Journal of Arthroplasty最新文献

Introduction: Despite the broad utilization of aspirin as a venous thromboembolism (VTE) chemoprophylactic agent following total knee (TKA) and total hip arthroplasty (THA), few studies have evaluated its safety and efficacy in patients who had a history of VTE. This study sought to evaluate the safety and efficacy of aspirin relative to enoxaparin in high-risk total joint arthroplasty (TJA) patients.

Methods: An all-payer claims database was queried for primary, elective THA, and TKA patients from January 2015 to December 2021. Patients who had a history of VTE were divided based on receipt of either aspirin (ASA) or enoxaparin as VTE prophylaxis. In a 1:1 ratio, 1,429 THA and 2,864 TKA high-risk ASA patients were matched to high-risk enoxaparin patients on age, sex, race, and presence of pertinent comorbidities. Multivariable regression analyses accounted for potential confounders.

Results: After multivariable analyses, similar risk of pulmonary embolism (PE) (THA: adjusted odds ratio [aOR]: 0.85, 95% confidence interval [CI]: 0.26 to 2.76; TKA: aOR: 0.71, 95% CI: 0.38 to 1.32) and deep vein thrombosis (DVT) (THA: aOR: 1.12, 95% CI: 0.53 to 2.36) was observed in the ASA cohorts relative to the enoxaparin cohorts. TKA patients in the ASA cohort had a lower risk of DVT than those in the enoxaparin cohort (aOR: 0.57, 95% CI: 0.33 to 0.96). THA ASA patients demonstrated a reduced risk of stroke (aOR: 0.03, 95% CI: 0.00 to 0.73), while TKA ASA patients had a lower risk of acute blood loss anemia (aOR: 0.77, 95% CI: 0.66 to 0.88).

Conclusion: High-risk patients who received ASA demonstrated similar risk of PE and DVT, but decreased risk of bleeding-related and medical complications compared to patients who received enoxaparin. The utilization of ASA in high-risk patients was not associated with an increased risk of adverse outcomes.

Background: Bilateral unicompartmental knee arthroplasty (bUKA) done on the same day (simultaneous) (sbUKA) has been shown to be safe and cost-effective in hospital settings. Given the popularity and increased use of ambulatory surgery centers (ASC), the purpose of this study was to compare safety and patient-reported outcome measures (PROMs) of sbUKA done at the hospital versus ASC.

Methods: Consecutive primary sbUKAs over 5 years done by a single surgeon were retrospectively collected. Surgeries were done at a hospital or ASC. Baseline demographics, intraoperative and postoperative results, and Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-jr) patient-reported outcome scores were collected between the two groups. Groups were compared utilizing Student's unpaired t-tests for continuous variables and χ2 tests for categorical variables.

Results: Of 146 patients (292 knees) who underwent sbUKA, 90 were done at a hospital, and 56 were done at an ASC. Length of stay was longer (53 versus five hours, P < 0.001), and operative time was longer (82 versus 68 minutes, P < 0.001) in the hospital group. In the hospital group, 11 (12.2%) were discharged to subacute rehab (SAR) and nine (10%) returned to the emergency department (ED) within 120 days compared to zero patients in the ASC group (P = 0.007 and 0.015, respectively). There was no significant difference in the final range of motion nor KOOS-jr scores postoperatively.

Conclusion: Outpatient SbUKA can safely be performed in selected patients. There is no difference in functional outcomes between outpatient and inpatient SbUKA.

Background: A tourniquet is commonly used during total knee arthroplasty (TKA) to improve surgical field visibility and minimize blood loss. While the short-term effects of tourniquet use on postoperative outcomes have been studied extensively and found to be minimal, its influence on longer-term outcomes remains underexplored. This study examined tourniquet use in TKA with up to five-year follow-up.

Methods: In this post hoc analysis of a randomized controlled trial, 227 patients who underwent primary TKA in the tourniquet (T) group (n = 112) or no tourniquet (NT) group (n = 115) were evaluated. Clinical outcomes and patient-reported outcome measures (PROMs) were compared between the two groups.

Results: The T group had non-significant trends toward reduced blood loss (131.8 versus 116.7 ml, P = 0.098) and shorter operative time (97.8 versus 95.7 minutes, P = 0.264), with slightly higher postoperative day-one Visual Analog Scale (VAS) pain scores (3.1 versus 3.6, P = 0.197). Length of stay (2.0 versus 2.1 days, P = 0.837) and home discharge rate (88.7 versus 92.0%, P = 0.340) were comparable. The NT group had three 90-day readmissions, while none occurred in the T group (2.7 versus 0%, P = 0.081). The active range of motion at the final follow-up was similar between groups (108.3 versus 106.5 degrees, P = 0.457). All-cause revision rates at five years were comparable between the NT and T groups (5.2 versus 3.6%, P = 0.546). Kaplan-Meier survivorship analysis revealed comparable aseptic implant survival at five years (P = 0.769). There were no significant differences in Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR), Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, PROMIS pain interference, or PROMIS physical health scores at three months, one year, and five years postoperatively.

Conclusion: Using a tourniquet during primary TKA was not associated with differences in clinical or patient-reported outcomes at up to five-year follow-up. These findings suggest that tourniquet use in TKA can be left to the surgeon's discretion.

Background: Tranexamic acid (TXA) is a renally-excreted antifibrinolytic commonly utilized in total joint arthroplasty (TJA). This study examined whether TXA administration affected clinical outcomes and kidney function in patients who had end-stage renal disease (ESRD) undergoing TJA or hemiarthroplasty.

Methods: Through a retrospective chart review, we identified 123 patients: 40 who underwent primary elective total knee arthroplasty (TKA; 65% received TXA), 34 who underwent primary elective total hip arthroplasty (THA; 52.9% TXA), and 49 who underwent nonelective THA or hemiarthroplasty (44.9% TXA) from January 2011 to February 2024. All patients had ESRD and/or were on dialysis, with no difference in percentage on dialysis between TXA groups (TKA: 65.4 versus 64.3%; THA: 55.6 versus 50.0%; nonelective/hemiarthroplasty: 86.4 versus 85.2%, P values ≥ 0.586). Demographic and perioperative characteristics, including preoperative hemoglobin, TXA administration, dose, and route of administration (ROA; intravenous, topical), were extracted. Pre- and postoperative (≤ 7 days) creatinine, perioperative transfusions, revisions, and 90-day emergency department (ED) visits, readmissions, and mortalities were recorded and compared between TXA groups.

Results: In the total sample and all cohorts, change in pre- to postoperative creatinine and incidence of postoperative acute kidney injury (AKI), per Kidney Disease Improving Global Outcomes (KDIGO) guidelines, did not significantly differ based on receiving TXA (P values ≥ 0.159). Among patients receiving TXA, change in creatinine did not significantly differ by dose (P values ≥ 0.428) or ROA (P values ≥ 0.256). There were no statistically significant differences in 90-day ED visits, readmissions, or mortalities based on receiving TXA (P values ≥ 0.055). Thromboembolic events occurred in four patients (one TXA, three no TXA, P = 0.617), and perioperative transfusions occurred in two patients (one TXA, one no TXA, P = 0.882) in the nonelective/hemiarthroplasty cohort, with none in the elective cohorts.

Conclusions: The administration of TXA does not portend a significant increase in complications for patients who have ESRD undergoing TJA or hemiarthroplasty for fracture, suggesting TXA should not be contraindicated in this population.

Introduction: Periprosthetic joint infection (PJI) with sepsis is a life-threatening condition and identification of synchronous foci of infection is challenging. Positron emission tomography using ¹⁸F-fluorodeoxyglucose combined with computed tomography (¹⁸F-FDG-PET/CT) is useful to detect PJI in elective, non-septic patients. We hypothesized that in patients who have PJI and concomitant sepsis requiring intensive care, ¹⁸F-FDG-PET/CT could accurately identify synchronous foci of infection. We addressed the following questions: (1) How often were synchronous foci of infection detected? (2) What were the confirmation rates of these infection foci by other complementary state-of-the-art methods? (3) Did ¹⁸F-FDG-PET/CT findings result in surgical treatment? and (4) What is the risk of synchronous PJI in patients who have PJI and concomitant sepsis who have another indwelling arthroplasty?

Methods: We retrospectively analyzed mechanically ventilated septic PJI patients who underwent ¹⁸F-FDG-PET/CT between January 1, 2017, and December 21, 2022. The identified synchronous foci of infection were categorized into musculoskeletal, cardiovascular, pulmonary, or other infections and compared to results from tissue culture, histopathology, magnetic resonance imaging, or transesophageal echocardiography.

Results: We identified 17 eligible patients. The ¹⁸F-FDG-PET/CT revealed at least one additional infection focus in 88% (15 of 17) of patients with the following distribution: musculoskeletal (71%, 12 of 17), cardiovascular (18%, 3 of 17), pulmonary (77%, 13 of 17), and other infections (35%, 6 of 17). Synchronous foci of infection identified with ¹⁸F-FDG-PET/CT were confirmed by another state-of-the-art method in 100% (15 of 15) of the patients. Diagnoses with ¹⁸F-FDG-PET/CT led to additional surgery in 65% (11 of 17) of the patients.Of the patients, 59% (10 of 17) had another arthroplasty with a risk of 30% (3 of 10) of synchronous PJI.

Conclusion: We highlight the value of ¹⁸F-FDG-PET/CT in patients who have PJI and sepsis, emphasizing its role in the comprehensive evaluation of these patients for subsequent therapeutic decision-making.

Background: Mental illness is a known risk factor for poor postoperative outcomes following total knee arthroplasty (TKA); however, a diagnosed mental illness does not always reflect the current state of a patient's mental health. Using the preoperative Patient-Reported Outcomes Measurement Information System (PROMIS)-10 Mental Health T-score (MHT), the purpose of this study was to understand the association between mental health and a patient's immediate inpatient recovery pattern following TKA.

Methods: This was a retrospective study of patients undergoing elective primary TKA. Patients were grouped based on their MHT score (Above Average [AA] > 50, Average [A] 40 to 50, Below Average [BA] < 40). Postsurgical parameters included inpatient opioid consumption, pain reporting, functional measures, and discharge disposition.

Results: A total of 2,740 patients were included in this study (AA 55.8%, A 35.4%, BA 8.8%). Multivariate modeling demonstrated that an MHT score below 40 was an independent risk factor for opioid consumption, pain reporting, discharge disposition, ambulation distance, and timed-up-and-go performance. A diagnosed mental illness was not associated with poor outcomes.

Conclusion: The MHT can be used as a preoperative screening tool that can identify an at-risk group not previously described. An MHT< 40 was associated with poor immediate postoperative outcomes.

Background: Ultra-congruent (UC) polyethylene liners are designed to add additional anterior-posterior stability in primary total knee arthroplasties (TKAs), compensating for actual or potential posterior cruciate ligament incompetence, somewhat like a posterior stabilized knee. The literature supports patella resurfacing in primary posterior-stabilized-compared to cruciate-retaining (CR)-TKA due to higher revision rates with non-resurfaced patella. However, it is unclear if UC liners alter patella-related revisions. The aim of the study was to compare patella revision rates and survivorship of UC versus CR liners in primary TKA without patella resurfacing using two common prostheses in patients who had osteoarthritis.

Methods: This was a retrospective cohort analysis of data from the Australian Orthopaedic Association National Joint Replacement Registry. Patients who underwent primary TKA utilizing one of two common knee systems with cemented tibial fixation for osteoarthritis and did not have their patella resurfaced between January 1, 2007, and December 31, 2022, were included for analysis. A total of 42,105 primary TKA procedures were included (UC n = 18,989, CR n = 23,116). The risk of patella-related revision and survivorship for primary TKA procedures with UC compared to CR liners were analyzed.

Results: The cumulative revision at 14 years was 5.7% (95% CI [confidence interval] 4.7 to 6.9) and 5.4% (95% CI 4.8 to 6.1) for the CR and UC group, respectively, with no difference between groups (entire period: HR [hazard ratio] = 1.07 (95% CI 0.95 to 1.20), P = 0.256). When revision TKA for patella-related diagnoses was analyzed, there was no difference between the CR and UC groups (entire period: HR = 1.10 (95% CI 0.88 to 1.38), P = 0.406). The prosthesis-specific analyses did not produce any differences between the groups for all-cause or patella-related revisions.

Conclusion: The use of UC compared to CR liners in primary TKA without patella resurfacing was not associated with an increased rate of all-cause or patella-related revisions. Surgeons should make clinical decisions on the need for patella resurfacing based on other patient, surgical, and implant factors.

Background: Minority patients have been shown to underutilize total knee arthroplasty (TKA) compared to non-Hispanic White (NHW) patients. Specific drivers of this underutilization have not been identified. We sought to determine if racial concordance between patient and physician is associated with the surgeon's likelihood to recommend TKA.

Methods: There were 402 patients who presented for management of knee osteoarthritis to the clinics of four fellowship-trained arthroplasty surgeons at a single academic center. We recorded the patient and surgeon's race/ethnicity as well as the physician-recommended treatment. Patient clinical data was input to the American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC) website to generate a guideline-based procedure recommendation for TKA. Patients who were not appropriate for TKA based on AAOS guidelines were excluded from analyses to minimize selection bias. Chi-square and multivariable regression analyses evaluated the relationship between TKA recommendation by surgeon and physician-patient racial concordance.

Results: Patients in this cohort who experienced racial concordance with their surgeon were more likely to receive a recommendation for TKA than patients who experienced racial discordance. Black patients who received racially concordant care were more likely to be offered surgery compared to those who received racially discordant care (55.1 versus 23.0%, P = 0.0001). The same effect was not observed in NHW patients, where there was no significant difference in surgery offers between patients who received concordant versus discordant care (P = 0.18). Multivariable analyses were also conducted to test factors associated with TKA recommendations. Racial concordance was found to be an independent predictor of TKA recommendation while controlling for patient factors and individual differences by the surgeon.

Conclusion: Patients receiving racially concordant care in this cohort were more likely to be offered TKA, and the effect of racial concordance on TKA recommendation was greater among Black patients. These findings provide insight into possible drivers of TKA underutilization among minority groups.

Background: Retrospective data supporting the use of tranexamic acid (TXA) among high-risk total joint arthroplasty (TJA) patients is limited by surgeon selection bias. This study sought to evaluate the thromboembolic risk associated with TXA administration among elective arthroplasty patients who have history of venous thromboembolism (VTE) while accounting for surgeon selection.

Methods: A healthcare database was retrospectively queried from 2015 to 2021 to identify all patients who had a history of deep vein thrombosis (DVT) or pulmonary embolism (PE) who underwent elective TJA. Patients were categorized into two cohorts: (1) patients treated by a surgeon who used TXA in 0 to 30% of cases and (2) patients treated by a surgeon who used TXA in 90 to 100% of cases. Patients were assessed based on the surgeon who treated them rather than their exposure to TXA. Demographics, comorbidities, and the incidence of 90-day postoperative complications were compared between the two groups. Multivariable and instrumental variable analyses (IVA) using surgeon as an instrument were conducted to account for confounding factors.

Results: In total, 70,759 high-risk elective TJA patients were identified, of which 7,190 (10.2%) were performed by surgeons in the infrequent-TXA cohort, and 9,478 (13.4%) were performed by surgeons in the frequent-TXA cohort. On IVA, patients treated by surgeons in the frequent-TXA cohort had a lower risk of aggregate bleeding complications (Instrumental Variable Odds Ratio [IVOR] 0.94, 95%-confidence interval [CI]: 0.89 to 0.98, P = 0.005), including transfusion (IVOR 0.60, 95%-CI:0.54 to 0.66, P < 0.001). However, no significant differences were observed in postoperative DVT, PE, stroke, and myocardial infarction between the two cohorts (P > 0.05).

Discussion: After accounting for surgeon selection, TXA administration was associated with a significant reduction in early postoperative bleeding complications with no observed increase in thromboembolic risk. Given the favorable safety profile, surgeons should consider TXA among high-risk arthroplasty patients.