Journal of Arthroplasty最新文献

Introduction: Extended oral antibiotic (EOA) prophylaxis has been shown to reduce rates of periprosthetic joint infection (PJI) in high-risk patients following total knee arthroplasty (TKA). Although national societies' recommendations against their use and clinical efficacy remain controversial, the increase in the literature surrounding EOA prophylaxis suggests a potential change in practice patterns that may warrant the creation of national guidelines. The purpose of this study was to investigate the trends in the utilization of EOA prophylaxis following TKA from 2010 to 2022.

Methods: Patients who underwent primary or aseptic revision TKA between 2010 and 2022 were identified in a national administrative claims database. Temporal trends in EOA usage following primary or revision TKA were calculated, and secondary analysis examined rates of utilization across demographics, including patients considered at high-risk for infection. In total, 1,258,759 primary and 91,530 aseptic revision TKA patients were included in this study.

Results: From 2010 to 2022, EOA prescriptions increased by 321 and 368% following primary and revision TKA, respectively. Rates of utilization among high-risk individuals were similar to those of the general population.

Discussion: The use of EOA prophylaxis after TKA has increased significantly since 2010. Given their increasing usage and variation in prescription patterns among patients at high risk of infection, guidelines surrounding their use are necessary to promote antibiotic stewardship while preventing rates of infection.

Introduction: Recent evidence suggests extended courses of oral antibiotics (EOA) after total hip (THA) and knee (TKA) arthroplasty may reduce the risk of periprosthetic joint infection (PJI) in high-risk patients. EOA rates after THA have risen significantly. However, there is a lack of epidemiologic data on EOA prophylaxis following TKA. Therefore, we investigated national trends in EOA prophylaxis for primary TKA and whether these rates were reflective of changes in patient risk or prescribing practices.

Methods: Adult patients undergoing TKA between 2009 and 2022 were identified in a national insurance claims database (Merative Marketscan). EOA was defined as a 7-14 day course of a first-generation cephalosporin, cefdinir, clindamycin, doxycycline, or trimethoprim-sulfamethoxazole filled between 5 days preoperatively to 3 days postoperatively. Annual EOA rates were calculated and stratified by preoperative PJI risk. Multivariable logistic regression was used to explore whether rates reflected changing patient characteristics. Future rates were predicted with time-series forecasting.

Results: We identified 712,212 eligible TKA cases. EOA rates rose from 0.91% in 2009 to 7.95% in 2022. Rates increased by 686% among standard-risk patients and 786% among high-risk patients. Logistic regression models using patient comorbidities could not account for changes in EOA rates. EOA rates were projected to rise to 18.3% (CF: 7.5-29.0%) by 2030.

Conclusion: Rates of EOA prophylaxis after TKA rose significantly from 2009 to 2022. This trend could not be explained by changing patient characteristics, suggesting widespread changes in antibiotic prescribing practices, which may be reflective of recent studies favoring EOA use. There is a need for further high-quality research examining the safety, efficacy, and role of EOA prophylaxis in the primary TKA patient population.

Background: Revision total knee arthroplasties (rTKAs) are being performed more frequently in the United States in younger patients. Few large studies have evaluated the effect of age following rTKA. The study sought to evaluate the effect of age on rTKA outcomes.

Methods: The American Joint Replacement Registry (AJRR) was utilized to identify aseptic rTKAs in younger (18 to 64 years, n = 32,631) and older (> 65 years, n = 43,992) patients from January 2012 to September 2020, allowing for a minimum two-year follow-up. The mean age was 56 years in the younger cohort and 73 years in the older cohort. The mean follow-up was 5.4 years. Sex and BMI were similar between groups. Kaplan-Meier survivorship analysis was performed with re-revision as the primary endpoint. Secondarily, multivariate analyses were performed to adjust for demographics and comorbidities.

Results: The proportion with re-revision was higher in the younger cohort compared to the older (8.1 versus 5.4%, P < 0.001). The ten-year survivorship free of all-cause re-revision was 90.2% (95% CI [confidence interval]: 89.7 to 90.7) in the younger cohort versus 93.7% (95% CI: 93.4 to 94.1) in the older cohort (P < 0.0001). Younger age was significantly associated with a higher adjusted hazard ratio (HR) for all-cause re-revision (HR: 1.4, 95% CI: 1.3 to 1.6), as were men (HR: 1.4, 95% CI: 1.2 to 1.5) and initial revision for instability (HR: 1.3, 95% CI: 1.1 to 1.5). In a subgroup analysis of patients aged < 65 years, a 5-year decrease in age was associated with a 10.0% increase in risk of re-revision. Indications for re-revisions differed among the younger and older cohorts (P < 0.01): infection (30.2 versus 34.9%), aseptic loosening (19.0 versus 15.8%), and instability (12.2 versus 12.7%).

Conclusion: Younger age, men, and initial revision performed for instability were associated with significantly increased risk for all-cause re-revision following aseptic rTKA. Notably, age may have a continuous effect on re-revision rates, as each 5-year decrease in age was associated with a 10% increase in risk of re-revision. Future research may further elucidate these increased risks in this younger patient population.

Background: Despite their effectiveness in postoperative analgesia regimens for total knee arthroplasty (TKA) and total hip arthroplasty (THA), opioid medications are accompanied by well-known side effects and a risk of long-term dependence. These drawbacks have prompted the exploration of opioid-free analgesia protocols. The purpose of this study was to summarize the nature and extent of evidence available on opioid-free analgesia protocols in THA and TKA management.

Methods: A scoping review of all Medline, Embase, and CENTRAL-indexed studies published between March 2019 and May 2023 was conducted, focusing on opioid-free analgesia regimens following THA and TKA. All included studies were assessed for potential risk of bias. Meta-analyses of pooled opioid-free percentages and pain scores were conducted using odds ratio and standardized mean difference, respectively, in a random-effects model.

Results: A total of 23 studies (15 TKA, 8 THA) were included. Among both TKA and THA, rescue opioids were the most commonly reported postoperative intervention. The most commonly investigated non-opioid analgesic modality was local anesthetics/nerve blocks with 52.2% (12 of 23) of the studies, followed by multimodal combinations (21.7%) and intravenous corticosteroids (13.0%). Only two of the ten included TKA randomized controlled studies (RCTs) demonstrated statistically significant increases in the postoperative opioid-free rates. Of the six included THA RCTs, four demonstrated significant increases in patients completing the postoperative period opioid-free. Our meta-analysis demonstrated a statistically significant impact of nerve blocks following TKA on the opioid-free rate and postoperative pain scores. Among the included THA studies, all studies in which patients received postoperative intravenous corticosteroids demonstrated significant increases in opioid-free percentage.

Conclusion: Despite some non-opioid analgesics demonstrating promise, rescue opioids remained the most frequently employed postoperative pain medication. The optimized opioid-free analgesic regimen likely requires a multimodal approach, especially utilizing both local anesthetics/nerve blocks and intravenous corticosteroids. Further investigation and reporting of opioid-free episodes of care are needed.

Background: Mortality rates following total hip (THA) and total knee (TKA) arthroplasty display distinct temporal patterns, often attributed to patient selection bias, perioperative optimization, and co-morbidities. Understanding these mortality patterns is essential for epidemiological and health-economic longitudinal modeling.

Methods: We conducted a national registry-based cohort study in Australia using data from 1999 to 2022, examining primary and revision THA and TKA procedures for osteoarthritis. We assessed patient factors (age, sex, body mass index [BMI], American Society of Anaesthesiologists [ASA] score), and surgical factors (procedure, fixation, bearing surface, implant volume) in relation to long-term mortality. Standardized mortality ratios (SMRs) were calculated by comparing observed and expected deaths based on national mortality rates.

Results: Our study included 540,181 THA and 880,036 TKA procedures. Temporal trends in mortality rates were observed, with a reduction in mortality rate observed up to seven years for both primary THA and primary TKA after the index procedure and an increased mortality rate observed thereafter. All patient factors were associated with differences in mortality rates, with younger (age range 45 to 49 years) patients for primary TKA demonstrating the strongest association with mortality excess (15 years; SMR 2.02; 95% confidence interval [CI] 1.66 to 2.46). Revision procedures were associated with higher mortality rates compared to their respective primary procedures at all time points.

Discussion: Our study finds non-causal associations between patient and surgical factors and mortality up to fifteen years following THA and TKA for osteoarthritis in Australia. These findings are crucial for calibrating epidemiological and economic models and enhancing the precision of longitudinal outcome predictions for arthroplasty patients. While limitations exist, our study informs clinical practice, healthcare policies, and future research in arthroplasty surgery on a national scale, with potential relevance to similar populations worldwide.

Background: Venous thromboembolism (VTE) and dislocation are well-described complications following total hip arthroplasty (THA). However, the relationship between THA dislocation and VTE remains unclear. This study sought to determine the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients who experience a hip dislocation and subsequent closed reduction following primary THA.

Methods: All primary THA patients were identified in an inpatient admissions database. The THA patients who had a dislocation within 90 days of surgery who were treated with closed reduction were compared to patients who did not dislocate within 90 days of surgery. Differences in patient demographics, comorbidities, hospital characteristics, postoperative chemoprophylactic agents, and 90-day postoperative infectious rates were calculated between cohorts. Univariate and multivariable regression were used to assess the impact of THA dislocation treated with closed reduction on 90-day DVT and PE risk.

Results: There were 550,208 primary THAs identified. Of these patients, 3,700 (0.7%) experienced a dislocation within 90 days, of which 2,487 (67.2%) were treated with closed reduction. Patients who dislocated and underwent closed reduction had increased rates of PE (0.9 versus 0.3%, P < 0.001) and DVT (1.6 versus 0.5%, P < 0.001) compared to patients who did not dislocate. After controlling for confounding factors, patients in the closed reduction group had elevated risks of both DVT (adjusted odds ratio [aOR] 2.5, 95% confidence interval [CI]: 1.8 to 3.4, P < 0.001) and PE (aOR 2.2, 95% CI: 1.4 to 3.3, P < 0.001).

Discussion: Patients who undergo closed reduction for dislocation following primary THA have an alarmingly high risk of DVT and PE. These findings should prompt surgeons to consider chemoprophylaxis among patients who experience a dislocation, even when treated with a closed reduction.