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Despite advances in total knee arthroplasty (TKA) technology, up to 1 in 5 patients remain dissatisfied. This study sought to evaluate if sensor-guided knee balancing improves postoperative clinical outcomes and patient satisfaction compared to a conventional gap balancing technique.We undertook a prospective double-blind randomized controlled trial of patients presenting for elective primary TKA to determine a difference in TKA soft tissue balance between a standard gap balancing (tensiometer) approach compared to augmenting the balance using a sensor-guided device. The sensor-guided experimental group had adjustments made to achieve a balanced knee to within 15 pounds of intercompartmental pressure difference. Secondary outcomes included differences in clinical outcome scores at 6 months and 1 year postoperative, including the Oxford Knee Score and Knee Society Score and patient satisfaction.The sample comprised of 152 patients, 76 controls and 76 experimental sensor-guided cases. Within the control group, 36% (27/76) of knees were unbalanced based on an average coronal plane intercompartmental difference15 pounds, compared to only 5.3% (4/76) within the experimental group (P.0001). There were no significant differences in 1-year postoperative flexion, Knee Society Score, or Oxford scores. Overall, TKA patient satisfaction at 1 year was comparable, with 81% of controls and experimental cases reporting they were very satisfied (P = .992).Despite the use of the sensor-guided knee balancer device to provide additional quantitative feedback in the evaluation of the soft tissue envelope during TKA, we were unable to demonstrate improved clinical outcomes or patient satisfaction compared to our conventional gap balancing technique.

Background We aimed to establish diagnostic criteria for bleeding independently associated with mortality after noncardiac surgery (BIMS) defined as bleeding during or within 30 days after noncardiac surgery that is independently associated with mortality within 30 days of surgery, and to estimate the proportion of 30-day postoperative mortality potentially attributable to BIMS. Methods This was a prospective cohort study of participants ≥45 yr old having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011. Cox proportional hazards models evaluated the adjusted relationship between candidate diagnostic criteria for BIMS and all-cause mortality within 30 days of surgery. Results Of 16 079 participants, 2.0% (315) died and 36.1% (5810) met predefined screening criteria for bleeding. Based on independent association with 30-day mortality, BIMS was identified as bleeding leading to a postoperative haemoglobin Conclusions Bleeding independently associated with mortality after noncardiac surgery (BIMS), defined as bleeding that leads to a postoperative haemoglobin Clinical trial registration NCT00512109.

Background Prosthetic joint infections (PJI) can be devastating postoperative complications after total joint replacement (TJR). The role of decolonization of Staphylococcus aureus carriers prior to surgery still remains unclear, and the most recent guidelines do not state a formal recommendation for such strategy. Our purpose was to seek further evidence supporting preoperative screening and S aureus decolonization in patients undergoing TJR. Methods This was a quasiexperimental quality improvement study comparing a 5-year baseline of deep and organ-space PJIs (2005- 2010) to a 1-year intervention period (May 2015 to July 2016). The intervention consisted of nasal and throat screening for S aureus preoperatively and decolonization of carriers over 5 days prior to surgery. Results Prior to the intervention, we identified 42 deep and/or organ-space PJIs in 8,505 patients undergoing TJR (0.5%). S aureus was the causal microorganism in 28 of 42 (66.6%) cases. During the intervention, 22.5% (424 of 1,883) of patients were S aureus carriers. The PJI rate was similar overall (0.4%, 7 of 1,883; odds ratio, 0.75; 95% confidence interval, 0.34-1.67; P = .58), but there was a significant reduction in S aureus PJI to only 1 case during the intervention (odds ratio, 0.15; 95% confidence interval, 0.004-0.94; P = .039). Conclusions Active screening for S aureus and decolonization of carriers prior to TJR was associated with a reduction in PJI due to S aureus, but no changes in overall PJI rates were observed.

Background Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia. Methods We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom. Results Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%). Conclusions One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements. Level of evidence Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

To the Editor: Acute kidney injury (AKI) is a lesser-known complication of hip fracture that may come about owing to decreased kidney perfusion and heightened inflammation from trauma, pain, bleeding, and fasting. Approximately 15%-20% of patients undergoing surgery for a hip fracture develop AKI, with 0.5%-1.8% receiving dialysis. [...]

Background Total joint arthroplasty (TJA) is among the most common operations performed worldwide, with global volumes on the rise. It is important to understand if the characteristics of this patient population are changing over time for resource allocation and surgical planning. The purpose of this study is to examine how this patient population has changed between 2003 and 2017. Methods A retrospective review of a prospective TJA database was conducted. Age, gender, body mass index, comorbidities, American Society of Anesthesiologists class, responsible diagnoses, and comorbidities were compared over 5-year intervals between 2003 and 2017. All patients undergoing primary, elective TJA were included. Results Overall, 17,138 TJAs were included. Mean body mass index increased over the study period for total hip arthroplasty (THA; 29.4-30.4 kg/m2, P Conclusion The key findings of this retrospective analysis of a large prospective database are that patients undergoing TJA are becoming younger and more obese. It is unclear whether patients are becoming more medically complex. These trends paint a concerning picture of a population that is increasingly complex, and may require a greater allocation of resources in the future. Level of Evidence Level III, retrospective cohort study.

Background A cross-sectional study of total knee arthroplasty (TKA) patients was conducted to determine the association of lower-extremity arterial calcification (LEAC) with acute perioperative cardiovascular events (CVEs). Methods Regression modeling was used to examine the association of radiographic presence of LEAC and acute myocardial infarction (MI), perioperative CVE, 30-day CVE readmit, and 30-day and 1-year mortality. Results Of 900 TKA patients, LEAC was identified in 21.1%. Of LEAC cases, 1.6% had an acute MI vs 0.1% of non-LEAC cases ( P = .031). Perioperative CVE rate was 5.8% for LEAC vs 1.5% for non-LEAC ( P = .002). Having LEAC was identified as a significant risk factor for a perioperative CVE (odds ratio [OR] 2.83; 95% confidence interval [CI] 1.09-7.35). Because of limited number of acute MI events, absence of 30-day CVE readmit, 30-day mortality, and few 1-year mortality events, computing OR for these was not possible. Likewise, because of small number of events (n = 3), estimates for the odds of LEAC cases having an acute MI are less reliable, yielding extremely large random errors (OR 11.37; 95% CI 0.09-597.93) and must be interpreted with caution. The OR for 1-year mortality was 1.88 (95% CI 0.17-13.20), but again with large random errors. Conclusion Our study shows that LEAC around the knee is associated with an increased risk of having a perioperative CVE. Crude radiographic detection of LEAC around the knee has the potential to improve risk stratification for TKA patients by informing the surgeon of the need for further preoperative cardiac workup.

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p

Background While hip and knee total joint arthroplasty (TJA) patients experience marked improvement in pain relief and function, many patients experience nuisance symptoms, which may cause discomfort and dissatisfaction. Methods A prospective survey study to determine type and prevalence of hip/knee TJA nuisance symptoms and impact on patient satisfaction at 1 year postoperative was conducted. The survey determined occurrence of common nuisance symptoms (eg, localized pain, swelling, instability, stiffness) and impact on overall satisfaction rated on a 10-point visual analog scale (VAS). Survey responses were analyzed using descriptive statistics. Results The sample comprised 545 TJA patients who completed the survey: 335 knees (61%) and 210 hips (39%). Among knees, the most commonly reported nuisance symptoms and associated impact on satisfaction included difficulty kneeling (78.2%; VAS, 4.3; SD, 3.3), limited ability to run/jump (71.6%; VAS, 3.3; SD, 3.3), and numbness around incision (46.3%; VAS, 3.8; SD, 3.3). Overall, 94% of knee patients experienced at least 1 nuisance symptom at 1 year, reporting mean satisfaction of 9/10 (SD, 1.7). Among hips, the most commonly reported nuisance symptoms and associated impact on satisfaction were limited ability to run/jump (68.6%; VAS, 3.4; SD, 3.4), thigh muscle pain (44.8%; VAS, 3; SD, 2.7), and limp when walking (37.6%; VAS, 4.1; SD, 3.2). Overall, 88% of hip patients experienced at least 1 self-reported nuisance symptom at 1 year, reporting mean satisfaction of 8.9/10 (SD, 1.7). Conclusion Nuisance symptoms after hip/knee TJA are very common. Despite the high prevalence, impact on overall satisfaction is minimal and patient satisfaction remains high. Careful preoperative counseling regarding prevalence is prudent and will help establish realistic expectations following TJA.

Background Diagnostic criteria for Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS) have been defined as bleeding that leads to a postoperative haemoglobin Methods In a prospective cohort study of 16 079 participants aged ≥45 yr having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011, 17.3% (2782) experienced BIMS. An electronic risk calculator for BIMS was developed and internally validated by logistic regression with bootstrapping, and further simplified to a risk index. Decision curve analysis assessed the potential utility of each prediction guide compared with a strategy of identifying risk of BIMS based on preoperative haemoglobin Results With information about the type of surgery, preoperative haemoglobin, age, sex, functional status, kidney function, history of high-risk coronary artery disease, and active cancer, the risk calculator accurately predicted BIMS (bias-corrected C-statistic, 0.84; 95% confidence interval, 0.837–0.852). A simplified index based on preoperative haemoglobin Conclusions BIMS, defined as bleeding that leads to a postoperative haemoglobin Clinical trial registration NCT00512109.

IntroductionAnnually, millions of adults suffer hip fractures. The mortality rate post a hip fracture is 7%–10% at 30 days and 10%–20% at 90 days. Observational data suggest that early surgery can improve these outcomes in hip fracture patients. We designed a clinical trial—HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) to determine the effect of accelerated surgery compared with standard care on the 90-day risk of all-cause mortality and major perioperative complications.Methods and analysisHIP ATTACK is a multicentre, international, parallel group randomised controlled trial (RCT) that will include patients ≥45 years of age and diagnosed with a hip fracture from a low-energy mechanism requiring surgery. Patients are randomised to accelerated medical assessment and surgical repair (goal within 6 h) or standard care. The co-primary outcomes are (1) all-cause mortality and (2) a composite of major perioperative complications (ie, mortality and non-fatal myocardial infarction, pulmonary embolism, pneumonia, sepsis, stroke, and life-threatening and major bleeding) at 90 days after randomisation. All patients will be followed up for a period of 1 year. We will enrol 3000 patients.Ethics and disseminationAll centres had ethics approval before randomising patients. Written informed consent is required for all patients before randomisation. HIP ATTACK is the first large international trial designed to examine whether accelerated surgery can improve outcomes in patients with a hip fracture. The dissemination plan includes publishing the results in a policy-influencing journal, conference presentations, engagement of influential medical organisations, and providing public awareness through multimedia resources.Trial registration numberNCT02027896; Pre-results.

We conducted a cross-sectional study of primary total joint replacement (TJR) patients to determine predictors for prolonged length of stay (LOS) in hospital to identify patient characteristics that may inform resource allocation, accounting for patient complexity.Preoperative demographics, medical comorbidities and acute hospital LOS from a consecutive series of primary TJR patients from an academic arthroplasty centre were abstracted. We categorized patients as LOS of 3 or fewer days, 4 days, or 5 or more days to align results with varying LOS benchmarks. To identify predictors for LOS, we used a generalized logistic regression model fitted on an LOS ternary outcome, using LOS of 3 or fewer days as a reference category.The sample included 1459 patients: 61.7% total knee and 38.3% total hip. Male sex was predictive of an LOS of 3 or fewer days (4 d: odds ratio [OR] 0.48, 95% confidence interval [CI] 0.364-0.631; ≥ 5 d: OR 0.57, 95% CI 0.435-0.758), as was current smoking status (4 d: OR 0.425, 95% CI 0.274-0.659; ≥ 5 d: OR 0.489, 95% CI 0.314-0.762). Strong predictors of prolonged LOS included total hip versus total knee arthroplasty, age 75 years or older, American Society of Anesthesiologists classification of 3 and 4 and number of cardiovascular comorbidities.Not all patients undergoing TJR are equal. The goal should be individual patient-focused care rather than a predetermined LOS that is not achievable for all patients. Hospital resource planning must account for patient complexity when planning future bed management.Nous avons réalisé une étude transversale auprès de patients soumis à une chirurgie pour prothèse articulaire totale (PAT) afin de déterminer les facteurs prédictifs d’une durée du séjour hospitalier (DSH) prolongée (en établissement de soins de courte durée) et de dégager les caractéristiques des patients qui permettraient d’orienter l’allocation des ressources en tenant compte de la complexité des cas.Nous avons extrait les données démographiques préopératoires, les comorbidités médicales et la DSH pour une série de cas consécutifs de PAT primaire dans un centre d’arthroplastie universitaire. Nous avons classé les patients par catégorie de DSH, soit 3 jours ou moins, 4 jours, ou 5 jours et plus, de manière à répartir les résultats selon les diverses cibles de DSH. Pour dégager les facteurs prédictifs de la DSH, nous avons utilisé un modèle de régression logistique généralisé intégré à un paramètre ternaire de DSH, en utilisant la DSH de 3 jours ou moins comme catégorie de référence.L’échantillon regroupait 1459 patients : 61,7 % recevant une prothèse totale du genou (PTG) et 38,3 % recevant une prothèse totale de la hanche (PTH). Le fait d’être de sexe masculin était prédictif d’une DSH de 3 jours ou moins (4 j : rapport des cotes [RC] 0,48, intervalle de confiance [IC] à 95 % 0,364–0,631; ≥ 5 j : RC 0,57, IC à 95 % 0,435–0,758), tout comme le statut à l’égard du tabagisme (4 j : RC 0,425, IC à 95 % 0,274–0,659; ≥ 5 j : RC 0,489, IC à 95 % 0,314–0,762). Les facteurs prédictifs fiables d’une DSH prolongée incluaient la PTH c. PTG, l’âge de 75 ans ou plus, une classification de 3 ou 4 selon l’American Society of Anesthesiologists et le nombre de comorbidités cardiovasculaires.Les patients soumis à une PAT ne s’équivalent pas tous. L’objectif devrait être d’administrer des soins centrés sur le patient plutôt que sur une DSH prédéterminée qui, dans les faits, ne s’applique pas à tous patients. La planification des ressources hospitalières devra à l’avenir tenir compte de la complexité des cas dans la planification de la gestion des lits.

To elicit current practice and attitudes toward use of antibiotic-prophylaxis among TJA patients prior to dental procedures, a cross-sectional survey of practicing Canadian orthopaedic (OS) and dental surgeons (DS) was undertaken. Of respondents, 77% of OS and 71% of DS routinely prescribe antibiotic-prophylaxis, but while 63% of OS advocate lifelong use, only 22% of DS choose to do so (P

Lower extremity osteoarthritis with concomitant low-back pain (LBP) may obscure a clinician's ability to properly evaluate the status of hip or knee osteoarthritis and subsequent total joint arthroplasty (TJA) candidacy. A prospective cohort study was conducted to determine prevalence and severity of preoperative LBP among TJA patients, and the effect of TJA on alleviating LBP. Preoperative moderate to worst imaginable LBP pain on the Oswestry Disability Index (ODI) was significantly higher among hips compared to knees (28.8% vs. 16.1%, P0.0001). Compared to knees, hips also saw significant ODI improvement from preoperative to one-year postoperative. TJA candidates with considerable preoperative LBP should be counselled that TJA outcome may be impaired by the coexistence of spine disease, and that residual spine pain may continue following otherwise successful TJA.

An RCT pilot-study was conducted to assess efficacy of a 48-h continuous local infiltration of intra-articular bupivacaine (0.5% at 2 cc/h) versus placebo (0.5% saline at 2 cc/h) in decreasing PCA morphine consumption following TKA. Secondary outcomes included 48-h VAS pain, opioid side effects, length of stay, and knee function scores up to 1-year postoperatively. Of 67 randomized patients, 49 completed the trial including 24 bupivacaine, and 25 placebo patients. Mean 48-h PCA morphine consumption did not differ significantly between treatment (39 mg ± 27.1) and placebo groups (53 mg ± 30.4) (P = .137). The intervention did not improve pain scores, or any other outcome studied. Given study results we would conclude that analgesia outcomes with a multimodal analgesia regimen are not significantly improved by adding 48 h of 0.5% bupivacaine infiltration at 2 cc/h.

Background The relationship between pain catastrophizing and emotional disorders including anxiety and depression in osteoarthritic patients undergoing total joint arthroplasty (TJA) is an emerging area of study. The purpose of this study was to examine the association of these factors with preoperative patient characteristics. Methods A prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale (PCS) and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Preoperative measures included visual analog pain scale (VAS), Harris Hip and Knee Society scores, Oxford Score, and Kellgren–Lawrence grade. Logistic and quantile regression were used to assess the relationship between preoperative characteristics and PCS or HADS, adjusting for covariate effects. Results We recruited 463 TJA patients. VAS pain (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.04-1.45) and Oxford (OR 1.13; 95% CI 1.07-1.20) were significant predictors for PCS and its subdomains excluding rumination. Oxford was the only significant predictor for abnormal HADS-A (OR 1.10; 95% CI 1.04-1.17). VAS pain (OR 1.27; 95% CI 1.02-1.52) and Oxford (OR 1.09; 95% CI 1.01-1.17) were significant predictors for abnormal HADS-D. The quantile regression showed similar patterns of association, with female gender, younger age, and higher ASA also associated with HADS-A. Conclusion The most important predictor of catastrophizing, anxiety and/or depression in TJA patients is preoperative pain and poor subjective function. At-risk patients include those with increased pain and generally good clinical function, as well as younger women with significant comorbidities. Such patients should be identified and targeted psychological therapy implemented preoperatively to optimize coping strategies and adaptive behavior to mitigate potential for inferior TJA outcomes including pain and patient dissatisfaction.

Previously reported antibiotic-impregnated cement strengths have been based on uniaxial and fatigue testing methodologies. These methods may not provide an accurate characterization of bone cement's true load-bearing capacity in total joint replacement (TJR). The present study utilized biaxial testing to report on the properties of antibiotic-impregnated cement. Test groups included: PMMA mixed with Vancomycin, Gentamicin, Tobramycin, or no antibiotic (control). In comparison to the control group, PMMA samples mixed with powdered gentamicin resulted in an increase in the mean elastic modulus by 6.50% versus a drop noted with powdered vancomycin and tobramycin by 2.65 and 1.37% respectively. The mean elastic modulus in samples containing liquid gentamicin dropped by 11.6%. This study supports the continued use of powdered antibiotics when clinically indicated, but suggest caution in the use of liquid gentamicin in TJR.

Failed open reduction internal fixation (ORIF) of the proximal femur can render patients severely disabled. This study analyzed the short-term functional results and complications of total hip arthroplasty (THA) for complications of ORIF after hip fracture. A retrospective arthroplasty database review identified 36 patients treated with a THA for complications of ORIF of the hip. These patients were matched to a cohort of 36 patients who underwent primary unilateral THA for osteoarthritis. Study results indicate that THA for failed ORIF of the hip is a successful procedure despite concerns of increased intraoperative difficulty and risk of fracture.

Roy BD, de Beer J, Harvey D, Tarnopolsky MA. Creatine monohydrate supplementation does not improve functional recovery after total knee arthroplasty. Objective To determine if creatine monohydrate supplementation can improve body composition and enhance recovery after total knee arthroplasty (TKA). Design Randomized trial in which creatine monohydrate or placebo was administered. Setting Public primary care facility. Participants Thirty-seven adults (17 men, 20 women) with osteoarthritis undergoing TKA. Intervention Subjects received creatine monohydrate (10g/d×10d presurgery to 5g/d×30d postsurgery) or placebo. Main Outcome Measures Body composition (dual-energy x-ray absorptiometry scanning), muscle metabolite concentrations (adenosine triphosphate, phosphocreatine, creatine, total creatine [phosphocreatine + creatine]), muscle histomorphometery, quadriceps, ankle dorsiflexion and handgrip strength, and functional capacity. All measurements were completed preoperatively (−7d) and 30 days postoperatively, except for that of muscle metabolites. Muscle metabolite samples were collected during surgery (0d) and at 30 days. Results A significant decrease in quadriceps and ankle dorsiflexion strength was observed at 30 days postoperatively ( P Conclusions Creatine monohydrate supplementation did not improve body composition or muscle strength when given before surgery, nor did it enhance recovery after TKA.

We report a retrospective analysis of the incidence of intraoperative femur fractures at the tip of the prosthesis in 45 consecutive, uncemented, long (205-mm), straight hydroxyapatite, fully coated stems used for revision arthroplasty of the hip. Five patients were lost to follow-up. Intraoperative fractures of the distal femur occurred in 7 cases (17.5%). In the remaining 33 cases in which no fracture occurred, the tip of the implanted stem was found to be potentially at risk for causing a fracture in 18 (55%) cases. We concluded that uncemented, 205-mm, straight femoral stems should be used with caution in the setting of revision hip surgery. A bowed stem of that length may be a safer alternative. Otherwise, a shorter, straight stem may reduce the risk of complications at the stem tip.

Given institutional pressures to reduce hospital length of stay (LOS) we hypothesized that "failure to cope" would be a significant factor for readmission following total joint arthroplasty (TJA). A retrospective review of 4288 TJA patients was conducted to determine readmission rates and reasons for readmit within 30 days of discharge. Ninety-five patients (2.2%; 95% CI: 1.8%-2.7%) were readmitted. Leading diagnoses were surgical site infection (23.2%) and cardiovascular event (16.8%). Of readmits 5.3% (5/95) were readmitted for failure to cope, representing 0.1% of the sample. In multivariate analysis, increased age was a significant predictor of readmission (OR = 0.974, 95% CI 0.952-0.997). Contrary to our hypothesis failure to cope was not a leading diagnosis for readmission; concerns remain that early discharge may however correlate with increased readmit rates.

A retrospective cohort study of 668 staged bilateral TKA patients was conducted to determine first-side versus second-side subjective and objective outcomes. Improvement in patient perceived function, measured by one-year Oxford Score (OKS) was defined by a minimal clinically important difference of5 points in OKS. Results indicate that patients who had a minimal clinically important improvement (MCII) on the first-side have a significantly greater chance of maintaining or improving benefit with second-side TKA (OR 3.2; 95% CI 1.63-6.22; P=0.000). Of those with no clinical improvement (NCI), 71.4% achieved MCII on the second-side, while 28.6% remained NCI (P=0.000). Patients who do not initially benefit from first-side TKA should not be denied second-side staged-TKA as they still have a significant chance of achieving an MCII.

A retrospective cohort study and a comparative literature review were undertaken to determine outcomes and survival/mortality rates among nonagenarian patients who underwent total joint arthroplasty (TJA). Thirty-nine patients who underwent TJA (14 hips, 25 knees) aged 90+ years were identified from a database of 9817 primary TJA cases performed at one hospital between 1998 and 2010. Findings were compared to synthesized data from relevant published literature review (LR). The mean age was 91.3 (±1.4) years, 79.5% were rated by the American Society of Anesthetists as 3+. Medical complication rate was 25.6% vs 36.2% for LR cases (P = .219). Perioperative death rate was 2.6% vs 2.1% among LR cases (P = 1.000). At 3.8-year follow-up, mortality rate was 59% (LR, 58.2%; 5.1 years), with a mean age of 95.2 (±3.5) years at death (LR, 96.3 ± 3.4). Excellent clinical outcomes were achieved. Primary TJA remains a viable and effective procedure in nonagenarian patients.

A retrospective case-control study was conducted to evaluate 1-year total knee arthroplasty (TKA) outcomes among preoperative stiff knees, range of motion (ROM) 80° or less, compared with nonstiff preoperative knees, ROM 100° or greater. A total of 134 stiff knee cases were compared with a matched cohort of 134 non-stiff knee controls. Knee Society Score and Oxford Knee Score change scores from baseline to 1 year were similar between the groups. Stiff knees experienced a significantly greater mean improvement in ROM from baseline to 1 year (30.8° ± 18.8°) as compared with nonstiff knees (1.1° ± 12.8°) (P.0001). Although ultimate ROM of a TKA can be restricted secondary to preoperative stiffness, improvements in outcomes and ROM are not affected. We conclude that progression of stiffness should not in and of itself lead to earlier intervention of TKA in most cases.

Purpose: Major cardiovascular complications associated with noncardiac surgery represent a substantial population health problem for which there are no established efficacious and safe prophylactic interventions. Acetyl-salicylic acid (ASA) represents a promising intervention. The objective of this study was to determine surgeons’ perioperative usage of ASA, and if they would enrol their patients in a perioperative ASA randomized controlled trial (RCT). Methods: Cross-sectional survey of all practicing Canadian general, orthopedic, and vascular surgeons. Our mailed, self-administered survey asked surgeons to consider only their patients who were at risk of a major perioperative cardiovascular complication. Results: The response rate was 906/1854 (49%). For patients taking ASA chronically, there was marked variability regarding ASA continuation prior to surgery amongst the general and orthopedic surgeons, whereas 76% of vascular surgeons continued ASA in 81-100% of their patients. For patients not taking ASA chronically, approaches to starting ASA prior to surgery were variable amongst the vascular surgeons, whereas 70% of general and 82% of orthopaedic surgeons did not start ASA. For patients taking ASA chronically, 73% of general surgeons, 70% of orthopaedic surgeons, and 36% of vascular surgeons would allow at least 40% of their patients to participate in a perioperative RCT comparing stopping versus continuing ASA. For patients not taking ASA chronically, most general (76%), orthopaedic (67%), and vascular (51%) surgeons would allow at least 40% of their patients to participate in a perioperative RCT comparing starting ASA versus placebo. Conclusion: This national survey demonstrates that perioperative ASA usage as reported by surgeons is variable, identifying the need for, and community interest in, a large perioperative ASA trial.

The role of perioperative antibiotic prophylaxis in total joint replacement (TJR) surgery is well established. Whereas guidelines have been published in some countries, in Canada controversy persists concerning the best clinical practice for perioperative antibiotic prophylaxis in TJR.We conducted a survey of 590 practising orthopedic surgeons performing TJR in Canada to assess current antibiotic prophylaxis practice. The survey included questions pertaining to antibiotic prophylaxis indications, antibiotic choice, dosing, route and timing of administration in the primary and revision arthroplasty setting, as well as postoperative wound drainage evaluation and management.The response rate after 2 mail-outs was 410 of 590 (69.5%). Current antibiotic prophylaxis regimens varied widely among surgeons, underscoring the controversy that exists regarding what constitutes best clinical practice.Opinions regarding use of perioperative antibiotic prophylaxis in TJR vary widely among orthopedic surgeons in Canada, illustrating the controversy as to what constitutes best clinical practice. This survey also points to a lack of consensus about the current management of postoperative wound drainage.

We analyzed the reproducibility and reliability of computer templating in primary uncemented total hip arthroplasties as compared to standard onlay templating techniques with hardcopy radiographs from a digital source. Digital templating showed good intraobserver and interoberserver reliability with intraclass correlation coefficient values greater than 0.7. Using computer templating, prediction of sizing to within 1 size was 85% accurate for femoral stem sizing and 80% accurate for acetabular sizing. Using onlay templating, prediction of sizing to within 1 size was 85% accurate for femoral sizing and 60% accurate for acetabular sizing. We conclude that the introduction of digital templating has significant benefits in preoperative planning for total hip arthroplasty over onlay templating.

This study was designed to address a recurring observation in our centre that, despite a satisfactory postoperative radiographic limb alignment, some patients are dissatisfied with the alignment and appearance of their operated leg. We carried out a prospective survey to determine patient perception of limb alignment after total knee arthroplasty (TKA) and whether level of satisfaction with alignment affects clinical outcome.Patients self-rated their alignment, their satisfaction with alignment and their level of knee pain on a visual analogue scale (VAS). Additional outcome measures included pre- and postoperative Knee Society Score (KSS), Oxford Knee Score (OKS) and the Health Survey Short Form (SF-12).Twenty of 87 (23%) patients were dissatisfied with their new leg alignment and had a poorer perception of pain and range of motion after TKA. Despite this finding, KSS and OKS were no different between patients who were satisfied and those who were dissatisfied with their limb alignment. The SF-12 showed a trend toward lower scores in patients who were dissatisfied with their limb alignment.Satisfaction with perceived limb alignment appears to influence outcome after TKA and is not reflected in current outcome scales. Perhaps patients should be counselled on how alignment is restored and on what to expect of their limb alignment and appearance after TKA.

Objective: To determine the level of physical activity participants are able to perform at a minimum of 1 year after primary total hip or knee replacement. Design: Cross-sectional survey. Setting: A tertiary care arthroplasty center. Participants: A total of 170 primary total hip and 184 primary total knee arthroplasty patients. Interventions: The University of California Los Angeles (UCLA) activity score was mailed to 242 primary hip and 225 primary knee arthroplasty patients. Patients were abstracted from a prospectively tabulated arthroplasty database and pre-selected for good/excellent clinical outcomes as determined by 1 year postoperative Knee Society (KSS) and Harris Hip (HHS) scores. Clinical outcomes including the Oxford Hip/Knee score were collected preoperatively, and at 6 and 12 months postoperatively. Correlations between UCLA scores, demographics, and clinical outcomes were calculated using Pearson's correlation. Main Outcome Measurements: Harris Hip Score, Oxford Hip Score, Knee Society Score, Oxford Knee Score, and UCLA Activity Scale. Results: Postal survey response rates for hips were 70.2% (170 of 242) and 81.8% for knees (184 of 225). Mean results at postoperative year 1 include: HHS (94.8), Oxford Hip Score (16.6), KSS clinical score (95.9), KSS function score (95.0), and Oxford Knee score (18.2). For both primary total hip arthroplasty and total knee arthroplasty patients, median UCLA score was 6, indicating moderate activity levels at a mean follow-up of 40.7 months for hips and 36.6 months for knees. Conclusions: UCLA scores indicate the average total joint replacement patient maintains a moderate activity level, and many perform active/very active levels of activity.

Historically, cemented total hip arthroplasty (THA) femoral stems inserted in varus have yielded poor clinical results. Few studies to date have addressed the question of the effects of varus alignment on cementless stems. We conducted a retrospective review of 125 uncemented THA femoral stems implanted by a single surgeon from 1994 to 1999.We conducted a retrospective radiographic review of 125 cementless primary THA femoral stems implanted by a single surgeon who used the Watson-Jones approach; we identified 16 stems implanted in varus, defined asor= 5 degrees and thus analyzed the effect of varus alignment on functional outcome. We matched varus stems to a cohort of 16 nonvarus cementless stems and measured radiographic signs of loosening and subsidence, defined as2 mm.At 4 years postsurgery, there was no significant difference in range of motion or in Harris Hip Score (p0.5), and no cases showed evidence of radiographic loosening or subsidence (p = 0.226).Study results suggest there is no consequence of varus femoral alignment in the cementless stems. Although it is not recommended to implant stems in varus, there were no apparent radiographic or clinical consequences observed at up to 4 years postoperative in this small case series.

Intramedullary instrument/device insertion during total joint replacement can generate high intramedullary pressures, with potential for clinical fat embolism syndrome. We evaluated effects of process parameters on intramedullary pressure generated when hammering an implant into a simulated femur analogue. Lower implant insertion speed, lower hammering force, a rubber- compared with steel-tipped hammer and a larger synthetic bone-to-implant radial gap reduced intramedullary pressure generated. Number of hammer strikes required to insert an implant increased with increasing marrow viscosity, whereas intramedullary pressure decreased with increasing viscosity. Significant intramedullary pressure reduction is obtained by applying more strikes of lower peak force using a rubber hammer tip, as opposed to fewer larger strikes. Caution should be exercised when instrumenting the distal femur, where viscosity is low and very high intramedullary pressures can be generated.

To determine the influence of Ontario Workplace Safety and Insurance Board (WSIB) benefits on short-term clinical outcomes of primary unilateral total knee arthroplasty (TKA).In a retrospective matched-cohort study at a single tertiary-care arthroplasty centre in Ontario, we compared a study cohort of 38 successive primary TKA patients receiving WSIB benefits from 1998 to 2002 to 38 controls, a matched cohort of non-WSIB patients, comparing Oxford Knee Score and Knee Society Score (both clinical and functional components) as well as flexion and pain variables, preoperatively and at postoperative intervals of 6 weeks, 6 months and 1 year. At least 1 year after their surgery, all patients were asked to complete a non-validated patient satisfaction survey. The number of clinic visits related to the operation was also compared, by means of Ontario Hospital Insurance Plan billing codes for each individual.Preoperative measurements showed the 2 groups to be similar. At follow-up, WSIB patients had significantly higher pain scores, poorer self-perceived functional outcomes and a lower range of knee flexion than the control group. WSIB patients also required more postoperative clinic visits and were more reluctant to answer questions about functional outcome.Short-term outcomes of primary TKA in patients receiving WSIB benefits are inferior to those of non-WSIB patients. WSIB patients are seen more frequently for postoperative follow-up, which we would attribute to the persistence of subjective complaints after TKA.

Retrospective review of 3471 patients who underwent total joint arthroplasty (TJA) (1479 hips, 1992 knees) to determine the incidence and timing of inhospital myocardial infarction (MI) after TJA. Sixty-three patients (1.8%; 95% CI, 1.4%-2.4%) suffered a perioperative MI occurring at a mean of 3 days post surgery. In multivariate analysis, increased age, body mass index, bilateral TJA, diabetes, and American Society of Anesthesiologists rating 3 were associated with perioperative MI. Our data cautions against hospital discharge within 3 days of surgery.

A pilot cohort study of 60 primary total hip arthroplasties (THAs) was undertaken to evaluate the technical aspects and possible clinical advantages of performing THA through a single-incision, minimally invasive, 10-cm-length, direct lateral approach compared with the same approach performed through a standard-length skin incision. We could not show any significant difference with regard to operative time; in-hospital equianalgesic opioid consumption; postoperative blood loss; complications; hospital length of stay; or flexion, Harris Hip and Oxford Scores at 6 weeks' postoperatively. Restricting the length of skin incision for THA performed through a direct lateral approach does not appear to afford any clinical advantage to the patient in the short term. The mini-exposure creates technical challenges that have the potential to adversely affect primary THA outcome.

Retrospective review of 1216 primary total knee arthroplasties (TKAs) to evaluate incidence and predictors of arthrofibrosis, defined as flexion less than 90 degrees 1 year post-TKA. Incidence of stiffness post-TKA was 3.7% (45/1216). A matched case-control study was then conducted to identify predictive factors for this outcome. Preoperative flexion and intraoperative flexion were predictive of ultimate postoperative flexion (P = .001 and P = .039, respectively). There was no correlation between postoperative stiffness and specific medical comorbidities, including diabetes. Preoperative and postoperative relative decreased patellar height and stiffness postoperative were significantly correlated (P = .001). Although stiffness post-TKA is multifactorial, careful attention to surgical exposure, restoring gap kinematics, minimizing surgical trauma to the patellar ligament/extensor mechanism, appropriate implant selection, and physiotherapy combined with a well-motivated patient may all serve to reduce the incidence of stiffness post-TKA.

Soft-tissue balancing and the amount of tension applied to the ligaments in a well-functioning total knee arthroplasty (TKA) has, thus far, not been accurately quantified. A ligament-tensioning device was used to measure displacement between the tibia and femur versus load during 86 consecutive TKAs. Measurements were made in flexion and extension following bone cuts and final soft-tissue balancing to calculate mean effective stiffness (MES) of the soft-tissue envelope and mean resting force on the implanted polyethylene component. MES was not affected by age or gender and did not differ in flexion versus extension. MES was significantly higher in posterior cruciate-retaining knees compared with posterior cruciate-sacrificing knees. There was no statistical difference between mean resting force on the polyethylene in flexion versus extension, or in posterior cruciate-retaining versus -sacrificing knees. These biomechanical data will serve as a good starting point for which to compare the expected stiffness of the ligaments and resting load on the polyethylene in well-balanced knees.

A 42-item survey was developed and administered to determine patient perception of and satisfaction with total hip arthroplasty (THA) vs total knee arthroplasty (TKA). A total of 153 patients who had both primary THA and TKA for osteoarthritis with 1-year follow-up were identified. Survey response rate was 72%. Patients were more satisfied with THA meeting expectations for improvement in function and quality of life (P < .05), whereas pain relief expectations were equivalent. Most patients (70.9%) reported that TKA required more physiotherapy. One-year Oxford score and improvement in Oxford score from preoperative to 1 year were superior for THAs (P = .000). Despite equivalent pain relief, THAs trend toward higher satisfaction compared with TKAs. THA is more likely to "feel normal" with greater improvement in Oxford score. Recovery from TKA requires more physiotherapy and a longer time to achieve a satisfactory recovery status. Patients should be counseled accordingly.