Identifying patients at risk in revision arthroplasty: a comprehensive single-centre analysis.

PurposeTo assess the effect of type 2 diabetes (T2DM) on hospital outcomes such as in hospital postoperative complications (IHPC), length of hospital stay (LOHS) and in-hospital mortality (IHM) after the revision of total hip arthroplasty (RHA) and total knee arthroplasty (RKA) and to identify factors associated with IHPC among T2DM patients undergoing these procedures.MethodsWe performed a retrospective study using the Spanish National Hospital Discharge Database, 2005–2014. We included patients who were ≥40 years old that had undergone RHA and RKA. For each T2DM patient, we selected a year-, gender-, age- and Charlson Comorbidity Index-matched non-diabetic patient.ResultsWe identified 44,055 and 39,938 patients who underwent RHA (12.72% with T2DM) and RKA (15.01% with T2DM). We matched 4,700 and 5,394 couples with RHA and RKA, respectively. Any IHPC was more frequent among patients with T2DM than among non-T2DM patients (19% vs. 15.64% in the RHA cohort and 12.94% vs. 11.09% in the RKA cohort, respectively). For patients who underwent RHA, postoperative infection (4.51% vs. 2.94%, p<0.001), acute post-hemorrhagic anemia (9.53% vs. 7.70%, p<0.001), mean LOHS and IHM were significantly higher in patients with T2DM. Among RKA patients, the incidence of acute posthemorrhagic anemia (7.21% vs. 5.62%; p = 0.001) and urinary tract infection (1.13% vs. 0.72%; p = 0.029) was significantly higher in patients with diabetes. Older age, obesity, infection due to internal joint prosthesis, myocardial infarction, congestive heart failure, mild liver disease and renal disease and emergency room admission were significantly associated with a higher risk of IHPC in T2DM patients. IHPC decreased over time only in T2DM patients who underwent RHA (OR 0.94, 95%CI 0.89–0.98).ConclusionsPatients with T2DM who underwent RHA and RKA procedures had more IHPC after controlling for the effects of possible confounders. LOHS and IHM were also higher among RHA patients with diabetes. Older age, comorbidity, obesity and emergency room admission were strong predictors of IHPC in diabetic patients.

Introduction The management of periprosthetic fractures is challenging and is guided by the configuration of the fracture, stability of implants and quality of the patient’s bone. This case report discusses the long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty. Case report We present the operative technique and long-term fate of a bivalved femoral allograft used for the treatment of a periprosthetic fracture around a stemmed femoral component of a revision total knee arthroplasty (TKA) in a patient with rheumatoid arthritis and osteoporosis. Regular radiographic follow-up confirmed incorporation and docking of the allograft. A subsequent ipsilateral femoral neck fracture 4 years after allograft implantation was treated with routine total hip replacement. Conclusion The use of femoral allograft for augmenting fixation of periprosthetic fractures above a TKA is not widely reported, and, at 11 years, this case represents the longest published follow-up above a revision TKA. Our case supports the use of a bivalved total femoral allograft in the treatment of long-bone periprosthetic fractures with poor bone stock. Introduction Data from joint registries indicate an increase in the number of primary and revision knee arthroplasties being performed each year internationally, and the volume of revision knee arthroplasty being performed in the USA alone is expected to increase by 601% between 2005 and 20301. Periprosthetic supracondylar femoral fractures can occur intraoperatively and postoperatively, with an overall incidence of 0.3–2.5% above primary total knee arthroplasties (TKAs)2–7. Estimates of the incidence after revision knee arthroplasty vary greatly from 1.7% to 38%3,6–8, with most reports quoting closer to 2%. Periprosthetic femoral fractures above TKA and revision TKA have historically been associated with high complication rates when treated nonoperatively or with internal fixation4,5,9. Periprosthetic fractures are more common in the elderly population and in females7. Additional risk factors include rheumatoid arthritis, chronic steroid treatment, reduced bone stock, neurological disorders, revision surgery, notching of the anterior cortex of the femur, and in particular poor bone stock3,9–11. Primary osteopenia or secondary to stress shielding around a stemmed revision femoral component further increases the difficulty of achieving good fracture fixation by traditional methods. Whilst the introduction of locked plate technology has revolutionized surgery in the presence of osteoporotic bone12, the use of a combination of cortical femoral allograft and compression plate13 or a bivalved total femoral allograft5,14 may be indicated when a periprosthetic fracture around a well-fixed implant is complicated by deficient bone stock or significant comminution. Unfortunately, there remains insufficient evidence to strongly support the use of a single method of surgical treatment in this complex fracture group. In this case report, we aim to provide further evidence that a bivalved total femoral allograft can be successfully used in the treatment of periprosthetic femoral fractures above/around a well-fixed stemmed revision TKA and that incorporation of the graft with the host femur is possible thereby increasing the patient’s bone stock. This technique can provide a reliable long-term solution in this complex fracture group. Case report One month after primary TKA for valgus arthritis, a 60-year-old lady with polyarticular rheumatoid arthritis and severe osteoporosis re-presented with a sintering fracture of the lateral femoral condyle after a simple stumble. The femoral component was revised to an uncemented stemmed implant, and the lateral femoral condyle was reconstructed with femoral head structural allograft. Three months after discharge, she fell and sustained a spiral periprosthetic fracture around the femoral stem (Figure 1). * Corresponding author Email: gavin.macpherson@nhs.net 1 Department of Orthopaedic Surgery, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK 2 Stiftung Orthopadische Universitatsklinik, Schlierbacher Landstrase 200a, 69118 Heidelberg, Germany 3 Orthopadischen Klinik Paulinenhilfe, Diakonie Klinikum Stuttgart, Rosenbergstrasse 38, D-70176 Stuttgart, Germany 4 Endoklinik Hamburg, Holstenstr. 2, 22767 Hamburg, Germany

What's New in Hip Replacement.

Trends in Management and Outcomes of Acute Nonvariceal Upper Gastrointestinal Bleeding: 1993–2003

Estimated Glomerular Filtration Rate as a Risk Stratification Tool for Early Complications in Revision Total Hip and Knee Arthroplasty

Summary. Periprosthetic fractures around total knee arthroplasty (TKA) are difficult to treat due to complex fracture morphology, high proportions of injuries associated with osteopenia, and the variability of injury patterns. Periprosthetic fractures associated with TKA are defined as fractures around the knee joint (femur, tibia, or patella) occurring within 5 cm of the intramedullary stem of the prosthesis or 15 cm of the joint. The incidence is estimated to be between 0.3% and 2.5% after primary TKA and up to 28% after revision TKA. There are several surgical and nonsurgical risk factors associated with postoperative periprosthetic fractures. Distal femoral periprosthetic fractures following TKA are the most common and reported to occur in 0.2–1.8% of patients after primary TKA. Tibial periprosthetic fractures have a reported prevalence of 0.07–0.1% in primary and 0.36% in revision knee arthroplasties. Patella fractures are the second most common periprosthetic fractures following TKA, with prevalence ranging from 0.68% to 1.19%, and are usually associated with a resurfaced patella. Several classification systems of periprosthetic fractures around TKA have been published and some treatment recommendations have been provided. However, most systems are subject to criticism and use different classification systems for the tibia, patella, and the femur.A variety of treatment methods are available for periprosthetic fractures. Conservative treatment can include protected weight bearing, splinting, or traction. Surgical treatment commonly involves closed intramedullary nailing or open reduction and internal fixation by plates. In cases of significant bone loss, a revision TKA may be indicated. In general, treatment must be guided based on the stability of the implant and the remaining bone quality, as determined by the presence of osteolysis and the location of the fracture.

Rehabilitation implications during the development of the Norwich Enhanced Recovery Programme (NERP) for patients following total knee and total hip arthroplasty

Total Hip and Knee Revisions are Really Outpatient Procedures? Implications of the Removal From the Inpatient Only List

Is an overnight stay after percutaneous nephrolithotomy safe?

P34. Increasing patient complexity is associated with longer in hospital lengths of stay and higher rates of medical complications following primary 1- to 2-level lumbar fusion

Contemporary Distal Femoral Replacements for Supracondylar Femoral Fractures Around Primary and Revision Total Knee Arthroplasties

This study investigated the influence of body mass index (BMI) on the post-operative fall in the level of haemoglobin (Hb), length of hospital stay (LOS), 30-day re-admission rate, functional outcome and quality of life, two years after total knee arthroplasty (TKA). A total of 7733 patients who underwent unilateral primary TKA between 2001 and 2010 were included. The mean age was 67 years (30 to 90). There were 1421 males and 6312 females. The patients were categorised into three groups: BMI < 25.0 kg/m(2) (normal); BMI between 25.0 and 39.9 kg/m(2) (obese); and BMI ≥ 40.0 kg/m(2) (morbidly obese). Compared with the normal and obese groups, the mean LOS was longer by one day (95% confidence interval (CI) 0 to 2) in the morbidly obese group (p = 0.003 and p=0.001 respectively). The 30-day re-admisison rate was also higher in the morbidly obese group compared to the obese group (OR 2.323, 95% CI 1.101 to 4.900, p = 0.024); and showed a higher trend compared to the normal group (OR 1.850, 95% CI 0.893 to 3.831, p = 0.100). However, the morbidly obese group had a smaller drop in post-operative Hb level by a mean of 0.5 g/dl (0.3 to 0.6) and 0.3 g/dl (0.1 to 0.5), when compared with the normal and obese groups respectively (both p < 0.001). Furthermore, the mean improvement in Oxford Knee Score (OKS) and Knee Society Knee Score (KSKS) at two years follow-up was three points (two to four) and five points (two to seven) more in the morbidly obese group than in the normal group (both p < 0.001). The mean improvement in Knee Society Function Score, and Physical and Mental Component Scores of Short Form-36 were comparable between the three BMI groups (p = 0.736, p = 0.739 and p = 0.731 respectively). The ten-year rate of survival was 98.8% (98.0 to 99.3), 98.9% (98.5 to 99.2) and 98.0% (95.8 to 100), for the normal, obese and morbidly obese groups, respectively (p = 0.703). Although morbidly obese patients have a longer LOS and higher 30-day re-admission rate after TKA, they have a smaller drop in post-operative Hb level and larger improvement in OKS and KSKS at two years follow-up. The ten-year rate of survival of TKA was also comparable with those with a normal BMI. Morbidly obese patients should not be excluded from the benefits of TKA. Cite this article: Bone Joint J 2016;98-B:780-5.

The aim of this retrospective cohort study was to investigate the reasons for total knee arthroplasty (TKA) revisions at a tertiary hospital over a four-year period. The study aimed to identify the primary causes of TKA revisions and shed light on the implications for patient care and outcomes.The study included 31 patients who underwent revisions after primary knee arthroplasty between January 2017 and December 2020. A retrospective approach was employed, utilizing medical records and radiological findings to identify the reasons for TKA revisions. The study excluded oncology patients to focus on non-oncologic indications for revision surgeries. Patient demographics, including age and gender, were recorded. Data analysis involved categorizing the reasons for revision based on clinical assessments and radiological evidence.Among the 31 patients included in the study, 9 were males and 22 were females. The age of the patients ranged from 43 to 81, with a median age of 65 and an interquartile range of 18.5. The primary reasons for TKA revisions were identified as aseptic loosening (10 cases) and prosthetic joint infection (PJI) (13 cases). Additional reasons included revision from surgitech hemicap (1 case), patella osteoarthritis (1 case), stiffness (2 cases), patella maltracking (2 cases), periprosthetic fracture (1 case), and patella resurfacing (1 case). The findings of this retrospective cohort study highlight aseptic loosening and PJI as the leading causes of TKA revisions in the examined patient population.These results emphasize the importance of optimizing surgical techniques, implant selection, and infection control measures to reduce the incidence of TKA revisions. Future research efforts should focus on preventive strategies to enhance patient outcomes and mitigate the need for revision surgeries in TKA procedures.

The aim of this study is to identify the common microorganisms causing PJI as well as the drug-resistant spectrum for each microorganism, to help orthopaedic surgeons to choose appropriate antibiotics. One hundred and sixty patients who suffered from failure of primary or revision total hip or knee arthroplasty for different reasons were prospectively recruited. These patients underwent revision or re-revision total hip or knee arthroplasty in our institution between August 2013 to August 2016. The details of patients' medical history and comprehensive physical examination, as well as demographic data were recorded precisely. Routine blood test results, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), high sensitive C-reactive protein (hs-CRP), interleukin-6 (IL-6) levels, and synovial leukocyte counts were collected. Additionally, aspiration was conducted during surgery to avoid pollution unless when PJI was strongly suspected, in which case, joint puncture and aspiration were conducted before surgery. Intraoperatively, the implant-surrounding tissue and the prosthesis were collected under aseptic conditions. Postoperatively, the prosthesis, implant-surrounding tissue and synovium were sent to the laboratory immediately. The sonicate extraction (the prosthesis was sent for ultrasound sonication first), implant surrounding tissue and synovium were sent for microbiologic culture, and the implant-surrounding tissue was also sent for pathological examination. The isolated bacteria strains and drug-resistance rates for each pathogen for different antibiotics were presented. There were 59 PJI cases in the infectious group and 101 cases in the non-infectious group (PJI is diagnosed according to the diagnosing criteria from the Workgroup of the Musculoskeletal Infection Society). Of 69 strains of pathogens isolated, Gram-positive bacterium is the most common pathogenic bacteria causing PJI (60, 86.96%). Staphylococcus epidermidis and Staphylococcus aureus played an important role as well, followed by Gram-negative bacteria (8, 11.59%) and fungus (1, 1.45%). Penicillin (78.57%), erythromycin (66.67%) and clindamycin (44.74%) showed high antibiotic resistance rate. In addition, the second-generation cephalosporin, usually as the prophylactic antibiotic, resistance rate was high (20%) as well. Fortunately, no vancomycin-resistant bacteria were discovered in the current study. This study provides some information on the most common pathogens in our institution and the selection of antibiotics in the perioperative period in northern China. Cefuroxime and clindamycin might not be appropriate for use as prophylactic antibiotics in revision total knee or hip arthroplasty. Vancomycin is ideal for empiric antibiotic use in suspected PJI cases because of the low drug-resistance rate.

BackgroundThe number of total knee arthroplasties (TKA) performed in the United States is projected to rise significantly, with a proportionate increase in the revision burden. Understanding the mechanism of failure in primary TKA is important as etiologies continue to evolve and reasons for revision change. The purpose of this study was to determine the reason for revision TKA at our institution among early and late failures and assess if the etiology has changed over a 10-year time-period.MethodsWe identified 258 revision TKAs performed at our institution between 2005 and 2014. Reasons for revision TKA were categorized according to diagnosis. We also conducted subgroup analysis for TKA revisions performed within two years of the primary TKA (early failures) and those performed after two years (late failures). Revision TKAs were also grouped by year of primary TKA (before and after 2000) and time period in which the revision TKA was performed (2005–2009 and 2010–2014).ResultsThe most common reason for revision TKA was infection (29.3%), followed by aseptic loosening (19.7%), which together accounted for half of all revisions. Other indications for revision were instability (11.6%), osteolysis (10.4%), arthrofibrosis (8.1%), polyethylene (PE) wear (7.7%), malalignment/malposition (5.4%), patellar complication (3.1%), periprosthetic fracture (2.3%), pain (1.5%), and extensor mechanism deficiency (0.8%). Nearly half of early failures (47%) were due to infection. Osteolysis and PE wear made of a significantly higher proportion of revisions of TKAs performed prior to 2000 compared to index TKAs performed after 2000.ConclusionAt our institution, infection was the most common reason for revision TKA. Infection had a higher rate of early revisions. Proportion of TKAs revised for osteolysis and PE wear was higher for TKAs performed prior to 2000. Proportion of revision TKA for infection and instability were higher with TKAs performed after 2000.