The aims of this study was to determine the incidence of
This paper presents the nutritional status of a geriatric population admitted for hip fracture.
Minimizing the risk of periprosthetic joint infection (PJI) is of interest to all surgeons performing hip and knee arthroplasty. Among the most critical factors to reducing the risk of infection include the use of pre-incisional antibiotics, appropriate skin preparation with clippers (as opposed to a razor for hair removal) and the use of an alcohol-based skin preparation. Host factors are also likewise critically important including obesity, diabetes, inflammatory arthritis, renal insufficiency, skin disorders and patients who are otherwise immune-compromised. If modifiable risk factors are identified, it would seem reasonable to delay elective surgery until these can be optimised. One other factor to consider is the nutritional status of the patient. In a study of 501 consecutive revisions, we found that serological markers suggestive of
Among the most critical factors to reducing the risk of infection include the use of pre-incisional antibiotics, appropriate skin preparation with clippers (as opposed to a razor for hair removal) and the use of an alcohol-based skin preparation. Host factors are also likewise critically important including obesity, diabetes, inflammatory arthritis, renal insufficiency, skin disorders and patients who are otherwise immune-compromised. If modifiable risk factors are identified, it would seem reasonable to delay elective surgery until these can be optimised. One other factor to consider is the nutritional status of the patient. In a study of 501 consecutive revisions, we found that serological markers suggestive of
Minimizing the risk of periprosthetic joint infection (PJI) is of interest to all surgeons performing hip and knee arthroplasty. Among the most critical factors to reducing the risk of infection include the use of pre-incisional antibiotics, appropriate skin preparation with clippers (as opposed to a razor for hair removal) and the use of an alcohol-based skin preparation. Host factors are also likewise critically important including obesity, diabetes, inflammatory arthritis, renal insufficiency, skin disorders and patients who are otherwise immune-compromised. If modifiable risk factors are identified, it would seem reasonable to delay elective surgery until these can be optimised. One other factor to consider is the nutritional status of the patient. In a study of 501 consecutive revisions, we found that serological markers suggestive of
Aim. Serum parameters continue to be a focus of research in diagnosing periprosthetic joint infections (PJI). Several workgroups have recently proposed serum Albumin-Globulin-Ratio (AGR) as a potential new biomarker. Due to controversies in the literature, its usability in clinical practice remains uncertain. The aim of this study was to assess the value of serum AGR in diagnosing PJI preoperatively, especially in comparison with the well-established marker C-reactive Protein (CRP). Method. From January 2015 to June 2022, patients with indicated revision hip (rTHA) and knee (rTKA) arthroplasty were included in this retrospective cohort study of prospectively collected data. A standardized diagnostic workup was performed using the 2021 European Bone and Joint Infection Society (EBJIS) definition of PJI, excluding CRP. Diagnostic accuracies of serum AGR and CRP were calculated by receiver operating characteristic curve (ROC) analysis. A z-test was used to compare the area under the curves (AUC). Results. A total of 275 patients with rTHA and rTKA were included, 144 joints (52.4%) were identified as septic. Decreased AGR and elevated CRP were strongly associated with PJI, optimal diagnostic thresholds were calculated with 1.253 and 9.4 mg/L, respectively. Sensitivities were 62.5% (95%-confidence interval: 54.3–70.0) and 73.6% (65.8–80.1), and specificities 84.7% (77.5–89.9) and 87.8% (80.9–92.4), respectively. CRP showed a significantly higher AUC than AGR (0.807 (0.761–0.853) and 0.736 (0.686–0.786); p<0.0001). Subgroup analysis of acute versus chronic infections yielded significantly higher diagnostic accuracies in acute PJI for both parameters (p<0.0001). Similar results were observed when focusing on the causative microorganism; a better diagnostic performance was observed in high-virulence PJI compared to low-virulence PJI (p≤0.005). Furthermore, higher AUCs were calculated in knee PJI compared with hip PJI, with a significant difference for AGR (p=0.043). Conclusions. Due to its limited diagnostic accuracy, serum AGR cannot be recommended as an additional marker for diagnosing PJI. Serum parameters are generally unspecific and can be influenced by comorbidities and other foci of infection. Additionally, parameters may remain within normal levels in low-grade PJI. Evaluating AGR, further possible pitfalls must be considered, for example an increased latency until bottom values are reached and the impact of
Background.
In a recent study, 54.5% of patients reporting to arthroplasty clinics in the US were obese. We performed a recent literature review to determine how obesity impacts outcomes in total hip and knee arthroplasty and what must be done to improve outcomes in the obese arthroplasty patient. Specifically, obese patients have shown increased rates of infection, dislocation, need for revision, wound dehiscence, increased operative time and prolonged hospital stay. Additionally, obese TKA patients have been shown to have increased rates of aseptic loosening, thromboembolic events, wound complications, and cardiopulmonary events. Worsening severity of obesity seems to correlate with worsening outcomes and super obesity (BMI>50) has been identified as an independent risk factor for complications. Patients with BMI>35 have shown to be 6.7 times more likely to develop infection after TKA. Patients with BMI>40 have a 3.35 times higher rate of revision for deep infection than those with BMI<35. The odds ratio for major complications increases dramatically beyond BMI>45. How can we improve outcomes in the obese patient? Preoperative care for the obese patient involves nutritional counseling, incorporating weight loss methods, physical therapy, metabolic workup and diagnosis and management of frequent comorbid conditions (OSA, DM2, HTN, HLD,
Aim. A large body of evidence is emerging to implicate that dysregulation of the gut microbiome (dysbiosis) increases the risk of surgical site infections. Gut dysbiosis is known to occur in patients with inflammatory bowel disease (IBD), allowing for translocation of bacteria across the inflamed and highly permeable intestinal mucosal wall. The null hypothesis was that IBD was not associated with increased risk of periprosthetic joint infection (PJI) after primary total hip and knee arthroplasty. Our aim was to investigate whether a prior diagnosis of IBD was associated with a higher risk of PJI following primary total hip and knee arthroplasty. Method. A matched cohort study was designed. Primary endpoint was the occurrence of PJI at 2-year. Secondary endpoints were aseptic revisions, as well as discharge to rehab facility, complications up to 30 days, and readmission up to 90 days after TJA. ICD-9 and −10 codes were used to identify patients with IBD and the control cohort. A chart review was performed to confirm diagnosis of IBD. Using our institutional database, 154 patients with IBD were identified and matched (3 to 1) for age, sex, body mass index (BMI), year of surgery, and joint affected with 462 individuals without IBD undergoing TJA. Results. The cumulative incidence of PJI was 4.55% among patients with IBD versus 1.32% among the control cohort (p=0.024). When bivariate logistic regression was performed, a diagnosis of IBD was found to be an independent risk factor for PJI (OR 3.56 95% C.I. 1.17 – 11.23; p=0.024) and aseptic revisions (OR 3.47, 95% C.I. 1.30 – 3.47; p=0.012). The rate of postoperative complications was also higher in patients with IBD. Conclusions. Based on the findings of this study, it appears that patients with IBD are at higher risk for failure due to PJI or aseptic loosening after TJA. The exact reason for this finding is not known but could be related to the bacterial translocation from the inflamed intestinal mucosa, the dysregulated inflammatory status of these patients,
Aim. Infection is one of the worst complications following total joint arthroplasty, which is often associated with significant morbidity and increased medical costs. Although Gram–positive bacteria remains the most prevalent causative agents, an increase in prosthetic joint infections (PJI) due to gram-negative bacteria (GNB) has been reported. Additionally, the emergence of multidrug resistant resistance (MDR) in GNB impacts the therapeutic options and may increase the rate of treatment failure and drug toxicity adverse effects due the prescription of harmful and toxics antimicrobial schemes. The purpose of the present study was to describe the predisposing factors associated to PJI caused by MDR-GNB in a specialized orthopedic reference hospital in Brazil from 2014 through 2018. Method. Retrospective case-control analysis of patients treated for MDR-GNB PJI over a four-year period (2014–2018). Data were collected from medical, surgical and laboratory records. PJI were defined according the criteria of MSIS. MDR was defined as non-susceptibility to at least one agent in three or more antimicrobial categories. Patients with prosthetic infection with at least two positive tissue cultures for MDR-GNB were selected. Univariate and multivariate logistic regression models were used to determine the independent risk factors associated with MDR-GNB PJI. Controls: patients with PJI with at least two positive tissue culture for non MDR- GNB. Results. A total of 104 patients were selected, 59 patients in the MDR-GNB PJI group and 44 in the control. Patients with MDR-GNB PJI were elderly (mean age of 68.36), distribution among sex was similar (49.2% female and 50.8% male) and 72.3% had one or more comorbidities. Most frequently identified comorbidities were diabetes (10.2%),
Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a devastating complication. It is associated with high morbidity and mortality. It remains, unfortunately, one of the most common modes of failure in TKA. Much attention has been paid to the treatment of PJI once it occurs. Our attention, however, should focus on how to reduce the risk of PJI from developing in the first place. Infection prevention should focus on reducing modifiable risk factors that place patients at increasing risk for developing PJI. These areas include pre-operative patient optimization and intra-operative measures to reduce risk. Pre-operative Modifiable Risk Factors: There are several patient related factors that have been shown to increase patient's risk of developing PJI. Many of these are modifiable risk factors can and should be optimised prior to surgery. Obesity and in particular Morbid Obesity (BMI >40) has a strong association with increased risk of PJI. Appropriate and healthy weight loss strategies should be instituted prior to elective TKA. Uncontrolled Diabetes (Hgb A1C >8) and poor glycemic control around the time of surgery increases the risk for complications, especially PJI.
As the American population ages and a trend toward performing total hip arthroplasty (THA) in younger patients continues, the number of Americans undergoing THA is projected to increase over time. The advent of the bundled payment system combined with the current medical utilization climate has placed considerable pressure on surgeons to produce excellent results with early functional recovery and short hospital stays. The US obesity epidemic has transcended into the arthroplasty patient population and surgeons must assess whether obesity is a risk factor for poor outcomes in THA and determine how it should be managed. We performed a recent literature review to determine how obesity impacts outcomes in total hip arthroplasty and what must be done to improve outcomes in the obese arthroplasty patient. Our goal is to answer 3 questions: does obesity increase the complication rate in THA, if obesity matters how obese is too obese, and what must be done to improve outcomes in the obese patient?. Ultimately, obesity has been shown to correlate with increased post-operative complications in THA. The arthroplasty surgeon must optimise the obese patient prior to surgery by identifying associated comorbidities and consider
Obesity and the diseases linked to it such as diabetes have been associated with higher complication rates and increased medical costs following total hip arthroplasty (THA). Due to the rising prevalence of obesity and the adverse impact it has on the development of osteoarthritis, there has been a worldwide surge in the number of obese patients presenting for THA procedures, including those morbidly obese (BMI > 40) and those who are super-obese (BMI > 50). The Reward. When THA is successful (as is true for the majority of morbidly obese patients) the operation is just as dramatically effective as it is for other patients. Excellent pain relief and dramatically improved function is the result, even though obese patients generally achieve a lower overall level of function than non-obese patients. Morbidly obese patients with a successful THA and without early complications are some of the most grateful of patients. This is especially true if they have been denied surgery for prolonged periods due to their weight and have had to bear severe joint changes and symptoms during a long period of time leading up to arthroplasty. The Risks. There is a nonlinear increase in complications, reoperations, and especially infection with increasing BMI that begins between a BMI of 25 to 30, and rises thereafter with a relative inflection point in some incidence curves for complications at around a BMI of 40. This has caused some surgeons to suggest a BMI of 40 as an upper limit for elective hip arthroplasty. Risks continue to rise after a BMI of 40 and when the BMI is over 50, in our series 52% of patients had at least one complication. Of these 24% had at least one major complication and 33% at least one minor complication with some suffering more than one complication overall. These data make it reasonable to ask whether the outcomes in some morbidly obese patients might be improved by weight loss, bariatric surgical intervention and other measures aimed at optimizing the multiple companion comorbidities and medical conditions (such as diabetes) that often accompany excess weight. Unfortunately there has been limited information to date on the best means for optimizing of these patients, and as important the effectiveness of these interventions, so that the timing and performance of the eventual arthroplasty procedures might have the highest possible success rate. The Costs. The adverse impact of obesity on medical resource utilization and costs associated with THA has been well documented, Due to longer initial length of stay, greater resource utilization, higher early complication rates and any readmissions and reoperations the costs for even a single individual patient can climb dramatically. In a review of data on primary THA patients from our institution, even after adjusting for age, sex, type of surgery, and other comorbidities, for every 5 unit increase in BMI beyond 30 kg/m2 there was an associated $500 higher cost of hospitalization and an increase of $900 in 90-day total costs (p=0.0001). The Future. The numbers of morbidly obese patients with severe osteoarthritis presenting for possible THA will only continue to increase in the years ahead. Comprehensive multidisciplinary programs are urgently needed to better manage obese patients with weight reduction options, optimization of medical comorbidities, and treatment of any associated issues, such as protein
The following checklist is derived from the “Proceedings of the International Consensus Meeting on Peri-prosthetic Joint Infection”, under the auspices of the Musculoskeletal Infection Society, August 1, 2013. It is available online at . http://www.msis-na.org/wp-content/themes/msis-temp/pdf/ism-peri-prosthetic-joint-information.pdf. . Pre-Operative: Patient Factors, AODM, Obesity, Smoking, Immunodeficiency, ASA score > 2, Prior open surgery?, MRSA history, EtOH abuse,
The following checklist is derived from the “Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection”, under the auspices of the Musculoskeletal Infection Society, August 1, 2013. It is available online at . http://www.msis-na.org/wp-content/themes/msis-temp/pdf/ism-periprosthetic-joint-information.pdf. . Pre-Operative: Patient Factors, AODM, Obesity, Smoking, Immunodeficiency, ASA score > 2, Prior open surgery?, MRSA history, EtOH abuse,
1. Reconstruction of Failed Hip Abductors following THA-A New Surgical Technique using Graft Jacket Matrix. 2. A Comparison of Modular Tapered versus Cylindrical Stems for Complex Femoral Revisions. 3. Clinical Presentation and Imaging Results of Patients With Symptomatic Gluteus Medius Tears. 4. Should Patients Undergoing Elective Arthroplasty Be Screened for
Wound complications are much more common following knee arthroplasty as compared to hip arthroplasty, due in part to the precarious blood supply to the knee, as well as the subcutaneous position of the joint. Many, if not most, infections are related to wound problems, and thus avoiding wound problems is a critical issue in knee replacement surgery. Many wound problems are avoidable and can be minimised by care to detail by the surgeon. The important steps are to first identify patients at risk and optimally addressing these risk factors. Patient risk factors include: chronic corticosteroid use, diabetes, rheumatoid arthritis,