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ABSTRACT: The purpose of this study was to determine if adherence to the surgical care improvement project (SCIP) measures could further reduce rate of surgical site infection (SSI) and venous thromboembolism (VTE) in total joint arthroplasty (TJA) patients. We retrospectively identified all patients who underwent primary or revision TJA at our institution between July 2000 and June 2009. After implementation of SCIP measures, rate of superficial SSI increased (0.42% versus 0.60%, P=0.05) while rate of deep SSI decreased from 0.92% to 0.82% (P=0.46). The rate of DVT was 0.92% before and 0.83% after implementation of SCIP (P=0.51); however, rate of PE increased from 0.87% to 1.30% (P=0.002). Our findings indicated that SCIP has not been successful in reducing complications in TJA patients.
The Journal of arthroplasty 04/2013; · 1.79 Impact Factor
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ABSTRACT: We observed a substantial increase in the incidence of pulmonary embolism (PE) after total joint arthroplasty (TJA) when multidetector computerized tomography (MDCT) replaced ventilation-perfusion (V/Q) scans as the diagnostic modality of choice. We questioned whether this resulted from the detection of clinically unimportant PE with the more sensitive MDCT and in 2007 instituted a hypoxia protocol to enhance the detection of PE.
We determined whether this new hypoxia protocol increased the specificity of our workups for suspected clinically important PE in the immediate postoperative period without affecting patient morbidity and mortality.
We compared the frequency of MDCT, V/Q scan and total investigations, incidence of PE, and overall mortality rates in the 3 years prior (January 2003 to December 2006) and 2 years after (January 2007 to November 2009) the implementation of the algorithm.
After instituting the protocol, we observed a trend toward a decrease in the number of patients worked up for PE (4.6 to 4.0 per 100 TJAs, 13.5% decrease). At the same time, there was an increase in the percent of positive findings of PE per workup for PE (23-33 positive PEs per 100 patients, 40.5% increase). All-cause mortality rates decreased for the 30-day period (3.1 to 1.4 per 1000 TJAs, 53.5% decrease) and the 90-day period (5.0 to 2.6 per 1000 TJAs, 48.3% decrease).
With the implementation of this algorithm, the specificity of our management of postoperative hypoxia and suspected clinically important PE improved without affecting patient morbidity or mortality.
Clinical Orthopaedics and Related Research 02/2012; 470(2):497-502. · 2.53 Impact Factor
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ABSTRACT: Preventing pulmonary embolism is a priority after major musculoskeletal surgery. The literature contains discrepant data regarding the influence of anticoagulation on the incidence of pulmonary embolism after joint arthroplasty. The American College of Chest Physicians guidelines recommend administration of oral anticoagulants (warfarin), aiming for an international normalized ratio (INR) level between 2 and 3. However, recent studies show aggressive anticoagulation (INR > 2) can lead to hematoma formation and increased risk of subsequent infection.
We asked whether an INR greater than 2 protects against pulmonary embolism.
We identified 9112 patients with 10,122 admissions for joint arthroplasty between 2004 and 2008. All patients received warfarin for prophylaxis, aiming for an INR level of 2 or lower. We assessed 609 of 10,122 admissions (6%) for pulmonary embolism using CT, ventilation/perfusion scan, or pulmonary angiography, and 163 of 10,122 admissions (1.6%) had a proven pulmonary embolism.
Fifteen of 163 admissions (9%) had an INR greater than 2 before or on the day of workup compared to 35 of 446 admissions (8%) who were negative. We observed no difference between the INR values in patients with or without pulmonary embolism.
We found no clinically relevant difference in the INR values of patients who did or did not develop pulmonary embolism. The risk of bleeding should be weighed against the risk of pulmonary embolism when determining an appropriate target INR for each patient, as an INR less than 2 may reduce the risk of bleeding while still protecting against pulmonary embolism.
Level III, therapeutic study. See Instructions to Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 08/2011; 470(2):547-54. · 2.53 Impact Factor
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ABSTRACT: Although it has been shown that the risk of anterior knee pain is greater in patients with nonresurfaced patellae, it is not exactly clear whether the pain would resolve with secondary resurfacing of the patella. Thirty-nine patients (41 knees) underwent secondary patellar resurfacing between January 2001 and January 2007. The mean age was 66 years. The mean body mass index was 29.2 kg/m(2). The average time from primary total knee arthroplasty to resurfacing procedure was 29 months. The mean follow-up was 54 months. Anterior knee pain was the indication for secondary resurfacing in all patients. Although the clinical and functional knee scores improved significantly for whole cohort, 8 patients (8 knees) were dissatisfied with the outcome of surgery. This study highlights that secondary resurfacing is not an always rewarding procedure and patients need to be consulted appropriately with regard to the outcome.
The Journal of arthroplasty 06/2011; 27(1):21-6. · 1.79 Impact Factor
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ABSTRACT: This study reports the outcome of total hip arthroplasty with use of an uncemented, tapered stem with a 5- to 9-year follow-up. The first 200 consecutive patients (214 hips) undergoing total hip arthroplasty with the Accolade TMZF stem (Stryker Orthopaedics, Mahwah, NJ) were enrolled prospectively. Follow-up for these patients averaged 7.6 years and encompassed review of clinical records as well as review of serial anteroposterior and lateral radiographs. There were 5 revision surgeries for aseptic loosening, 2 cases of infection, instability, and polyethylene wear. Our failure rate, defined as hips needing revision, was 2.6%, and the failure rate due to aseptic loosening of the femoral component was 0.6%. These results demonstrate the high success rate of this implant providing support for its continued use.
The Journal of arthroplasty 04/2011; 26(6):838-41. · 1.79 Impact Factor
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ABSTRACT: Conflicting results are available about the efficacy of routine preoperative autologous donation (PAD) in reducing allogenic blood transfusion during total joint arthroplasty (TJA). This study aimed to determine if PAD is effective in reducing the need for allogenic transfusion after TJA. For this retrospective study, data on 409 patients who received total knee arthroplasty (TKA) and 513 who underwent total hip arthroplasty (THA) from January to June 2005 were evaluated. It is our institutional policy to offer preoperative donation to all patients. Based on patient decision, preoperative hemoglobin, and other factors, PAD may or may not take place. Five hundred forty-six (61%) patients donated on average 1.3 units (range, 1 to 2) of blood. Autologous and allogenic transfusions were respectively performed in 91% (514 patients) and 24% of our cohort. The rate of allogenic transfusion after TKA was lower in the PAD group at 21% versus 27% among the nondonors, although it was not statistically significant (p = 0.10). The allogenic transfusion rate after THA was significantly lower among autologous donors (16% versus 34%, p = 0.003). Advanced age, lower body mass index, simultaneous bilateral arthroplasty, and lower preoperative hemoglobin were independently associated with increased allogenic blood transfusion. PAD seems to be effective in reducing allogenic transfusions after THA but not TKA.
The journal of knee surgery 03/2011; 24(1):25-31.
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ABSTRACT: Squeaking is reportedly a complication in patients having ceramic-on-ceramic total hip implants. The etiology remains unknown and multifactorial with recent studies suggesting a relationship between the audible squeak and implant design. When we evaluated our ceramic-on-ceramic cohort, we noticed squeaking primarily in patients receiving an acetabular system designed with an elevated titanium rim. OBJECTIVES/PURPOSES: We therefore (1) determined the incidence of squeaking among four different ceramic-on-ceramic bearing surfaces used for THA at our institution; (2) evaluated the association between different acetabular designs and the incidence of squeaking; and (3) assessed other potential variables associated with squeaking.
We retrospectively reviewed 1507 patients having a ceramic-on-ceramic THA between 2002 and 2009; we separately analyzed those receiving an acetabular system with and without an elevated titanium rim. Data were collected through phone-administered questionnaires and retrospective reviews of patient charts for intraoperative findings, followup reports, demographic information, and radiographic findings.
Squeaking occurred in 92 of the 1507 patients (6%). All 92 patients with squeaking received an elevated rim design (1291 patients) or an incidence of 7% with that design. We found no association between squeaking and any other examined factors.
Our findings complement the theory from in vitro studies suggesting that neck impingement on the elevated titanium rim is the probable cause of the increased frequency of squeaking with this design.
Clinical Orthopaedics and Related Research 01/2011; 469(6):1598-605. · 2.53 Impact Factor
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ABSTRACT: In 2005, we reported removal of functional restriction after primary THA performed through the anterolateral approach did not increase the incidence of dislocation.
To develop a current practice guideline, we evaluated the incidence of early dislocation after primary THA after implementation of a no-restriction protocol.
Between January 2005 and December 2007, 2532 patients (2764 hips; 1541 women, 1223 men; mean age, 63.2 years [28-98 years]) underwent primary THA at our institution. Bilateral THA was performed in 232 patients (464 hips). The direct anterior or anterolateral approach was used in all patients. Femoral head size was 28, 32, or 36 mm. Patients were given no traditional functional restrictions postoperatively, such as use of elevated seats, abduction pillows, and restriction from driving. All patients received standard care at the judgment of the attending surgeon. One hundred forty-six patients missed followup appointments despite efforts to be contacted by telephone. The remaining 2386 of 2532 patients (94%) had a minimum followup of 6 months (mean, 14.2 months; range, 6-34 months).
Four known dislocations occurred in the followed cohort of 2386 patients with 2612 hips (0.15%) at a mean of 5 days (3-12 days) postoperatively, none related to high-impact trauma. One dislocation occurred in a patient with a history of developmental dysplasia of the hip, two dislocations occurred while at the toilet (one with a previous hip fracture treated with a modular system), and one dislocation was idiopathic.
We confirmed a low incidence of dislocation after primary THA in the absence of early postoperative restrictions. We conclude a no-restriction protocol does not increase the incidence of early dislocation after primary THA.
Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 11/2010; 469(2):417-22. · 2.53 Impact Factor
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ABSTRACT: In recent years, a number of alternative bearing surfaces, such as ceramic on ceramic, are being used in THA. Squeaking after THA is a recently recognized complication; however, its incidence is unknown.
Find the incidence of squeaking; when it ensues; activities associated to squeaking; its natural history, and outcome of revisions for squeaking.
A prospective observational study between 2002 and 2007; yield 1486 ceramic-on-ceramic THA performed at our institution. All patients were followed up by office visits or by phone, to obtain information regarding squeaking, pain and function. Minimum followup was 2.5 years (mean, 5.5 years; range, 2.5-7.9 years).
Ninety-five of the 1486 hips (6%) developed squeaking after THA, 39 females (44%) and 49 males (56%) with an average age of 49.9 years. Squeaking began on average 19.7 months after surgery but not associated with pain or functional impairment in any patient. Squeaking could be heard during walking (38%), ascending stairs (24%), bending forward (21%), and other activities (18%), was constant in 26% of the patients and intermittent in 74%. The intensity and frequency remained similar over time in 70% of the patients.
Squeaking is a real phenomenon that occurred in about 6% of our patients. The etiology for this problem remains elusive and is likely to be multifactorial in nature. Squeaking, when developed, does not seem to be self-limited and persists in the majority. Nine patients underwent revision arthroplasty for squeaking. No fractures or other implant-related issues were observed.
Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 09/2010; 468(9):2340-5. · 2.53 Impact Factor
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ABSTRACT: It is assumed that prevention of deep venous thrombosis (DVT) is likely to lead to a reduction in the incidence of pulmonary embolus (PE). This study examines the association between symptomatic DVT and PE in patients undergoing orthopedic procedures. We reviewed medical records of 1495 patients who underwent evaluation for DVT or PE within 90 days of an index orthopedic procedure at our institution between 2004 and 2008. Only 27 cases were positive for both DVT and PE (1.7% of the total cohort, 10.8% of cases scanned for both DVT and PE). Tests of association, performed across the entire cohort and within specific subsets of patients, did not demonstrate that patients were more likely to have both DVT and PE than to have either DVT or PE. The high association between DVT and PE that is assumed to exist does not seem to hold true for orthopedic surgery patients.
The Journal of arthroplasty 09/2010; 25(6 Suppl):138-44. · 1.79 Impact Factor
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ABSTRACT: The risk of perioperative stroke following cardiac and carotid artery surgery is well documented. There is an apparent lack of recognition and appreciation of this complication after total joint arthroplasty. The present study was designed to determine the prevalence of, and outcome after, perioperative stroke following total joint arthroplasty. In addition, risk factors for the development of this complication were evaluated in an attempt to identify a strategy that could minimize the prevalence of this complication.
We performed an observational study of 18,745 consecutive patients undergoing primary or revision total hip or total knee arthroplasty from 2000 to 2007 at our institution. The institutional perioperative stroke rate was 0.2% (thirty-six of 18,745). The thirty-six patients who had a stroke included seventeen men and nineteen women with a mean age of 68.2 years (range, forty-five to eighty-seven years). The average duration of follow-up for all patients and controls in the present study was sixty-two months (range, zero to 124.9 months). In a predictive model, different patient-related and surgery-related factors that could predispose patients to this complication and/or affect outcome were evaluated.
The first-year mortality among stroke patients was 25% (nine of thirty-six), and four of these nine patients died in the hospital following total joint arthroplasty. Of three patients who received emergency intra-arterial thrombolysis, two had complete neurologic recovery and one died in the hospital. The final regression model showed that a history of noncoronary heart disease, urgent (versus elective) surgery, general (versus regional) anesthesia, and an intraoperative arrhythmia or other alterations in the heart rate during surgery are significant predictors of perioperative stroke.
Perioperative stroke is a rare but potentially devastating complication of total joint arthroplasty, with a high rate of morbidity and mortality. Vigilant attention to prevent, detect, and treat this complication in a timely manner may alter the course of the disease.
The Journal of Bone and Joint Surgery 09/2010; 92(11):2095-101. · 3.27 Impact Factor
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ABSTRACT: Many patients with degenerative joint disease of the hip have substantial degeneration of the lumbar spine. These patients may have back and lower extremity pain develop after THA and it may be difficult to determine whether the source of the pain is the hip or spine.
We therefore: (1) identified the incidence/prevalence of pain in the lower back in a group of patients with end-stage arthritis of the hip undergoing THA; (2) described the natural history of low back pain in this cohort undergoing THA; and (3) determined factors that were predictive of persistent low back pain after THA.
We administered a detailed questionnaire and a diagram of the human body on which the patients could draw the site of their pain, to 344 patients preoperatively, at 6 weeks, 6 months, and 1-year after THA. Before the THA, 170 patients (49.4%) reported pain localized to the lower lumbar region, whereas 174 patients did not have low back pain.
Low back pain was variable in location. Postoperatively, the low back pain resolved in 113 (66.4%) of the 170 patients. Thirty-seven of the remaining 57 patients had known spine disorders. Thirty-five of the 174 patients (20%) without prior low back pain had low back pain develop within 1 year postoperatively. The low back pain improved in 17 of these 35 patients; 12 of the remaining 18 patients had preexistent spine disorders. Pain radiating below the knee was associated most closely with preexisting spine disorders.
Hip and spine arthritis often coexist. Most patients who presented with hip arthritis and lower lumbar pain experienced resolution or improvement of their pain after THA.
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 05/2010; 468(5):1325-30. · 2.53 Impact Factor
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ABSTRACT: Pulmonary embolism (PE) is a potentially fatal complication of total joint arthroplasty. Therefore, it is essential to have reliable means for diagnosis and evaluation of severity. In the study reported here, we evaluated the reliability of common clinical signs and symptoms in the diagnosis of PE. In addition, we used correlation analysis to assess for a correlation between clinical presentation and size and location of the embolus within the pulmonary vasculature. Included in this study were 13,133 patients who underwent total joint arthroplasty between 2000 and 2005. PE was diagnosed in 144 patients (1.1%). Shortness of breath (31.9%) and hypotension (30.6%) were the most frequent symptom and sign. Oxygen desaturation was the only indication for investigation of PE in 10% of patients. A pulse-oximetry reading of less than 90% was present in 63% of patients, and 92% of patients presented with an increased alveolar-arterial gradient. Overall, clinical signs and symptoms as well as severity of hypoxia did not correlate with size and location of PE. Patients with PE demonstrated a significant decrease in arterial oxygen content; an abnormal alveolar-arterial gradient was the most consistent finding in these patients. Common clinical signs and symptoms, as well as changes in vital signs, have a low sensitivity for diagnosis.
American journal of orthopedics (Belle Mead, N.J.) 04/2010; 39(4):185-9.
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ABSTRACT: An extended-release epidural morphine (EREM) has been introduced to improve postoperative pain management. Studies have shown the effectiveness of this agent in providing better pain control and patient satisfaction for patients undergoing total joint arthroplasty. We evaluated postoperative pain relief by comparing average daily pain scores and opioid use with those of the control group. Safety was measured by comparing the occurrence of postoperative complications, nausea and vomiting, pruritus, and respiratory depression between the two groups. Between February 2006 and March 2008, we selected 203 patients to receive EREM for THA. These patients were matched in a 2:1 ratio with patients undergoing THA and receiving spinal anesthesia. We retrospectively reviewed all major and minor postoperative complications from a prospective database. Patients receiving EREM had lower pain scores than patients not receiving EREM on Postoperative Day 1 (POD 1) but not POD 2, or POD 3. Patients receiving EREM experienced a slightly higher incidence of pulmonary embolism and supraventricular tachycardia. Patients receiving EREM also experienced more nausea and vomiting and pruritus. We found EREM provided better pain relief on POD 1 at the expense of a slightly higher incidence of side effects compared with spinal anesthesia alone. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Clinical Orthopaedics and Related Research 12/2009; 468(4):1082-7. · 2.53 Impact Factor
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ABSTRACT: Total joint arthroplasty (TJA) is categorized as a major risk factor for thromboembolic complications. The importance of hypoxemia during the postoperative period is subject of controversy. This prospective study elucidates the incidence and etiology of hypoxemia after TJA. Furthermore, we intended to assess the predictive value of clinical findings in identifying the etiology of hypoxemia after TJA. Of 1971 patients, 78 (4.0%) experienced an acute episode of hypoxemia during their hospitalization after TJA. Hypoxemia as the initial presenting sign, predicted major complications, defined as life-threatening if left untreated, in 32% of the hypoxic population. These diagnoses included pulmonary embolism, pulmonary edema, and pneumonia. Tachypnea was the only independent factor associated with pulmonary embolism. Our study presents the incidence and etiology of hypoxemia after TJA, and we recommend a heightened appreciation for the hypoxemic patient.
The Journal of arthroplasty 11/2008; 23(7):1016-21. · 1.79 Impact Factor
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ABSTRACT: The orthopedic community continues to face a challenge with regard to the prevention of thromboembolism after total joint arthroplasty. The first and foremost issue facing surgeons is how to select the best agent or modality that is effective in preventing the untoward consequences of thromboembolism without causing other complications that can have dire consequences. Other challenges include the uncertainty regarding the dose and duration of various agents, the value of mechanical prophylaxis alone, and the exact end points that should be used to measure the efficacy of prophylaxis. This article discusses some of the recent developments in prevention and management of thromboembolism after total joint arthroplasty, in particular highlighting the guidelines that were developed by American Academy of Orthopedic Surgeons.
The Journal of arthroplasty 10/2008; 23(7 Suppl):2-5. · 1.79 Impact Factor
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ABSTRACT: Total joint arthroplasty is a safe and successful procedure. However, numerous complications may present after elective arthroplasty. This study prospectively collected data on systemic and local in hospital complications after 15383 joint arthroplasties, which included 8230 total hip arthroplasties and 7153 total knee arthroplasties. In general, the incidence of complications was higher after knee arthroplasty, simultaneous bilateral surgery, and revision surgery. There were 22 (0.16%) deaths in this cohort. We identified 486 major systemic complications, the most common was pulmonary embolism (152), followed by tachyarrhythmia (92) and acute myocardial infarction (36). There were 109 major local complications, including 16 vascular injuries, 29 peripheral nerve injuries, 25 periprosthetic fractures, and 18 dislocations. Total joint arthroplasty, despite its success, can be associated with rare serious and life-threatening complications. This study provides a baseline of complications that can occur after elective joint arthroplasty.
The Journal of arthroplasty 10/2008; 23(6 Suppl 1):139-45. · 1.79 Impact Factor
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ABSTRACT: Vascular injuries, although highly feared, can occur after total joint arthroplasty, often resulting in legal suits. This study evaluates the circumstances related to vascular injuries after joint arthroplasty. Using prospectively collected data on 13,517 patients undergoing total joint arthroplasty at our institution, 16 (0.1%) vascular injuries were identified. Eleven injuries occurred after total knee arthroplasty (TKA) and 5 after total hip arthroplasty (THA). Indirect injury was the most common mechanism in TKA. In contrast, direct injury was most prevalent in THA. One patient died of complications related to vascular injury. Of 16 patients, 8 (50%) had launched a legal suit against the operating surgeon. There appears to be no further specific measure that can be taken to absolutely avoid this complication. Patient awareness regarding this real problem may play a role in defraying the high likelihood of legal suits associated with this complication.
The Journal of arthroplasty 09/2008; 23(8):1115-21. · 1.79 Impact Factor
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ABSTRACT: Noisy ceramics bearing surfaces are a recently recognized problem in total hip arthroplasty. Component malposition as a potential cause has been proposed. Squeaking occurred in 28 (2.7%) of 999 patients undergoing ceramic on ceramic total hip arthroplasty at our institution. Patients were matched, in a 1:2 ratio by anthropometric and demographic variables and also prosthesis size and type. The acetabular position was measured using radiographs and computed tomography. There was no statistically significant difference in cup inclination (P = .25) or version (P = .38) between groups. Four hips that have been revised were available for retrieval analysis. Stripe wear and metal transfer to ceramic components were observed. Etiology of squeaking ceramic total hip arthroplasty remains elusive. Although malposition could be an important contributing factor, the latter cannot be the sole reason based on our findings. Further investigation to elucidate the etiology is warranted.
The Journal of arthroplasty 08/2008; 23(5):643-9. · 1.79 Impact Factor
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ABSTRACT: We evaluated the incidence and risk factors for postoperative ileus (POI) after total joint arthroplasty in a consecutive group of patients between January 2004 and December 2005 using regional anesthesia and multimodal pain management protocols. Postoperative ileus developed in 31 (0.7%) of 4567 patients. Of these patients, 21 (67.7%) were men, and 10 (32.3%) were women, with a mean age of 68 years (range, 52-91 years). The ileus was treated successfully in 29 patients during the hospitalization. One patient died from this complication, and another one required sigmoid colon resection due to perforation. The risk factors for developing POI after joint arthroplasty were older age, male sex, hip arthroplasty, and prior history of abdominal surgery. The type and dose of narcotic medications, as administered using our current protocol, did not appear to influence the development of POI.
The Journal of Arthroplasty 05/2008; 23(3):360-5. · 2.38 Impact Factor
