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The Bone & Joint Journal
Vol. 104-B, Issue 6 | Pages 696 - 702
1 Jun 2022
Kvarda P Puelacher C Clauss M Kuehl R Gerhard H Mueller C Morgenstern M

Aims. Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort. Methods. We prospectively included consecutive patients at high cardiovascular risk (defined as age ≥ 45 years with pre-existing coronary, peripheral, or cerebrovascular artery disease, or any patient aged ≥ 65 years, plus a postoperative hospital stay of > 24 hours) undergoing septic or aseptic major orthopaedic surgery between July 2014 and October 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T. All-cause mortality was assessed at one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery for PJI or FRI, and patients receiving aseptic major bone and joint surgery. Results. In total, 911 consecutive patients were included. The overall perioperative myocardial injury (PMI) rate was 15.4% (n = 140). Septic revision surgery for PJI was associated with a significantly higher PMI rate (43.8% (14/32) vs 14.5% (57/393); p = 0.001) and one-year mortality rate (18.6% (6/32) vs 7.4% (29/393); p = 0.038) compared to aseptic revision or primary arthroplasty. The association with PMI persisted in multivariable analysis with an adjusted odds ratio (aOR) of 4.7 (95% confidence interval (CI) 2.1 to 10.7; p < 0.001), but was not statistically significant for one-year mortality (aOR 1.9 (95% CI 0.7 to 5.4; p = 0.240). PMI rate (15.2% (5/33) vs 14.1% (64/453)) and one-year mortality (15.2% (5/33) vs 9.1% (41/453)) after FRI revision surgery were comparable to aseptic long-bone fracture surgery. Conclusion. Patients undergoing revision surgery for PJI were at a risk of PMI and death compared to those undergoing aseptic arthroplasty surgery. Screening for PMI and treatment in specialized multidisciplinary units should be considered in major bone and joint infections. Cite this article: Bone Joint J 2022;104-B(6):696–702


Bone & Joint Open
Vol. 4, Issue 11 | Pages 899 - 905
24 Nov 2023
Orfanos G Nantha Kumar N Redfern D Burston B Banerjee R Thomas G

Aims. We aim to evaluate the usefulness of postoperative blood tests by investigating the incidence of abnormal results following total joint replacement (TJR), as well as identifying preoperative risk factors for abnormal blood test results postoperatively, especially pertaining to anaemia and acute kidney injury (AKI). Methods. This is a retrospective cohort study of patients who had elective TJR between January and December 2019 at a tertiary centre. Data gathered included age at time of surgery, sex, BMI, American Society of Anesthesiologists (ASA) grade, preoperative and postoperative laboratory test results, haemoglobin (Hgb), white blood count (WBC), haematocrit (Hct), platelets (Plts), sodium (Na. +. ), potassium (K. +. ), creatinine (Cr), estimated glomerular filtration rate (eGFR), and Ferritin (ug/l). Abnormal blood tests, AKI, electrolyte imbalance, anaemia, transfusion, reoperation, and readmission within one year were reported. Results. The study included 2,721 patients with a mean age of 69 years, of whom 1,266 (46.6%) were male. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥ 65 years), female sex, and ASA grade ≥ III as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dl) and packed cell volume (≤ 0.395 l/l) were noted to be significant risk factors for postoperative anaemia, and potassium (≤ 3.7 mmol/l) was noted to be a significant risk factor for AKI. Conclusion. The costs outweigh the benefits of ordering routine postoperative blood tests in TJR patients. Clinicians should risk-stratify their patients and have a lower threshold for ordering blood tests in patients with abnormal preoperative haemoglobin (≤ 127 g/l), blood loss > 300 ml, chronic kidney disease, ASA grade ≥ III, and clinical concern. Cite this article: Bone Jt Open 2023;4(11):899–905


Bone & Joint Open
Vol. 4, Issue 5 | Pages 357 - 362
17 May 2023
Naathan H Ilo K Berber R Matar HE Bloch B

Aims. It is common practice for patients to have postoperative blood tests after total joint replacement (TJR). However, there have been significant improvements in perioperative care with arthroplasty surgery, and a drive to reduce the length of stay (LOS) and move towards day-case TJR. We should reconsider whether this intervention is necessary for all patients. Methods. This retrospective study included all patients who underwent a primary unilateral TJR at a single tertiary arthroplasty centre during a one-year period. Electronic medical records of 1,402 patients were reviewed for patient demographics, LOS, and American Society of Anesthesiologists (ASA) grade. Blood tests were examined to investigate the incidence of postoperative anaemia, electrolyte abnormalities, and incidence of acute kidney injury (AKI). Results. For total knee arthroplasties, preoperative (R = −0.22) and postoperative haemoglobin (R = 0.2) levels were both negatively correlated with LOS (p < 0.001). For all patients who had undergone a TJR, 19 patients (0.014%) required a blood transfusion postoperatively due to symptomatic anaemia. Risk factors identified were age, preoperative anaemia, and long-term aspirin use. Significant abnormal sodium levels were found in123 patients (8.7%). However, only 36 patients (2.6%) required intervening treatment. Risk factors identified were age, preoperative abnormal sodium level, and long-term use of non-steroidal anti-inflammatory drugs, angiotensin receptor blockers, and corticosteroids. Similarly, abnormal potassium levels were evident in 53 patients (3.8%), and only 18 patients (1.3%) required intervening treatment. Risk factors identified were preoperative abnormal potassium level, and long-term use of angiotensin-converting enzyme inhibitors and diuretics. The incidence of AKI was 4.4% (61 patients). Risk factors identified were age, increased ASA grade, preoperative abnormal sodium, and creatinine level. Conclusion. Routine blood tests after primary TJR is unnecessary for most patients. Blood tests should only be performed on those with identifiable risk factors such as preoperative anaemia and electrolyte abnormalities, haematological conditions, long-term aspirin use, and electrolyte-altering medications. Cite this article: Bone Jt Open 2023;4(5):357–362


The Bone & Joint Journal
Vol. 105-B, Issue 6 | Pages 649 - 656
1 Jun 2023
Dagneaux L Amundson AW Larson DR Pagnano MW Berry DJ Abdel MP

Aims

Nonagenarians (aged 90 to 99 years) have experienced the fastest percent decile population growth in the USA recently, with a consequent increase in the prevalence of nonagenarians living with joint arthroplasties. As such, the number of revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) in nonagenarians is expected to increase. We aimed to determine the mortality rate, implant survivorship, and complications of nonagenarians undergoing aseptic revision THAs and revision TKAs.

Methods

Our institutional total joint registry was used to identify 96 nonagenarians who underwent 97 aseptic revisions (78 hips and 19 knees) between 1997 and 2018. The most common indications were aseptic loosening and periprosthetic fracture for both revision THAs and revision TKAs. Mean age at revision was 92 years (90 to 98), mean BMI was 27 kg/m2 (16 to 47), and 67% (n = 65) were female. Mean time between primary and revision was 18 years (SD 9). Kaplan-Meier survival was used for patient mortality, and compared to age- and sex-matched control populations. Reoperation risk was assessed using cumulative incidence with death as a competing risk. Mean follow-up was five years.


Bone & Joint Open
Vol. 5, Issue 4 | Pages 367 - 373
26 Apr 2024
Reinhard J Lang S Walter N Schindler M Bärtl S Szymski D Alt V Rupp M

Aims

Periprosthetic joint infection (PJI) demonstrates the most feared complication after total joint replacement (TJR). The current work analyzes the demographic, comorbidity, and complication profiles of all patients who had in-hospital treatment due to PJI. Furthermore, it aims to evaluate the in-hospital mortality of patients with PJI and analyze possible risk factors in terms of secondary diagnosis, diagnostic procedures, and complications.

Methods

In a retrospective, cross-sectional study design, we gathered all patients with PJI (International Classification of Diseases (ICD)-10 code: T84.5) and resulting in-hospital treatment in Germany between 1 January 2019 and 31 December 2022. Data were provided by the Institute for the Hospital Remuneration System in Germany. Demographic data, in-hospital deaths, need for intensive care therapy, secondary diagnosis, complications, and use of diagnostic instruments were assessed. Odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality were calculated.


The Bone & Joint Journal
Vol. 106-B, Issue 9 | Pages 935 - 941
1 Sep 2024
Ailaney N Guirguis PG Ginnetti JG Balkissoon R Myers TG Ramirez G Thirukumaran CP Ricciardi BF

Aims

The purpose of this study was to determine the association between prior sleeve gastrectomy in patients undergoing primary total hip and knee arthroplasty, and 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up.

Methods

This is a retrospective, single-centre analysis. Patients undergoing primary hip or knee arthroplasty with a prior sleeve gastrectomy were eligible for inclusion (n = 80 patients). A morbidly obese control group was established from the same institutional registry using a 1:2 match, for cases:controls with arthroplasty based on propensity score using age, sex, pre-sleeve gastrectomy BMI, Current Procedural Terminology code to identify anatomical location, and presurgical haemoglobin A1C. Outcomes included 90-day complications, incidence of revision arthroplasty, and patient-reported outcome scores at final follow-up. Multivariable logistic regressions evaluated associations of underlying preoperative demographic and treatment characteristics with outcomes.


Aims

The aim of this study was to evaluate the healthcare costs and benefits of enoxaparin compared to aspirin in the prevention of symptomatic venous thromboembolism (VTE) after total hip arthroplasty (THA) or total knee arthroplasty (TKA) using data from the CRISTAL trial.

Methods

This trial-based economic analysis reports value for money as incremental cost per quality-adjusted life-year (QALY) gained in 2022 Australian dollars, compared to a single threshold value of AUD$70,000 per QALY. Event costs were estimated based on occurrence of VTEs and bleeds, and on published guidelines for treatment. Unit costs were taken from Australian sources. QALYs were estimated using CRISTAL six-month follow-up data. Sensitivity analyses are presented that vary the cost of VTE treatment, and extend the analyses to two years.


The Bone & Joint Journal
Vol. 105-B, Issue 5 | Pages 526 - 533
1 May 2023
Harmer JR Wyles CC Duong SQ Morgan III RJ Maradit-Kremers H Abdel MP

Aims

The aim of this study was to determine the prevalence of depressive and anxiety disorders prior to total hip (THA) and total knee arthroplasty (TKA) and to assess their impact on the rates of any infection, revision, or reoperation.

Methods

Between January 2000 and March 2019, 21,469 primary and revision arthroplasties (10,011 THAs; 11,458 TKAs), which were undertaken in 15,504 patients at a single academic medical centre, were identified from a 27-county linked electronic medical record (EMR) system. Depressive and anxiety disorders were identified by diagnoses in the EMR or by using a natural language processing program with subsequent validation from review of the medical records. Patients with mental health diagnoses other than anxiety or depression were excluded.


The Bone & Joint Journal
Vol. 105-B, Issue 8 | Pages 888 - 894
1 Aug 2023
Murray J Jeyapalan R Davies M Sheehan C Petrie M Harrison T

Aims

Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit.

Methods

Data were collected retrospectively from a large tertiary referral revision arthroplasty unit’s database. Inclusion criteria included all patients who underwent TFA in our unit. Preoperative demographics, operative factors, and short- and long-term outcomes were collected for analysis. Outcome was defined using the Musculoskeletal Infection Society (MSIS) outcome reporting tool.


Bone & Joint Open
Vol. 5, Issue 2 | Pages 139 - 146
15 Feb 2024
Wright BM Bodnar MS Moore AD Maseda MC Kucharik MP Diaz CC Schmidt CM Mir HR

Aims

While internet search engines have been the primary information source for patients’ questions, artificial intelligence large language models like ChatGPT are trending towards becoming the new primary source. The purpose of this study was to determine if ChatGPT can answer patient questions about total hip (THA) and knee arthroplasty (TKA) with consistent accuracy, comprehensiveness, and easy readability.

Methods

We posed the 20 most Google-searched questions about THA and TKA, plus ten additional postoperative questions, to ChatGPT. Each question was asked twice to evaluate for consistency in quality. Following each response, we responded with, “Please explain so it is easier to understand,” to evaluate ChatGPT’s ability to reduce response reading grade level, measured as Flesch-Kincaid Grade Level (FKGL). Five resident physicians rated the 120 responses on 1 to 5 accuracy and comprehensiveness scales. Additionally, they answered a “yes” or “no” question regarding acceptability. Mean scores were calculated for each question, and responses were deemed acceptable if ≥ four raters answered “yes.”


The Bone & Joint Journal
Vol. 104-B, Issue 9 | Pages 1060 - 1066
1 Sep 2022
Jin X Gallego Luxan B Hanly M Pratt NL Harris I de Steiger R Graves SE Jorm L

Aims

The aim of this study was to estimate the 90-day periprosthetic joint infection (PJI) rates following total knee arthroplasty (TKA) and total hip arthroplasty (THA) for osteoarthritis (OA).

Methods

This was a data linkage study using the New South Wales (NSW) Admitted Patient Data Collection (APDC) and the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), which collect data from all public and private hospitals in NSW, Australia. Patients who underwent a TKA or THA for OA between 1 January 2002 and 31 December 2017 were included. The main outcome measures were 90-day incidence rates of hospital readmission for: revision arthroplasty for PJI as recorded in the AOANJRR; conservative definition of PJI, defined by T84.5, the PJI diagnosis code in the APDC; and extended definition of PJI, defined by the presence of either T84.5, or combinations of diagnosis and procedure code groups derived from recursive binary partitioning in the APDC.


Bone & Joint Open
Vol. 2, Issue 11 | Pages 966 - 973
17 Nov 2021
Milligan DJ Hill JC Agus A Bryce L Gallagher N Beverland D

Aims

The aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis.

Methods

Between May and December 2019, 100 patients requiring hip or knee arthroplasty were enrolled with the intention that each would have a preadmission discharge plan, a preoperative education class with nominated helper, a day of surgery admission and mobilization, a day one discharge, and access to a 24/7 dedicated helpline. Each was matched with a patient under the pre-existing pathway from the previous year.


Bone & Joint Open
Vol. 2, Issue 10 | Pages 871 - 878
20 Oct 2021
Taylor AJ Kay RD Tye EY Bryman JA Longjohn D Najibi S Runner RP

Aims

This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events.

Methods

A retrospective review of 124 consecutive primary arthroplasty procedures performed after resuming elective procedures on 11 May 2020 were compared to the previous 124 consecutive patients treated prior to 17 March 2020, at a single urban safety net hospital. Revision arthroplasty and patients with < 90-day follow-up were excluded. The primary outcome measures were hospital LOS and the number of SDDs. Secondary outcome measures included 90-day complications, 90-day readmissions, and 30day emergency department (ED) visits.


Bone & Joint Open
Vol. 2, Issue 8 | Pages 671 - 678
19 Aug 2021
Baecker H Frieler S Geßmann J Pauly S Schildhauer TA Hanusrichter Y

Aims

Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI.

Methods

From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined.


The Bone & Joint Journal
Vol. 103-B, Issue 3 | Pages 515 - 521
1 Mar 2021
van den Kieboom J Tirumala V Box H Oganesyan R Klemt C Kwon Y

Aims

Removal of infected components and culture-directed antibiotics are important for the successful treatment of chronic periprosthetic joint infection (PJI). However, as many as 27% of chronic PJI patients yield negative culture results. Although culture negativity has been thought of as a contraindication to one-stage revision, data supporting this assertion are limited. The aim of our study was to report on the clinical outcomes for one-stage and two-stage exchange arthroplasty performed in patients with chronic culture-negative PJI.

Methods

A total of 105 consecutive patients who underwent revision arthroplasty for chronic culture-negative PJI were retrospectively evaluated. One-stage revision arthroplasty was performed in 30 patients, while 75 patients underwent two-stage exchange, with a minimum of one year's follow-up. Reinfection, re-revision for septic and aseptic reasons, amputation, readmission, mortality, and length of stay were compared between the two treatment strategies.


Bone & Joint Research
Vol. 9, Issue 6 | Pages 302 - 310
1 Jun 2020
Tibbo ME Limberg AK Salib CG Turner TW McLaury AR Jay AG Bettencourt JW Carter JM Bolon B Berry DJ Morrey ME Sanchez-Sotelo J van Wijnen AJ Abdel MP

Aims

Arthrofibrosis is a relatively common complication after joint injuries and surgery, particularly in the knee. The present study used a previously described and validated rabbit model to assess the biomechanical, histopathological, and molecular effects of the mast cell stabilizer ketotifen on surgically induced knee joint contractures in female rabbits.

Methods

A group of 12 skeletally mature rabbits were randomly divided into two groups. One group received subcutaneous (SQ) saline, and a second group received SQ ketotifen injections. Biomechanical data were collected at eight, ten, 16, and 24 weeks. At the time of necropsy, posterior capsule tissue was collected for histopathological and gene expression analyses (messenger RNA (mRNA) and protein).


The Bone & Joint Journal
Vol. 102-B, Issue 3 | Pages 336 - 344
1 Mar 2020
Ji B Li G Zhang X Wang Y Mu W Cao L

Aims

In the absence of an identified organism, single-stage revision is contraindicated in prosthetic joint infection (PJI). However, no studies have examined the use of intra-articular antibiotics in combination with single-stage revision in these cases. In this study, we present the results of single-stage revision using intra-articular antibiotic infusion for treating culture-negative (CN) PJI.

Methods

A retrospective analysis between 2009 and 2016 included 51 patients with CN PJI who underwent single-stage revision using intra-articular antibiotic infusion; these were compared with 192 culture-positive (CP) patients. CN patients were treated according to a protocol including intravenous vancomycin and a direct intra-articular infusion of imipenem and vancomycin alternately used in the morning and afternoon. In the CP patients, pathogen-sensitive intravenous (IV) antibiotics were administered for a mean of 16 days (12 to 21), and for resistant cases, additional intra-articular antibiotics were used. The infection healing rate, Harris Hip Score (HHS), and Hospital for Special Surgery (HSS) knee score were compared between CN and CP groups.


The Bone & Joint Journal
Vol. 100-B, Issue 4 | Pages 455 - 460
1 Apr 2018
Mumith A Thomas M Shah Z Coathup M Blunn G

Increasing innovation in rapid prototyping (RP) and additive manufacturing (AM), also known as 3D printing, is bringing about major changes in translational surgical research.

This review describes the current position in the use of additive manufacturing in orthopaedic surgery.

Cite this article: Bone Joint J 2018;100-B:455-60.


The Bone & Joint Journal
Vol. 99-B, Issue 7 | Pages 921 - 926
1 Jul 2017
Märdian S Perka C Schaser K Gruner J Scheel F Schwabe P

Aims

Periprosthetic fracture is a significant complication of total hip and knee arthroplasty. This study aimed to describe the survival of patients sustaining periprosthetic femoral fractures and compare this with that of the general population, as well as to identify the factors that influence survival.

Patients and Methods

A total of 151 patients (women: men 116:35, mean age 74.6 years, standard deviation 11.5) that sustained a periprosthetic fracture between January 2005 and October 2012 were retrospectively analysed. Epidemiological data, comorbidities, type of surgical management, type of implant, and mortality data were studied.


The Bone & Joint Journal
Vol. 99-B, Issue 12 | Pages 1603 - 1610
1 Dec 2017
Dattilo J Gittings D Sloan M Charette R Hume E Lee G

Aims

To evaluate the effectiveness of an institutionally developed algorithm for evaluation and diagnosis of prosthetic joint injection and to determine the impact of this protocol on overall hospital re-admissions.p

Patients and Methods

We retrospectively evaluated 2685 total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients prior to (1263) and following (1422) the introduction of an infection detection protocol. The protocol used conservative thresholds for C-reactive protein to direct the medical attendant to aspirate the joint. The protocol incorporated a clear set of laboratory and clinical criteria that allowed a patient to be discharged home if all were met. Patients were included if they presented to our emergency department within 120 days post-operatively with concerns for swelling, pain or infection and were excluded if they had an unambiguous infection or if their chief complaint was non-orthopaedic in nature.