Persistent wound drainage after total joint arthroplasty (TJA) has been associated with a higher incidence of superficial and deep periprosthetic infection but the predictors for prolonged drainage and its outcome have not been thoroughly studied.

A consecutive series of 7,153 TJA cases performed between 2000 and 2006 at our institute, were recruited into this study. There were 301 cases (4.2%) of persistent wound drainage, defined as discharge from the wound for > 48 hours. The cases were matched in a 2:1 ratio for type of surgery, joint replaced, and date of surgery.

This study identified higher BMI (p< 0.005), malnutrition as defined by serum albumin< 3.4g/dl (p< 0.04), longer operative time (p< 0.01), and higher medical comorbidities, in particular diabetes (p< 0.001) as important risk factors for persistent wound drainage. In addition, patients in the drainage group were more likely to have a peak INR of > 1.5 (p< 0.001) during their hospital stay. Patients with wound drainage had a significantly lower hemoglobin postoperatively (p< 0.01) that necessitated greater number of postoperative allogenic transfusions (p=0.004). The hospital length of stay for the drainage group was also significantly higher (p< 0.005). One of the major risk factors for development of deep infection was prolonged drainage (> 7 days). In the deep hematoma and periprosthetic subgroups, the mean of delay in treatment was 6 days in those with retention of the prosthesis and successful outcome, and 9.5 days for those with failure of incision and drainage leading to resection arthroplasty (p= 0.03).

72% of the patient were successfully treated by oral or intravenous antibiotics. 27% required at least one re-operation for deep hematoma and 13% developed deep periprosthetic infection, resulting in 6% rate of resection arthroplasty. 1.5% of those with drainage remained in girdlestone status.

This study suggests early surgery for persistent drainage and avoidance of aggressive anticoagulation.

Introduction: Many patients with DJD of the hip may have co-existent spinal arthritis. This prospective study sought to determine: how hip arthritis commonly presents, the incidence of low back pain- as identified by patients- before and after THA and the correlation between LBP and hip arthritis.

Methods: 344 consecutive patients undergoing THA were recruited prospectively at a single institution. A detailed questionnaire containing diagrams on which the patient could draw out the site of their pain was administered to all patients preoperatively and postoperatively. Detailed clinical, radiographic, and cross sectional imaging of all the patients were reviewed in detail by a hip surgeon, a spine surgeon, and a neurologist.

Results: 170 patients (49.4%) had true LBP which resolved in 63 patients (37%). Of the remaining 107 patients the back pain was of the same intensity following THA in 33 patients (30%) and had decreased in 74 (70%) patients. 22 of the 33 patients with continued LBP were known to have spine pathology. 35 patients developed LBP after THA.18 patients in the latter group were investigated further and 12 were found to have severe previously unrecognized spine pathology.

Discussion: Hip and spine arthritis often co-exist. Majority of patients with ‘back’ pain experience a complete resolution of their pain following THA so long as prior spine pathology did not exist. THA seems to be beneficial in reducing the symptoms even for those with a pre-existent LBP and spine pathology. A number of patients may develop LBP following THA that may relate to unidentified spine pathology. Patients with true LBP may benefit form evaluation of their spine prior to THA.

Introduction: The potential benefits of Minimally invasive total hip arthroplasty (MIS THA) continues to be heavily debated. We hypothesized that the potential benefits of MIS THA may relate to factors such as patient selection, patient preconditioning, improvements in anesthesia technique, pain management, and not the incision size. This randomized, prospective study was designed to investigate the role of these confounding factors in general and aggressive rehabilitation in particular on the outcome of THA.

Methods: 100 patients undergoing THA at our institution were randomized into one of four groups. Group A was patients who had standard THA (incision length> 10 cm) and received standard preoperative and postoperative care. Group B patients had THA using small incision (< 10 cm) and standard protocols. Group C patients had regular incision THA, but received aggressive rehabilitation and pain control regimen. Group D patients had THA through small incision and received aggressive regimen.

Results: The demographic distribution amongst all the groups was similar. There was a significant improvement in function as measured by Harris Hip Score, LASA (validated rehabilitation score), SF-36, and lower extremity function test in all groups. The extent of functional improvement, home discharge, patient satisfaction, and analgesia requirement was better in patients who received aggressive preoperative and postoperative care regimen regardless of the size of their incision. There was no difference in estimated blood loss, mean operative time, transfusion needs, and complications between the groups.

Discussion: This study highlights the importance of family education, patient conditioning, pre-emptive analgesia, and aggressive preoperative and postoperative rehabilitation in influencing the outcome of THA. The aforementioned factors, and perhaps not the surgical technique per se, may play a major role in imparting advantageous outcome to MIS THA that is reported by various investigators.