Faculty Bibliography

Background/UNASSIGNED:Periprosthetic joint infection (PJI) remains one of the most devastating complications following total joint arthroplasty. Appropriate prophylactic antimicrobial administration and antibiotic stewardship are major factors impacting the risk of PJI in total hip arthroplasty (THA). The purpose of our study was to evaluate whether cefazolin administration was superior to noncefazolin antibiotics in prevention of PJI after primary THA. Material and methods/UNASSIGNED:A review of 9910 patients undergoing primary THA from 2013 to 2019 at a single institution was conducted. The primary outcome was PJI within 90 days of surgery. The Musculoskeletal Infection Society definition of PJI was used for this analysis. Groups were those receiving cefazolin + expanded gram-negative antimicrobial prophylaxis (EGNAP) and those receiving an alternative to cefazolin + EGNAP. Chi-square tests were conducted to determine statistical significance. Multivariate logistic regression was performed to eliminate confounders. Results/UNASSIGNED: = .007). Conclusion/UNASSIGNED:Our data demonstrate that in the presence of EGNAP in THA, there was a higher PJI rate when clindamycin was given as an alternative to cefazolin. The number of THA patients receiving alternatives to cefazolin must be minimized. Level of Evidence/UNASSIGNED:III, Retrospective Cohort Study.

Dual mobility designs in total arthroplasty allow for increased range of motion prior to impingement and dislocation. While valuable for reducing dislocation, dual mobility has its own unique complication profile that includes intraprosthetic dislocation, corrosion, and femoral notching. Despite these relatively rare complications, dual mobility articulations are valuable options for patients at higher risk of dislocation-both early and contemporary reports on dual mobility in total hip arthroplasty suggest that it can reduce the risk of dislocation without leading to unacceptable rates of complication or early revision. Cost analyses and longer follow-up studies on newer dual mobility designs will help determine the future of dual mobility in total hip arthroplasty.

Current trajectories are set to create a large gap between total joint arthroplasty (TJA) supply and demand. Economics dictates that when the demand of consumers (TJA patients) exceeds supply (surgeons performing TJA), a new equilibrium should ideally be established at a higher price point. However, in TJA, the price is set by the government and, therefore, not subject to traditional economic models. Thus, reimbursements for TJA have decreased steadily over time. Fee for service is no longer the dominant reimbursement model for most orthopedic care. Surgeons play a critical role in the evolution and success of Value-Based Care (VBC) models, but this work is not reflected in recent payment changes for TJA. The regulatory environment is notoriously complex and affects our patients, surgeons, and institutions. It is imperative for orthopedic surgeons to continue to advocate for themselves by engaging with leadership, responding to surveys, and balancing outside influences to preserve patient access to TJA. Future payment models for musculoskeletal care must risk-stratify patients, appropriately reimburse for the work of revision TJA, and consider non-modifiable socioeconomic factors. Perioperative orthopedic surgical home (POSH) tools can ensure early appropriate care and proper care coordination for discharge. All of these factors, despite being framed within payment policy, ultimately affect access to orthopedic care for our patients.

BACKGROUND:Emerging evidence has suggested that both obesity and a short, native tibial stem (TS) design may be associated with early aseptic loosening in total knee arthroplasty. The use of short, fully cemented stem extensions may mitigate this risk. As such, we devised a multicenter study to confirm or negate these claims. METHODS:A search of our institutional research databases was done. A minimum 2-year time from index procedure was selected. Cohorts were created according to patient body mass index and the presence (stemmed tibia [ST]) or absence (nonstemmed tibia [NST]) of a short TS extension. Kaplan-Meier survival analyses for aseptic loosening and log-rank tests were done. RESULTS:A total of 1,350 patients were identified (ST = 500, NST = 850). The mean time to the final follow-up in cases without aseptic loosening for the ST cohort was 3.5 years (2.8-6.3) and 5.0 years (2.9-6.3) for the NST cohort (P < 0.001). Kaplan-Meier survival analysis at 6 years was superior for the ST cohort (100%, 98.5%; P = 0.025), and a trend toward superior 5-year survival was observed for body mass index <40 kg/m2 (99.1%, 93.2%; P = 0.066). The mean time to aseptic loosening was 2.4 years (0.9-4.5), with approximately 40% occurring within the first 2 years. CONCLUSIONS:Short, native TS design is associated with early aseptic loosening in primary cemented total knee arthroplasty. This can be mitigated through the use of an ST. More cost-effective solutions include (1) use of implants with longer native stem designs or (2) redesign of short TS implants.

BACKGROUND:There are a variety of methods available to treat periprosthetic joint infection (PJI), including 2-stage revision with the use of an antibiotic spacer. This study compares the outcomes of real-component (RC) and all-cement (AC) articulating spacers for total hip arthroplasty (THA) PJI treatment. METHODS:This multicenter retrospective study assessed all articulating spacers placed for THA PJI between April 2011 and August 2020. Patients were dichotomized based on spacer type (RC vs AC). RESULTS:One hundred four patients received articulating spacer constructs (RC group = 75, AC group = 29). Leg-length discrepancy was significantly greater in the AC group after the second stage (3.58 vs 12.00 mm, P = .023). There were no significant differences in reoperation rates following first-stage spacer placement (P = .752) and time to reimplantation (P = .127) between the groups. There were no significant differences in reinfection rates (RC group = 10.0%, AC group = 7.1%, P = 1.000) and reoperation rates following second-stage revision THA (RC group = 11.7%, AC group = 10.7%, P = 1.000). Hospital length of stay (in days) had a trend toward being shorter following the first (7.35 vs 11.96, P = .166) and second stage (3.95 vs 5.43, P = .107) for patients in the RC group. Patients in the RC group were more likely to be discharged home following the first (P = .020) and second (P = .039) stages. CONCLUSION/CONCLUSIONS:Given that there were no differences in reinfection and reoperation rates between the 2 spacer constructs, RC articulating spacers may provide a significant benefit for patient comfort during 2-stage exchange treatment of PJI while adding no increase in risk profile.

INTRODUCTION/BACKGROUND:Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is challenging to diagnose. We aimed to evaluate the impact of dry taps requiring saline lavage during preoperative intraarticular hip aspiration on the accuracy of diagnosing PJI before revision surgery. METHODS:A retrospective review was conducted for THA patients with suspected PJI who received an image-guided hip aspiration from May 2016 to February 2020. Musculoskeletal Infection Society (MSIS) diagnostic criteria for PJI were compared between patients who had dry tap (DT) versus successful tap (ST). Sensitivity and specificity of synovial markers were compared between the DT and ST groups. Concordance between preoperative and intraoperative cultures was determined for the two groups. RESULTS:In total, 335 THA patients met inclusion criteria. A greater proportion of patients in the ST group met MSIS criteria preoperatively (30.2%vs.8.3%, p<0.001). Patients in the ST group had higher rates of revision for PJI (28.4%vs.17.5%, p=0.026) and for any indication (48.4%vs.36.7%, p=0.039). MSIS synovial WBC count thresholds were more sensitive in the ST group (90.0%vs.66.7%). There was no difference in culture concordance (67.9%vs.65.9%,p=0.709), though the DT group had a higher rate of negative preoperative cultures followed by positive intraoperative cultures (85.7%vs.41.1%, p=0.047). CONCLUSION/CONCLUSIONS:Our results indicate that approximately one-third of patients have dry hip aspiration, and in these patients cultures are less predictive of intraoperative findings. This suggests that surgeons considering potential PJI after THA should apply extra scrutiny when interpreting negative results in patients who require saline lavage for hip joint aspiration.

AIMS/OBJECTIVE:Despite recent literature questioning their use, vancomycin and clindamycin often substitute cefazolin as the preoperative antibiotic prophylaxis in primary total knee arthroplasty (TKA), especially in the setting of documented allergy to penicillin. Topical povidone-iodine lavage and vancomycin powder (VIP) are adjuncts that may further broaden antimicrobial coverage, and have shown some promise in recent investigations. The purpose of this study, therefore, is to compare the risk of acute periprosthetic joint infection (PJI) in primary TKA patients who received cefazolin and VIP to those who received a non-cephalosporin alternative and VIP. METHODS:This was a retrospective cohort study of 11,550 primary TKAs performed at an orthopaedic hospital between 2013 and 2019. The primary outcome was PJI occurring within 90 days of surgery. Patients were stratified into two groups (cefazolin vs non-cephalosporin) based on their preoperative antibiotic. All patients also received the VIP protocol at wound closure. Bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify the odds ratio of PJI. RESULTS:In all, 10,484 knees (90.8%) received cefazolin, while 1,066 knees (9.2%) received a non-cephalosporin agent (either vancomycin or clindamycin) as preoperative prophylaxis. The rate of PJI in the cefazolin group (0.5%; 48/10,484) was significantly lower than the rate of PJI in the non-cephalosporin group (1.0%; 11/1,066) (p = 0.012). After controlling for confounding variables, the odds ratio (OR) of developing a PJI was increased in the non-cephalosporin cohort compared to the cefazolin cohort (OR 2.389; 1.2 to 4.6); p = 0.01). CONCLUSION/CONCLUSIONS: 2022;3(1):35-41.

INTRODUCTION/BACKGROUND:Although tourniquet use in primary total knee arthroplasty (TKA) has been widely studied, the outcomes associated with tourniquet use in revision TKA (rTKA) remains relatively unexplored. This study investigates surgical outcomes and patient satisfaction in association with tourniquet use during aseptic rTKA. METHODS:We retrospectively reviewed all patients who underwent rTKA for aseptic causes at our institution from 2011-2020. Patients were separated into two cohorts based on tourniquet inflation during the procedure. Outcomes of interest included estimated blood loss (EBL), change in hemoglobin (Hb), surgical time, length-of-stay (LOS), reoperation rate, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS,JR) scores. RESULTS:Of the 1,212 patients included, 1,007 (83%) underwent aseptic rTKA with the use of a tourniquet and 205 (17%) without the use of a tourniquet. The mean tourniquet inflation time was 93.0 minutes (SD:33.3 minutes). Blood loss was significantly less for patients in the tourniquet cohort as measured through EBL(224.1vs.325.1 mL,p<0.001) and change in preoperative to postoperative Hb(1.75vs.2.04 g/dL,p<0.001). There were no statistical differences in surgical time(p=0.267) and LOS(p=0.206) between the two groups. The reoperation rate was significantly greater for patients who did not have a tourniquet utilized (20.5%vs.15.0%,p=0.038). Delta improvement in KOOS,JR scores from baseline to 3-months postoperatively did not statistically differ between the two cohorts (p=0.560). CONCLUSION/CONCLUSIONS:While delta improvements in KOOS,JR scores were similar for both cohorts, patients who did not have a tourniquet inflated during aseptic rTKA had increased blood loss and were more likely to undergo subsequent reoperation compared to patients who did.

BACKGROUND:Patients undergoing total joint arthroplasty (TJA) are at risk for developing periprosthetic joint infection (PJI). To treat PJI, orthopaedic surgeons can perform 1-stage or 2-stage revision arthroplasty. Although 2-stage revision yields superior long-term outcomes, the optimal antibiotic therapy duration and route of administration between stages remain uncertain. In this systematic review, we aimed to identify if variations in antibiotic therapy, duration, and administration during 2-stage hip or knee revision arthroplasty affect PJI eradication rates and surgical outcome measures. METHODS:A literature search was performed using the PubMed and Google Scholar databases to identify all original reports from January 2000 to June 2021 involving 2-stage revision arthroplasty to treat PJI. Studies were included if they specified antibiotic duration, an intravenous (IV) route of antibiotic administration, type of antibiotic, and 2-stage revision PJI eradication rate and had a mean or median follow-up of at least 2 years after the second-stage operation. Included studies were classified into 3 groups based on the length of IV antibiotic therapy after prosthesis explantation: prolonged IV antibiotic therapy of 4 to 6 weeks, shortened IV antibiotic therapy of ≤2 weeks, and shortened course of IV antibiotic therapy followed by 6 to 12 weeks of oral antibiotics. RESULTS:Nine studies were included. Three studies utilizing a prolonged IV antibiotic therapy had PJI eradication rates of 79% to 96%. Four studies using a shortened IV antibiotic therapy showed PJI eradication rates of 88% to 100%. Finally, 2 studies utilizing a shortened course of IV antibiotic therapy with oral antibiotics had PJI eradication rates of 95% and 97%. There was no significant difference in eradication rates across IV antibiotic duration strategies, despite a diverse array of cultured microorganisms across the studies. CONCLUSIONS:Although the numbers are small, this systematic review suggests that prolonged IV antibiotic duration, shortened IV antibiotic duration, and shortened IV antibiotic duration supplemented with oral antibiotics confer similar PJI eradication rates after hip or knee arthroplasty. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/BACKGROUND:The purpose of this study is to report on the association between the number of stairs to enter home and length of stay (LOS), discharge disposition, and patient reported outcome measures (PROMs) among patients who underwent primary total joint arthroplasty (TJA). MATERIALS AND METHODS/METHODS:We retrospectively reviewed patients who underwent primary total hip or knee arthroplasty between January 2016 and March 2020. Only patients with documentation of the number of stairs to enter their homes were included in the study. The two cohorts were separated into four groups: none, 1-10, 11-20, and > 20 stairs. Collected variables included demographic data, LOS, discharge disposition, and PROMs. Chi-square and ANOVA were utilized to determine significance. RESULTS:Of the 1116 patients included, 510 underwent THA, and 606 underwent TKA. There was no statistical difference in LOS (THA: p = 0.308; TKA: p = 0.701) and discharge disposition (THA: p = 0.371; TKA: p = 0.484) in both cohorts regardless the number of stairs. There was no statistical difference in FJS-12 scores at 3 months (THA: p = 0.590; TKA: p = 0.206), 12 months (THA: p = 0.217; TKA: p = 0.845), and 21 months (THA: p = 0.782; TKA: p = 0.296) postoperatively for both cohorts. There was no statistical difference in HOOS, JR scores preoperatively (p = 0.278) and at 3 months postoperatively (p = 0.527) for the THA cohort, as well as KOOS, JR scores preoperatively and at 3 and 12 months postoperatively (p = 0.557; p = 0.522; p = 0.747) for the TKA cohort. CONCLUSION/CONCLUSIONS:We found no statistical differences in LOS, discharge disposition, and PROMs in patients who underwent TJA, irrespective of the number of stairs negotiated to enter their home. These findings can aid surgeons to provide preoperative education and reassurance to patients who have concerns with their discharge planning due to the walk-up stairway at their residence.