Regional Periprosthetic Joint Infection Centers: The Time Has Come for a Paradigm Change in the Treatment of Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infection (PJI) is a rare, yet devastating complication with high mortality rates, unpredictable treatment outcomes, and high costs. The purpose of this study was to determine 90-day and 1-year mortality rates at a specialized PJI center, assess the impact of delayed referral to a PJI center on outcomes, and determine the cost of PJI treatment prior to referral to a PJI center. METHODS: A review of our institution's PJI registry was performed to identify patients who had a chronic PJI treated with a 2-stage exchange arthroplasty at our PJI Center from 2017 to 2021. Patients not referred from an external location were excluded. Mortality at 90 days and 1 year was collected. The date of infection diagnosis until the date of referral was recorded. Outcomes were documented as failure of treatment at the final clinical follow-up. The number and type of prior infection treatments were documented for each patient. The estimated cost was calculated using established PJI literature. RESULTS: There were 172 patients (182 joints) who met inclusion criteria during this timeframe. The 90-day and 1-year mortality rates were 0 and 3.9%, respectively. There was a higher failure rate in patients referred >90 days after the diagnosis of chronic PJI (23 versus 11%, P = 0.031). The total cost of PJI treatment prior to referral for this group of patients was $6.9 million. CONCLUSIONS: Implementation of a specialized PJI referral center leads to lower mortality rates, improved outcomes, and decreased cost for the health-care system.

Nitinol Staple Use in Primary Arthrodesis of Lisfranc Fracture-Dislocations.

BACKGROUND: Primary arthrodesis of Lisfranc fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion. Nitinol staple use has recently proliferated in midfoot arthrodesis. The purpose of this study is to examine the union rate of primary arthrodesis of acute Lisfranc fracture-dislocations treated with nitinol staples compared with traditional plate-and-screw fixation. The secondary objective is to assess the difference in operative times and reoperation rates. METHODS: Midfoot fracture-dislocations treated with primary arthrodesis by 7 foot and ankle orthopaedic surgeons were reviewed. Of 160 eligible patients, 121 patients (305 joints) met the required 4-month minimum radiographic follow-up. Radiographic outcomes were analyzed at the individual joint level. Each joint was classified as either staples alone (45 patients, 154 joints), staples plus plates and screws (hybrid) (45 patients, 40 joints), or plates and screws alone (31 patients, 111 joints). The primary outcome was arthrodesis union at each joint fused. RESULTS: Nonunion was more common (9.0%, 10/111) among joints fixed with plate and screws than with hybrid (2.5%, 1/40) or staples only (1.3%, 2/154) (P = .0085). Multivariable regression demonstrated that autograft use was independent associated with union (P = .0035) and plate-and-screw only fixation was an independent risk factor for nonunion (P = .0407). Median operating room and tourniquet times were shorter for hybrid (92 and 83 minutes) and staple only (67 and 63 minutes) constructs compared to plate-and-screw only fixation (105 and 95 minutes) (P ≤ .0001 and .0003). There was no difference in reoperation rates among patients with different fixation types. CONCLUSION: We found that use of nitinol compression staple and bone autograft in primary arthrodesis of Lisfranc and midfoot fracture-dislocations was associated with both improved union rates and shorter tourniquet and operative times compared to traditional plate-and-screw fixation techniques. LEVEL OF EVIDENCE: Level III, therapeutic.

Opioid-Free Analgesia is Safe and Effective in Anterior Cervical Spine Surgery: A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial (RCT). OBJECTIVE: Compare the efficacy of a multimodal, opioid-free (OF) pain management pathway with a traditional opioid-containing (OC) pathway in patients undergoing anterior cervical procedures. SUMMARY OF BACKGROUND DATA: Previous studies have compared opioid-based pain regimens to opioid-sparing regimens following cervical spine surgery, but have been limited by high rates of crossover, retrospective designs, reliance on indwelling pain catheters, opioid utilization for early postoperative analgesia, and/or a lack of patient-reported outcome measures. METHODS: This is a RCT in which patients were allocated to either an OF or OC perioperative pain management protocol. Eligible study participants included adult (age up to 18 y) patients who underwent primary, 1-level or 2-level anterior cervical surgery [anterior cervical discectomy and fusion (ACDF), anterior cervical disc arthroplasty (ACDA), or hybrid (ACDF and ACDA at different levels)] for degenerative pathology. The primary outcome variable was subjective pain level at 24 hours postoperative. The final study cohort consisted of 50 patients (22 OF, 28 OC). RESULTS: Patients in the OF group reported lower median postoperative pain levels at 6 hours (4 for OF vs. 7 for OC; P =0.041) and 24 hours (3 for OF vs. 5 for OC; P =0.032). At 2-week and 6-week follow-up, pain levels were similar between groups. Patients in the OF group reported greater comfort at 12 hours (9 for OF vs. 5 for OC; P =0.003) and 24 hours (9 for OF vs. 5 for OC; P =0.011) postoperatively. Notably, there were no significant differences in patients' reported pain satisfaction, overall surgical satisfaction, or overall sense of physical and mental well-being. In addition, there were no significant differences in falls, delirium, or constipation postoperatively. CONCLUSIONS: A multimodal OF pain management pathway following anterior cervical surgery for degenerative disease results in statistically noninferior pain control and equivalent patient-reported outcome measures compared with a traditional OC pathway.

Opioid-Free Analgesia Provides Pain Control Following Thumb Carpometacarpal Joint Arthroplasty.

BACKGROUND: We hypothesized that an opioid-free (OF), multimodal pain management pathway for thumb carpometacarpal (CMC) joint arthroplasty would not have inferior pain control compared with that of a standard opioid-containing (OC) pathway. METHODS: This was a single-center, randomized controlled clinical trial of patients undergoing primary thumb CMC joint arthroplasty. Patients were randomly allocated to either a completely OF analgesic pathway or a standard OC analgesic pathway. Patients in both cohorts received a preoperative brachial plexus block utilizing 30 mL of 0.5% ropivacaine that was administered via ultrasound guidance. The OF group was given a combination of cryotherapy, anti-inflammatory medications, acetaminophen, and gabapentin. The OC group was only given cryotherapy and opioid-containing medication for analgesia. Patient-reported pain was assessed with use of a 0 to 10 numeric rating scale at 24 hours, 2 weeks, and 6 weeks postoperatively. We compared the demographics, opioid-related side effects, patient satisfaction, and Veterans RAND 12-Item Health Survey (VR-12) results between these 2 groups. RESULTS: At 24 hours postoperatively, pain scores in the OF group were statistically noninferior to, and lower than, those in the OC group (median, 2 versus 4; p = 0.008). Pain scores continued to differ significantly at 2 weeks postoperatively (median, 2 versus 4; p = 0.001) before becoming more similar at 6 weeks (p > 0.05). No difference was found between groups with respect to opioid-related side effects, patient satisfaction, or VR-12 results. CONCLUSIONS: A completely opioid-free perioperative protocol is effective for the treatment of pain following thumb CMC joint arthroplasty in properly selected patients. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Impact of Geodemographic Factors on Antibiotic Prescribing for Acute, Uncomplicated Bronchitis or Upper Respiratory Tract Infection.

OBJECTIVE: To assess the impact of geodemographic factors on antibiotic prescribing for adult acute, uncomplicated bronchitis or upper respiratory tract infection. METHODS: A retrospective, observational study of 63,051 single health-system, outpatient discharges with a primary diagnosis of bronchitis or upper respiratory tract infection in 2019. Univariate analyses of prescribing predictors and multivariable stepwise logistic modeling were performed. RESULTS: Patients who were older (aOR 1.02; 95% CI 1.02, 1.02), male (1.10; 1.06, 1.14), black (1.29; 1.22, 1.38), smoked (1.18; 1.14, 1.23), seen in urgent care (1.26; 1.22, 1.31) and living in an area with more owner-occupied housing (1.41; 1.30, 1.53) were more likely to receive antibiotics. Patients who were Asian (0.88; 0.77, 0.99), had Medicare (0.83; 0.78, 0.87), Medicaid (0.84; 0.79, 0.87) or Exchange insurance (0.90; 0.82, 0.98), or seen in the emergency department (0.43; 0.40, 0.46) were less likely to receive antibiotics. Distance from a patient's address and their encounter location did not predict antibiotic prescribing. CONCLUSIONS: Antibiotic prescribing interventions for adult acute bronchitis and upper respiratory tract infections could target patients living in an area with higher socioeconomic status.