Deep vein thrombosis (DVT) of lower limb is one of the common complications after total hip arthroplasty(THA), we aimed to evaluate the potential risk factors of DVT of lower limb in patients with THA, to provide insights into the management of THA. Patients who underwent THA in our hospital from January 1, 2017 to November 30, 2020 were included. The personal characteristics and clinical data of DVT and no-DVT patients were compared and analyzed. Logistic regression analyses were perfomed to identify the potential risk factors of DVT in patients with THA. A total of 182 THA patients were included, the incidence of DVT of lower limb in patients with THA was 19.78 %. There were significant differences in the age, BMI, diabetes, number of replacement, duration of surgery, type of prosthesis and duration of days in bed between DVT and no-DVT patients(all P   0.05). Logistic regression analysis indicated that age > 70y(OR4.406, 95 %CI1.744 ~ 6.134), BMI ≥ 28(OR2.275, 95 %CI1.181 ~ 4.531), diabetes(OR3.949, 95 %CI1.284 ~ 5.279), bilateral joint replacements(OR2.272, 95 %CI1.402 ~ 4.423), duration of surgery ≥ 120 min(OR3.081, 95 %CI1.293 ~ 5.308), cemented prosthesis(OR2.435, 95 %CI1.104 ~ 4.315), and duration of days in bed > 3 days(OR1.566, 95 %CI1.182 ~ 1.994) were the risk factors of DVT of lower limb in patients with THA. DVT in the lower limb after THA is common, and its onset is affected by many factors. In clinical work, attention should be paid to identify the risk factors for DVT and targeted interventions are highlighted to prevent the postoperative DVT.

/pdf/the-deep-vein-thrombosis-of-lower-limb-after-total-hip-3nu8gitpua.pdf

The deep vein thrombosis of lower limb after total hip arthroplasty: what should we care

Background Revision total knee arthroplasty (rTKA) is associated with significant risk of wound-related morbidity. The present study aimed to evaluate the 1) efficacy of closed-incision negative-pressure therapy (ciNPT) vs silver-impregnated antimicrobial dressing (AMD) in mitigating postoperative surgical site complications (SSCs), 2) the effect of ciNPT vs AMD on certain postoperative health utilization parameters, and on 3) patient-reported outcomes (PROs) improvement at 90-day postoperative follow-up. Methods This multicenter randomized controlled trial was conducted between December 2017 and August 2019. Patients ≥22 years, at high risk for SSC, and receiving rTKA with full exchange and reimplantation of new prosthetic components or open reduction and internal fixation of periprosthetic fractures were screened for inclusion. Eligible patients were randomized to receive a commercially available ciNPT system or a silver-impregnated AMD (n = 147, each) for minimum of 5-day duration. Primary outcome was the 90-day incidence of SSCs with stratification in accordance with revision type (aseptic/septic). Secondary outcomes were the 90-day health care utilization parameters (readmission, reoperation, dressing changes, and visits) and PROs. Results Of 294 patients randomized (age: 64.9 ± 9.0 years, female: 59.6%), 242 (82.0%) patients completed the study (ciNPT: n = 124; AMD: n = 118). The incidence of 90-day SSCs was lower for the ciNPT cohort (ciNPT: 3.4% vs AMD: 14.3%; odds ratio (OR): 0.22, 95% confidence interval (0.08, 0.59); P = .0013). Readmission rates (3.4% vs 10.2%, OR: 0.30(0.11, 0.86); P = .0208) and mean dressing changes (1.1 ± 0.3 vs 1.3 ± 1.0; P = .0003) were lower with ciNPT. The differences in reoperation rates, number of visits, and PRO improvement between both arms were not statistically significant (P > .05). Conclusion ciNPT is effective in reducing the 90-day postoperative SSCs, readmission, and number of dressing changes after rTKA. Recommending routine implementation would require true-cost analyses.

The Effectiveness of Closed-Incision Negative-Pressure Therapy Versus Silver-Impregnated Dressings in Mitigating Surgical Site Complications in High-Risk Patients After Revision Knee Arthroplasty: The PROMISES Randomized Controlled Trial

Degenerative arthritis is a major indication for both anatomic and reverse total shoulder arthroplasty (TSA). Degenerative arthritis is an age-related process that can be secondary to mechanical wear or inflammatory or autoimmune diseases, such as rheumatoid arthritis or systemic lupus erythematosus. Management of these diseases can include chronic corticosteroid for their anti-inflammatory and immunosuppressive effects. Given the well-known complications of chronic steroid use on other surgical procedures, investigation into postoperative complications specific to TSA will assist physicians in risk stratification and preoperative planning. The purpose of this study was to investigate the association between chronic preoperative steroid use and postoperative complications following TSA.The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2020. Patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. Multivariate logistic regression was used to identify postoperative complications associated with chronic preoperative steroid use. Reasons and risk factors for readmission among chronic steroid users were subsequently identified, as well.A total of 26,669 patients were included in this study: 25,376 (95.2%) were included in the nonsteroid cohort and 1293 (4.8%) were included in the chronic steroid cohort. The postoperative complications that were significantly associated with chronic preoperative steroid use were septic shock (P = .007), urinary tract infection (P = .016), myocardial infarction (P = .022), ventilator >48 hours (P = .028), readmission (P < .001), nonhome discharge (P < .001), and mortality (P = .007). The only postoperative complication independently associated with chronic preoperative steroid use was readmission (odds ratio, 1.36; 95% confidence interval, 1.04-1.79; P = .027).Preoperative chronic steroid use is an independent predictor for readmission following TSA. As procedural improvement increases surgical volume for TSA, a better understanding of preoperative risk factors can improve perioperative risk stratification and help to minimize adverse outcomes. 

https://doi.org/10.1016/j.jseint.2022.06.006

Chronic steroid use and readmission following total shoulder arthroplasty

Abstract Purpose Total knee arthroplasty (TKA) in patients with osteoarthritis (OA) are considered to be a successful procedure, but with little being known about outcomes in patients with rheumatoid arthritis (RA). The aim of this study was to compare the outcomes of TKA in patients with RA versus OA. Methods Data were obtained from PubMed, Cochrane Library, EBSCO and Scopus for all available studies comparing the outcomes of THA in RA and OA patients (From January 1, 2000 to October 15, 2022). Outcomes of interest included infection, revision, venous thromboembolism (VTE), mortality, periprosthetic fractures, prosthetic loosening, length of stay, and satisfaction. Two reviewers independently assessed each study for quality and extracted data. The quality of the studies was scored using the Newcastle-Ottawa scale (NOS). Results Twenty-four articles with a total 8,033,554 patients were included in this review. The results found strong evidence for increased risk of overall infection (OR = 1.61, 95% CI, 1.24–2.07; P = 0.0003), deep infection (OR = 2.06, 95% CI, 1.37–3.09; P = 0.0005), VTE (OR = 0.76, 95% CI, 0.61–0.93; P = 0.008), pulmonary embolism (PE) (OR = 0.84, 95% CI, 0.78–0.90; P &lt;0.00001), periprosthetic fractures (OR = 1.87, 95% CI, 1.60–2.17; P &lt;0.00001); and reasonable evidence for increased risk of deep venous thrombosis (DVT) (OR = 0.74, 95% CI, 0.54–0.99; P = 0.05), and length of stay (OR = 0.07, 95% CI, 0.01–0.14; P = 0.03) after TKA in patients with RA versus OA. There were no significant differences in superficial site infection (OR = 0.84,95% CI, 0.47–1.52; P = 0.57), revision (OR = 1.33,95% CI, 0.79–2.23; P = 0.28), mortality (OR = 1.16,95% CI, 0.87–1.55; P = 0.32), and prosthetic loosening (OR = 1.75, 95% CI, 0.56–5.48; P = 0.34) between the groups. Conclusion Our study demonstrated that patients with RA have a higher risk of postoperative infection, VTE, periprosthetic fracture, and lengths of stay, but did not increase revision rate, prosthetic loosening and mortality compared to patients with OA following TKA. In conclusion, despite RA increased incidence of postoperative complications, TKA should continue to be presented as an effective surgical procedure for patients whose conditions are intractable to conservative and medical management of RA. 

/pdf/a-systematic-review-and-meta-analysis-comparing-outcomes-3spcexxx.pdf

A systematic review and meta-analysis comparing outcomes following total knee arthroplasty for rheumatoid arthritis versus for osteoarthritis

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014. After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added. The glucocorticoid dose should be reduced to as low as possible 2–3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1–2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1–2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3–4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing. Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval. 

/pdf/perioperative-management-of-patients-with-inflammatory-cse89lvn.pdf

Perioperative management of patients with inflammatory rheumatic diseases

BACKGROUND Osteoarthritis may be caused by or concurrent with diseases such as rheumatoid arthritis or systemic lupus erythematosus, which rely on chronic corticosteroids regimens for treatment. If a total knee or hip arthroplasty is needed, this chronic treatment method has been associated with poorer surgical outcomes. METHODS A retrospective analysis of data collected by the American College of Surgeons National Surgical Quality Improvement Program was conducted. The Current Procedural Terminology codes were used to identify 403,566 total knee arthroplasty and total hip arthroplasty patients who were then stratified by the use of chronic corticosteroids for univariate analysis. RESULTS Forteen thousand seven hundred seventy-four of the patients identified were prescribed chronic corticosteroid regimens. A statistically significant difference was observed in perioperative complications for patients prescribed with corticosteroids, including higher rates of surgical site infection (P = 0.0001), occurrence of deep incisional surgical site infection (P < 0.0001), occurrences of organ space surgical site infection (P < 0.0001), wound dehiscence (P < 0.0001), general would infection (P < 0.0001), pneumonia (P < 0.0001), occurrences of unplanned intubation (P = 0.0002), urinary tract infection (P < 0.0001), and readmission (P < 0.0001). No statistically significant difference was observed in the 30-day mortality between the 2 groups (0.63), venous thromboembolic event (0.42), cerebrovascular accident (0.12), myocardial infarction (0.49), cardiac arrest (0.098), deep vein thrombosis (0.17), or sepsis (0.52). CONCLUSION Many of the notable differences in complications may be directly attributed to the immunosuppressive nature of corticosteroids. With increased knowledge of which perioperative complications to monitor, surgeons can tailor treatment strategies to this population that reduce morbidity and improve outcomes.

Chronic Corticosteroid Use as a Risk Factor for Perioperative Complications in Patients Undergoing Total Joint Arthroplasty.

Background Reinfected total knee arthroplasty can be managed with a second two-stage exchange or a knee arthrodesis procedure. Methods Twenty-three patients with knee arthrodesis after failed exchange arthroplasty for infection were reviewed. Patients were managed with a staged protocol of implant extraction, debridement, and implantation of an antibiotic spacer, with subsequent arthrodesis. Follow-up averaged 40.4 months, with a minimum of 1 year. Results Bony union with eradication of infection was achieved in 20/23 knees. Sixteen of the 20 patients were able to ambulate with minimal pain. The average time to union was 11.3 months, and the average leg length discrepancy was 4.85 cm. The average Knee Society Score after arthrodesis was 44, and the average visual analog scale pain score was 1.73. Three patients underwent above-knee amputation. Discussion Knee arthrodesis performed for persistent periprosthetic infection allowed for eradication of infection and union in 87% of the patients, creating a stable knee fusion.

Knee Arthrodesis Outcomes After Infected Total Knee Arthroplasty and Failure of Two-stage Revision With an Antibiotic Cement Spacer.

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Papers

Chronic Corticosteroid Use as a Risk Factor for Perioperative Complications in Patients Undergoing Total Joint Arthroplasty.

Knee Arthrodesis Outcomes After Infected Total Knee Arthroplasty and Failure of Two-stage Revision With an Antibiotic Cement Spacer.