (PearlDiver Inc., Colorado Springs, CO). Patients with HCV who underwent rTKA (n = 1448) were matched 1:4 with controls (n = 5792) on age, sex, and several comorbidities. Rates of medical complications within 90 days and prothesis-related complications within 2 years postoperatively were compared with logistic regression for (1) patients with vs without HCV and (2) HCV patients who underwent aseptic vs septic rTKA. Results: Relative to controls, patients with HCV exhibited significantly higher rates of medical complications (27.7% vs 20.9%; odds ratio [OR] 1.47), periprosthetic fractures (2.3% vs 1.1%; OR 2.20), all-cause repeat rTKA (11.7% vs 9.4%; OR 1.29), and repeat rTKA for prosthetic joint infection (PJI) (6.7% vs 3.6%; OR 1.92). Within the HCV cohort, HCV patients with initial septic rTKA exhibited significantly higher rates of medical complications (41.7% vs 22.7%; OR 2.39), all-cause subsequent rTKA (15.9% vs 10.2%; OR 1.67), and repeat rTKA for PJI (15.9% vs 3.4%; OR 5.39). Conversely, HCV patients with initial aseptic rTKA exhibited significantly higher rates of aseptic loosening (2.6% vs 7.4%; OR 0.33). Conclusions: Patients with HCV exhibited significantly higher rates of medical and prosthesis-related complications after rTKA than controls. Among patients with HCV, initial septic rTKA was associated with significantly higher rates of medical complications, repeat rTKA, and PJI.

Fixation vs Arthroplasty for Femoral Neck Fracture in Patients Aged 40-59 Years: A Propensity-Score-Matched Analysis.

Background: Internal fixation (IF) has historically been favored for the treatment of femoral neck fractures (FNFs) in young, nongeriatric patients. However, recent literature reporting high reoperation rates among those receiving IF, taken in conjunction with favorable survivorship of modern bearing surfaces in total hip arthroplasty (THA), has begun to question this paradigm. Our study sought to compare outcomes between IF and THA for FNFs in patients aged 40-59 years. Methods: Using the Truven MarketScan Database, we performed a retrospective propensity-score-matched cohort study on patients aged 40-59 years who underwent surgical management of an isolated FNF (THA or IF). Patients with pathologic fracture were not included. Analysis was conducted on patients aged 40-49 and 50-59 years separately. A subgroup analysis was performed on those patients with 1 year and 3 years of follow-up. Multivariate analysis, controlling for baseline patient information, was then performed. Results: Seven hundred sevety-eight 40- to 49-year-old patients and 3470 50- to 59-year-old matched patients (IF and THA) were included in this study. A multivariate analysis found that patients aged 40-49 years who underwent IF were at higher odds of both 1-year (odds ratio 2.35, 95% confidence interval 1.22-4.54, P = .011) and 3-year (odds ratio 5.68, 95% confidence interval 2.21-14.60, P < .001) reoperation. Similar results were found in those aged 50-59 years. While complication rates were similar, postoperative anemia and 90-day visits to the emergency room were more common after THA in both age cohorts. Conclusions: While THA is associated with increased postoperative anemia and resource utilization compared with IF, patients aged 40-59 years who undergo IF for FNF are at increased risk of reoperation in the first 3 postoperative years. This information should be used to assist in shared decision-making with patients in this age group.

Postoperative acetabular component position in revision hip arthroplasty: a comparison of the anterior and posterior approaches.

BACKGROUND: While previously considered unsuitable for revision total hip arthroplasty (rTHA), the direct anterior approach (DAA) can be extended to allow for safe acetabular component revision. In primary hip arthroplasty, the DAA and its associated fluoroscopy, has been shown to produce more acceptable component positioning. However, there is little data comparing the DAA to the posterior approach (PA) for rTHA. We hypothesised that, the DAA with intraoperative fluoroscopy would allow for more precise acetabular component positioning when compared to those performed using a PA. METHODS: 50 consecutive patients (25 DAA and 25 PA) undergoing rTHA were included. Radiographic analysis of postoperative acetabular component position was then performed. Univariate and multivariate analyses was performed to assess the contribution of approach on cup positioning inside classically defined "safe zones". RESULTS: Baseline patient characteristics were similar. The PA was associated with more cups placed outside the Lewinnek (48% vs. 12%, p = 0.005) and the Danoff (52% vs. 28%, p = 0.083) "safe zones" when compared to the DAA. Multivariate analysis revealed that operative approach was the only patient or surgical factor associated with component position outside of the "safe zones" (Lewinnek [OR = 13.6; 95% CI, 2.12-87.9, p = 0.006] and Danoff [OR = 7.7; 95% CI, 1.48-40.1, p = 0.015]). CONCLUSION: Our results suggest that the DAA allows for more reproducible and precise cup placement in RTHA. The safe-zone paradigm remains a useful index of accurate cup positioning and the DAA, with use of intraoperative fluoroscopy, offers more consistent acetabular component positioning when compared to the PA.

Preoperative opioid use is a risk factor for complication following revision total hip arthroplasty.

BACKGROUND: The demand for revision total hip arthroplasty (THA) procedures continues to increase. A growing body of evidence in primary THA suggests that preoperative opioid use confers increased risk for complication. However, it is unknown whether the same is true for patients undergoing revision procedures. The purpose of this study was to investigate whether or not there was a relationship between preoperative opioid use and surgical complications, medical complications, and healthcare utilisation following revision THA. METHODS: This is a retrospective cohort study using the Truven Marketscan database. Patients undergoing revision THA were identified. Preoperative opioid prescriptions were queried for 1 year preoperatively and were used to divide patients into cohorts based on temporality and quantity of opioid use. This included an opioid naïve group as well as an "opioid holiday" group (6 months opioid naïve period after chronic use). Demographic and complication data were collected and both univariate and multivariate analysis was then performed. RESULTS: 62.5% of patients had received an opioid prescription in the year preceding surgery. Patients with continuous preoperative opioid use had higher odds of the following: infection (superficial or deep surgical site infection; OR 1.29; 95% CI, 1.03-1.62, p = 0.029), wound complication (OR 1.36; 95% CI, 1.02-1.82, p = 0.037), sepsis (OR 1.90; 95% CI 1.08-3.34, p = 0.026), and revision surgery (OR 1.54, 95% CI, 1.28-1.85, p < 0.001). This group also had higher care utilisation including extended length of stay, non-home discharge, 90-day readmission, and emergency room visits (p < 0.001). An opioid holiday mitigated some of this increased risk as this cohort has baseline (i.e. same as opioid naïve) risk (p > 0.05 for all comparison). CONCLUSIONS: Opioid use prior to revision THA is common and is associated with increased risk of postoperative complication. Given that risk was reduced by a preoperative opioid holiday, this represents a modifiable risk factor which should be discussed and addressed preoperatively to optimise outcomes.

Medicaid Payer Status Is Associated With Increased 90-Day Resource Utilization, Reoperation, and Infection Following Aseptic Revision Total Hip Arthroplasty.

Background: Prior literature has demonstrated increased resource utilization and perioperative complications in patients with a Medicaid payor status undergoing primary total hip and knee arthroplasty. This relationship has yet to be explored in patients undergoing revision total hip arthroplasty (rTHA). Methods: The National Readmissions Database was queried from 2010 to 2015 for all patients undergoing aseptic rTHA. 90-day complication data were collected, and patients were separated into two cohorts based on insurance payor type: Medicaid and non-Medicaid. Patients were propensity score matched 2:1 on a number of comorbid and operative characteristics. The relationship between Medicaid payor status and postoperative outcomes was then assessed using binomial logistic regression analysis. Results: 3,110 Medicaid patients were identified and matched to 6,175 non-Medicaid patients. Medicaid patients had increased odds of an early prosthetic joint infection (Odds Ratio [OR] 1.29, p=0.019), superficial surgical site infection (OR: 1.48, p=0.003), and early reoperation (OR: 1.18, p=0.045). Medicaid patients also experienced higher odds of readmissions, extended length of stay, non-home discharge status, and medical complications. Finally, the Medicaid cohort had a $3,332 (95% CI: 2,412-4,253, p<0.001) increased adjusted total cost of care when compared to the non-Medicaid cohort. Conclusion: This study identifies the Medicaid payor status as an independent risk factor for increased resource utilization, reoperation, and infection in the early postoperative period for patients undergoing rTHA. This relationship is likely due to an interplay of multiple variables, including socioeconomic status and access to care. Level of Evidence: IV.

Rural Hospital Designation Is Associated With Increased Complications and Resource Utilization After Primary Total Hip Arthroplasty: A Matched Case-Control Study.

BACKGROUND: As the prevalence of hip osteoarthritis increases, the demand for total hip arthroplasty (THA) has grown. It is known that patients in rural and urban geographic locations undergo THA at similar rates. This study explores the relationship between geographic location and postoperative outcomes. METHODS: In this retrospective cohort study, the Truven MarketScan database was used to identify patients who underwent primary THA between January 2010 and December 2018. Patients with prior hip fracture, infection, and/or avascular necrosis were excluded. Two cohorts were created based on geographic locations: urban vs rural (rural denotes any incorporated place with fewer than 2500 inhabitants). Age, gender, and obesity were used for one-to-one matching between cohorts. Patient demographics, medical comorbidities, postoperative complications, and resource utilization were statistically compared between the cohorts using multivariate conditional logistic regression. RESULTS: In total, 18,712 patients were included for analysis (9356 per cohort). After matching, there were no significant differences in comorbidities between cohorts. The following were more common in rural patients: dislocation within 1 year (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.08-1.41, P < .001), revision within 1 year (OR 1.17, 95% CI 1.05-1.32, P = .027), and prosthetic joint infection (OR 1.14, 95% CI 1.04-1.34, P = .033). Similarly, rural patients had higher odds of 30-day readmission (OR 1.31, 95% CI 1.09-1.56, P = .041), 90-day readmission (OR 1.41, 95% CI 1.26-1.71, P = .023), and extended length of stay (≥3 days; OR 1.52, 95% CI 1.22-1.81, P < .001). CONCLUSION: THA in rural patients is associated with increased cost, healthcare utilization, and complications compared to urban patients. Standardization between geographic areas could reduce this discrepancy.

Synthetic Mesh Reconstruction of Chronic, Native Quadriceps Tendon Disruptions following Failed Primary Repair.

CASE: Two patients presented with chronic knee extensor mechanism disruption after failed primary repairs. Both patients had minimal ambulatory knee function prior to surgical intervention and were treated with a synthetic mesh reconstruction of their extensor mechanism. Our technique has been modified from previously described techniques used in revision knee arthroplasty. At the one-year follow-up, both patients had improvement in their active range of motion and had returned to their previous activity. CONCLUSION: Synthetic mesh reconstruction of chronic extensor mechanism disruption is a viable technique that can be utilized as salvage for the persistently dysfunctional native knee.

The Impact of Prior Fragility Fractures on Complications After Total Hip Arthroplasty: A Propensity Score-Matched Cohort Study.

BACKGROUND: The impact of prior fragility fractures and osteoporosis treatment before total hip arthroplasty (THA) on postoperative complications is unclear. The purpose of this study was to characterize the effect of prior fragility fractures and preoperative osteoporosis treatment on short-term complications and secondary fragility fractures after THA. METHODS: A propensity score-matched retrospective cohort study was conducted using a commercially available database to (1) characterize the impact of prior fragility fractures on rates of short-term complications after THA and (2) evaluate if osteoporosis treatment before arthroplasty reduces risk of postoperative complications. Rates of periprosthetic fracture, revision THA, and fragility fractures were compared via multivariable logistic regression. RESULTS: After 1:1 propensity score matching, 2188 patients were assigned to each cohort. Patients with a fragility fracture in the 3 years preceding THA were more likely to sustain a periprosthetic fracture (1 year: 1.7% vs 1.0%, odds ratio [OR] 1.89; 2 years: 2.1% vs 1.1%, OR 1.82), fragility fracture (1 year: 4.7% vs 1.1%, OR 3.59; 2 years: 6.7% vs 1.7%, OR 3.21), and revision THA (1 year: 2.7% vs 1.7%, OR 1.65; 2 years: 3.1% vs 1.9%, OR 1.58). Among patients with a prior fragility fracture, only 13.8% received osteoporosis pharmacotherapy before THA. Rates of all complications were statistically comparable postoperatively for patients with and without pre-THA osteoporosis treatment. CONCLUSIONS: Fragility fractures within 3 years before THA are associated with significantly increased risk of periprosthetic fracture, all-cause revision, and secondary fragility fractures postoperatively. Preoperative osteoporosis treatment may not decrease risk of postoperative complications.

Trunnion Failure in Revision Total Knee Arthroplasty.

In revision total knee arthroplasty, joint kinematics must be maintained amid bone and ligamentous insufficiency. Current modular designs address defects while allowing for intraoperative prosthesis customization through a variety of stem extensions and constraints. Additional constraint improves knee stability while increasing stress at the implant-host interface and modular junction of the implant. This renders the prosthetic stem-condyle junction more prone to fatigue failure. We report 2 cases of prosthetic stem-condyle junction failure in in a varus-valgus constrained revision total knee arthroplasty.

New-Onset Depression After Total Knee Arthroplasty: Consideration of the At-Risk Patient.

BACKGROUND: Postoperative new-onset depression (NOD) has gained recent attention as a previously unrecognized complication which may put patients at risk for poor outcomes after elective total hip arthroplasty. We aimed to investigate risk factors for the development of NOD after total knee arthroplasty (TKA) and assess its association with postoperative complications. METHODS: This is a retrospective, population-level investigation of elective TKA patients. Patients with a preoperative diagnosis of depression were excluded from this study. Two groups were compared: patients who were diagnosed with depression within one year after TKA (NOD) and those who did not (control). The association of both preoperative patient factors and postoperative surgical and medical complications with NOD was then determined using multivariate and univariate analyses. RESULTS: Of 196,728 unique TKA patients in our cohort, 5351 (2.72%) were diagnosed with NOD within one year of TKA. Age <54 year old, female gender, preoperative anxiety disorder, drug, alcohol, and/or tobacco use, multiple comorbidities, and opioid use before TKA were all associated with a diagnosis of NOD postoperatively (all P < .001). Postoperative NOD was associated with periprosthetic fracture (OR 2.11; 95% CI 1.29-3.52; P = .033), aseptic failure (OR 1.61; 95% CI 1.24-2.07; P = .020), prosthetic joint infection (OR 1.55, 95% CI 1.30-1.85; P < .001), stroke (OR 1.24; 95% CI 1.09-1.42; P = .006), and venous thromboembolism (OR 1.24; 95% CI 1.12-1.37; P < .001). CONCLUSION: Post-TKA NOD is common and is associated with poor outcomes. This may aid surgeons in developing both anticipatory measures and institute preventative measures for patients at risk for developing NOD.

The Effectiveness of Closed-Incision Negative-Pressure Therapy Versus Silver-Impregnated Dressings in Mitigating Surgical Site Complications in High-Risk Patients After Revision Knee Arthroplasty: The PROMISES Randomized Controlled Trial.

BACKGROUND: Revision total knee arthroplasty (rTKA) is associated with significant risk of wound-related morbidity. The present study aimed to evaluate the 1) efficacy of closed-incision negative-pressure therapy (ciNPT) vs silver-impregnated antimicrobial dressing (AMD) in mitigating postoperative surgical site complications (SSCs), 2) the effect of ciNPT vs AMD on certain postoperative health utilization parameters, and on 3) patient-reported outcomes (PROs) improvement at 90-day postoperative follow-up. METHODS: This multicenter randomized controlled trial was conducted between December 2017 and August 2019. Patients ≥22 years, at high risk for SSC, and receiving rTKA with full exchange and reimplantation of new prosthetic components or open reduction and internal fixation of periprosthetic fractures were screened for inclusion. Eligible patients were randomized to receive a commercially available ciNPT system or a silver-impregnated AMD (n = 147, each) for minimum of 5-day duration. Primary outcome was the 90-day incidence of SSCs with stratification in accordance with revision type (aseptic/septic). Secondary outcomes were the 90-day health care utilization parameters (readmission, reoperation, dressing changes, and visits) and PROs. RESULTS: Of 294 patients randomized (age: 64.9 ± 9.0 years, female: 59.6%), 242 (82.0%) patients completed the study (ciNPT: n = 124; AMD: n = 118). The incidence of 90-day SSCs was lower for the ciNPT cohort (ciNPT: 3.4% vs AMD: 14.3%; odds ratio (OR): 0.22, 95% confidence interval (0.08, 0.59); P = .0013). Readmission rates (3.4% vs 10.2%, OR: 0.30(0.11, 0.86); P = .0208) and mean dressing changes (1.1 ± 0.3 vs 1.3 ± 1.0; P = .0003) were lower with ciNPT. The differences in reoperation rates, number of visits, and PRO improvement between both arms were not statistically significant (P > .05). CONCLUSION: ciNPT is effective in reducing the 90-day postoperative SSCs, readmission, and number of dressing changes after rTKA. Recommending routine implementation would require true-cost analyses.

Metformin Use Is Associated with Fewer Complications in Patients with Type-2 Diabetes Undergoing Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

BACKGROUND: Diabetes is a well-established risk factor for complications following total knee arthroplasty (TKA), and the incidence of type-2 diabetes is increasing. Metformin is considered first-line therapy for type-2 diabetes and has been shown to reduce all-cause mortality and to possess anti-inflammatory properties. The impact of metformin use as it relates to outcomes following TKA is unknown. The purpose of this study was to investigate this relationship. METHODS: This is a retrospective cohort study using the Truven MarketScan database. Adult patients undergoing unilateral, primary TKA were identified. We included only patients with a preoperative diagnosis of type-2 diabetes and established 2 cohorts based on metformin status. Propensity score matching was performed to match patients who used metformin to those who did not (1-to-1). Patients were matched on factors including age, sex, insulin status, other diabetic medications, comorbidities, complexity of diabetes, and smoking status. Regression analysis was then performed on matched cohorts to examine 90-day outcomes. A subgroup analysis was performed on 1-year revision rates. RESULTS: After matching, there were 32,186 patients in both the metformin group and the no-metformin group, resulting in a total of 64,372 included patients. Baseline characteristics were similar between groups. Regression analysis, performed on matched cohorts, demonstrated that the no-metformin group had increased odds of readmission (odds ratio [OR], 1.09 [95% confidence interval (CI), 1.04 to 1.15]; p < 0.001), emergency department presentation (OR, 1.09 [95% CI, 1.04 to 1.14]; p < 0.001), extended length of stay (OR, 1.12 [95% CI, 1.06 to 1.15]; p < 0.001), periprosthetic joint infection (OR, 1.30 [95% CI, 1.13 to 1.50]; p < 0.001), deep vein thrombosis (OR, 1.17 [95% CI, 1.09 to 1.26]; p < 0.001), acute kidney injury (OR, 1.21 [95% CI, 1.09 to 1.33]; p < 0.001), hypoglycemic events (OR, 1.25 [95% CI, 1.01 to 1.54]; p = 0.039), and 1-year revision (OR, 1.16 [95% CI, 1.01 to 1.33]; p = 0.033). CONCLUSIONS: Metformin use in patients with type-2 diabetes undergoing TKA appears to be associated with lower odds of multiple complications and resource utilization parameters, including periprosthetic joint infection and 1-year revision rates. Given the frequency with which TKA is performed in patients with type-2 diabetes, this knowledge has the potential to improve optimization protocols and outcomes in this group of patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.