Limited strong data exists in current literature comparing the 90-day morbidity and mortality following general or spinal anesthetic in patients who underwent total hip or knee arthroplasty, especially between matched cohorts. Because of this, there continues to be an ongoing debate regarding the risks and benefits of using general versus spinal anesthetic for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) for end-stage osteoarthritis.

The Alberta Bone and Joint Health Institute (ABJHI) database was searched to identify all patients who underwent either primary THA or TKA between April 2005 and December 2015. Those identified were matched 1:1 based on age, sex, type of joint replacement (THA or TKA), American Society of Anesthesiologists (ASA) score, and anesthetic type. Patients were stratified into two groups based on whether they received a general anesthesia (GA) or a spinal anesthesia (SA) at the time of their index surgery. Perioperative complications (medical events, mechanical events, deep infection, need for blood transfusion), length of stay (LOS), 30-day readmission, and 90-day mortality were compared between cohorts.

Included in this study are 5,580 patients who underwent THA and 7,712 patient who underwent TKA. All were successfully matched based on similar categorical criteria (THA, 2,790 matched-pairs, TKA, 3,856 matched-pairs). Following stratifications of cohorts, no statistical differences were appreciated between patient baseline demographics. Patients who underwent GA showed a trend towards higher 90-day mortality, however no statistical differences were found between anesthetic type on rates of 90-day mortality following either THA or TKA (THA, p = 0.290, TKA, p = 0.291). Considering this, patients who underwent THA with SA experienced fewer 90-day complications (medical events, p = 0.022, mechanical events, p = 0.017), needed fewer blood transfusions (p < 0 .001), and required shorter LOS (p = 0.038). Moreover, patient who underwent TKA with SA had fewer blood transfusion (p < 0 .001), 30-day readmission rates (p = 0.011), and fewer deep infections (p = 0.030) that required additional surgery compared to those in the GA cohort. Regardless of surgery performed, patients in the SA cohorts were more commonly discharged home without requiring additional support (i.e. home care).

General anesthesia during THA and TKA appears to be associated with increased 90-day morbidity and more frequent need for allogenic blood transfusion. No statistical difference in 90-day mortality is reported between cohorts for either THA or TKA, yet a trend is appreciated favoring SA. Surgeons who commonly perform these surgeries should consider the added benefits of spinal anesthesia for those patients who are candidates.

Background

Standard preoperative protocols in total joint arthroplasty utilize the International Normalized Ratio (INR) to determine patient coagulation profiles. However, the relevance of preoperative INR values in joint arthroplasty remains controversial. Acceptable INR cutoff values for joint replacement are inconsistent, and are often based on studies of primary arthroplasty, or even non-orthopedic procedures. This analysis examined the relationship between preoperative INR values and post-operative outcomes in revision total hip arthroplasty (rTHA). Optimal cutoff INR values correlated with specific outcomes were subsequently determined.

Introduction

Interferon (IFN) based treatments for chronic hepatitis C (HCV) have been the standard of care until 2014 when direct antiviral agents (DAA) were introduced. Patients with HCV have had extremely high complication rates after total hip arthroplasty (THA). It is unknown whether HCV is a modifiable risk factor for these complications prior to THA. The purpose of this study was 1) to compare perioperative complication rates between untreated and treated HCV in THA and 2) to compare these rates between patients treated with two different therapies (IFN vs. DAA).

Objectives

Although most joint surgeons have reached a consensus that preoperative risk assessment and appropriate medical intervention for elderly patients of primary total hip arthrplasty (PTHA) could significantly reduce postoperative complications and mortality, there is still lack of a detailed and comprehensive approach for risk stratifying and a systematic method for risk allaying. We aimed to explore the risk factors related to the aggravation of preoperative complications and the appearance of complications post-operation of primary total hip arthrplasty (PTHA) in elderly patients for hip fracture.

Aim: Mental disorder has been recognized as one of the troublesome factors in the perioperative management of the patients with total hip arthroplasty. However, precise clinical analysis regarding outcome of efficacy and complication in the surgery has not been reported in detail. Our institute has owed the treatment of the patients with various severe complications in the district of 1.2 million. The patients of hip disability with mental disorders have been introduced for the treatment and managed under co-operation with division of Psychiatry. This study focused on perioperative status and complications of the patients with mental disorders under went total hip arthroplasty.

Materials and methods: Retrospective survey included consecutive 354 THAs of the 309 patients performed from January 1986 to December 2006. Reason for the surgery was due to dysplastic osteoarthritis; 251 cases (85.1 %), rheumatoid arthritis; 45 (14.6 %), idiopathic osteonecrosis of femoral head; 12 (3.9 %) and post-traumatic arthritis 1 (0.3 %). The mean age was 61.0 (29–83) years. The rate and status of the patients with mental disorders, their perioperative complications and hospitalization period were analyzed, and compared with those of the patients without disorders.

Results: Fifteen patients with mental disorders (4.9 %) received THA and the mean age was 54.8 (34–76) years. Eleven patients (73.3 %) was due to dysplastic osteoarthritis, 3 (20.0 %) to osteonecrosis of the femoral head, and 1 (6.7 %) to rheumatoid arthritis. The disorder was categorized into mood disorder (7 cases), schizophrenia (6), somatoform disorder (1) and alcohol dependence (1). Pain relief was achieved and gait ability was improved in all the patients. Dislocation was found in 3 cases (20.0%), who were all dysplastic osteoarthritis, and which occurred after 8, 30, and 49 days, respectively. One patient had a possibility of implant malposition. Two-thirds was due to inactivity and/or impairments of attention influenced by the psychotic drugs, but not failed into recurrent type of dislocation. The rate was significantly higher than that of the patients without the disorders (2.3%), (p< 0.05). Infection, major bleeding, serious thrombo-embolitic events, and anesthetic complications were not found. Type of psychotropic drug was antideprssant (13 cases), antipsychotic (9), anticholinergic (5), antialcohl(3), antimanic(2) and antiepileptic (1). Their mean number of the drug type was 4.1 in the patients of mental disorders, 4.7 in the patients with dislocation and 3.9 without dislocation, which was significantly high in the patients with dislocation. P< 0.05. Hospitalization period of the patients was 37.2 (8–47) days, which was not significantly different from those of the patients without the disorders; 36.9 (10–94) days P=0.86.

Discussion: Postsurgical dislocation was evident finding in the series of the patients with mental disorders. Two thirds seemed to be affected by the medicated drugs, but not failed into recurrent type. Other major complication was not experienced and the treatment was successfully achieved under management under co-operation with division of Psychiatry and rehabilitation unit. THA for the patients with mental disorders contributed to recovery of hip disability.

The use of tapered titanium femoral stems has gained in popularity for primary total hip arthroplasty. One of the basic stem designs is a fully grit blast square tapered stem with distal fixation (Zweymuller-type). Another stem design (Muller-type), a proximally porous coated flat wedge stem with proximal fixation is associated with a low but significant perioperative femoral fracture risk. Both of these implant types are inserted with a broach-only technique. We theorize that the Zweymuller-type implant can be inserted safely with pneumatic broaching with a very low fracture risk even when broached by rotating residents with no prior experience.

We prospectively reviewed 300 consecutive hip arthroplasty cases using Zweymuller-type stems from eight different manufacturers implanted using the Woodpecker TM pneumatic broaching system. The series included both THA and hemiarthroplasty cases with a wide range of cortical/canal indexes. Patient age ranged from 14 to 98 (avg. 68). Half of the hip stems were inserted through a posterolateral modified Kocher-Gibson approach, and half through an anterolateral Hardinge approach. Approximately 25 rotating residents who were initially unfamiliar with this broaching technique and stem implant type performed the majority of the procedures. We routinely obtained an intra-operative AP pelvis x-ray to confirm trial implant size, alignment, and adjust the leg lengths.

The overall technique/implant-related perioperative complication rate was 2% (6/300). These included intra-operative femoral fractures(2), post-operative femoral fractures (1), dislocations(3), and deep infections(2). There were no cases of nerve palsy or leg length inequality > 1cm. Rates of post-op blood transfusions and venous thromboembolism were not reviewed for the purposes of this study. Only one of the complications (one deep infection) required exchange of the original femoral component. There was no significant difference in complication rates between type of surgical approach, brand of square tapered stem manufacturer, or experience of the operating surgeon.

We conclude that hip arthroplasty using pneumatically broached, square tapered, cementless distal fixation (Zweymuller-type) hip stems has a low learning curve and can be implanted safely even in very osteoporotic bone. This technique/implant gives the surgeon control of stem anteversion for stability and leg length inequality correction. The incidence of certain perioperative complications can be reduced by using Zweymuller-type stems using pneumatic broaching regardless of approach, implant manufacturer, or surgeon experience. These patients will continue to be followed clinically for implant survivorship.

Background: The purpose of the present study was to report the perioperative complications that occurred among the initial 50 consecutive cases of HINTEGRA total ankle replacement.

Methods: This was a retrospective study of 50 cases composed of 30 men and 18 women of average age 57 years. Perioperative complications were used to compare the first 25 cases (Group A) with the subsequent 25 (Group B).

Results: Perioperative complications occurred in 15 cases (60%) in Group A but in only five (20%) in Group B. No major wound complications requiring a soft-tissue coverage procedure were encountered. Minor wound complications occurred in three cases in each group, and resolved with skin grafting or topical dressing changes. One deep infection occurred in Group A, which required implant removal and antibiotic impregnated spacer prior to revision TAR. Four patients sustained intraoperative malleolus fractures in Group A, but only one in Group B. Coronal malposition of the tibial component occurred in three cases in Group A and in two in Group B. Sagittally increased slope of the tibial component occurred in two cases in only Group B and sagittal malposition of the talar component occurred in two cases in only Group A. There were 7 instances of anterior translation of the talar component with respect to the tibial component; four in Group A and three in Group B.

Conclusions: The results of the present study suggest that TAR has a steep learning curve. Moreover, knowledge of the perioperative complications of TAR may reduce the incidence of potential complications.

Introduction: Risk-profiling of patients in hip arthroplasty to prepare for perioperative complications is becoming more important. Materials and Methods Major complications (haematoma, cardiovascular complication, deep venous thrombosis, pulmonary embolism, joint infection, injuries of neurovascular structures and pneumonia) following 29994 hip arthroplasties occurring within the postoperative hospitalisation period have been documented based on a standardised protocol used for external quality assessment in Germany. Using logistic regression, the influence of potential risk factors was assessed for their significance on postoperative complications and univariate analysis was used to assess this influence on every single major complication. The influence of patient age and the surgery time on major complications were calculated using ANOVA.

Results: Major perioperative complications occurred in 7,26 per cent. Haematomas were reported in 3.22, cardiovascular complications in 1.55, joint infections in 0.94, injuries of neuro-vascular structures in 0,63, deep venous thrombosis in 0.37, pulmonary embolism in 0.26 and pneumonia in 0.28 per cent of all cases. Patient age, length of surgery and allogeneic blood transfusion significantly increased the rate of major perioperative complications. Increased patient age increased the risk for all major complications but neuro-vascular injuries. Increased surgery time elevated the risk for all major complications except haematoma. Allogeneic blood transfusions were associated with an elevated risk for all major postoperative complications except deep venous thrombosis. In contrast, autologous blood transfusions did not increase the risk for suffering a postoperative complication. Surprisingly, gender did not have a significant influence on the occurrence of immediate postoperative complications. Conclusions Allogeneic blood transfusion, increased age and surgery time contribute to an elevated incidence of perioperative complications following hip arthroplasty.