Time-to-Surgery and Short-Term Outcomes of Trimalleolar Ankle Fracture During the COVID-19 Pandemic.

Introduction During the coronavirus disease 2019 (COVID-19) pandemic, a rapid and significant transformation in patient management occurred across the healthcare system in order to mitigate the spread of the disease and address resource constraints. Numerous surgical cases were either postponed or canceled, permitting only the most critical and emergent cases to proceed. The impact of these modifications on patient outcomes remains uncertain. The purpose of this study was to compare time-to-surgery and outcomes of open reduction and internal fixation for trimalleolar ankle fractures during the pandemic to a pre-pandemic group. We hypothesized that the pandemic group would have a prolonged time-to-surgery and worse outcomes compared to the pre-pandemic cohort. Materials and methods This retrospective cohort study was conducted within a single healthcare system, examining the treatment of trimalleolar ankle fractures during two distinct periods: April to July 2020 (COVID-19 group) and January to December 2018 (2018 group). Cases were identified using Current Procedural Terminology code 27822. Information on demographics, fracture characteristics, and outcomes was obtained through chart review. Outcomes analyzed included time-to-surgery, mean visual analog scale scores, ankle strength and range of motion, and complications. Results COVID-19 and 2018 groups consisted of 32 and 100 patients, respectively. No significant difference was observed in group demographics and comorbidities (p > 0.05). Fracture characteristics were similar between groups apart from tibiofibular syndesmosis injury, 62.5% (20/32) in COVID-19 vs 42.0% (42/100) in 2018 (p = 0.03). Time-to-surgery was not significantly different between the two groups (8.84 ± 6.78 days in COVID-19 vs 8.61 ± 6.02 days in 2018, p = 0.85). Mean visual analog scale scores, ankle strength, and ankle range of motion in plantarflexion were not significantly different between the two groups at three and six months postoperatively (p > 0.05). Dorsiflexion was significantly higher in the COVID-19 group at three months (p = 0.03), but not six months (p = 0.94) postoperatively. No significant difference in postoperative complication was seen between groups, 25.0% (8/32) COVID-19 group compared to 15.0% (15/100) 2018 group (p = 0.11). Conclusions Patients who underwent surgery during the early months of the COVID-19 pandemic did not experience prolonged time-to-surgery and had similar outcomes compared to patients treated prior to the pandemic.

Preoperative Opioid Use Increases the Cost of Care in Total Joint Arthroplasty.

INTRODUCTION: Predictors of financial costs related to total joint arthroplasty (TJA) have become increasingly important becuase payment methods have shifted from fee for service to bundled payments. The purpose of this study was to assess the relationship between preoperative opioid use and cost of care in primary TJA. METHODS: A retrospective study was conducted in Medicare patients who underwent elective unilateral primary total knee or hip arthroplasty between 2015 and 2018. Preoperative opioid usage, comorbidities, length of stay, and demographic information were obtained from chart review. The total episode-of-care (EOC) cost data was obtained from the Centers of Medicare and Medicaid Services based on Bundled Payments for Care Improvement Initiative Model 2, including index hospital and 90-day postacute care costs. Patients were grouped based on preoperative opioid usage. Costs were compared between groups, and multivariate linear regression analyses were performed to analyze whether preoperative opioid usage influenced the cost of TJA care. Analyses were risk-adjusted for patient risk factors, including comorbidities and demographics. RESULTS: A total of 3,211 patients were included in the study. Of the 3,211 TJAs, 569 of 3,211 patients (17.7%) used preoperative opioids, of which 242 (42.5%) only used tramadol. EOC costs were significantly higher for opioid and tramadol users than nonopioid users ($19,229 versus $19,403 versus $17,572, P < 0.001). Multivariate regression predicted that the use of preoperative opioids in TJA was associated with increased EOC costs by $789 for opioid users (95% confidence interval [CI] $559 to $1,019, P < 0.001) and $430 for tramadol users (95% CI $167 to $694, P = 0.001). Total postacute care costs were also increased by 70% for opioid users (95% CI 44% to 102%, P < 0.001) and 48% for tramadol users (95% CI 22% to 80%, P < 0.001). DISCUSSION: This study demonstrated that preoperative opioid usage was associated with higher cost of care in TJA. Limiting preoperative opioid use for pain management before TJA could contribute to cost savings within a bundled model.

A Postdischarge Multimodal Pain Management Cocktail Following Total Knee Arthroplasty Reduces Opioid Consumption in the 30-Day Postoperative Period: A Group-Randomized Trial.

BACKGROUND: Traditional pain management after total knee arthroplasty (TKA) relies heavily on opioids. Although there is evidence that in-hospital multimodal pain management (MMPM) is more effective than opioid-only (OO) analgesia, there has been little focus on postdischarge pain management. The hypothesis of this study was that MMPM after TKA would reduce pain scores and opioid consumption in the 30-day period after hospital discharge. METHODS: This is a prospective, 2-group, comparative study with a provider cross-over design comparing a 30-day OO prn regimen with a MMPM regimen and opioid medications prn. The primary outcome measure was visual analog scale pain score and opioid-related side effects. Secondary outcome measures included morphine milligram equivalents consumed, failure of the protocol, and opioid refills. RESULTS: There were 216 patients included in the trial, with final data available for 143. There was no clinically meaningful difference in visual analog scale score between the 2 groups at any time. Average opioid consumption at 30 days was 582.5 and 386.4 morphine milligram equivalents for the OO and MMPM cohorts, respectively (P = .0006). Average number of opioid pills consumed at 30 days was 91.8 and 60.4 for OO and MMPM cohorts, respectively (P = .0004). CONCLUSION: A 30-day postdischarge multimodal pain regimen reduced opioid use after TKA while maintaining a similar level of pain control as the OO regimen. OO regimens are at an increased risk of needing additional medications to control pain. LEVEL OF EVIDENCE: Level II. REGISTRY NAME: www.clinicaltrials.gov. TRIAL NUMBER: NCT04003350.

Extended Postoperative Prophylactic Antibiotics with First-Generation Cephalosporin Do Not Reduce the Risk of Periprosthetic Joint Infection following Aseptic Revision Total Knee Arthroplasty.

Postoperative prophylactic antibiotics administered within 24 hours of primary total knee arthroplasty (TKA) have been documented to prevent periprosthetic joint infection (PJI). However, the effectiveness of this regimen is still unclear in aseptic revision TKA. The purpose of this study was to evaluate whether extended postoperative prophylactic antibiotics would reduce the PJI rate compared with the current 24-hour standard postoperative prophylactic antibiotics after aseptic revision TKA. A retrospective review of 236 patients (46 men, 190 women, 252 knees) who underwent aseptic revision TKA between 2005 and 2013 was conducted. Patients who underwent septic revision, had a positive intraoperative culture, or who had less than 2 years of follow-up were excluded. Patients were divided according to the duration of postoperative prophylactic antibiotics to standard group (76 knees, ≤ 24 hours) or extended group (176 knees, > 24 hours). PJI was determined by the Musculoskeletal Infection Society criteria. A multivariate Cox proportional hazards regression analysis was performed. The mean follow-up was 5.2 ± 2.5 years. Patients with extended postoperative prophylactic antibiotics had a lower PJI rate (1.1%) compared with standard group (3.9%), but the difference was not statistically significant (p = 0.14). Body mass index ≥ 30 kg/m2 was the only independent risk factor of PJI (adjusted hazard ratio [HR]: 9.59; 95% confidence interval [CI]: 1.07-86.04, p = 0.043). The use of extended postoperative prophylactic antibiotics was not a risk factor for PJI (adjusted HR: 0.34; 95% CI: 0.06-2.04, p = 0.238). After 10 years, the two groups had similar infection-free implant survival rate (95.9 vs. 98.9%, p = 0.15). Our findings demonstrate that extended postoperative prophylactic antibiotics did not reduce PJI rate compared with the standard group in aseptic revision TKA. A further prospective, randomized study with a standardized postoperative antibiotic protocol is necessary to address this topic. Level of evidence is prognostic Level III.

Impact of Co-Morbidities on the Cost of Care in Primary Elective Joint Arthroplasty.

BACKGROUND: The Comprehensive Care for Joint Replacement model is the newest iteration of the bundled payment methodology introduced by the Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement model, while incentivizing providers to deliver care at a lower cost, does not incorporate any patient-level risk stratification. Our study evaluated the impact of specific medical co-morbidities on the cost of care in total joint arthroplasty (TJA) patients. METHODS: A retrospective study was conducted on 1258 Medicare patients who underwent primary elective TJA between January 2015 and July 2016 at a single institution. There were 488 males, 552 hips, and the mean age was 71 years. Cost data were obtained from the Centers for Medicare and Medicaid Services. Co-morbidity information was obtained from a manual review of patient records. Fourteen co-morbidities were included in our final multiple linear regression models. RESULTS: The regression models significantly predicted cost variation (P < .001). For index hospital costs, a history of cardiac arrhythmias (P < .001), valvular heart disease (P = .014), and anemia (P = .020) significantly increased costs. For post-acute care costs, a history of neurological conditions like Parkinson's disease or seizures (P < .001), malignancy (P = .001), hypertension (P = .012), depression (P = .014), and hypothyroidism (P = .044) were associated with increases in cost. Similarly, for total episode cost, a history of neurological conditions (P < .001), hypertension (P = .012), malignancy (P = .023), and diabetes (P = .029) were predictors for increased costs. CONCLUSION: The cost of care in primary elective TJA increases with greater patient co-morbidity. Our data provide insight into the relative impact of specific medical conditions on cost of care and may be used in risk stratification in future reimbursement methodologies.

Pigmented villonodular synovitis does not influence the outcome following cementless total hip arthroplasty using ceramic-on-ceramic articulation: a case-control study with middle-term follow-up.

BACKGROUND: Pigmented villonodular synovitis (PVNS) is a relatively rare, locally aggressive, and potentially recurrent synovial disease of large joints. The purpose of this study was to investigate (1) the disease recurrence rate and (2) the treatment outcomes including Harris hip scores, complications, and revision following cementless total hip arthroplasty (THA) with ceramic-on-ceramic (CoC) articulation in patients with PVNS. METHODS: Twenty-two patients (14 females and 8 males) with histologically confirmed PVNS underwent cementless THA using CoC bearings between 2000 and 2013. Three patients with less than 5-year follow-up were excluded. The mean age was 35.2 years (range, 22-58 years) with a mean follow-up of 8.6 years (range, 6.9-10.8 years). A control group was matched in a 2:1 ratio with the PVNS group for age, sex, body mass index (BMI), year of surgery, and American Society of Anesthesiologists score (ASA). Postoperative outcome variables included disease recurrence, Harris Hip Scores (HHS) at the latest follow-up, complications (dislocation, squeaking, ceramic fracture), and any-cause revision. A Kaplan-Meier implant survivorship curve with 95% confidence interval (CI) of the two groups was generated. RESULTS: No recurrence of PVNS was noted in the follow-up period. The HSS in the PVNS group was 92.6 ± 5.5, which was similar to the control group (93.4 ± 4.6, p = 0.584) at the last follow-up visit. No patients sustained dislocation, osteolysis, or any ceramic fracture within the study duration. One patient in the PVNS group had a complication of squeaking, but did not require revision. Another patient in the PVNS group underwent revision surgery due to aseptic loosening. There was no significant difference in revision rates between the two groups (p = 1.000). The implant survivorship free of any revision was 90.0% (95% CI, 73.2% to 100%) in the PVNS group and 92.5% (95% CI, 82.6% to 100%) in the control group at 10 years (p = 0.99). CONCLUSIONS: For young and active patients with end-stage PVNS of the hips, cementless THA using CoC bearing has similar functional outcome scores, a low complication rate, and similar implant survivorship compared to the control group.

Preoperative Opioids Increase the Risk of Periprosthetic Joint Infection After Total Joint Arthroplasty.

BACKGROUND: Opioids have well-known immunosuppressive properties and preoperative opioid consumption is relatively common among patients undergoing total joint arthroplasty (TJA). The hypothesis of this study was that utilization of opioids preoperatively would increase the incidence of subsequent periprosthetic joint infection (PJI) in patients undergoing primary TJA. METHODS: A comparative cohort study design was set up that used a cohort of 23,754 TJA patients at a single institution. Patient records were reviewed to extract relevant information, in particular details of opioid consumption, and an internal institutional database of PJI was cross-referenced against the cohort to identify patients who developed a PJI within 2 years of index arthroplasty. Univariate and multivariate linear regression analyses were used to examine the potential association between preoperative opioid consumption and the development of PJI. RESULTS: Among the total cohort of 23,754 patients, 5051 (21.3%) patients used opioids before index arthroplasty. Preoperative opioid usage overall was found to be a significant risk factor for development of PJI in the univariate (odds ratio, 1.63; P = .005) and multivariate analyses (adjusted odds ratio, 1.53 [95% confidence interval, 1.14-2.05], P = .005). CONCLUSION: Preoperative opioid consumption is independently associated with a higher risk of developing a PJI after primary TJA. These findings underscore a need for caution when prescribing opioids in patients with degenerative joint disease who may later require arthroplasty.

No Difference in Morbidity and Mortality After Total Joint Arthroplasty in Liver Transplant Recipients: A Propensity Score-Matched Analysis of a Nationwide, Population-Based Study Using Universal Healthcare Data.

BACKGROUND: Controversy remains regarding the outcomes after total joint arthroplasty (TJA) among patients with or without liver transplantation (LT). This study aimed at investigating the prevalence of TJA in patients after LT and comparing the morbidity and mortality with the non-LT group. METHODS: We conducted a nationwide, population-based study, with data extracted from a universal health insurance database, based on the International Classification of Disease, Ninth Revision, Clinical Modification. Patients who underwent TJAs between January 2001 and December 2014 were included. Patients who had bilateral TJAs or a TJA before LT were excluded. A total of 43 patients with LT and 350,337 patients without LT were included. The analysis was implemented using data from all patients and those matched by 1-to-10 propensity score matching. Multivariable logistic regression was used to control confounding variables. RESULTS: The prevalence of patients undergoing TJA after LT was 1.3% (43/3276). After propensity score matching, patients with LT were not associated with 30-day complications (adjusted odds ratio [aOR], 0.98; 95% confidence interval [CI], 0.93-1.03; P = .35), 30-day readmission rates (aOR, 0.93; 95% CI, 0.92-1.08; P = .87), 90-day complication rates (aOR, 0.95; 95% CI, 0.88-1.02; P = .16), 1-year infection rates (aOR, 1.04; 95% CI, 0.96-1.12; P = .35), reoperation rates (aOR, 1.06; 95% CI, 0.92-1.23; P = .41), or mortality (aOR, 0.91; 95% CI, 0.80-1.04; P = .18). CONCLUSION: The morbidity and mortality seem to be comparable whether TJA is performed in patients with or without LT. Methods for risk assessment would be feasible in liver transplant recipients.

Predictors of Treatment Failure After 2-Stage Reimplantation for Infected Total Knee Arthroplasty: A 2- to 10-Year Follow-Up.

BACKGROUND: The aim of this study is to identify risk factors which may lead to treatment failure following 2-stage reimplantation for chronic infected total knee arthroplasty (TKA). METHODS: We retrospectively reviewed 106 patients (108 knees) who underwent consecutive 2-stage revision for chronic PJI of the knee at our institution between January 2005 and December 2015. A total of 31 risk factors, including patient characteristics, comorbidities, surgical variables, and microbiology data, were collected. Kaplan-Meier survival and Cox regression analyses were used to calculate survival rates and adjusted hazard ratios (HRs) of treatment failure. RESULTS: Within the cohort, 16 of the 108 2-stage reimplantations (14.8%) had treatment failure. The treatment success for 2-stage reimplantation was 91% (95% confidence interval [CI] 0.8-1.0) at 2 years and 84% (95% CI 0.8-0.9) at 5 and 10 years. Multivariate analysis provided the strongest predictors of treatment failure, including body mass index ≥30 kg/m2 (adjusted HR 9.3, 95% CI 2.7-31.8, P < .001), operative time >4 hours (adjusted HR 11.3, 95% CI 3.9-33.1, P < .001), gout (adjusted HR 13.8, 95% CI 2.9-66.1, P = .001), and the presence of Enterococcus species during resection arthroplasty (adjusted HR 14.1, 95% CI 2.6-76.3, P = .002). CONCLUSION: Our study identified 4 potential risk factors that may predict treatment failure following 2-stage revision for chronic knee PJI. This finding may be useful when counseling patients regarding the treatment success and prognosis of 2-stage reimplantation for infected TKA.