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The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review

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Abstract

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive. PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics. Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI. Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described. The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available. Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054

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... However, risk of infection associated with pharmacological VTE prophylaxis was another important issue that has not been well evaluated. Pharmacological VTE prophylaxis might lead to (1) postoperative hematoma, which acts as a nidus for bacteria to settle, and (2) prolonged wound drainage, which increases wound tension, bypasses the natural barrier of the skin, increases risk of wound dehiscence and provides a retrograde pathway for pathogens 8,11,16 , but whether the pharmacological agents for prophylaxis would increase the risk of infection following TJA procedures was inconsistent 7 . The rates of SSC were generally higher in studies with routine pharmacological VTE prophylaxis than those studies in which pharmacological VTE prophylaxis were not routinely [17][18][19][20] . ...
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Background: Venous thromboembolism (VTE) prophylaxis has been suggested for patients who underwent total join arthroplasty (TJA). However, the morbidity of surgical site complications (SSC) and periprosthetic joint infection (PJI) has not been well evaluated. We aimed to evaluate the impact of VTE prophylaxis on the risk of early postoperative SSC and PJI in a Taiwanese population. Methods: We retrospectively reviewed 7511 patients who underwent primary TJA performed by a single surgeon from 2010 through 2019. We evaluated the rates of SSC and PJI in the early postoperative period (30-day, 90-day) as well as 1-year reoperations. Multivariate regression analysis was used to identify possible risk factors associated with SSC and PJI, including age, sex, WHO classification of weight status, smoking, diabetes mellitus (DM), rheumatoid arthritis(RA), Charlson comorbidity index (CCI), history of VTE, presence of varicose veins, total knee or hip arthroplasty procedure, unilateral or bilateral procedure, or receiving VTE prophylaxis or blood transfusion. Results: The overall 90-day rates of SSC and PJI were 1.1% (N=80) and 0.2% (N=16). VTE prophylaxis was a risk factor for 90-day readmission for SSC (aOR: 1.753, 95% CI:1.081-2.842), 90-day readmission for PJI (aOR: 3.267, 95% CI:1.026-10.402) and all 90-day PJI events (aOR: 3.222, 95% CI:1.200-8.656). Other risk factors included DM, underweight, obesity, bilateral TJA procedure, younger age, male sex and RA. Conclusion: Pharmacological thromboprophylaxis appears to be a modifiable risk factor for SSC and PJI in the early postoperative period. The increased infection risk should be carefully weighed in patients who received pharmacological VTE prophylaxis.
... However, patients undergoing knee replacement are prone to postoperative complications such as pain, deep vein thrombosis, and pulmonary infection, in particular, the elderly patients with comorbid basic diseases such as diabetes mellitus and hypertension tend to have abnormal blood glucose index and blood pressure index, leading to higher complication rates [4,5] and resulting in significantly increased length of hospital stay and hospital costs. To improve the surgical outcomes of elderly patients, current clinical efforts have been devoted to promoting the concept of enhanced recovery after surgery (ERAS), which refers to a multidisciplinary approach in the perioperative period to scientifically and effectively reduce the perioperative stress response and complication rate, thus reducing the incidence of infectious complications and chronic complications and achieving the goal of rapid rehabilitation [6,7]. At present, ERAS concept has been mostly used in gastrointestinal surgery and urinary surgery [8], and most studies only focused on the effect of ERAS concept on patients' surgical indicators and QOL, and lacked the exploration of the central role of ERAS, i.e., reducing stress levels. ...
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Purpose: This retrospective study aimed to evaluate the benefits of closed suction drainage (CSD) in hybrid total hip arthroplasty (THA) with intra-articular administration of tranexamic acid (TXA). Methods: We included 369 hips that underwent primary hybrid THA between November 2015 and September 2020. We compared peri-operative blood test results, blood loss, and post-operative complications including transfusion, wound complications, and venous thromboembolism (VTE) with or without CSD. Propensity score matching was performed to balance baseline patient demographics. Results: Transfusion, wound complications, and VTE were observed in 1.9% (seven), 2.4% (nine), and 2.2% (eight) of hips, respectively. There were no significant differences in transfusion, blood loss, wound complications, and deep venous thrombosis in both overall patients and propensity score-matched patients with or without CSD. The calculated total blood loss was approximately 600 ml and showed no significant difference between the two groups in the matched cohort (p = 0.59). Conclusion: CSD does not provide any benefits and is not needed in primary hybrid THA with intra-articular administration of TXA.
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Background Perioperative antibiotic prophylaxis in non-infected orthopedic surgery is evident, in contrast to prophylaxis during surgery for infection. Epidemiological data are lacking for this particular situation. Methods and findings It is a single-center cohort on iterative surgical site infections (SSIs) in infected orthopedic patients. We included 2480 first episodes of orthopedic infections (median age 56 years and 833 immune-suppressed): implant-related infections (n = 648), osteoarticular infections (1153), and 1327 soft tissue infections. The median number of debridement was 1 (range, 1–15 interventions). Overall, 1617 infections (65%) were debrided once compared to 862 cases that were operated multiple times (35%). Upon iterative intraoperative tissue sampling, we detected pathogens in 507 cases (507/862; 59%), of which 241 (242/507; 48%) corresponded to the initial species at the first debridement. We witnessed 265 new SSIs (11% of the cohort) that were resistant to current antibiotic therapy in 174 cases (7% of the cohort). In multivariate analysis, iterative surgical debridements that were performed under current antibiotic administration were associated with new SSIs (odds ratio 1.6, 95%CI 1.2–2.2); mostly occurring after the 2nd debridement. However, we failed to define an ideal hypothetic prophylaxis during antibiotic therapy to prevent further SSIs. Conclusions Selection of new pathogens resistant to ongoing antibiotic therapy occurs frequently during iterative debridement in orthopedic infections, especially after the 2nd debridement. The new pathogens are however unpredictable. The prevention, if feasible, probably relies on surgical performance and wise indications for re-debridement instead of new maximal prophylactic antibiotic coverage in addition to current therapeutic regimens.
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Background: This meta-analysis was performed to determine the efficacy of negative pressure wound therapy (NPWT) versus conventional wound dressings for closed incisions in orthopedic trauma surgery. Methods: A systematic search was performed in PubMed, Embase, and the Cochrane Library databases. The outcome measures included deep surgical site infection (SSI), superficial SSI; wound dehiscence and length of hospital stay. Cochrane collaboration's tool and the Newcastle-Ottawa Scale (NOS) were used to evaluate literature qualities. Meta-analysis was performed using RevMan 5.3 software. Results: A total of 6 studies including 2 randomized controlled trials (RCTs) and 4 cohort studies met our inclusion criteria. NPWT resulted in a significantly lower incidence of deep SSI, superficial SSI, and wound dehiscence than conventional wound dressings. However, no statistically significant difference was found in the length of hospital stay. Conclusions: NPWT appeared to be an efficient alternative to help prevent SSIs and wound dehiscence on closed incisions in orthopedic trauma surgery. Rational use of NWPT should be based on the presence of patient's condition and risk factors.
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Background: Persistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJIs), arguably the most dreaded complication after total joint arthroplasty (TJA). The aim of this study was to identify the risk factors for PWD and provide a stepwise management protocol for it. Methods: A retrospective review of 4873 TJAs was performed. After determining patients with PWD, a logistic regression model was designed to identify the risk factors using Charlson and Elixhauser comorbidity indexes. Finally, the protocol that was instituted for the management of PWD and its success rate was presented. Results: The prevalence of PWD was 6.2% (302 of 4873). Of these, 196 did not require any surgical interventions, and drainage stopped with local wound care. 106 patients required surgical intervention, of which, 64 underwent superficial irrigation and debridement and 42 underwent deep irrigation and debridement with modular components exchange. Patients with PWD had significantly higher rates of PJI (odds ratio [OR]: 16.9; 95% confidence interval [CI]: 9.1-31.6). Risks factors were diabetes (OR: 21.2; 95% CI: 12.8-25.1), morbid obesity (OR: 17.3; 95% CI: 14.7-21.5), rheumatoid arthritis (OR: 14.2; 95% CI: 11.7-16.5), chronic alcohol use (OR: 4.3; 95% CI: 2.3-6.1), hypothyroidism (OR: 2.8; 95% CI: 1.3-4.2), and female gender (OR: 1.9; 95% CI: 1.1-2.2). Conclusions: Several modifiable risk factors of PWD were identified. Surgeons must be cognizant of these comorbidities and optimize patients' general health before an elective TJA. Our results demonstrated that PWD ceased in about 65% of the patients with local wound care measures alone. Patients with PWD were at substantially higher risk for PJI.
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Background: Persistent wound drainage after total joint arthroplasty (TJA) is an important complication with potential substantial adverse consequences, in particular periprosthetic joint infection. Methods: This review evaluated the available literature regarding several issues in the field of persistent wound drainage after TJA and offers a classification of persistent wound drainage and an algorithmic approach to the decision-making process. Results: Available literature addressing the diagnosis and treatment of persistent wound drainage after TJA is scarce and an evidence-based clinical guideline is lacking. This is partially caused by the absence of a universally accepted definition of persistent wound drainage. In patients with persistent wound drainage, clinical signs and serological tests can be helpful in the diagnosis of a developing infection. Regarding the treatment of persistent wound drainage, nonsurgical treatment consists of absorbent dressings, pressure bandages, and temporary joint immobilization. Surgical treatment is advised when wound drainage persists for more than 5-7 days and consists of open debridement with irrigation and exchange of modular components and antimicrobial treatment. Conclusion: Based on this literature review, we proposed a classification and algorithmic approach for the management of patients with persistent wound drainage after TJA. Hopefully, this offers the orthopedic surgeon a practical clinical guideline by finding the right balance between overtreatment and undertreatment, weighing the risks and benefits. However, this classification and algorithmic approach should first be evaluated in a prospective trial.
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Background: The purpose of this investigation was to determine the effects of fondaparinux on postoperative wound drainage, length of hospital stay (LOS) and rate of surgical site infection in total joint patients. Methods: 117 patients undergoing total joint arthroplasty treated with fondaparinux for venous thromboembolism (VTE) prophylaxis were prospectively studied. Results: The average time to a dry wound was 3.4 days, with an average LOS of 3.77 days. Perioperative complications included 2 cases each of superficial cellulitis, deep vein thrombosis, and pulmonary embolism; there were no cases of deep infection. Multi-variate analysis showed increased patient BMI increased LOS (p = 0.0169). Conclusion: Fondaparinux is an effective drug for VTE prophylaxis in total joint arthroplasty with wound drainage and LOS comparable to historical controls of enoxaparin, warfarin, and rivaroxaban.
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Introduction Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are highly successful treatment modalities for advanced osteoarthritis. However, prolonged wound leakage after arthroplasty is linked to prosthetic joint infection (PJI), which is a potentially devastating complication. On the one hand, wound leakage is reported as a risk factor for PJI with a leaking wound acting as a porte d’entrée for micro-organisms. On the other hand, prolonged wound leakage can be a symptom of PJI. Literature addressing prolonged wound leakage is scarce, contradictory and of poor methodological quality. Hence, treatment of prolonged wound leakage varies considerably with both non-surgical and surgical treatment modalities. There is a definite need for evidence concerning the best way to treat prolonged wound leakage after joint arthroplasty. Methods and analysis A prospective nationwide randomised controlled trial will be conducted in 35 hospitals in the Netherlands. The goal is to include 388 patients with persistent wound leakage 9–10 days after THA or TKA. These patients will be randomly allocated to non-surgical treatment (pressure bandages, (bed) rest and wound care) or surgical treatment (debridement, antibiotics and implant retention (DAIR)). DAIR will also be performed on all non-surgically treated patients with persistent wound leakage at day 16–17 after index surgery, regardless of amount of wound leakage, other clinical parameters or C reactive protein. Clinical data are entered into a web-based database. Patients are asked to fill in questionnaires about disease-specific outcomes, quality of life and cost effectiveness at 3, 6 and 12 months after surgery. Primary outcome is the number of revision surgeries due to infection within a year of arthroplasty. Ethics and dissemination The Review Board of each participating hospital has approved the local feasibility. The results will be published in peer-reviewed scientific journals. Trial registration number NTR5960;Pre-results.
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Background: Persistent wound leakage after joint arthroplasty is a scantily investigated topic, despite the claimed relation with a higher risk of periprosthetic joint infection. This results in a lack of evidence-based clinical guidelines for the diagnosis and treatment of persistent wound leakage after joint arthroplasty. Without such guideline, clinical practice in orthopaedic hospitals varies widely. In preparation of a nationwide multicenter randomized controlled trial on the optimal treatment of persistent wound leakage, we evaluated current Dutch orthopaedic care for persistent wound leakage after joint arthroplasty. Methods: We conducted a questionnaire-based online survey among all 700 members of the Netherlands Orthopaedic Association, consisting of 23 questions on the definition, classification, diagnosis and treatment of persistent wound leakage after joint arthroplasty. Results: The questionnaire was completed by 127 respondents, representing 68% of the Dutch hospitals that perform orthopaedic surgery. The results showed wide variation in the classification, definition, diagnosis and treatment of persistent wound leakage among Dutch orthopaedic surgeons. 56.7% of the respondents used a protocol for diagnosis and treatment of persistent wound leakage, but only 26.8% utilized the protocol in every patient. Most respondents (59.1%) reported a maximum period of persistent wound leakage before starting non-surgical treatment of 3 to 7 days after index surgery and 44.1% of respondents reported a maximum period of wound leakage of 10 days before converting to surgical treatment. Conclusions: The wide variety in clinical practice underscores the importance of developing an evidence-based clinical guideline for the diagnosis and treatment of persistent wound leakage after joint arthroplasty. To this end, a nationwide multicenter randomized controlled trial will be conducted in the Netherlands, which may provide evidence on this important and poorly understood topic.
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Persistent wound drainage after total joint arthroplasty can potentiate periprosthetic joint infection. Although current recommendations are to treat persistent wound drainage with surgical debridement, we believe nonoperative treatment may be successful in selected patients. We performed a retrospective analysis of 25 persistently draining hip and knee arthroplasty wounds treated with a protocol consisting of a combination of surgical site aspiration, closure of open wound edges, cessation of anticoagulants, activity modification, and antibiotics (in select patients). Wound drainage ceased in 24 of 25 wounds treated with this protocol. One patient who continued to drain for 3 more days was successfully treated with surgical debridement and evacuation of hematoma. No patient developed infection. We believe this protocol can be successful in many arthroplasty patients.
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Prosthetic joint infection (PJI) is a devastating complication in total knee arthroplasty (TKA) and third most common cause of revision of TKA with significant morbidity and surgical challenges. Treatment options include non-operative measures with long term antibiotic suppression, debridement and implant retention (DAIR), one- or two-stage revision arthroplasty, arthrodesis and amputation. Implant retention without infection is ideal and DAIR has been reported to have variable success rates depending on patient factors, duration of infection, infecting micro-organisms, choice of procedure, single or multiple debridement procedures, arthroscopic or open, antibiotic choice and duration of antibiotic use. We present a thorough literature review of DAIR for infected TKA. The important factors contributing to failure are presence of sinus, immunocompromised patient, delay between onset of infection and debridement procedure, Staphylococcal infection in particular Meticillin Resistant Staphylococcal aureus, multiple debridement procedures, retention of exchangeable components and short antibiotic duration. In conclusion DAIR can be successful procedure to eradicate infection in TKA in selective patients with factors contributing to failure taken into account.
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Background: Surgical site infection (SSI) is a major complication following total joint arthroplasty. Host susceptibility to infection has emerged as an important predictor of SSI. The purpose of this study was to develop and validate a preoperative SSI risk-assessment tool for primary or revision knee and hip arthroplasty. Methods: Data for 6,789 patients who underwent total joint arthroplasty (from the years 2000 to 2011) were obtained from a single hospital system. SSI was defined as a superficial infection within 30 days or deep infection within 1 year. Logistic regression modeling was utilized to create a risk scoring system for a derivation sample (n = 5,789; 199 SSIs), with validation performed on a hold-out sample (a subset of observations chosen randomly from the initial sample to form a testing set; n = 1,000; 41 SSIs). Results: On the basis of logistic regression modeling, we created a scoring system to assess SSI risk (range, 0 to 35 points) that is the point sum of the following: primary hip arthroplasty (0 points); primary knee (1); revision hip (3); revision knee (3); non-insulin-dependent diabetes (1); insulin-dependent diabetes (1.5); chronic obstructive pulmonary disease (COPD) (1); inflammatory arthropathy (1.5); tobacco use (1.5); lower-extremity osteomyelitis or pyogenic arthritis (2); pelvis, thigh, or leg traumatic fracture (2); lower-extremity pathologic fracture (2.5); morbid obesity (2.5); primary bone cancer (4); reaction to prosthesis in the last 3 years (4); and history of staphylococcal septicemia (4.5). The risk score had good discriminatory capability (area under the ROC [receiver operating characteristic] curve = 0.77) and calibration (Hosmer-Lemeshow chi-square test, p = 0.34) and was validated using the independent sample (area under the ROC curve = 0.72). A small subset of patients (5.9%) had a >10% estimated infection risk. Conclusions: The patient comorbidities composing the risk score heavily influenced SSI risk for primary or revision knee and hip arthroplasty. We believe that infection risk can be objectively determined in a preoperative setting with the proposed SSI risk score.
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Background: Surgical site infection (SSI) is a dreaded postoperative complication. Although preoperative skin cleansing in order to prevent surgical site infection (SSI) is standard surgical practice, there is clinical equipoise concerning whether povidone iodine (PI) or chlorhexidine alcohol (CHA) is the antiseptic agent of choice. Objectives: To determine whether CHA or PI is the preferred preoperative skin preparation for reducing SSI in clean, clean-contaminated and contaminated surgery. Search methods: PubMed, Embase, and gray literature sources were searched for randomized controlled trials (RCTs) comparing both CHA and PI between 1980 and 2014. Comparative RCTs of preoperative CHA versus PI studying SSI in clean, clean-contaminated and contaminated surgery were included. Risk of bias was assessed using Cochrane risk of bias. Main result: We identified six eligible studies with an overall 2484 participants. The overall rate of SSI was 6.8% in the CHA group versus 11.0% in the PI group (P
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Background: National guidelines exist regarding preoperative antibiotic treatment for the prevention of surgical site infection (SSI); however, there are no published studies showing rates of compliance with them. Aim: To establish compliance with national guidelines within our institution, and the impact of adherence, on SSI rate. Methods: This was a retrospective observational study of 1019 patients undergoing hip or knee arthroplasty. Procedures were conducted at three metropolitan hospitals in Melbourne, Australia, throughout a 2.5-year period. Antibiotic prophylaxis recommendations were taken from the Australian Therapeutic Guidelines. Findings: Of the procedures included, 61.3% adhered to prophylaxis guidelines, 38.7% did not. The total SSI rate was 2.7%; with an infection rate of 1.7% in those adherent to antibiotic guidelines, compared with a rate of 5.0% if non-adherent (P < 0.01). Overall, 98.4% of patients received a dedicated prophylactic antibiotic dose as per guidelines. Of the procedures, 1.7% lasted >4h with re-dosing being poorly adhered to (23.5% of procedures). In patients weighing >80kg (49.5% of surgeries), guideline-concordant dosing occurred in only 58.7% of cases. For patients >80kg without guideline-concordant dosing, the SSI rate was 6.6% and the odds ratio of SSI was 3.89 (confidence interval: 1.17-7.84; P = 0.01). Conclusion: Non-adherence to guidelines increased the risk of SSI in patients undergoing total knee and hip arthroplasty. Dosing adjustment recommendations of prophylaxis for patients weighing >80kg was poorly adhered to, and these patients were subsequently at higher risk of infection.
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Determine risk factors for infection following hip or knee total joint arthroplasty in patients with rheumatoid arthritis. All rheumatoid arthritis patients with a hip or knee arthroplasty between years 2000 and 2010 were identified from population-based administrative data from the Calgary Zone of Alberta Health Services. Clinical data from patient charts during the hospital admission and during a one year follow-up period were extracted to identify incident infections. We identified 381 eligible procedures performed in 259 patients (72.2% female, mean age 63.3 years, mean body mass index 27.6 kg/m2). Patient comorbidities were hypertension (43.2%), diabetes (10.4%), coronary artery disease (13.9%), smoking (10.8%) and obesity (32%). Few infectious complications occurred: surgical site infections occurred within the first year after 5 procedures (2 joint space infections, 3 deep incisional infections). Infections of non-surgical sites (urinary tract, skin or respiratory, n=4) complicated the hospital admission. The odds ratio for any post-arthroplasty infection was increased in patients using prednisone doses exceeding 15 mg/day (OR 21.0, 95%CI 3.5-127.2, p=<0.001), underweight patients (OR 6.0, 95%CI 1.2-30.9, p=0.033) and those with known coronary artery disease (OR 5.1, 95%CI 1.3-19.8, p=0.017). Types of disease-modifying therapy, age, sex, and other comorbidities were not associated with an increased risk for infection. Steroid doses over 15 mg/day, being underweight and having coronary artery disease were associated with significant increases in the risk of post-arthroplasty infection in rheumatoid arthritis. Maximal tapering of prednisone and comorbidity risk reduction must be addressed in the peri-operative management strategy.
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Louis Pasteur once said that: “Fortune favours the prepared mind.” As one of the great scientists who contributed to the fight against infection, he emphasised the importance of being prepared at all times to recognise infection and deal with it. Despite the many scientific discoveries and technological advances, such as the advent of antibiotics and the use of sterile techniques, infection continues to be a problem that haunts orthopaedic surgeons and inflicts suffering on patients. The medical community has implemented many practices with the intention of preventing infection and treating it effectively when it occurs. Although high-level evidence may support some of these practices, many are based on little to no scientific foundation. Thus, around the world, there is great variation in practices for the prevention and management of periprosthetic joint infection. This paper summaries the instigation, conduct and findings of a recent International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection. Cite this article: Bone Joint J 2013;95-B:1450–2.
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Background Surgical site infections cause substantial morbidity and mortality. Negative pressure wound therapy may reduce the risk of surgical site infections, but current evidence is unclear. The objective of this study was to examine whether negative pressure wound therapy reduces the risk of surgical site infections and other wound complications when compared with conventional dressings in all patients with primarily closed surgical wounds. Methods A comprehensive systematic review of randomized controlled trials was conducted. Trials that compared a negative pressure wound therapy system to any non-negative pressure wound therapy dressing in surgical wound(s) intended to heal by primary intention were eligible. Surgical site infection was the primary outcome, and secondary outcomes included wound dehiscence, pain, seroma, healing time, length of stay, device-related complications, cost-effectiveness, and quality of life. Selection, extraction, and risk of bias steps were done in duplicate, and data were synthesized using random effects meta-analyses. A priori sensitivity and subgroup analyses of the primary outcome were completed. The Grading of Recommendations, Assessment, Development, and Evaluations framework was used to appraise the quality of the evidence. Results Forty-four randomized controlled trials with N = 5,693 patients were included. Patients treated with negative pressure wound therapy experienced nearly a 40% reduction in the risk of surgical site infections relative to those with conventional dressings, which was statistically significant: pooled risk ratio 0.61, 95% confidence interval 0.49–0.74, I² = 26%. The effect remained consistent across surgical specialties and brands of negative pressure wound therapy devices. A statistically significant reduction in wound dehiscence and seroma incidence was also observed. Conclusion There is moderate certainty that negative pressure wound therapy applied to closed surgical incisions reduces the risk of surgical site infections across all surgical procedures.
Article
Aims: The aim of this study was to assess the influence of operating time on 30-day complications following total hip arthroplasty (THA). Patients and methods: We identified patients aged 18 years and older who underwent THA between 2006 and 2016 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We identified 131 361 patients, with a mean age of 65 years (sd 12), who underwent THA. We used multivariable regression to determine if the rate of complications and re-admissions was related to the operating time, while adjusting for relevant covariables. Results: The mean operating time decreased from 118.3 minutes (29.0 to 217.0) in 2006, to 89.6 minutes (20.0 to 240.0) in 2016. After adjustment for covariables, operating times of between 90 and 119 minutes increased the risk of minor complications by 1.2 (95% confidence interval (CI) 1.1 to 1.3), while operating times of between 120 and 179 minutes increased the risk of major complications by 1.4 (95% CI 1.3 to 1.6) and minor complications by 1.4 (95% CI 1.2 to 1.5), and operating times of 180 minutes or more increased the risk of major complications by 2.1 (95% CI 1.8 to 2.6) and minor complications by 1.9 (95% CI 1.6 to 2.3). There was no difference in the overall risk of complications for operating times of between 20 and 39, 40 and 59, or 60 and 89 minutes (p > 0.05). Operating times of between 40 and 59 minutes decreased the risk of re-admission by 0.88 (95% CI 0.79 to 0.97), while operating times of between 120 and 179 minutes, and of 180 minutes or more, increased the risk of re-admission by 1.2 (95% CI 1.1 to 1.3) and 1.6 (95% CI 1.3 to 1.8), respectively. Conclusion: These findings suggest that an operating time of more than 90 minutes may be an independent predictor of major and minor complications, as well as re-admission, following THA, and that an operating time of between 40 and 90 minutes may be ideal. Prospective studies are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B(6 Supple B):51-56.
Article
Background: To reduce the risk of infection after orthopedic surgery, patients are asked to undergo preoperative assessments in various medical domains. However, to our knowledge, there has been no systematic review to evaluate the performance of a preoperative dental assessment before orthopedic surgery. We focus on two questions as follows: (1) is there a link between the presence of preoperative dental assessment and orthopedic infections?; (2) is the probability of an orthopedic infection increased in the presence of dental risk factors and comorbidities? Patients and methods: Databases including PubMed, the Cochrane Library databases and Google Scholar were searched for English-language articles until November 2018. The inclusion criteria were descriptions of infections of joint prostheses and dental infections, and potential dental origins of pathogenic infections. Studies dealing with oral assessments performed before orthopedic surgery were included. Results: Based on eligibility criteria, 12 case series, 4 case-control studies and 12 cohort studies were included. In case-controls, prosthesis infection was presumably associated with a dental abscess in 6/224 of cases (2.9%). In cohort studies, exposure was defined as "any dental assessment or dental treatment performed before surgery". Even if only 4 cohort studies provide this information exposure, it would seem that the presence of an infectious complication is less frequent if the preoperative examination has been performed. Dental treatment given before surgery was mainly for scaling-polishing in 78/205 (38%), extraction in 49/205 of cases (24%) and restorative work in 37/205 (18%). Discussion: The literature review was made complex by the substantial heterogeneity among included studies. Although there is no formal evidence for or against preoperative dental assessment, it is advisable to perform this with the aim of maintaining favorable oral hygiene and thus reduce the risk factors. Level of evidence: Level III, systematic review.
Article
Background: Smoking is a potentially modifiable risk factor that may impact the overall outcomes of total hip arthroplasty (THA). In an era of bundled payments for THA, the purpose of this study was to evaluate, on a national level, the inpatient complications and additional costs of smokers undergoing THA. Methods: The Nationwide Inpatient Sample was used to identify all primary elective THAs performed in the United States in 2014. This cohort was further stratified by smoking status. Inpatient hospital characteristics, costs, and complications rates were assessed. Results: The Nationwide Inpatient Sample had 63,446 admissions recorded for primary THAs in 2014, corresponding to an estimated 317,230 cases nationwide. The smoking rate was 20.7%. Smokers were slightly yet significantly younger than nonsmokers (63.5 years vs 64.8 years; P < .0001). The smoking group had a significantly longer hospital stay and higher total hospital costs (both P < .0001). After using a multivariable logistic model adjusting for age, gender, and comorbidities, smokers were found to have a significantly higher odds ratio (OR [95% confidence interval {CI}]) for myocardial infarction (15.5 [5.0-47.5]), cardiac arrest (10.1 [2.2-47.6]), pneumonia (4.7 [2.4-9.1]), urinary tract infection (1.9 [1.4-2.7]), sepsis (13.1 [3.5-49.0]), acute renal failure (2.9 [2.2-3.7]), discharge to a skilled nursing facility (1.3 [1.2-1.4]), and mortality (11.7 [2.0-70.5]). Conclusions: Smoking remains a highly prevalent and important risk factor for complications in elective primary THA in the United States. Patients who smoke have a significantly higher rate of complications and generate significantly higher postoperative inpatient costs. These findings are important for risk stratification, bundled payment considerations, as well as perioperative patient education and intervention.
Article
Background: Periprosthetic joint infection (PJI) is the leading cause of early revisions after total knee arthroplasty. Debridement, antibiotics, and implant retention (DAIR) procedures are often the initial treatment for PJI. However, there is concern that failed DAIR undermines the future success of revision procedures. This study aims to investigate the impact of DAIR on the success of subsequent staged revisions for PJI. Methods: A multicenter retrospective review was performed over a 15-year period. Treatment success was defined as implant retention without the use of long-term suppressive antibiotics. This was compared between patients who underwent a staged revision as the first procedure for PJI (staged-only) and patients who failed DAIR before staged revision (F-DAIR). Competing risk survival analysis was performed to compare the 2 groups and considered for patient demographics, American Society of Anesthesiologists score, organism type, body mass index, age of prosthesis, and duration of symptoms. Results: Of 291 eligible patients, 63 underwent staged revision and 228 underwent DAIR as the first procedure for PJI. Of the 228 DAIR patients, 75 failed DAIR and underwent subsequent staged revision (F-DAIR). At mean follow-up of 6.2 years, the success rate was 72% in the F-DAIR group and 81% in the staged-only group. On survival analysis, there was no significant difference in subdistribution hazard ratio comparing the probability of failure (implant retention) in the 2 treatments groups (subdistribution hazard ratio = 0.72; 95% confidence interval 0.32-1.61; P = .42). Conclusion: This study suggested that a previously failed DAIR does not compromise the success rate of a subsequent staged revision.
Article
Background: Malnutrition continues to be prevalent in the general population. A variety of studies have correlated poor nutritional status with reduced perioperative outcomes. However, the correlation between serologic malnutrition and arthroplasty outcomes has not been systematically evaluated. The purpose of this study was to determine if serologic malnutrition has a correlation with postoperative wound infection, as well as other complications, after total joint arthroplasty. Methods: A systematic review of the literature was performed to identify studies that reported on outcomes for patients who were malnourished and had undergone a total hip or knee arthroplasty. Results: Twenty studies were included for review. Based on the quality of the evidence of the different studies, the balance between desirable/undesirable outcomes and the values of patients, there was a strong recommendation that preoperative serologic markers of malnutrition are significantly associated with inferior postoperative outcomes. All 20 studies analyzed albumin as a marker for malnutrition. Eleven (55%) studies used the total lymphocyte count, and 6 (30%) studies reported transferrin as a marker for malnutrition. Among 20 studies, 18 (90%) studies reported a correlation with at least one serological marker and poor postoperative outcomes. Finally, patients with an albumin level <3.5 dg/L were more likely to develop a postoperative wound complication (odds ratio: 2.176; 95% confidence interval: 1.916-2.471). Conclusions: There is strong evidence that serologic malnutrition was associated with increased risk of poor postoperative outcome across all total joint replacement interventions.
Article
Background: The purpose of this study was to perform a systematic review and meta-analysis to quantitatively assess the association between tobacco use and the risk of any wound complication and periprosthetic joint infection (PJI) after primary total hip and total knee arthroplasty procedures. Methods: Relevant articles published before January 2018 were identified by systematically searching PubMed, EMBASE, and Cochrane library databases. Pooled odds ratios (OR) and 95% confidence intervals were calculated for end points of any wound complication and PJI. Additional analyses were performed to evaluate risks between current, former, and non-tobacco users. Results: Fourteen studies were included in the meta-analysis. Tobacco users had a significantly higher risk of wound complications (OR, 1.78 [1.32-2.39]) and PJI (OR, 2.02 [1.47-2.77]) compared to non-tobacco users. Compared to non-tobacco users, there was an increased risk of PJI among current (OR, 2.16 [1.57-2.97] and former (OR, 1.52 [1.16-1.99]) tobacco users. Current tobacco users also had a significantly increased risk of PJI compared to former tobacco users (OR, 1.52 [1.07-2.14]). Conclusion: Tobacco use before total hip and total knee arthroplasty significantly increases the risk of wound complications and PJI. This increased risk is present for both current and former tobacco users. However, former tobacco users had a significantly lower risk of wound complications and PJI compared to current tobacco users, suggesting that cessation of tobacco use before TJA can help to mitigate these observed risks.
Article
Introduction: Evidence about the optimal timing for total hip replacement (THR) in HIV-positive patients is scant. Hypothesis: Preoperative criteria: cluster of differentiation 4 (CD4) counts>200 cells/mm3 and an undetectable HIV virus load before THR, improve infection rates, aseptic loosenings, and functional outcomes. Materials and methods: We recruited 16 HIV-positive patients who had undergone 25 THRs between 2003 and 2015. None had hemophilia, and none were intravenous drug users (IVDUs). Results: Their mean age was 41.2 years (range: 24-60); minimum follow-up was 12 months (mean: 64.6); mean duration of prophylactic antibiotics was 2.9 days (range: 1-5); and mean hospital length of stay was 6.0 days (range: 4-11). No patients were treated with subsequent oral antibiotics. The mean preoperative CD4 count was 464.1±237.0 (range: 235-904) cells/mm3. There were no early superficial surgical site infections, late periprosthetic joint infections, or aseptic loosenings. Post-surgery Harris Hip score was significantly (P<0.001) better. Discussion: A preoperative CD4 count>200 cell/mm3 and an undetectable HIV virus load might indicate optimal timing for elective THRs in HIV-positive patients without hemophilia and not IVDUs. Level of evidence: IV, retrospective or historical series.
Article
Background Although morbid obesity is considered a modifiable risk factor for periprosthetic joint infection (PJI), there is no consensus regarding an appropriate threshold for body mass index (BMI) above which a high risk for infection may outweigh the benefits of surgery. Questions/purposes (1) Is there a BMI cutoff threshold that is associated with increased risk for PJI? (2) Is the risk of PJI increased in higher obesity classes? Methods A retrospective study was conducted of all primary THAs and TKAs performed at one institution between 2006 and 2015. Overall 19,226 patients were eligible to be included in the study; 1053 patients were excluded as a result of incomplete data, resulting in a final cohort of 18,173 patients (8757 TKAs and 9416 THAs). PJI was defined using the International Consensus Meeting criteria. To ensure accurate followup, and because there is evidence to support the association between obesity and early infection, we identified PJI within 90 days of the index surgery. This relationship was examined separately for BMI as a continuous variable and for each BMI category as defined by the Centers for Disease Control and Prevention (underweight ≤ 18.49 kg/m2; normal 18.5-24.9 kg/m2; overweight 25-29.9 kg/m2; obese class I 30-34.9 kg/m2; obese class II 35-39.9 kg/m2; obese class III ≥ 40 kg/m2). Analyses were performed with logistic regression, accounting for both patient and surgical risk factors. A BMI threshold was evaluated with a receiver operating characteristic (ROC) curve and the Youden index. Results The area under the ROC curve for BMI and risk of PJI within 90 days was only 0.58 (confidence interval [CI], 0.52-0.63) suggesting such a cutoff was not much better than random chance. Among the BMI classes, patients with class III obesity (≥ 40 kg/m2) were the only ones showing a higher risk for PJI within 90 days (odds ratio [OR], 3.09 [1.46-6.54]; p = 0.003). The risk of developing PJI was not greater for overweight (OR, 0.72; 95% CI, 0.38-1.4), class I obese (OR, 1.06; 95% CI, 0.57-2.0), or class II obese (OR, 1.08; 95% CI, 0.52-2.2) patients. Underweight patients also demonstrated no increased risk for PJI (OR, 1.80; 95% CI, 0.23-13.9). Conclusions The risk for infection increases gradually throughout the full range of BMI, but no threshold exists. Weight reduction before surgery may mitigate risk for infection for all patients with a BMI above normal. Of note, patients with a BMI > 40 kg/m2 carried a threefold higher risk for PJI and for these patients, the risks of surgery must be carefully weighed against its benefits. Level of Evidence Level III, therapeutic study.
Article
Background: Total knee arthroplasty (TKA) utilization is increasing in older Americans. The incidence of chronic obstructive pulmonary disease (COPD) has been steadily rising over the past few decades. In particular, COPD is being increasingly more common in patients undergoing revision TKA. The aim of this study is to identify the impact of COPD on postoperative complications for patients undergoing revision TKA. Methods: A retrospective cohort study was conducted using data collected through the American College of Surgeons National Quality Improvement Program Database. All patients who underwent revision TKA between 2007 and 2014 were identified and stratified into groups based on COPD status. The incidence of adverse events after surgery was evaluated with univariate and multivariate analyses where appropriate. Results: Patients with COPD were found to develop more postoperative complications, including deep wound infection, organ infection, wound dehiscence, pneumonia, reintubation, renal insufficiency, urinary tract infection, myocardial infarction, sepsis, and death. Patients with COPD were also shown to have to return back to the operating room and have an extended length of hospital stay. COPD was shown to be an independent risk factor for development of wound dehiscence, pneumonia, reintubation, renal insufficiency, and renal failure. Finally, COPD was identified as an independent risk factor for unplanned return to the operating room. Conclusion: Patients with COPD have greater risk for postoperatively developing wound dehiscence, pneumonia, reintubation, renal insufficiency, and renal failure complications than those without COPD. While risks for independent complications remain relatively low, consideration of COPD status is an important factor to consider when selecting surgical candidates and preoperative risk assessment.
Article
Background: Debridement, antibiotics, and implant retention (DAIR) is a widely used treatment modality for early acute prosthetic joint infection (PJI). A preoperative risk score was previously designed for predicting DAIR failure, consisting of chronic renal failure (K), liver cirrhosis (L), index surgery (I), cemented prosthesis (C), and C-reactive protein >115 mg/L (KLIC). The aim of this study was to validate the KLIC score in an external cohort. Methods: We retrospectively evaluated patients with early acute PJI treated with DAIR between 2006 and 2016 in 3 Dutch hospitals. Early acute PJI was defined as <21 days of symptoms and DAIR performed within 90 days after index surgery. Failure was defined as the need for (1) second DAIR, (2) implant removal, (3) suppressive antimicrobial treatment, or (4) infection-related death within 60 days after debridement. Results: A total of 386 patients were included. Failure occurred in 148 patients (38.3%). Patients with KLIC scores of ≤2, 2.5-3.5, 4-5, 5.5-6.5, and ≥7 had failure rates of 27.9%, 37.1%, 49.3%, 54.5%, and 85.7%, respectively (P < .001). The receiver-operating characteristic curve showed an area under the curve of 0.64 (95% confidence interval 0.59-0.69). A KLIC score higher than 6 points showed a specificity of 97.9%. Conclusion: The KLIC score is a relatively good preoperative risk score for DAIR failure in patients with early acute PJI and appears to be most useful in clinical practice for patients with low or high KLIC scores.
Article
Avoidance of early wound complications is critical to the success of total joint arthroplasty. The magnitude of postoperative complications can be as simple as quickly resolving wound drainage, to persistent wound drainage and full-thickness soft tissue necrosis. Persistent postoperative drainage and wound complications can lead to a devastating deep periprosthetic infection. Attention to several steps in the clinical and perioperative pathway should be addressed to avoid this complication including addressing modifiable patient risk factors, implementing meticulous surgical technique, and following an algorithmic approach in response to persistent wound drainage.
Article
Background Little is known regarding the impact of operative time on adverse events following arthroplasty procedures. The present study tests for associations between a 15-minute increase in operative time and the occurrence of adverse events following primary total joint arthroplasty (TJA). Methods Patients undergoing primary total hip or knee arthroplasty (THA or TKA) between 2006 and 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program. Operative time (as a continuous variable) was tested for association with perioperative outcomes using multivariate regression. All regressions were adjusted for differences in demographic, comorbidity, and procedural characteristics. Results 165,474 Patients met inclusion criteria. The mean (± standard deviation) operative time was 91.9±32.5 minutes. Following adjustment for demographic, comorbidity, and procedural characteristics, an increase in operative time by 15 minutes increased the risk for anemia requiring transfusion by 9% (95% confidence interval [CI]=8-10%, p<0.001), wound dehiscence by 13% (95% CI=8-19%, p<0.001), renal insufficiency by 9% (95% CI=3-14%, p<0.001), sepsis by 10% (95% CI=6-14%, p<0.001), surgical site infection by 9% (95% CI=7-12%, p<0.001), and urinary tract infection by 4% (95% CI=2-6%, p<0.001). Similarly, an increase in operative time by 15 minutes increased the risk for hospital readmission by 5% (95% CI=4-6%, p<0.001) and for extended hospital length of stay (≥4 days) by 9% (95% CI=8-10%, p<0.001). Conclusions The present study suggests that greater operative time increases the risk for multiple postoperative complications following TJA. These data suggest that surgeons should consider steps to minimize operative time without compromising the technical components of the surgical procedure.
Article
Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Furthermore, COPD patients are at increased risk of complications following surgery. The purpose of this study was to evaluate the postoperative total hip arthroplasty (THA) outcomes of COPD patients. Specifically, we asked the following questions: (1) Is COPD associated with adverse perioperative outcomes and (2) Does COPD increase the risk of short-term complications following THA? Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 64,796 patients who underwent THA between 2008 and 2014. A total of 2426 patients with COPD were identified. COPD and non-COPD cohorts were compared based on the following outcomes: hospital length-of-stay, operative times, discharge disposition, and 30-day postoperative complications. Results: COPD patients were found to have a longer length-of-stay and be discharged to an extended care facility (P < .001). COPD patients were also at significantly (P < .05) increased risk for any complication, such as mortality, myocardial infarction, pneumonia, septic shock, unplanned reintubation, use of a mechanical ventilator >48 hours, deep infection, require a blood transfusion, return to operating room, and a readmission within 30 days postoperatively. Conclusions: COPD patients are more likely to suffer from postoperative complications following THA when compared to non-COPD patients. Many of these complications are medical, pulmonary evaluation and medical optimization are a critical step in preoperative management for these patients.
Article
Patients with diabetes mellitus are known to have a high risk of postoperative complications, including infections, impaired wound healing, cardiovascular events, venous thromboembolism, and mortality. Because hyperglycemia has been thought to mediate this risk, there is a clinical propensity for improving glycemic control, as assessed by hemoglobin A1c (HbA1c) level, prior to proceeding with elective surgery, particularly joint replacement surgery. However, it is not established whether chronic poor glycemic control, indicated by elevated HbA1c levels, predicts increased risk of postoperative complications. The benefit of improving glycemic control must be weighed against risks of delaying necessary elective surgery, such as joint replacement surgery, which risks may include negative impact on long-term glycemic control. Thus, we review the current evidence to determine the relationship between HbA1c and postoperative surgical risk, especially on joint replacement surgery.
Article
Optimal prophylaxis for prevention of venous thromboembolism (VTE) after total joint arthroplasty (TJA) remains debated. The purpose of this study was to compare postoperative complications in patients receiving different VTE chemoprophylactic regimens. Using a nationwide healthcare database, 72,670 THA patients without a history of VTE were identified. Study cohorts received VTE prophylaxis within 30 days postoperatively. Odds ratios and 95% confidence intervals were used to assess 30-day and 90-day postoperative complications (hematoma, hemorrhage, transfusion, pulmonary embolism (PE), VTE, prosthetic joint infection (PJI), and incision/drainage (I&D)). Of the 72,670 THA patients, 25,966 received single medication VTE prophylaxis; 551 (2.12%) aspirin, 6791 (26.15%) enoxaparin, 12,008 (46.25%) warfarin, 5403 (20.81%) rivaroxaban, 876 (3.37%) fondaparinux and 337 (1.30%) apixaban. 30-day complications included; aspirin: I&D; warfarin: I&D, hematoma, hemorrhage, transfusion, PJI, PE and DVT; apixaban: hematoma and hemorrhage. 90-day complications included; aspirin: I&D; warfarin: I&D, hematoma, hemorrhage, transfusion, PJI, PE and DVT. Warfarin was the only anticoagulant associated with a higher risk for DVT, and the highest risk for 30-day and 90-day complications. Aspirin had the highest risk for I&D. Despite three times increased 30-day risk for bleeding, apixaban was effective in preventing VTE during the high-risk 3-month-period. Enoxaparin had the lowest risk for PE and DVT while rivaroxaban had the lowest risk for PJI, hematoma, I&D, hemorrhage and transfusion.
Article
Background The aim of this study was to determine whether negative pressure wound therapy, used prophylactically in clean surgical incisions, reduces surgical site infection (SSI), hematoma, and seroma after total joint replacement. Methods A single center, open-label study with a prospective cohort of patients undergoing primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) treated with closed incision negative pressure therapy (ciNPT) of clean surgical wounds. 196 incisions treated with ciNPT in 192 patients were compared to a historical control group of 400 patients treated with traditional gauze dressing. The rates of clinically significant hematoma, seroma, dehiscence, SSI, and complication were compared using univariate analyses and multiple logistic regression. Results The rate of deep infection was unchanged in the ciNPT group compared to control (1.0% vs 1.25%), however the overall rate of infection (including superficial wound infection) decreased significantly (3.5% vs 1.0%, p=0.04) Overall complication rate was lower in the ciNPT group than controls (1.5% vs. 5.5%, p=0.02). Upon logistic regression, only treatment group was associated with complication; patients treated with ciNPT were about four times less likely to experience a surgical site complication compared to control (p=0.0277, OR=4.251 95% CI 1.172 – 15.414). Conclusions Closed incision negative pressure therapy for TKA and THA in a comprehensive patient population reduced overall incidence of complication, but did not significantly impact the rate of deep infection. Further research to determine clinical and economic advantages of routine use of ciNPT in total joint arthroplasty is warranted.
Article
Aims Periprosthetic femoral fractures (PFF) following total hip arthroplasty (THA) are devastating complications that are associated with functional limitations and increased overall mortality. Although cementless implants have been associated with an increased risk of PFF, the precise contribution of implant geometry and design on the risk of both intra-operative and post-operative PFF remains poorly investigated. A systematic review was performed to aggregate all of the PFF literature with specific attention to the femoral implant used. Patients and Methods A systematic search strategy of several journal databases and recent proceedings from the American Academy of Orthopaedic Surgeons was performed. Clinical articles were included for analysis if sufficient implant description was provided. All articles were reviewed by two reviewers. A review of fundamental investigations of implant load-to-failure was performed, with the intent of identifying similar conclusions from the clinical and fundamental literature. Results In total 596 articles were initially identified, with 34 being eligible for analysis. Aggregate analysis of 1691 PFFs in 342 719 primary THAs revealed a significantly higher number of PFFs with cementless femoral implants (p < 0.001). Single-wedge and double-wedge (fit-and-fill) femoral implants were associated with a threefold increase in PFF rates (p < 0.001) compared with anatomical, fully coated and tapered/rounded stems. Within cemented stems, loaded-taper (Exeter) stems were associated with more PFFs than composite-beam (Charnley) stems (p = 0.004). Review of the fundamental literature revealed very few studies comparing cementless component designs. Conclusion Very few studies within the PFF literature provide detailed implant information. Cementless implants, specifically those of single-wedge and double-wedge, have the highest PFF rates in the literature, with most investigations recommending against their use in older patients with osteoporotic bone. This review illustrates the need for registries and future PFF studies to record implant name and information for future analysis. Furthermore, future biomechanical investigations comparing modern implants are needed to clarify the precise contribution of implant design to PFF risk. Cite this article: Bone Joint J 2017;99-B(1 Supple A):50–9.
Article
Learning objectives: After studying this article, the participant should be able to: 1. Describe the basic physiologic events in normal wound healing. 2. Understand the differences in healing among skin, bone, cartilage, and tendon. 3. Identify factors that may compromise or delay wound healing. 4. Describe methods for optimal closure of a wound. Summary: Understanding the physiology and pathophysiology of normal wound healing and potential impediments to its end will allow the plastic surgeon to maximize postoperative outcomes and, in some instances, avoid unnecessary surgical interventions. Continuous advancements in our understanding of this process require frequent reviews of available data to permit reliable, evidence-based recommendations for clinical application. This is the first of a two-part article summarizing the science and clinical recommendations necessary for successful wound healing.
Article
Background: Deep infection after elective total joint arthroplasty remains a devastating complication. Preoperative nasal swab screening for Staphylococcus aureus colonization and subsequent treatment of colonized patients is one proposed method to identify at-risk patients and decrease surgical site infections (SSIs). The purpose of this study was to determine whether a preoperative staphylococcus screening and treatment program would decrease the incidence of SSI in elective joint arthroplasty patients. Methods: Since January 2009, a total of 9690 patients having an elective joint arthroplasty were screened before surgery for Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus (MSSA) with nares swabs. All patients with positive nare colonization for MSSA and MRSA were treated with mupirocin and chlorhexidine gluconate showers for 5 days before surgery. MRSA patients received vancomycin preoperatively and were placed in contact isolation. All elective arthroplasty patients used chlorhexidine gluconate antiseptic cloths the evening prior and the day of surgery. Perioperative infection rates were compared from 1 year before implementation to 5 years after implementation of this screening protocol. Results: SSI rates have decreased from 1.11% (prescreening) to 0.34% (nasal screening; P < .05) after initiation of the process. Staphylococcus was identified in 66.7% of the SSI infections before nasal screening and in 33.3% of the SSI after routine screening (P > .05). Conclusion: The addition of MRSA and/or MSSA nares screening along with a perioperative decolonization protocol has resulted in a decreased SSI rate by 69%.
Article
Background: Previous studies have suggested that wound complications may be higher after direct anterior approach (DAA) hip arthroplasty, but, specific risk factors have not been closely examined. Methods: We conducted a retrospective case-control study of 651 consecutive DAA hip arthroplasty surgeries performed by 2 surgeons over a 3-year period. Outcome measures included any postoperative wound problem (including prolonged drainage, wound dehiscence, wound necrosis, suture granuloma, and superficial infection) requiring additional intervention or reoperation. Univariate odds ratios (ORs) were calculated, and multivariate logistic regression analysis was performed to determine risk correlation. Receiver operator characteristic (ROC) curves were created to determine disease predictability. Results: A total of 75 patients (11.5%) experienced wound complications requiring additional intervention, of which, 13 (1.9%) required reoperation. Multivariate regression analysis found that development of wound complications was significantly and independently associated with body mass index (BMI) 30-35 kg/m(2) (OR 2.05; 95% confidence interval [CI] 1.08-3.88), BMI 35-40 kg/m(2) (OR 3.40; 95% CI 1.42-8.26), BMI > 40 kg/m(2) (OR 7.28; 95% CI 2.55-20.78), and diabetes mellitus (OR 2.97; 95% CI 1.46-6.07). Reoperation for wound complication was significantly associated with BMI > 40 kg/m(2) (OR 5.68; 95% CI 1.17-27.48) and diabetes mellitus (OR 13.08; 95% CI 3.97-43.11). Optimal cutoff values for BMI were found through receiver operator characteristic curve analysis to be 28.0 kg/m(2) for development of wound complications and 28.2 kg/m(2) for reoperation for wound complications. Conclusion: Obesity and diabetes mellitus are significantly associated with postoperative wound-healing complications and the need for reoperation for these wound complications after DAA hip arthroplasty.
Article
Background: The orthopedic literature documents that obesity can place patients at increased risk for complications. This is the first study to document the increased risk of infection in obese patients after direct anterior approach (DAA) primary total hip arthroplasty (THA). Methods: We retrospectively evaluated 1621 consecutive primary THAs performed with a DAA. Patients were stratified by body mass index <35 kg/m(2) (group 1) or ≥35 kg/m(2) (group 2). Rates of postoperative infection requiring revision, superficial wound dehiscence, return to the operating room, and total wound complications were compared. There were 1417 cases in group 1 and 204 in group 2. Results: Five cases in each group had a deep infection, resulting in a significantly higher rate in group 2 (0.35% vs 2.5%, P = .0044, relative risk = 7.1). Superficial wound dehiscence was diagnosed in 13 (0.92%) THA in group 1 and 4 (1.96%) in group 2 (P = .256). The all-cause reoperation rate was 0.92% and 3.43% in each group, respectively (P = .008). The total rate of all studied complications was 1.27% compared to 4.41% (P = .0040, relative risk = 3.5). Conclusion: This is the first study to report on significantly increased rates of postoperative infection requiring revision in patients with body mass index ≥35 kg/m(2) after anterior approach hip arthroplasty. We believe it is the combination of immune dysfunction and proximity of the anterior incision to the inguinal crease and genitalia with overlying abdominal pannus that contributes to this risk. Further studies comparing other surgical approaches in obese patients are needed to determine if this complication is truly attributable to the DAA alone.
Article
BACKGROUND: With recent advances in the treatment of infection with hepatitis C increasing lifespan and quality of life, the need for total joint arthroplasty in this patient population is expected to grow. Presently, there are limited and conflicting data on the perioperative outcomes of lower-extremity total joint arthroplasty among patients with hepatitis C. The purpose of our study was to assess the association between hepatitis C and perioperative outcomes of lower-extremity total joint arthroplasty.
Article
» Clinical practice guidelines from the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) and a clinical effectiveness literature review from the Agency for Healthcare Research and Quality (AHRQ) are in agreement about the need for active intervention in preventing venous thromboembolism after total hip arthroplasty or total knee arthroplasty, but a paucity of clinical end-point data provide no basis for the endorsement of any specific regimen over another. » The adjunctive use of mechanical compression devices is associated with a reduction in venous thromboembolism and no incremental bleeding risk, but data are not sufficient to recommend the use of mechanical compression devices as the sole means of venous thromboembolism prophylaxis at this time. » Warfarin remains popular among North American surgeons for venous thromboembolism prophylaxis, largely because of its delayed onset of action and correspondingly low bleeding risk. However, it is not an ideal option because of the need for monitoring and unpredictable drug sensitivity in some patients that can result in occasional bleeding complications. » Newer anticoagulants are very specific and more potent in their actions. They are highly effective in reducing deep venous thrombosis, but have not resulted in a meaningful decrease in clinical pulmonary embolism and are accompanied by a substantial increase in major and non-major clinically important bleeding. » Recent observational data on aspirin prophylaxis suggest rates of clinical pulmonary embolism that are comparable with those observed with more potent anticoagulants, particularly when used in combination with regional anesthesia and pneumatic compression devices. » The optimal regimen for the prevention of clinically important deep venous thrombosis and pulmonary embolism remains to be identified. Copyright
Article
This study investigates the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the 30 days after total joint arthroplasty. Patients who underwent elective primary total hip and knee arthroplasty as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Outcomes were compared between patients with and without hypoalbuminemia (serum albumin concentration <3.5 g/dL) with adjustment for patient and procedural factors. A total of 49603 patients were included. In comparison to patients with normal albumin concentration, patients with hypoalbuminemia had a higher risk for surgical site infection, pneumonia, extended length of stay, and readmission. Future efforts should investigate methods of correcting nutritional deficiencies prior to total joint arthroplasty. If successful, such efforts could lead to improvements in short-term outcomes for patients.
Article
Background: Total joint arthroplasty is the most frequently performed orthopaedic procedure in the United States. The purpose of the present study was to identify differences in thirty-day morbidity and mortality following primary total hip and total knee arthroplasty according to smoking status and pack-year history of smoking. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who had undergone primary total hip or total knee arthroplasty between 2006 and 2012. Patients were stratified by smoking status and pack-year history of smoking. Thirty-day rates of mortality, wound complications, and total complications were compared with use of univariate and multivariate analyses. Results: We identified 78,191 patients who had undergone primary total hip or total knee arthroplasty. Of these, 81.8% (63,971) were nonsmokers, 7.9% (6158) were former smokers, and 10.3% (8062) were current smokers. Current smokers had a higher rate of wound complications (1.8%) compared with former smokers and nonsmokers (1.3% and 1.1%, respectively; p < 0.001). Former smokers had a higher rate of total complications (6.9%) compared with current smokers and nonsmokers (5.9% and 5.4%, respectively; p < 0.001). Multivariate analysis identified current smokers as being at increased risk of wound complications (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.21 to 1.78), particularly deep wound infection, while both current smokers (OR, 1.18; 95% CI, 1.06 to 1.31) and former smokers (OR, 1.20; 95% CI, 1.08 to 1.34) were at increased total complication risk. Increasing pack-year history of smoking resulted in increasing total complication risk. Conclusions: On the basis of our findings, current smokers have an increased risk of wound complications and both current and former smokers have an increased total complication risk following total hip or total knee arthroplasty.
Article
The authors assessed the incidence of and risk factors associated with 30-day surgical site infections (SSIs) following primary (p) and revision (r) THA and TKA. In total, 23,128 primary and 2170 revision TJAs were identified between 2005 and 2010 in the ACS NSQIP database. The 30-day SSI rates, overall and deep, were 1.1 and 0.1% for pTKA, 1.18 and 0.4% for pTHA, 1.68 and 0.7% for rTKA, and 2.9 and 1.7% for rTHA. After primary TJA, independent risk factors were BMI>40, hypertension, prolonged operative time, electrolyte disturbance and previous infection, and after revision TJA, dyspnea and bleeding disorder were risk factors. This study should help provide benchmark data for SSI following TJA. Copyright © 2015. Published by Elsevier Inc.
Article
Periprosthetic joint infection continues to potentially complicate an otherwise successful joint replacement. The treatment of this infection often requires multiple surgical procedures associated with increased complications and morbidity. This study examined the relationship between periprosthetic joint infection and mortality and aimed to determine the effect of periprosthetic joint infection on mortality and any predictors of mortality in patients with periprosthetic joint infection. Four hundred and thirty-six patients with at least one surgical intervention secondary to confirmed periprosthetic joint infection were compared with 2342 patients undergoing revision arthroplasty for aseptic failure. The incidence of mortality at thirty days, ninety days, one year, two years, and five years after surgery was assessed. Multivariate analysis was used to assess periprosthetic joint infection as an independent predictor of mortality. In the periprosthetic joint infection population, variables investigated as potential risk factors for mortality were evaluated. Mortality was significantly greater (p < 0.001) in patients with periprosthetic joint infection compared with those undergoing aseptic revision arthroplasty at ninety days (3.7% versus 0.8%), one year (10.6% versus 2.0%), two years (13.6% versus 3.9%), and five years (25.9% versus 12.9%). After controlling for age, sex, ethnicity, number of procedures, involved joint, body mass index, and Charlson Comorbidity Index, revision arthroplasty for periprosthetic joint infection was associated with a fivefold increase in mortality compared with revision arthroplasty for aseptic failures. In the periprosthetic joint infection population, independent predictors of mortality included increasing age, higher Charlson Comorbidity Index, history of stroke, polymicrobial infections, and cardiac disease. Although it is well known that periprosthetic joint infection is a devastating complication that severely limits joint function and is consistently difficult to eradicate, surgeons must also be cognizant of the systemic impact of periprosthetic joint infection and its major influence on fatal outcome in patients. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Article
Satisfactory primary wound healing following total joint replacement is essential. Wound healing problems can have devastating consequences for patients. Assessment of their healing capacity is useful in predicting complications. Local factors that influence wound healing include multiple previous incisions, extensive scarring, lymphoedema, and poor vascular perfusion. Systemic factors include diabetes mellitus, inflammatory arthropathy, renal or liver disease, immune compromise, corticosteroid therapy, smoking, and poor nutrition. Modifications in the surgical technique are necessary in selected cases to minimise potential wound complications. Prompt and systematic intervention is necessary to address any wound healing problems to reduce the risks of infection and other potential complications. Cite this article: Bone Joint J 2013;95-B, Supple A:144–7.