Periprosthetic Joint Infection in Patients With Arthroplasty Undergoing Perioperative Colonoscopy.

Importance: Periprosthetic joint infection (PJI) is a rare but devastating complication. Most patients undergoing total joint arthroplasty (TJA) also need routine screening colonoscopy, in which transient bacteremia may be a potential source for hematogenous PJI. Patients and surgeons must decide on an optimal time span or sequence for these 2 generally elective procedures, but no such guidelines currently exist. Objective: To evaluate associations of colonoscopy with the risk of post-TJA PJI for the development of clinical practice recommendations for colonoscopy screening in patients undergoing TJA. Design, Setting, and Participants: This retrospective cohort study of Military Health System (MHS) beneficiaries older than 45 years who underwent TJA from January 1, 2010, to December 31, 2016, used propensity score matching and logistic regression to evaluate associations of colonoscopy with PJI risk. Statistical analyses were conducted between January and October 2023. Exposure: Colonoscopy status was defined by Current Procedural Terminology code for diagnostic colonoscopy within 6 months before or 6 months after TJA. Main Outcomes and Measures: Periprosthetic joint infection status was defined by a PJI International Classification of Diseases code within 1 year after TJA and within 1 year from the post-TJA index colonoscopy date. Results: Analyses included 243 671 patients (mean [SD] age, 70.4 [10.0] years; 144 083 [59.1%] female) who underwent TJA in the MHS from 2010 to 2016. In the preoperative colonoscopy cohort, 325 patients (2.8%) had PJI within 1 year postoperatively. In the postoperative colonoscopy cohort, 138 patients (1.8%) had PJI within 1 year from the index colonoscopy date. In separate analyses of colonoscopy status within 6 months before and 6 months after TJA, younger age, male sex, and several chronic health conditions (diabetes, kidney disease, and pulmonary disease) were each associated with higher PJI risk. However, no association was found with PJI risk for perioperative colonoscopy preoperatively (adjusted odds ratio, 1.10; 95% CI, 0.98-1.23) or postoperatively (adjusted odds ratio, 0.90; 95% CI, 0.74-1.08). Conclusions and Relevance: In this large retrospective cohort of patients undergoing TJA, perioperative screening colonoscopy was not associated with PJI and should not be delayed for periprocedural risk. However, health conditions were independently associated with PJI and should be medically optimized.

The Effect of Preoperative Behavioral Intervention on Pain, Anxiety, Opioid Use, and Function in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Study.

OBJECTIVE: To evaluate the efficacy of preoperative cognitive-behavioral psychoeducation (CBE) for improved pain, anxiety, opioid use, and postoperative function in total knee arthroplasty (TKA) patients. METHODS: A randomized controlled trial was conducted among 36 military health system beneficiaries attending preoperative education for TKA. The standard of care (SOC) group (n = 18) received information on home safety, rehabilitation, postoperative precautions, and pain management. In addition, the occupational therapy led CBE group (n = 16) received information on principles of holistic wellness (healing process, effects of stress on healing, heart-rate control through diaphragmatic breathing, anti-inflammatory nutrition, goal setting, and mental imagery). Outcomes of interest: knee active range of motion, pain (Defense and Veterans Pain Rating Scale), opioid medication use, heart-rate coherence (emwave2), anxiety (Generalized Anxiety Disorder Scale), and function (Knee Outcome Survey Activities of Daily Living [KOS-ADL], modified Functional Independence Measure, and Global Rate of Change). RESULTS: The CBE group demonstrated significantly greater decline in pain overall, with activity, and during sleep in relation to the SOC group when comparing visit 1 to visit 5. Opioid medication use was significantly lower for CBE versus SOC. Postoperative General Anxiety Disorder-7 scores decreased significantly among CBE participants with similar increase in high heart rate coherence. Function significantly improved postoperatively based on KOS-ADL and Global Rate of Change scores. Twice as many CBE participants had same-day discharge compared to SOC participants and most CBE participants continued with healthy lifestyle recommendations at the 3-month follow-up. CONCLUSION: A cognitive-behavioral approach to preoperative education may improve postoperative pain, anxiety, and function while decreasing opioid use among TKA patients. Findings from this pilot study support further research to examine similar interventions among distinct surgical populations and encourage further evaluation on the effects of CBE to enhance health and healthcare delivery.

A Case of Periprosthetic Joint Infection Because of Rothia Mucilaginosa.

Periprosthetic joint infection (PJI) is a rare but devastating complication of total joint arthroplasty. Identifying the offending infectious agent is essential to appropriate treatment, and uncommon pathogens often lead to a diagnostic delay. This case describes the first known instance of a total knee arthroplasty (TKA) with Rothia mucilaginosa, a typical respiratory tract organism. This report aims to provide insight into the treatment of this atypical PJI, as there are only six previously published cases of Rothia species PJI septic arthritis. The patient is a 64-year-old diabetic male who underwent a right TKA and left TKA ∼6 months later. Approximately 3 weeks status post-left TKA, he showed evidence of left PJI. One year after treatment and recovery from his left PJI, he presented with several months of right knee pain and fatigue. Subsequent labs and imaging revealed right PJI. No recent history of dental disease or work was observed. He then underwent two-stage revision right knee arthroplasty and microbial cultures yielded Rothia mucilaginosa. After initial empiric treatment, antibiotic therapy was narrowed to 6 weeks of vancomycin. Following negative aspiration cultures the patient underwent reimplantation of right TKA components. One year following treatment, the patient was fully recovered with no evidence of infection. This case emphasizes the possibility of microbial persistence despite various antibiotic treatment regimens for the patient's contralateral knee arthroplasty and PJI. Additionally, this case demonstrates the importance of two-stage revision in patients with PJI, and the viability of treating Rothia species PJIs with vancomycin.

Repeated Noise Exposure Does Not Reach Hazardous Levels During Total Joint Arthroplasty.

INTRODUCTION: Noise exposure is an occupational health concern for certain professions, especially military servicemembers and those using power tools on a regular basis. The purpose of this study was to quantify noise exposure during total hip arthroplasty (THA) and total knee arthroplasty (TKA) cases compared to the recommended standard for occupational noise exposure. MATERIALS AND METHODS: A sound level meter was used to record cumulative and peak noise exposure levels in 10 primary THA and 10 primary TKA surgeries, as well as 10 arthroscopy cases as controls. Measurements at the distance of the surgeon were taken in all cases. In TKA cases, measurements were taken at 3 feet and 8 feet from the surgeon, to simulate the position of the anesthetist and circulating nurse, respectively. RESULTS: Time-weighted average was significantly higher in THA (64.7 ± 5.2 dB) and TKA (64.5 ± 6.8 dB) as compared to arthroscopic cases (51.1 ± 7.5 dB, P < 0.001) and higher at the distance of the surgeon (64.5 ± 6.8 dB) compared to the anesthetist (52.9 ± 3.8 dB) and the circulating nurse (54.8 ± 11.2 dB, P = 0.006). However, time-weighted average was below the recommended exposure level of 85 dB for all arthroplasty cases. Peak levels did not differ significantly between surgery type or staff role, and no values above the ceiling limit of 140 dB were recorded. Surgeon's daily noise dose percentage per case was 1.78% for THA and 2.04% for TKA. CONCLUSION: Noise exposure in THA and TKA was higher than arthroscopic cases but did not exceed occupational standards. A daily dose percentage of approximately 2% per case indicates that repeated noise exposure likely does not reach hazardous levels in modern arthroplasty practice.

The Double-Cup Construct: A Novel Treatment Strategy for the Management of Paprosky IIIA and IIIB Acetabular Defects.

BACKGROUND: Treatment of massive acetabular bone loss in revision total hip arthroplasty is complex, and various treatment strategies have been described. We describe a novel technique of using a Trabecular Metal Revision Shell as a buttress augment creating a "double-cup" construct rather than the use of custom triflanges or cup-cage constructs for Paprosky types IIIA and IIIB acetabular defects. METHODS: We retrospectively reviewed 20 double-cup cases at a mean of 2.4 years follow-up at a single institution between 2005 and 2014. We evaluated postoperative radiographic evidence of acetabular loosening and complication rates, restoration of hip center of rotation, preoperative and postoperative modified Harris Hip Score, and Merle d'Aubigne-Postel pain and walking scores. RESULTS: There were no revisions for acetabular loosening and no cases of aseptic loosening. We observed a 25% dislocation rate, which was the most common complication. Most dislocations occurred within the first year after surgery and most were acetabulum only revisions. Hip center of rotation was restored to an average of 22.5 mm within the interteardrop line. Average Harris Hip Score improved from 28.2 to 68.7 (P < .001) and Merle d'Aubigne-Postel pain and walking scores improved from 2.7 to 5.1 and 2.4 to 4, respectively (P < .001). CONCLUSION: The double-cup construct is a reliable option for reconstruction of Paprosky type IIIA and IIIB acetabular defects with no cases of acetabular loosening both clinically and radiographically at a mean of 2 years follow-up. The most common complication was dislocation in the acetabulum-only revisions, and clinical outcome measures were reliably improved in surviving cases.

Isolated avulsion of the medial head of the triceps tendon: an anatomic study and arthroscopic repair in 2 cases.

PURPOSE: The purpose of this study was to determine the area and characteristics of the triceps tendon footprint on the olecranon, with special attention to the medial head insertion. The secondary goal was to report 2 cases of isolated avulsions of the medial head of the triceps tendon treated successfully with arthroscopic repair. METHODS: Fifteen cadaveric upper extremities were examined to investigate the triceps tendon insertion, and two case reports of an arthroscopic repair technique are described. RESULTS: In 8 specimens (53%) there was a separate insertion of the medial head of the triceps tendon on the olecranon, which was deep to the long and lateral head insertions. The mean area of the medial head insertion was 44 mm(2), and the mean area of the combined long and lateral head insertions was 115 mm(2). In 7 specimens (47%) the long, lateral, and medial heads of the triceps inserted together and had a mean area of 134 mm(2). Although the 3 heads of the triceps inserted together, the medial head tendon fiber orientation was still directed deep to the long and lateral heads. At 2 years' follow-up, both patients described no pain, had better strength, and had improved Disabilities of the Arm, Shoulder and Hand scores and Mayo Elbow Performance Scores. CONCLUSIONS: We have determined the characteristics of the distal triceps tendon footprint and the insertional orientation on the olecranon. For cases with an isolated avulsion of the medial head of the triceps tendon, an arthroscopic repair technique is described. LEVEL OF EVIDENCE: Level IV, anatomic study and therapeutic case series.