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Shimizu MR, Grayson W, Winfrey S, Brown NM. Wound complication rates after anterior total hip arthroplasty: A case series comparison of interrupted vs. continuous sutures for skin closure. J Orthop 2025; 63:130-134. [PMID: 39568496 PMCID: PMC11574554 DOI: 10.1016/j.jor.2024.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Accepted: 10/30/2024] [Indexed: 11/22/2024] Open
Abstract
Background The anterior approach for total hip arthroplasty (THA) carries a higher risk of wound complications, which can significantly affect patient outcomes and increase healthcare costs. There is limited research comparing infection rates based on closure techniques in patients who undergo THA. Therefore, this study aims to compare wound complications based on interrupted or continuous sutures for skin closure after anterior approach THA. Methods This single-surgeon retrospective study extracted data from 388 patients who had undergone a primary THA using the anterior approach. Patient demographics, comorbidities, perioperative factors, and infection-related complications were recorded. All variables associated with a given infection complication were controlled for in a binary logistic regression model. Results After controlling for confounding variables, wound closure type was not associated with any infectious complications. BMI was a strongly associated factor in PJI (p = 0.028; 95 % CI = 1.02-1.34), prolonged drainage (p < 0.001; 95 % CI = 1.08-1.28), readmission (p = 0.023; 95 % CI = 1.01-1.20), and I&D and revision surgery (p = 0.021; 95 % CI = 1.02-1.31). Conclusion Body mass index was the sole factor associated with a higher risk of wound complications postoperatively. These findings suggest a non-inferiority between continuous and interrupted suture closure techniques regarding wound-related infectious complications in anterior total hip arthroplasty.
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Affiliation(s)
| | - Whisper Grayson
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Sara Winfrey
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - Nicholas M Brown
- Department of Orthopaedic Surgery & Rehabilitation, Loyola University Health System, Maywood, IL, USA
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Orringer M, Palmer RC, Ball JR, Telang S, Lieberman JR, Heckmann ND. Effect of BMI on the risk of postoperative complications following total hip arthroplasty. Bone Joint J 2025; 107-B:47-54. [PMID: 40306649 DOI: 10.1302/0301-620x.107b5.bjj-2024-1098.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2025]
Abstract
Aims While obesity is associated with an increased risk of complications after total hip arthroplasty (THA), the relationship between BMI and the risk of early postoperative complications has not been fully characterized. This study sought to describe the relationship between BMI and the risk of early postoperative complications, including periprosthetic joint infection (PJI), and composite surgical and composite medical complications. Methods Primary, elective THAs performed from 1 October 2015 to 31 December 2021 were identified using the Premier Healthcare Database. The study's primary outcome was the diagnosis of PJI within 90 days of THA. Using BMI as a continuous variable, logistic regression was used to develop restricted cubic splines (RCSs) to determine the impact of BMI on PJI risk. Bootstrap simulation was used to identify an inflection point in the final RCS model. The same technique was used to characterize the effects of BMI on composite medical and surgical complications. Results We found that PJI risk increased exponentially beyond a BMI threshold of 37.4 kg/m2. Relative to this threshold, patients with a BMI of 40 or 50 kg/m2 were at a 1.22-fold and 2.55-fold increased risk of developing PJI, respectively. Surgical complications increased at a BMI of 32 kg/m2 and medical complications increased at a BMI of 39 kg/m2. Relative to these cut points, patients with a BMI of 50 kg/m2 were at a 1.36-fold and 2.07-fold increased risk of developing medical and surgical complications, respectively. Conclusion The results of this study indicate a non-linear relationship between patient BMI and early postoperative risk of PJI, composite medical complications, and composite surgical complications following THA. The identified cut points with associated odds ratios can serve as tools to help risk-stratify and counsel patients seeking primary THA.
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Affiliation(s)
- Madeleine Orringer
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Ryan C Palmer
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Jacob R Ball
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Sagar Telang
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
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Lützner J, Melsheimer O, Grimberg A, Perka C, Günther KP, Lützner C, Steinbrück A. [Influence of obesity on midterm outcome after primary hip and knee arthroplasty in Germany : Analysis from the EPRD]. ORTHOPADIE (HEIDELBERG, GERMANY) 2025; 54:244-252. [PMID: 39875722 DOI: 10.1007/s00132-025-04614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/02/2025] [Indexed: 01/30/2025]
Abstract
OBJECTIVES To determine the influence of obesity on revision rates and mortality after primary elective hip and knee arthroplasty in Germany. MATERIALS AND METHODS In the German Arthroplasty Registry (EPRD) there were 403,073 elective total hip arthroplasties (THA), 320,913 bicondylar total knee arthroplasties (TKA) and 48,480 unicondylar knee arthroplasties (UKA) with valid BMI available for analysis. Cumulative revision rates and 1‑year mortality was calculated for BMI groups. RESULTS There were increased revision rates with increasing BMI, most distinctive for septic revisions in THA during the first year after surgery (non-obese 0.7%, obesity grade 1 1.3%, grade 2 2.1%, grade 3 4.2%). In TKA and UKA this increase was generally less pronounced. Age- and gender-standardized mortality was lower than expected in most groups, but also increasing with increasing BMI. CONCLUSION The risk for revisions in obese patients is more distinctive in hip arthroplasty than in knee arthroplasty and is especially high in morbidly obese patients (BMI ≥ 40 kg/m2). Nonetheless, this risk may be acceptable for affected patients. Therefore, the possible benefits and risks of an arthroplasty should be weighed against each other and individually discussed with the patient.
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Affiliation(s)
- Jörg Lützner
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie (OUPC), Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
- Endoprothesenregister Deutschland (EPRD), Berlin, Deutschland.
| | | | | | - Carsten Perka
- Endoprothesenregister Deutschland (EPRD), Berlin, Deutschland
- Centrum für Muskuloskeletale Chirurgie (CMSC), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Klaus-Peter Günther
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie (OUPC), Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Endoprothesenregister Deutschland (EPRD), Berlin, Deutschland
| | - Cornelia Lützner
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie (OUPC), Universitätsklinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Arnd Steinbrück
- Endoprothesenregister Deutschland (EPRD), Berlin, Deutschland
- Orthopädisch Chirurgisches Kompetenzzentrum Augsburg (OCKA), Augsburg, Deutschland
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Grzelecki D, Kocon M, Mazur R, Grajek A, Kowalczewski J. The diagnostic accuracy of blood C-reactive protein and erythrocyte sedimentation rate in periprosthetic joint infections - A 10-year analysis of 1510 revision hip and knee arthroplasties from a single orthopaedic center. J Orthop Surg Res 2025; 20:276. [PMID: 40082905 PMCID: PMC11907961 DOI: 10.1186/s13018-025-05531-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2024] [Accepted: 01/22/2025] [Indexed: 03/16/2025] Open
Abstract
BACKGROUND Despite the availability of many highly accurate biomarkers and novel criteria, serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are still the basis for diagnosing periprosthetic joint infection (PJI). This study aims to analyze the influence of different demographical and clinical factors on the cut-off values and accuracy of CRP and ESR in diagnosing chronic PJI. METHODS A total number of 4757 patients (with ICD-10 codes T84.0 and T84.5) operated on between January 2014 to December 2023 in a single orthopaedic center were screened in terms of the inclusion and exclusion criteria. Finally, 1510 patients (1032 aseptic revisions and 478 periprosthetic joint infections [PJI]) were included in the analysis. The best cut-off values, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for both CRP and ESR for all cohort and for subgroups divided depending on the demographical (gender, joint and BMI) and clinical factors (prosthesis fixation, specific diagnostic criteria, and virulence of the bacteria) were calculated. RESULTS For all cohort, the best cut-off value for CRP was 9.6 mg/L with an area under the curve (AUC) of 0.93 and for ESR was 29 mm/h with the AUC of 0.891. For CRP the sensitivity was higher (84.9%) than for ESR (75.1%), with the same values of specificity (90.5% and 90.8%, respectively). According to the specific subgroups, for CRP higher sensitivity was observed for males (89.6%) than for females (82.6%) if lower thresholds were used. Similarly, when the higher cut-off value for CRP was applied, better specificity for high-virulent (94.8%) than for low-virulent pathogens (88.9%) was observed. For ESR, superior sensitivity values were observed if a fistula was observed, for lower BMI thresholds and for infections caused by high-virulent pathogens. Higher optimal threshold and better specificity were observed for knees than for hips, without the appearance of fistula, when minor criteria were used and infection was caused by high-virulent pathogens. CONCLUSIONS Our study indicates better sensitivity for CRP than ESR and similar specificity values for diagnosing chronic PJI. If results oscillate close to 10 mg/L for CRP and between 25 and 30 mm/h for ESR we propose to use different cut-off values depending on the demographic and/or clinical factors to increase diagnostic accuracy.
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Affiliation(s)
- Dariusz Grzelecki
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Professor Adam Gruca Orthopedic and Trauma Teaching Hospital, Konarskiego 13, Otwock, 05- 400, Poland.
| | - Maciej Kocon
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Professor Adam Gruca Orthopedic and Trauma Teaching Hospital, Konarskiego 13, Otwock, 05- 400, Poland
| | - Rafał Mazur
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Professor Adam Gruca Orthopedic and Trauma Teaching Hospital, Konarskiego 13, Otwock, 05- 400, Poland
| | - Aleksandra Grajek
- Central Laboratory of Professor Adam Gruca Orthopedic and Trauma Teaching Hospital, Konarskiego 13, Otwock, 05-400, Poland
| | - Jacek Kowalczewski
- Department of Orthopedics and Rheumoorthopedics, Centre of Postgraduate Medical Education, Professor Adam Gruca Orthopedic and Trauma Teaching Hospital, Konarskiego 13, Otwock, 05- 400, Poland
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Salimy MS, Buddhiraju A, Chen TLW, Mittal A, Xiao P, Kwon YM. Machine learning to predict periprosthetic joint infections following primary total hip arthroplasty using a national database. Arch Orthop Trauma Surg 2025; 145:131. [PMID: 39820648 DOI: 10.1007/s00402-025-05757-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 01/07/2025] [Indexed: 01/19/2025]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) following total hip arthroplasty (THA) remains a devastating complication for patients and surgeons. Given the implications of these infections and the current paucity of risk calculators utilizing machine learning (ML), this study aimed to develop an ML algorithm that could accurately identify risk factors for developing a PJI following primary THA using a national database. MATERIALS AND METHODS A total of 51,053 patients who underwent primary THA between 2013 and 2020 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Demographic, preoperative, intraoperative, and immediate postoperative outcomes were collected. Five ML models were created. The receiver operating characteristic curves, the area under the curve (AUC), calibration plots, slopes, intercepts, and Brier scores were evaluated. RESULTS The histogram-based gradient boosting (HGB) model demonstrated good PJI discriminatory ability with an AUC of 0.88. The test-specific metrics supported the model's performance and validation in predicting PJI (calibration curve slope: 0.79; intercept: 0.32; Brier score: 0.007). The top five predictors of PJI were the length of stay (> 3 days), patient weight at the time of surgery (> 94.3 kg), an American Society of Anesthesiologists (ASA) class of 4 or higher, preoperative platelet count (< 249,890/mm3), and preoperative sodium (< 139.5 mEq/L). CONCLUSION This study developed a highly specific ML model that could predict patient-specific PJI development following primary THA. Considering the feature importance of the top predictors of infection, surgeons should counsel at-risk patients to optimize resource utilization and potentially improve surgical outcomes.
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Affiliation(s)
- Mehdi S Salimy
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Anirudh Buddhiraju
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Tony L-W Chen
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Ashish Mittal
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Pengwei Xiao
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA
| | - Young-Min Kwon
- Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Budin M, Luo TD, Gehrke T, Citak M. How reliable is the soft tissue radiological knee index in predicting superficial surgical site infection following total knee arthroplasty? Arch Orthop Trauma Surg 2024; 144:5191-5198. [PMID: 38693290 DOI: 10.1007/s00402-024-05346-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/15/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION The purpose of this study was to evaluate the association between the Soft Tissue Radiological Knee (SToRK) Index and the risk of developing a superficial surgical site infection (SSSI) following primary total knee arthroplasty (TKA). METHODS The SToRK Index was measured using calibrated long leg radiographs (LLR) in 174 patients undergoing TKA. RESULTS A moderate correlation was found between the SToRK Index and body mass index (BMI) (rs=0.574; p < 0.001). The SToRK Index was a better predictor of SSSI in females than males. In females, a SToRK Index cutoff of 2.01 had a sensitivity and specificity of 41.3% and 74.6% for developing SSSI, respectively, with a positive likelihood ratio of 1.63. CONCLUSION The SToRK Index can be used as an additional tool in assessing the risk for SSSI after TKA. It might be more predictive in females due to the different fat distribution compared to males.
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Affiliation(s)
- Maximilian Budin
- Department of Orthopaedic Surgery, HELIOS ENDO-Clinic Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - T David Luo
- Department of Orthopaedic Surgery, HELIOS ENDO-Clinic Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, HELIOS ENDO-Clinic Hamburg, Holstenstraße 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, HELIOS ENDO-Clinic Hamburg, Holstenstraße 2, 22767, Hamburg, Germany.
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Zalikha AK, Waheed MA, Twal C, Keeley J, El-Othmani MM, Hajj Hussein I. Metabolic syndrome in the setting of obesity: impact on in-hospital complications and outcomes after total knee and hip arthroplasty. Bone Jt Open 2024; 5:837-843. [PMID: 39370143 PMCID: PMC11456367 DOI: 10.1302/2633-1462.510.bjo-2024-0055.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/08/2024] Open
Abstract
Aims This study aims to evaluate the impact of metabolic syndrome in the setting of obesity on in-hospital outcomes and resource use after total joint replacement (TJR). Methods A retrospective analysis was conducted using the National Inpatient Sample from 2006 to the third quarter of 2015. Discharges representing patients aged 40 years and older with obesity (BMI > 30 kg/m2) who underwent primary TJR were included. Patients were stratified into two groups with and without metabolic syndrome. The inverse probability of treatment weighting (IPTW) method was used to balance covariates. Results The obese cohort with metabolic syndrome was significantly older, more likely to be female, had higher rates of Medicare insurance, and more likely to be non-Hispanic Black than the obese cohort without metabolic syndrome. In the unweighted analysis, patients with obesity and metabolic syndrome were more likely to experience cardiac, gastrointestinal, genitourinary, and postoperative anemia complications, had a longer length of stay, and were less likely to be discharged home compared to obese patients without metabolic syndrome. After adjusting for covariates using IPTW, patients with obesity and metabolic syndrome were more likely to experience postoperative anemia complications only and had lower rates of home discharge, but there were no significant differences in any other complication variables or length of stay. Conclusion Given the variability of metabolic health in obesity, the development of tailored perioperative protocols and recommendations acknowledging this variability in metabolic health in obese patients would ultimately potentially benefit patients and improve outcomes of TJR.
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Affiliation(s)
- Abdul K. Zalikha
- Department of Orthopaedic Surgery, Detroit Medical Center/Wayne State University, Detroit, Michigan, USA
| | - Muhammad A. Waheed
- Department of Orthopaedic Surgery, Detroit Medical Center/Wayne State University, Detroit, Michigan, USA
| | - Christeena Twal
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Jacob Keeley
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Mouhanad M. El-Othmani
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Inaya Hajj Hussein
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
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Maez DA, Richter DL, Schenck RC. Long-term Follow-up for Successful Salvage of Knee Dislocation Complicated by Infection: A Case Report. JBJS Case Connect 2024; 14:01709767-202412000-00054. [PMID: 39637053 DOI: 10.2106/jbjs.cc.24.00374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2024]
Abstract
CASE A 44-year-old morbidly obese man suffered an ultra-low velocity knee dislocation with anterior and posterior cruciate and medial collateral ligament tears after falling from a stationary bike. He underwent open reduction, external fixator application, and multiligamentous reconstruction. Postoperatively, he developed septic arthritis requiring debridement, graft removal, and antibiotic therapy, with eventual conversion to total knee arthroplasty (TKA). We present nearly 20-year follow-up on this complex case. CONCLUSION Morbid obesity amplifies the risks of knee dislocation management, including ligament reconstruction failure and septic arthritis. Long-term follow-up allows for analysis of treatment strategies of severe complications.
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Affiliation(s)
- Devin A Maez
- University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Dustin L Richter
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - Robert C Schenck
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
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Sigurdardottir M, Sigurdsson MI, Vias RD, Olafsson Y, Gunnarsdottir I, Sigurdsson EL, Karason S. Preoperative optimization of modifiable risk factors is associated with decreased superficial surgical site infections after total joint arthroplasty: a prospective case-control study. Acta Orthop 2024; 95:392-400. [PMID: 39016247 PMCID: PMC11253708 DOI: 10.2340/17453674.2024.41012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 06/08/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND AND PURPOSE The aim of our study was to investigate change in modifiable risk factors following preoperative optimization and whether risk of superficial surgical site infection (SSI) after total joint arthroplasty (TJA) could be reduced. METHODS This is a prospective study of implementation of a preoperative optimization pathway for patients waiting for primary TJA. Information regarding the intervention arm was collected from January 2019 to January 2021, first at decision for operation and then at preoperative assessment 1 week prior to operation. The control arm was included between August 2018 and September 2020 after receiving conventional preoperative preparation and information gathered at preoperative assessment. Follow up occurred 6 weeks postoperatively for both groups. The primary outcome was postoperative superficial SSI. RESULTS The optimization effort resulted in improvement of weight, anemia, HbA1c, vitamin D, and patient engagement. At preoperative assessment the baseline characteristics of the 2 groups were similar except that the intervention group had substantially more comorbidities. Regarding superficial SSI, association was found with BMI ≥ 30 and HbA1c ≥ 42 mmol/mol in the control group but not in the intervention group. When corrected for differences in ASA classification (reflecting comorbidities), age, and sex, being in the intervention group was associated with lower odds of occurrence of superficial SSI compared with the control group (OR 0.64, 95% confidence interval 0.42-0.97). CONCLUSION We showed that preoperative optimization in a structured cooperation between hospital and primary care was associated with a reduced risk of superficial SSI.
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Affiliation(s)
- Maria Sigurdardottir
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik; Faculty of Medicine, University of Iceland, Reykjavik
| | - Martin Ingi Sigurdsson
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik; Faculty of Medicine, University of Iceland, Reykjavik
| | - Rafael Daniel Vias
- Department of Mathematics, Faculty of Physical Sciences, University of Iceland, Reykjavik
| | - Yngvi Olafsson
- Department of Orthopeadics, Landspitali - The National University Hospital of Iceland, Reykjavik
| | - Ingibjorg Gunnarsdottir
- Department of Clinical Nutrition, Landspitali - The National University Hospital of Iceland, Reykjavik; Faculty of Food Science and Nutrition, University of Iceland
| | - Emil L Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik; Development Centre for Primary Health Care, Reykjavik, Iceland
| | - Sigurbergur Karason
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik; Faculty of Medicine, University of Iceland, Reykjavik.
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De Groot J, Brokelman R, Fransen B, Jiya T, Pakvis D. Antibiotic prophylaxis before tissue biopsy has no effect on culture results in presumed aseptic revision total hip arthroplasty. J Bone Jt Infect 2024; 9:67-74. [PMID: 38601000 PMCID: PMC11004665 DOI: 10.5194/jbji-9-67-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/26/2023] [Indexed: 04/12/2024] Open
Abstract
Background: Antibiotic prophylaxis (AP) is considered to be the gold standard for revision total hip arthroplasty (R-THA) due to the high incidence of prosthetic joint infection (PJI). To diagnose PJI, intraoperative tissue biopsies for culture are of particular importance. However, antibiotic interference could theoretically lead to less reliable culture results. Currently, there is no consensus on whether AP should be administered before or after tissue biopsy. In this study, we aimed to investigate the effect of AP timing on culture results and PJI rates in presumed aseptic R-THA. Methods: A retrospective single-center cohort study among 490 patients was performed; 61 patients received AP pre-incision, and 429 patients received AP post-biopsy. At least three intraoperative tissues were sampled for each patient and cultured for a minimum of 2 weeks. Minimum follow-up was 6 months. Epidemiological and clinical data (including culture results and incidence of PJI during follow-up) were gathered and analyzed. Results: Positive (4.9 % vs. 5.4 %, p = 0.89 ) and contaminated culture results (23.0 % vs. 22.6 %, p = 0.95 ) were not significantly different between pre-incisional and post-biopsy AP administration. Post-operative PJI incidence during follow-up was 1.6 % and 3.0 %, respectively. This difference was not statistically significant (p = 0.54 ). Conclusion: Pre-incisional AP administration does not yield fewer culture results compared to post-biopsy AP administration. Although statistically not significant, PJI during follow-up was almost twice as high when AP was withheld until after tissue biopsy. Other literature also supports the additional protective benefit of pre-incisional AP. Therefore, we believe pre-incisional AP administration is preferable for presumed aseptic R-THA.
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Affiliation(s)
- Jesse D. De Groot
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
| | - Roy G. B. Brokelman
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
| | - Bas L. Fransen
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
| | - Tim U. Jiya
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
| | - Dean F. M. Pakvis
- Department of Orthopedic surgery, OCON Orthopedic Clinic, Geerdinksweg 144, 7555 DL Hengelo, the Netherlands
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Sequeira SB, Hasenauer MD, McKinstry R, Ebert F, Boucher HR. Decreased Risk of Periprosthetic Joint Infection with Concurrent Hardware Removal During Conversion Total Hip Arthroplasty Compared to Staged Removal: A Matched Cohort Analysis. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202312000-00013. [PMID: 38149941 PMCID: PMC10752441 DOI: 10.5435/jaaosglobal-d-23-00261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/26/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Hardware removal before conversion total hip arthroplasty (cTHA) is a challenging task for the orthopaedic surgeon, although there is little consensus on the timing of hardware removal to mitigate risk of surgery-related complication following cTHA. METHODS Using a national insurance database, we evaluated patients who underwent hardware removal either on the same day or within 1 year before cTHA, resulting in a total of 7,756 patients. After matching based on demographic factors and comorbidities, both staged and concurrent groups consisted of 2,752 patients. The 90-day and 1-year risk of revision surgery, periprosthetic joint infection (PJI), periprosthetic fracture, and aseptic loosening were calculated and compared. Demographic factors and comorbidities were further evaluated as risk factors for PJI. RESULTS The rates of infection were 1.85% and 3.05% at 90 days postoperatively and 2.94% and 4.14% at 1 year postoperatively for concurrent versus staged cohorts, respectively (P = 0.004 and P = 0.02). No difference was observed at 90 days or 1 year between the two cohorts in risk of fracture, revision surgery, or aseptic loosening. Diabetes (P = 0.002 and P < 0.001), tobacco use (P < 0.001 and P < 0.001), and obesity (P = 0.026 and P = 0.025) were identified as risk factors for PJI at both 90 days and 1 year postoperatively. DISCUSSION The timing of hardware removal is associated with an increased risk of PJI, although no difference was observed in revision surgery, fracture, or loosening among staged versus concurrent cohorts. These findings are important to consider when surgeons are evaluating patients with periarticular implants surrounding their hip.
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Affiliation(s)
- Sean B. Sequeira
- From the Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD
| | - Mark D. Hasenauer
- From the Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD
| | - Robert McKinstry
- From the Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD
| | - Frank Ebert
- From the Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD
| | - Henry R. Boucher
- From the Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD
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Ma YP, Shen Q. Impact of being underweight on peri-operative and post-operative outcomes of total knee or hip arthroplasty: A meta-analysis. World J Clin Cases 2022; 10:10967-10983. [PMID: 36338222 PMCID: PMC9631143 DOI: 10.12998/wjcc.v10.i30.10967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/06/2022] [Accepted: 09/16/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Many systematic reviews have focused on assessing the effect of body mass index (BMI) on the outcomes and complications associated with total hip arthroplasty (THA) and total knee arthroplasty (TKA), but primarily dealt with obesity compared to normal weight (NW). None of these reviews attempted to assess the effect of low BMI or underweight (UW) compared to NW in patients undergoing THA or TKA.
AIM This review aims to compare specific operative outcomes such as operation duration, length of hospital stay, and post-operative complications including mortality, infections, deep vein thrombosis, etc. along with re-hospitalization and reoperation rates between UW and NW patients undergoing THA, TKA or both.
METHODS An electronic search was performed in PubMed, Scopus, Excerpta Medica database (EMBASE), Web of Science (WoS), and Cochrane Central Register of Controlled Trials (CENTRAL) along with a manual search. The quality of the studies was assessed using the Newcastle-Ottawa scale for cohort studies. The data were subjected to both qualitative and quantitative analysis.
RESULTS Thirteen retrospective and five prospective cohort studies were included. The quality of included studies was assessed to be good to fair. The length of hospital stay after TKA or THA was found to be significantly higher for UW patients when compared to NW patients, with a mean difference: 0.39 95%CI: [0.06, 0.72], P = 0.02 (in days). Studies presenting both THA and TKA together as total joint arthroplasty showed an increased incidence of mortality in patients treated with THA or TKA alone, Odds ratio: 4.18 95%CI: [2.88, 6.07]. A higher incidence of post-operative complications was also observed in UW patients undergoing THA.
CONCLUSION UW patients undergoing THA or TKA had a higher incidence of post-operative complications and were associated with a higher readmission rate. Moreover, UW patients were associated with an increased incidence of mortality in the studies that reported THA and TKA together.
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Affiliation(s)
- Yun-Ping Ma
- Department of Orthopedics, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou 313000, Zhejiang Province, China
| | - Qiu Shen
- Department of Orthopedics, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou 313000, Zhejiang Province, China
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PAMILO KJ, HAAPAKOSKI J, SOKKA-ISLER T, REMES V, PALONEVA J. Decreased burden of revision hip replacements despite substantial rise in prevalence: a register-based analysis in Finland. Acta Orthop 2022; 93:801-807. [PMID: 36222593 PMCID: PMC9555216 DOI: 10.2340/17453674.2022.4837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE While the incidence of THR operations has been established, little is known about the prevalence or the ratio of the annual number of revision THRs to the total number of THRs in the general population. By combining data from nationwide registers, we calculated the annual prevalence of THRs and the revision burden caused by THR survivors in Finland. PATIENTS AND METHODS All primary THRs performed between 1980 and 2020 were identified from the Finnish Arthroplasty Register (FAR). Patient deaths were extracted from the Finnish Digital and Population Data Services Agency and THR revisions and removals from the FAR and the Finnish Hospital Discharge Register. We analyzed annual THR prevalence by dividing the number of THRs by the population aged 40 or older and the revision burden factor (RBF) by dividing the annual number of revisions by the total number of primary and revision THRs in the population. The proportions of bilateral implants and patients with THRs performed more than 10 years earlier (older THRs) were identified. RESULTS THR prevalence in Finland increased rapidly, reaching 3.6% in 2020. Between 2010 and 2020, the number of THRs increased by 50% and the prevalence of THRs by 38%. In 2020, the proportion of bilateral THRs had risen to 29% and the proportion of patients with older THRs to 36%. The RBF decreased between 1996 and 2020 from 3.1% to 1.3% (age- and sex-adjusted proportion ratio PR 0.42 [95% CI 0.39-0.45]). INTERPRETATION Despite the decrease in the RBF, the rapidly increasing prevalence of THRs potentially increases the number of revisits and revisions and thus poses a challenge for healthcare in the future.
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Affiliation(s)
| | | | - Tuulikki SOKKA-ISLER
- Hospital Nova of Central Finland, Central Finland Health Care District, Jyväskylä,University of Eastern Finland, Kuopio
| | - Ville REMES
- SYNLAB Suomi, Helsinki,Jokilaakso Hospital, Jämsä, Finland
| | - Juha PALONEVA
- Hospital Nova of Central Finland, Central Finland Health Care District, Jyväskylä,University of Eastern Finland, Kuopio
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Prentice HA, Chan PH, Royse KE, Hinman AD, Reddy NC, Paxton EW. Revision Risk in a Cohort of US Patients Younger Than 55 Undergoing Primary Elective Total Hip Arthroplasty. J Arthroplasty 2022; 37:303-311. [PMID: 34718107 DOI: 10.1016/j.arth.2021.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/11/2021] [Accepted: 10/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND As indications for elective total hip arthroplasty (THA) expand to younger patients, we sought to (1) compare revision risk following primary elective THA in patients <55 years at the time of their THA to patients aged ≥65 years and (2) identify specific risk factors for revision in patients <55 years. METHODS A Kaiser Permanente's total joint replacement registry was used to conduct a cohort study including primary elective THA patients aged ≥18 (2001-2018). In total, 11,671 patients <55 years and 53,106 patients ≥65 years were included. Multiple Cox regression was used to evaluate cause-specific revision risk, including septic revision, aseptic loosening, instability, and periprosthetic fracture. Stepwise Cox regression was used to identify patient and surgical factors associated with cause-specific revision in patients <55 years. RESULTS Patients <55 years had a higher risk of septic revision (hazard ratio [HR] = 1.30, 95% confidence interval [CI] = 1.02-1.66), aseptic loosening (HR = 2.60, 95% CI = 1.99-3.40), and instability (HR = 1.35, 95% CI = 1.09-1.68), but a lower risk of revision for periprosthetic fracture (HR = 0.36, 95% CI = 0.22-0.59) compared to patients aged ≥65 years. In the <55 age group, risk factors for septic revision included higher body mass index, drug abuse, and liver disease. Hypertension, anterior approach, and ceramic-on-ceramic were associated with aseptic loosening. White race, American Society of Anesthesiologists classification ≥3, smoker, paralysis, posterior approach, ceramic-on-ceramic, and smaller head diameter were associated with instability. CONCLUSION Identified risk factors varied depending on the cause for revision. Although septic revisions were related to patient characteristics, more modifiable factors, such as implant or surgical approach, were associated with revision due to aseptic loosening and instability. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Kathryn E Royse
- Surgical Outcomes & Analysis, Kaiser Permanente, San Diego, CA
| | - Adrian D Hinman
- Department of Orthopaedics, The Permanente Medical Group, San Leandro, CA
| | - Nithin C Reddy
- Department of Orthopaedics, Southern California Permanente Medical Group, San Diego, CA
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Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining. J Clin Med 2020; 9:jcm9072190. [PMID: 32664491 PMCID: PMC7408657 DOI: 10.3390/jcm9072190] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.
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