Publications by authors named "Carlos A Higuera"

168 Publications

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

J Arthroplasty 2021 May 26. Epub 2021 May 26.

Department of Orthopedics, Rothman Orthopedics, Philadelphia, PA.

Background: Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging.

Methods: A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits.

Results: Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution.

Conclusion: Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.
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http://dx.doi.org/10.1016/j.arth.2021.05.032DOI Listing
May 2021

What's New in Musculoskeletal Infection.

J Bone Joint Surg Am 2021 May 28. Epub 2021 May 28.

Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.2106/JBJS.21.00311DOI Listing
May 2021

Orthopaedic clinical research: building a team that lasts.

EFORT Open Rev 2021 Apr 1;6(4):245-251. Epub 2021 Apr 1.

Cleveland Clinic Department of Orthopaedic Surgery, Cleveland, Ohio, USA.

Medical progress, including in the orthopaedic surgery field, depends on the interaction and collaboration between: physicians, with their expertise on the clinical setting; scientists, with their expertise on the research setting; and professionals who are skilled in both settings (clinical scientists). This leads to the need to develop research approaches which involves people who are committed and support the process, strategic planning, and a cohesive team that can execute the tasks. All these interactions must be supported financially in order to maintain the long-term viability of such team.Time management is crucial for the clinical research team. To ensure success, the research team must be flexible in order to adapt to dynamic clinical and surgical schedules. It is especially important that surgeons have regular, dedicated quality research time to maintain a consistent interaction with the team.Building a successful and productive orthopaedic clinical research programme involves many challenges in creating proper leadership, obtaining funding, setting proper resources, establishing necessary training, and providing guidance and insight around the importance of each role that every member plays on the team. Cite this article: 2021;6:245-251. DOI: 10.1302/2058-5241.6.200058.
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http://dx.doi.org/10.1302/2058-5241.6.200058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8142594PMC
April 2021

Variability and Interpretation of Synovial Cell Count and Differential: A Perspective in Hip and Knee Arthroplasty.

Orthopedics 2021 May-Jun;44(3):e320-e325. Epub 2021 May 1.

Multiple threshold values have been proposed for synovial leukocyte count (white blood cell count) and synovial neutrophil percentage (percent polymorphonuclear neutrophils) in the diagnosis of periprosthetic joint infection (PJI). The objective of this study was to elucidate the variability of these criteria under diverse patient/surgical settings. Hip PJIs yield higher synovial white blood cell counts and percent polymorphonuclear neutrophils than knee PJIs. Periprosthetic joint infection of failed unicompartmental knee arthroplasty produces a higher white blood cell count than that of failed total knee arthroplasty. Synovial white blood cell count and percent polymorpho-nuclear neutrophils PJI thresholds also vary in patients with antibiotic cement spacers and depend on the timing from primary arthroplasty (<6 weeks vs >6 weeks). Similarly, test results should be carefully interpreted for patients with comorbidities so that PJI is not missed or falsely identified. [. 2021;44(3):e320-e325.].
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http://dx.doi.org/10.3928/01477447-20210508-01DOI Listing
May 2021

Diagnostic Utility of a Novel Point-of-Care Test of Calprotectin for Periprosthetic Joint Infection After Total Knee Arthroplasty: A Prospective Cohort Study.

J Bone Joint Surg Am 2021 Jun;103(11):1009-1015

Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, Florida.

Background: Despite several synovial fluid biomarkers for the diagnosis of periprosthetic joint infection (PJI) having been investigated, point-of-care (POC) tests using these biomarkers are not widely available. Synovial calprotectin has recently been reported to effectively exclude the diagnosis of PJI. Thus, the objective of this study was to test the value of a calprotectin POC test for PJI diagnosis in patients undergoing total knee arthroplasty (TKA) using the 2013 Musculoskeletal Infection Society (MSIS) PJI diagnosis criteria as the gold standard.

Methods: Synovial fluid samples were prospectively collected from 123 patients who underwent revision TKA at 2 institutions within the same health-care system from October 2018 to January 2020. The study was conducted under institutional review board approval. Data collection comprised demographic, clinical, and laboratory data in compliance with the MSIS criteria. Synovial fluid samples were analyzed by calprotectin POC tests in accordance with the manufacturer's instructions. Revisions were categorized as septic or aseptic using MSIS criteria by 2 independent reviewers blinded to the calprotectin results. Calprotectin test performance characteristics with sensitivities, specificities, positive predictive values, negative predictive values, and areas under the receiver operating characteristic curve (AUC) were calculated for 2 different PJI diagnosis scenarios: (1) a threshold of ≥50 mg/L, and (2) a threshold of ≥14 mg/L.

Results: According to the MSIS criteria, 53 revision TKAs were septic and 70 revision TKAs were aseptic. In the ≥50-mg/mL threshold scenario, the calprotectin POC performance showed a sensitivity of 98.1%, a specificity of 95.7%, a positive predictive value of 94.5%, a negative predictive value of 98.5%, and an AUC of 0.969. In the ≥14-mg/mL threshold scenario, the sensitivity was 98.1%, the specificity was 87.1%, the positive predictive value was 85.2%, the negative predictive value was 98.4%, and the AUC was 0.926.

Conclusions: The calprotectin POC test has excellent PJI diagnostic characteristics, including high sensitivity and specificity in patients undergoing revision TKA. This test could be effectively implemented as a rule-out test. However, further investigations with larger cohorts are necessary to validate these results.

Level Of Evidence: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01089DOI Listing
June 2021

Florida State Opioid Prescription Restriction Law: Impact on Opioid Utilization After Total Joint Arthroplasty.

J Arthroplasty 2021 Apr 19. Epub 2021 Apr 19.

Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL.

Background: In response to the opioid epidemic, Florida recently passed the opioid prescription limiting law, effective since July 1, 2018. However, its impact on opioid prescription after total joint arthroplasty (TJA) has not been elucidated. Thus, our objective was to assess if this new law led to reduced opioid prescription after TJA and to determine its impact on perioperative clinical outcomes.

Methods: A retrospective chart review was conducted on a consecutive series of 658 primary TJAs (618 patients), performed by four surgeons in a single institution [1/2/2018-10/23/2018]. Based on effective date of the law, cases were divided into: prelaw (327 cases; 168 hips/159 knees) and postlaw (331 cases; 191 hips/140 knees) phases. Baseline demographics and surgical characteristics were compared. The effect of the law on perioperative outcomes: length of stay, complications, emergency department/office visits, patient phone calls, reoperation or readmission (90 days), and total morphine equivalents prescribed was investigated. Independent sample t-tests and chi-square analyses were performed.

Results: Prelaw and postlaw phases had no significant difference in baseline demographics and characteristics. No difference was found in length of stay. Opioid law implementation led to significantly lower total oral morphine equivalents after TJAs [Prelaw: 1059.9 ± 825.4 vs postlaw: 942.8 ± 691.7; P = .04], but did not result in a significant increase in 90-day complications, patient visits (office or emergency) or phone calls, and reoperation or readmission.

Conclusion: Our data suggest that Florida state opioid prescription limiting law has resulted in a marked decline in opioid prescription without any increase in rates of patient visits, phone calls, or readmission after TJA.
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http://dx.doi.org/10.1016/j.arth.2021.03.055DOI Listing
April 2021

Plasma D-dimer Does Not Anticipate the Fate of Reimplantation in Two-stage Exchange Arthroplasty for Periprosthetic Joint Infection: A Preliminary Investigation.

Clin Orthop Relat Res 2021 07;479(7):1458-1468

Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA.

Background: Inflammatory markers such as the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels have always been a part of the diagnostic criteria for periprosthetic joint infection (PJI), but they perform poorly anticipating the outcome of reimplantation. D-dimer has been reported in a small series as a potential marker to measure infection control after single-stage revisions to treat PJI. Nonetheless, its use to confirm infection control and decide the proper timing of reimplantation remains uncertain.

Questions/purposes: (1) What is the best diagnostic threshold and accuracy values for plasma D-dimer levels compared with other inflammatory markers (ESR and CRP) or what varying combinations of these tests are associated with persistent infection after reimplantation? (2) Do D-dimer values above this threshold, ESR, CRP, and varying test combinations at the time of reimplantation indicate an increased risk of subsequent persistent infection after reimplantation?

Methods: We retrospectively studied the electronic medical records of all 53 patients who had two-stage revisions for PJI and who underwent plasma D-dimer testing before reimplantation at one of two academic institutions from November 22, 2017 to December 5, 2020. During that period, all patients undergoing two-stage revisions also had a D-dimer test drawn. The minimum follow-up duration was 1 year. We are reporting at this early interval (rather than the more typical 2-year time point) because of the poorer-than-expected performance of this diagnostic test. Of these 53 patients, 17% (9) were lost to follow-up before 1 year and could not be analyzed; the remaining 44 patients (17 hips and 27 knees) were studied here. The mean follow-up was 503 ± 135 days. Absence or persistence of infection after reimplantation were defined according to the Delphi criteria. The conditions included in these criteria were: (1) control of infection, as characterized by a healed wound without fistula, drainage, or pain; (2) no subsequent surgical intervention owing to infection after reimplantation; and (3) no occurrence of PJI-related mortality. The absence of any of the aforementioned conditions until the final follow-up examination was deemed a persistent infection after reimplantation. Baseline patient characteristics were not different between patients with persistent infection (n = 10) and those with absence of it after reimplantation (n = 34) as per the Delphi criteria. Baseline patient characteristics evaluated were age, gender, self-reported race (white/Black/other) or ethnicity (nonHispanic/Hispanic), BMI, American Society of Anesthesiologists (ASA) status, smoking status(smoker/nonsmoker), and joint type (hip/knee). The optimal D-dimer threshold to differentiate between persistence of infection or not after reimplantation was calculated using the Youden index. A receiver operating characteristic curve analysis was performed to test the accuracy of D-dimer, ESR, CRP, and their combinations to establish associations, if any, with persistent infection after reimplantation. A Kaplan-Meier survival analysis (free of infection after reimplantation) with a log-rank test was performed to investigate if D-dimer, ESR, and CRP were associated with absence of infection after reimplantation. Survival or being free of infection after reimplantation was determined as per Delphi criteria. Alpha was set at p < 0.05.

Results: In the receiver operating characteristic curve analysis, with an area under the curve of 0.62, D-dimer showed low accuracy and did not anticipate persistent infection after reimplantation. The optimal D-dimer threshold differentiating between persistence of infection or not after reimplantation was 3070 ng/mL. When using this threshold, D-dimer demonstrated a sensitivity of 90% (95% CI 55.5% to 99.7%) and negative predictive value of 94% (95% CI 70.7% to 99.1%), but low specificity (47% [95% CI 29.8% to 64.9%]) and positive predictive value (33% [95% CI 25.5% to 42.2%]). Although D-dimer showed the highest sensitivity, the combination of D-dimer with ESR and CRP showed the highest specificity (91% [95% CI 75.6% to 98%]) defining the persistence of infection after reimplantation. Based on plasma D-dimer levels, with the numbers available, there was no difference in survival free from infection after reimplantation (Kaplan-Meier survivorship free from infection at minimum 1 year in patients with D-dimer below 3070 ng/mL versus survivorship free from infection with D-dimer above 3070 ng/mL: 749 days [95% CI 665 to 833 days] versus 615 days [95% CI 471 to 759 days]; p = 0.052). Likewise, there were no associations between high ESR and CRP levels and persistent infection after reimplantation, but the number of events was very small, and insufficient power is a concern with this analysis.

Conclusion: In this preliminary series, with the numbers available, D-dimer alone had poor accuracy and was not associated with survival free from infection after reimplantation in patients who underwent two-stage exchange arthroplasty. D-dimer alone might be used to establish that PJI is unlikely, and the combination of D-dimer, ESR, and CRP should be considered to confirm PJI diagnosis in the setting of reimplantation.Level of Evidence Level IV, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001738DOI Listing
July 2021

Direct Anterior Approach for Total Hip Arthroplasty with Subtrochanteric Shortening Osteotomy: A Case Report.

JBJS Case Connect 2021 03 18;11(1). Epub 2021 Mar 18.

Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida.

Case: A patient with Aitken type A proximal focal femoral deficiency (PFFD) and significant limb length discrepancy managed with total hip arthroplasty making use of a novel technique that features a direct anterior approach (DAA) and a subtrochanteric shortening osteotomy.

Conclusion: Although the current description of the shortening osteotomy is for PFFD, it is versatile enough to allow its application in other hip pathologies requiring subtrochanteric shortening in the setting of total hip arthroplasty. The authors believe that the description of this case report and surgical technique may be an option for the experienced DAA surgeon.
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http://dx.doi.org/10.2106/JBJS.CC.20.00336DOI Listing
March 2021

No clinically meaningful difference in 1-year patient-reported outcomes among major approaches for primary total hip arthroplasty.

Hip Int 2021 Mar 7:1120700021992013. Epub 2021 Mar 7.

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA.

Background: Debate continues around the most effective surgical approach for primary total hip arthroplasty (THA). This study's purpose was to compare 1-year patient-reported outcome measures (PROMs) of patients who underwent direct anterior (DA), transgluteal anterolateral (AL)/direct lateral (DL), and posterolateral (PL) approaches.

Methods: A prospective consecutive series of primary THA for osteoarthritis ( = 2,390) were performed at 5 sites within a single institution with standardised care pathways (20 surgeons). Patients were categorised by approach: DA ( = 913; 38%), AL/DL ( = 505; 21%), or PL ( = 972; 41%). Primary outcomes were pain, function, and activity assessed by 1-year postoperative PROMs. Multivariable regression modeling was used to control for differences among the groups. Wald tests were performed to test the significance of select patient factors and simultaneous 95% confidence intervals were constructed.

Results: At 1-year postoperative, PROMs were successfully collected from 1842 (77.1%) patients. Approach was a statistically significant factor for 1-year HOOS pain ( = 0.002). Approach was not a significant factor for 1-year HOOS-PS ( = 0.16) or 1-year UCLA activity ( = 0.382). Pairwise comparisons showed no significant difference in 1-year HOOS pain scores between DA and PL approach (  0.05). AL/DL approach had lower (worse) pain scores than DA or PL approaches with differences in adjusted median score of 3.47 and 2.43, respectively (  0.05).

Conclusions: Patients receiving the AL/DL approach had a small statistical difference in pain scores at 1 year, but no clinically meaningful differences in pain, activity, or function exist at 1-year postoperative.
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http://dx.doi.org/10.1177/1120700021992013DOI Listing
March 2021

The EBJIS definition of periprosthetic joint infection.

Bone Joint J 2021 Jan;103-B(1):18-25

Orthopaedic Hospital Valdoltra, Ankaran, Slovenia.

Aims: The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition.

Methods: This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS), and supported by the Musculoskeletal Infection Society (MSIS) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Implant-Associated Infections (ESGIAI). It comprised a comprehensive review of the literature, open discussion with Society members and conference delegates, and an expert panel assessment of the results to produce the final guidance.

Results: This process evolved a three-level approach to the diagnostic continuum, resulting in a definition set and guidance, which has been fully endorsed by EBJIS, MSIS, and ESGIAI.

Conclusion: The definition presents a novel three-level approach to diagnosis, based on the most robust evidence, which will be useful to clinicians in daily practice. Cite this article: 2021;103-B(1):18-25.
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http://dx.doi.org/10.1302/0301-620X.103B1.BJJ-2020-1381.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954183PMC
January 2021

Bilateral Simultaneous Total Knee Arthroplasty May Not Be Safe Even in the Healthiest Patients.

J Bone Joint Surg Am 2021 02;103(4):303-311

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio.

Background: Bilateral total knee arthroplasty (TKA) has been shown to increase both mortality and complications, but has potential benefits including decreased length of stay, rehabilitation time, and costs. The purpose of this study was to use data from a nationally representative database to identify if there is a population of patients undergoing TKA in whom bilateral TKA can be safely performed, by comparing 30-day mortality and complication rates with those of patients undergoing unilateral TKA.

Methods: The National Surgical Quality Improvement Program (NSQIP) was queried to compare 30-day rates of mortality and any complication between bilateral TKA and unilateral TKA. A total of 8,291 patients who underwent bilateral TKA were matched 1:1 with a unilateral TKA control cohort (n = 315,219) by morbidity probability, which is a cumulative variable encompassing demographic characteristics, comorbidities, and laboratory values. Patients were divided into quartiles based on morbidity probability. Binary logistic regression comparing bilateral TKA and unilateral TKA for the same quartiles was performed to establish if any population could safely have bilateral TKA performed.

Results: Bilateral TKA had an increased risk for all complications (p < 0.001) and major complications (p < 0.001) when compared with unilateral TKA regardless of health status. For all complications, there was a greater than threefold increase for the first quartile (healthiest patients) (p < 0.001), a greater than fourfold increase for the second and third quartiles (p < 0.001), and a greater than threefold increase for the fourth quartile (least healthy patients) (p < 0.001). For major complications, there was a greater than twofold increase for the first quartile (p = 0.001) and the second quartile (p < 0.001), an almost threefold increase for the third quartile (p < 0.001), and a 57% increase for the fourth quartile (p = 0.005).

Conclusions: This study will assist shared decision-making between orthopaedic surgeons and patients by suggesting that bilateral TKA may not be as safe an option for even healthy individuals compared with unilateral TKA.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.20.01046DOI Listing
February 2021

The Effect of the COVID-19 Pandemic on Hip and Knee Arthroplasty Patients in the United States: A Multicenter Update to the Previous Survey.

Arthroplast Today 2021 Feb 3;7:268-272. Epub 2020 Dec 3.

Department of Orthopaedics, Louisiana State University Health Sciences Center, New Orleans, LA, USA.

Background: In March 2020, elective total hip and knee arthroplasty (THA and TKA) were suspended across the United States in response to the COVID-19 pandemic. We had previously published the results of a survey to the affected patients from 6 institutions. We now present the results of a larger distribution of this survey, through May and June 2020, to electively scheduled patients representing different regions of the United States.

Methods: Fifteen centers identified through the American Association of Hip and Knee Surgeons Research Committee participated in a survey study of THA and TKA patients. Patients scheduled for primary elective THA or TKA but canceled due to the COVID-19 elective surgery stoppage (3/2020-5/2020) were included in the study. Descriptive statistics along with subgroup analysis with Wilcoxon rank were performed.

Results: In total, surveys were distributed to 2135 patients and completed by 848 patients (40%) from 15 institutions. Most patients (728/848, 86%) had their surgery postponed or canceled by the surgeon or hospital. Unknown length of surgical delay remained the highest source of anxiety among survey participants. Male patients were more likely to be willing to proceed with surgery in spite of COVID-19. There were minimal regional differences in responses. Only 61 patients (7%) stated they will continue to delay surgery for fear of contracting COVID-19 while in the hospital.

Conclusion: Similar to the previous study, the most anxiety-provoking thought was the uncertainty, over if and when the canceled joint replacement surgery could be rescheduled. Patients suffering from the daily pain of hip and knee arthritis who have been scheduled for elective arthroplasty remain eager to have their operation as soon as elective surgery is allowed to resume.
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http://dx.doi.org/10.1016/j.artd.2020.11.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713541PMC
February 2021

Blood Management in Total Knee Arthroplasty: A Nationwide Analysis from 2011 to 2018.

J Knee Surg 2020 Nov 25. Epub 2020 Nov 25.

Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio.

Both advances in perioperative blood management, anesthesia, and surgical technique have improved transfusion rates following primary total knee arthroplasty (TKA), and have driven substantial change in preoperative blood ordering protocols. Therefore, blood management in TKA has seen substantial changes with the implementation of preoperative screening, patient optimization, and intra- and postoperative advances. Thus, the purpose of this study was to examine changes in blood management in primary TKA, a nationwide sample, to assess gaps and opportunities. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify TKA ( = 337,160) cases from 2011 to 2018. The following variables examined, such as preoperative hematocrit (HCT), anemia (HCT <35.5% for females and <38.5% for males), platelet count, thrombocytopenia (platelet count < 150,000/µL), international normalized ration (INR), INR > 2.0, bleeding disorders, preoperative, and postoperative transfusions. Analysis of variances were used to examine changes in continuous variables, and Chi-squared tests were used for categorical variables. There was a substantial decrease in postoperative transfusions from high of 18.3% in 2011 to a low of 1.0% in 2018, ( < 0.001), as well as in preoperative anemia from a high of 13.3% in 2011 to a low of 9.5% in 2016 to 2017 ( < 0.001). There were statistically significant, but clinically irrelevant changes in the other variables examined. There was a HCT high of 41.2 in 2016 and a low of 40.4 in 2011 to 2012 ( < 0.001). There was platelet count high of 247,400 in 2018 and a low of 242,700 in 201 ( < 0.001). There was a high incidence of thrombocytopenia of 5.2% in 2017 and a low of low of 4.4% in 2018 ( < 0.001). There was a high INR of 1.037 in 2011 and a low of 1.021 in 2013 ( < 0.001). There was a high incidence of INR >2.0 of 1.0% in 2012 to 2015 and a low of 0.8% in 2016 to 2018 ( = 0.027). There was a high incidence of bleeding disorders of 2.9% in 2013 and a low of 1.8% in 2017 to 2018 ( < 0.001). There was a high incidence of preoperative transfusions of 0.1% in 2011 to 2014 and a low of <0.1% in 2015 to 2018 ( = 0.021). From 2011 to 2018, there has been substantial decreases in patients receiving postoperative transfusions after primary TKA. Similarly, although a decrease in patients with anemia was seen, there remains 1 out 10 patients with preoperative anemia, highlighting the opportunity to further improve and address this potentially modifiable risk factor before surgery. These findings may reflect changes during TKA patient selection, optimization, or management, and emphasizes the need to further advance multimodal approaches for perioperative blood management of TKA patients. This is a Level III study.
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http://dx.doi.org/10.1055/s-0040-1721414DOI Listing
November 2020

Periprosthetic Tibial Fractures After Total Knee Arthroplasty: Early and Long-Term Clinical Outcomes.

J Arthroplasty 2021 04 26;36(4):1429-1436. Epub 2020 Oct 26.

University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, MA.

Background: Although periprosthetic fractures are increasing in prevalence, evidence-based guidelines for the optimal treatment of periprosthetic tibial fractures (PTx) are lacking. Thus, the purpose of this study is to assess the clinical outcomes in PTx after a total knee arthroplasty (TKA) which were treated with different treatment options.

Methods: A retrospective review was performed on a consecutive series of 34 nontumor patients treated at 2 academic institutions who experienced a PTx after TKA (2008-2016). Felix classification was used to classify fractures (Felix = I-II-III; subgroup = A-B-C) which were treated by closed reduction, open reduction/internal fixation, revision TKA, or proximal tibial replacement. Patient demographics and surgical characteristics were collected. Failure of treatment was defined as any revision or reoperation. Independent t-tests, one-way analysis of variance, chi-squared analyses, and Fisher's exact tests were conducted.

Results: Patients with Felix I had more nonsurgical complications when compared to Felix III patients (P = .006). Felix I group developed more postoperative anemia requiring transfusion than Felix III group (P = .009). All fracture types had >30% revision and >50% readmission rate with infection being the most common cause. These did not differ between Felix fracture types. Patients who underwent proximal tibial replacement had higher rate of postoperative infection (P = .030), revision surgery (P = .046), and required more flap reconstructions (P = .005).

Conclusion: PTx after a TKA is associated with high revision and readmission rates. Patients with Felix type I fractures are at higher risk of postoperative nonsurgical complications and anemia requiring transfusion. Fractures treated with proximal tibial replacement are more likely to develop postoperative infections and undergo revision surgery.
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http://dx.doi.org/10.1016/j.arth.2020.10.035DOI Listing
April 2021

The Potential Effects of Imposing a Body Mass Index Threshold on Patient-Reported Outcomes After Total Knee Arthroplasty.

J Arthroplasty 2021 Jul 8;36(7S):S198-S208. Epub 2020 Sep 8.

Cleveland Clinic Department of Orthopaedic Surgery, Cleveland, OH.

Background: Operative eligibility thresholds based on body mass index (BMI) alone may risk restricting access to improved pain control, function, and quality of life. This study evaluated the use of BMI-cutoffs to offering TKA in avoiding: 1) 90-day readmission, 2) one-year mortality, and 3) failure to achieve clinically important one-year PROMS improvement (MCID).

Methods: A total of 4126 primary elective unilateral TKA patients from 2015 to 2018 were prospectively collected. For specific BMI(kg/m) cutoffs: 30, 35, 40, 45, and 50, the positive predictive value (PPV) for 90-day readmission, one-year mortality, and failure to achieve one-year MCID were calculated. The number of patients denied complication-free postoperative courses per averted adverse outcome/failed improvement was estimated.

Results: Rates of 90-day readmission and one-year mortality were similar across BMI categories (P > .05, each). PPVs for preventing 90-day readmission and one-year mortality were low across all models of BMI cutoffs. The highest PPV for 90-day readmission and one-year mortality was detected at cutoffs of 45 (6.4%) and 40 (0.87%), respectively. BMI cutoff of 40 would deny 18 patients 90-day readmission-free, and 194 patients one-year mortality-free postoperative courses for each averted 90-day readmission/one-year mortality. Such cutoff would also deny 11 patients an MCID per avoided failure. Implementing BMI thresholds alone did not influence the rate of improvements in KOOS-PS, KRQOL, or VR-12.

Conclusion: Utilizing BMI cutoffs as the sole determinants of TKA ineligibility may deny patients complication-free postoperative courses and clinically important improvements. Shared decision-making supported by predictive tools may aid in balancing the potential benefit TKA offers to obese patients with the potentially increased complication risk and cost of care provision.
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http://dx.doi.org/10.1016/j.arth.2020.08.060DOI Listing
July 2021

Developing a personalized outcome prediction tool for knee arthroplasty.

Bone Joint J 2020 Sep;102-B(9):1183-1193

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA.

Aims: The purpose of this study was to develop a personalized outcome prediction tool, to be used with knee arthroplasty patients, that predicts outcomes (lengths of stay (LOS), 90 day readmission, and one-year patient-reported outcome measures (PROMs) on an individual basis and allows for dynamic modifiable risk factors.

Methods: Data were prospectively collected on all patients who underwent total or unicompartmental knee arthroplasty at a between July 2015 and June 2018. Cohort 1 (n = 5,958) was utilized to develop models for LOS and 90 day readmission. Cohort 2 (n = 2,391, surgery date 2015 to 2017) was utilized to develop models for one-year improvements in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score, KOOS function score, and KOOS quality of life (QOL) score. Model accuracies within the imputed data set were assessed through cross-validation with root mean square errors (RMSEs) and mean absolute errors (MAEs) for the LOS and PROMs models, and the index of prediction accuracy (IPA), and area under the curve (AUC) for the readmission models. Model accuracies in new patient data sets were assessed with AUC.

Results: Within the imputed datasets, the LOS (RMSE 1.161) and PROMs models (RMSE 15.775, 11.056, 21.680 for KOOS pain, function, and QOL, respectively) demonstrated good accuracy. For all models, the accuracy of predicting outcomes in a new set of patients were consistent with the cross-validation accuracy overall. Upon validation with a new patient dataset, the LOS and readmission models demonstrated high accuracy (71.5% and 65.0%, respectively). Similarly, the one-year PROMs improvement models demonstrated high accuracy in predicting ten-point improvements in KOOS pain (72.1%), function (72.9%), and QOL (70.8%) scores.

Conclusion: The data-driven models developed in this study offer scalable predictive tools that can accurately estimate the likelihood of improved pain, function, and quality of life one year after knee arthroplasty as well as LOS and 90 day readmission. Cite this article: 2020;102-B(9):1183-1193.
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http://dx.doi.org/10.1302/0301-620X.102B9.BJJ-2019-1642.R1DOI Listing
September 2020

International Organism Profile of Periprosthetic Total Hip and Knee Infections.

J Arthroplasty 2021 01 16;36(1):274-278. Epub 2020 Jul 16.

Orthopaedic Department, Helios Klinikum, Berlin, Germany.

Background: There is scarce literature describing pathogens responsible for periprosthetic joint infections (PJIs) around the world. Therefore, we sought to describe periprosthetic joint infection causative organisms, rates of resistant organisms, and polymicrobial infections at 7 large institutions located in North/South America and Europe.

Methods: We performed a retrospective study of 654 periprosthetic hip (n = 361) and knee (n = 293) infections (January 2006 to October 2019) identified at Cleveland Clinic Ohio/Florida in the United States (US) (n = 159), Hospital Italiano de Buenos Aires in Argentina (n = 99), Hospital Asociación Española in Uruguay (n = 130), Guy's and St Thomas' Hospital in the United Kingdom (UK) (n = 103), HELIOS Klinikum in Germany (n = 59), and Vreden Institute for Orthopedics in St. Petersburg, Russia (n = 104). Analyses were performed for the entire cohort, knees, and hips. Alpha was set at 0.05.

Results: Overall, the most frequent organisms identified were Staphylococcus aureus (24.8%) and Staphylococcus epidermidis (21.7%). The incidence of organisms resistant to at least one antibiotic was 58% and there was a significant difference between hips (62.3%) and knees (52.6%) (P = .014). Rates of resistant organisms among countries were 37.7% (US), 66.7% (Argentina), 71.5% (Uruguay), 40.8% (UK), 62.7% (Germany), and 77.9% (Russia) (P < .001). The overall incidence of polymicrobial infections was 9.3% and the rates across nations were 9.4% in the US, 11.1% in Argentina, 4.6% in Uruguay, 4.9% in UK, 11.9% in Germany, and 16.3% in Russia (P = .026).

Conclusion: In the evaluated institutions, S aureus and S epidermidis accounted for almost 50% of all infections. The US and the UK had the lowest incidence of resistant organisms while Germany and Russia had the highest. The UK and Uruguay had the lowest rates of polymicrobial infections.
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http://dx.doi.org/10.1016/j.arth.2020.07.020DOI Listing
January 2021

An Update on Venous Thromboembolism Rates and Prophylaxis in Hip and Knee Arthroplasty in 2020.

Medicina (Kaunas) 2020 Aug 19;56(9). Epub 2020 Aug 19.

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.

Patients undergoing total hip and knee arthroplasty are at high risk for venous thromboembolism (VTE) with an incidence of approximately 0.6-1.5%. Given the high volume of these operations, with approximately one million performed annually in the U.S., the rate of VTE represents a large absolute number of patients. The rate of VTE after total hip arthroplasty has been stable over the past decade, although there has been a slight reduction in the rate of deep venous thrombosis (DVT), but not pulmonary embolism (PE), after total knee arthroplasty. Over this time, there has been significant research into the optimal choice of pharmacologic VTE prophylaxis for individual patients, with the objective to reduce the rate of VTE while minimizing adverse side effects such as bleeding. Recently, aspirin has emerged as a promising prophylactic agent for patients undergoing arthroplasty due to its similar efficacy and good safety profile compared to other pharmacologic agents. However, there is no evidence to date that clearly demonstrates the superiority of any given prophylactic agent. Therefore, this review discusses (1) the current prevalence and trends in VTE after total hip and knee arthroplasty and (2) provides an update on pharmacologic VTE prophylaxis in regard to aspirin usage.
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http://dx.doi.org/10.3390/medicina56090416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558636PMC
August 2020

Periprosthetic Joint Infection: A Review of Antibiotic Treatment.

JBJS Rev 2020 07;8(7):e1900224

1Departments of Infectious Disease (R.M. and M.B.), Pharmacy (J.W.), and Orthopedic Surgery (A.K. and N.S.P.), Cleveland Clinic, Cleveland, Ohio 2Department of Orthopedic Surgery, Cleveland Clinic, Weston, Florida.

A team approach among orthopaedic surgeons, infectious disease specialists, and patients is of paramount importance when treating periprosthetic joint infections (PJIs). Treatment usually includes various surgical approaches along with antibiotic treatment. Antibiotic selection requires a multifactorial decision that depends on the organism that is identified, its antibiotic-resistance profile, the extent of the infection, and factors associated with the host. Antibiotic duration is dependent on surgical intervention and the type of organism. Typically, patients are treated for 6 weeks after debridement, antibiotics, and implant retention (DAIR) and for 4 to 6 weeks after single-stage and 2-stage revision arthroplasty. Levofloxacin in combination with rifampin has shown favorable outcomes for Staphylococcus PJI treatment. Quinolones have excellent bioavailability and bone and joint concentrations. Ciprofloxacin can be used for sensitive gram-negative infections. Evidence is emerging that supports the use of oral antibiotics after 7 days of intravenous antibiotics for the treatment of PJI. Although this should be considered carefully, it can potentially alleviate the burden on patients and caregivers, with fewer intravenous lines and the potential for fewer complications.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00224DOI Listing
July 2020

Opioid Use Disorder Is Associated with an Increased Risk of Infection after Total Joint Arthroplasty: A Large Database Study.

Clin Orthop Relat Res 2020 08;478(8):1752-1759

N. Sodhi, P. A. Gold, L. J. Garbarino, J. O. Ehiorobo, M. A. Mont, Lenox Hill Hospital, New York, NY, USA.

Background: Recent studies have shown that patients with opioid use disorder have impaired immunity. However, few studies with large patient populations have evaluated the risks of surgical site infection (SSI) and prosthetic joint infection (PJI) with opioid use disorder after total joint arthroplasty (TJA), and there is a lack of evidence for revision TJA in particular.

Questions/purposes: Are patients with opioid use disorder who undergo (1) primary THA, (2) primary TKA, (3) revision THA, or (4) revision TKA at a higher risk of experiencing SSIs 90 days after surgery or PJIs 2 years after surgery than those who do not have opioid use disorder?

Methods: All primary and revision TJAs performed between 2005 and 2014 were identified from the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is one of the largest nationwide databases; it comprehensively and longitudinally tracks patients based on all insurance claims rather than particular hospital visits, and has a low error rate (estimated at 1.3%). Boolean command operators were used to form a study group of patients with a history of opioid use disorder before surgery. ICD-9 diagnosis codes 304.00 to 304.02 and 305.50 to 305.52 were used to identify patients with opioid use disorder. Study group patients were matched 1:1 to control participants without opioid use disorder undergoing TJA, according to age, sex, and comorbidity burden (Elixhauser comorbidity index [ECI]). The ECI is comprised of 31 different comorbidities and can be used for large administrative databases. The query yielded a study population of 54,332 patients: 14,944 undergoing primary THA (opioid use disorder: n = 7472), 23,680 undergoing primary TKA (opioid use disorder: n = 11,840), 8116 undergoing revision THA (opioid use disorder: n = 4058), and 7592 undergoing revision TKA (opioid use disorder: n = 3796). The primary outcomes analyzed were SSI at 90 days and PJI at 2 years postoperatively, which were identified with ICD-9 codes. Logistic regression analyses were performed to calculate the risk that an infection would develop in a patient with opioid use disorder compared with the matched control patients without opioid use disorder.

Results: Patients with opioid use disorder undergoing primary THA had an increased risk of SSI at 90 days (OR 1.85 [95% CI 1.51 to 2.25]; p < 0.001) and PJI at 2 years (OR 1.66 [95% CI 1.42 to 1.93]; p < 0.001). Compared with matched controls, opioid use disorder patients undergoing primary TKA had an increased risk of SSI at 90 days (OR 1.72 [95% CI 1.46 to 2.02]; p < 0.001) and PJI at 2 years (OR 1.31 [95% CI 1.16 to 1.47]; p < 0.001). Similarly, for revision THAs, there was an increase in 90-day SSIs (OR 1.89 [95% CI 1.53 to 2.32]; p < 0.001) and 2-year PJIs (OR 4.24 [95% CI 3.67 to 4.89]; p < 0.001). The same held for revision TKAs for 90-day SSIs (OR 1.88 [95% CI 1.53 to 2.29]; p < 0.001) and 2-year PJIs (OR 4.94 [95% CI 4.24 to 5.76]; p < 0.001).

Conclusions: After accounting for age, sex, and comorbidity burden, these results revealed that patients with opioid use disorder undergoing TJA were at increased risk of having SSIs and PJIs. Based on these findings, healthcare systems and/or administrators should recognize the increased associated PJI and SSI risks in patients with opioid use disorder and enact clinical policies that reflect these associated risks. Additionally, these findings should encourage surgeons to pursue multidisciplinary approaches to help patients reduce their opioid consumption before their arthroplasty procedure.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371033PMC
August 2020

Greater Prevalence of Mental Health Conditions in Septic Revision Total Knee Arthroplasty: A Call to Action.

J Knee Surg 2020 Jul 13. Epub 2020 Jul 13.

Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio.

The purpose of this study was to compare the prevalence of mental health conditions among patients undergoing (1) primary total knee arthroplasty (pTKA), (2) septic revision total knee arthroplasty (rTKA), and (3) aseptic revision total knee arthroplasty (TKA). The State Inpatient Databases were queried for all TKAs from 2005 to 2014 yielding 563,144 patients. Patients were separated into the following cohorts: primary, septic revision, and aseptic revision. Diagnoses of any mental health condition and the following specific conditions were compared between the three cohorts: schizophrenia/delusion, bipolar disorder, depression/mood disorder, personality disorder, anxiety/somatic/dissociative disorder, eating disorders, attention deficit hyperactivity disorder /conduct/impulse control, alcohol abuse, and drug abuse. Throughout the study period, an increase in the prevalence of mental health conditions was observed in septic and aseptic revision patients. Overall, there was a significantly higher prevalence of mental health conditions in the septic revision cohort (22.7%) compared with the primary (17.8%,  < 0.001) and aseptic revision (20.0%,  < 0.001) cohorts. Specifically, septic revision TKA patients had a higher prevalence of depression ( < 0.001), alcohol abuse ( < 0.001), drug abuse ( < 0.001), schizophrenia ( = 0.0007), and bipolar disorder ( < 0.001), compared with primary TKA patients. Additionally, there was a significantly higher prevalence of depression ( < 0.001), alcohol abuse ( < 0.001), and drug abuse ( < 0.001) among septic revision patients compared with aseptic revision patients. Mental health conditions were significantly higher among septic revision patients. Alcohol and drug abuse were approximately twice as prevalent in septic revision patients compared with primary and aseptic revision patients. These findings should serve as a call to action for mental health support for patients suffering from PJI.
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http://dx.doi.org/10.1055/s-0040-1713756DOI Listing
July 2020

Neuromuscular Electrical Stimulation Use after Total Knee Arthroplasty Improves Early Return to Function: A Randomized Trial.

J Knee Surg 2020 Jul 1. Epub 2020 Jul 1.

Cleveland Clinic Florida, Weston, Florida.

Neuromuscular electrical stimulation (NMES) has been reported as an effective method for quadriceps strengthening which could attenuate muscle loss in the early total knee arthroplasty (TKA) postoperative recovery period. The purpose of this randomized controlled trial was to test whether postoperative use of NMES on TKA patients results in increased quadriceps strength and ultimately improved functional outcomes. This randomized controlled clinical trial of 66 primary TKA patients was conducted at a large academic medical center. Patients were randomized 2:1 into treatment (NMES use,  = 44) or control arm (no NMES,  = 22). Patients who used the device for an average of 200 minutes/week or more (starting 1 week postoperative and continuing through week 12) were considered compliant. Baseline measurements and outcomes were recorded at 3, 6, and 12 weeks postoperatively, and included quadriceps strength, range of motion (ROM), resting pain, functional timed up and go (TUG), stair climb test, and knee injury and osteoarthritis outcome score (KOOS) and veterans rand 12-item health survey (VR-12) scores. Patients in the treatment arm (NMES use) experienced quadriceps strength gains over baseline at 3, 6, and 12 weeks following surgery, which were statistically significant compared with controls with quadriceps strength losses at 3 ( = 0.050) and 6 weeks ( = 0.015). The TUG improvements for patients treated with NMES showed significant improvements at 6 ( = 0.018) and 12 weeks ( = 0.003) postoperatively. Use of a home-based application-controlled NMES therapy system added to standard of care treatment showed statistically significant improvements in quadriceps strength and TUG following TKA, supporting a quicker return to function.
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http://dx.doi.org/10.1055/s-0040-1713420DOI Listing
July 2020

Preoperative cut-off values for body mass index deny patients clinically significant improvements in patient-reported outcomes after total hip arthroplasty.

Bone Joint J 2020 Jun;102-B(6):683-692

Aims: Thresholds for operative eligibility based on body mass index (BMI) alone may restrict patient access to the benefits of arthroplasty. The purpose of this study was to evaluate the relationship between BMI and improvements in patient-reported outcome measures (PROMs), and to determine how many patients would have been denied improvements in PROMs if BMI cut-offs were to be implemented.

Methods: A prospective cohort of 3,449 primary total hip arthroplasties (THAs) performed between 2015 and 2018 were analyzed. The following one-year PROMs were evaluated: hip injury and osteoarthritis outcome score (HOOS) pain, HOOS Physical Function Shortform (PS), University of California, Los Angeles (UCLA) activity, Veterans Rand-12 Physical Component Score (VR-12 PCS), and VR-12 Mental Component Score (VR-12 MCS). Positive predictive values for failure to improve and the number of patients denied surgery in order to avoid a failed improvement were calculated for each PROM at different BMI cut-offs.

Results: There was a trend to improved outcomes in terms of pain and function improvements with higher BMI. Patients with BMI ≥ 40 kg/m had median (Q1, Q3) HOOS pain improvements of 58 points (interquartile range (IQR) 41 to 70) and those with BMI 35 to 40 kg/m had median improvements of 55 (IQR 40 to 68). With a BMI cut-off of 30 kg/m, 21 patients would have been denied a meaningful improvement in HOOS pain score in order to avoid one failed improvement. At a 35 kg/m cut-off, 18 patients would be denied improvement, at a 40 kg/m cut-off 21 patients would be denied improvement, and at a 45 kg/m cut-off 21 patients would be denied improvement. Similar findings were observed for HOOS-PS, UCLA, and VR-12 scores.

Conclusion: Patients with higher BMIs show greater improvements in PROMs. Using BMI alone to determine eligibility criteria did not improve the rate of clinically meaningful improvements. BMI thresholds prevent patients who may benefit the most from surgery from undergoing THA. Surgeons should consider PROMs improvements in determining eligibility for THA while balancing traditional metrics of preoperative risk stratification. Cite this article: 2020;102-B(6):683-692.
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http://dx.doi.org/10.1302/0301-620X.102B6.BJJ-2019-1644.R1DOI Listing
June 2020

The Cost-Effectiveness of Platelet-Rich Plasma Injections for Knee Osteoarthritis: A Markov Decision Analysis.

J Bone Joint Surg Am 2020 Sep;102(18):e104

Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: Use of platelet-rich-plasma (PRP) injections for treating knee osteoarthritis has increased over the past decade. We used cost-effectiveness analysis to evaluate the value of PRP in delaying the need for total knee arthroplasty (TKA).

Methods: We developed a Markov model to analyze the baseline case: a 55-year-old patient with Kellgren-Lawrence grade-II or III knee osteoarthritis undergoing a series of 3 PRP injections with a 1-year delay to TKA versus a TKA from the outset. Both health-care payer and societal perspectives were included. Transition probabilities were derived from systematic review of 72 studies, quality-of-life (QOL) values from the Tufts University Cost-Effectiveness Analysis Registry, and individual costs from Medicare reimbursement schedules. Primary outcome measures were total costs and quality-adjusted life years (QALYs), organized into incremental cost-effectiveness ratios (ICERs) and evaluated against willingness-to-pay thresholds of $50,000 and $100,000. One and 2-way sensitivity analyses were performed as well as a probabilistic analysis varying PRP-injection cost, TKA delay intervals, and TKA outcomes over 10,000 different simulations.

Results: From a health-care payer perspective, PRP resulted in 14.55 QALYs compared with 14.63 for TKA from the outset, with total health-care costs of $26,619 and $26,235, respectively. TKA from the outset produced a higher number of QALYs at a lower cost, so it dominated. From a societal perspective, PRP cost $49,090 versus $49,424 for TKA from the outset. The ICER for TKA from the outset was $4,175 per QALY, below the $50,000 willingness-to-pay threshold. Assuming the $728 published cost of a PRP injection, no delay time that was <10 years produced a cost-effective course. When the QOL value was increased from the published value of 0.788 to >0.89, PRP therapy was cost-effective with even a 1-year delay to TKA.

Conclusions: When considering direct and unpaid indirect costs, PRP injections are not cost-effective. The primary factor preventing PRP from being cost-effective is not the price per injection but rather a lack of established clinical efficacy in relieving pain and improving function and in delaying TKA. PRP may have value for higher-risk patients with high perioperative complication rates, higher TKA revision rates, or poorer postoperative outcomes.

Level Of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.01446DOI Listing
September 2020

The Effects of Opioid Use on Thromboembolic Complications, Readmission Rates, and 90-Day Episode of Care Costs After Total Hip Arthroplasty.

J Arthroplasty 2020 06 13;35(6S):S237-S240. Epub 2020 Feb 13.

Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY.

Background: The purpose of this study was to investigate whether opioid use disorder (OUD) patients are at greater odds than non-opioid use disorder (NUD) patients in developing (1) thromboembolic complications; (2) readmission rates; and (3) costs of care.

Methods: All patients with a 90-day history of OUD before total hip arthroplasty (THA) were identified from a national database. Patients were matched 1:5 to controls by age, gender, Elixhauser Comorbidity Index scores, and high-risk medical comorbidities, yielding 38,821 patients with (n = 6398) and without (n = 31,883) OUD. Multivariate logistic regression analyses were performed to compare the risks of developing venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) 90 days after the index procedure, 90-day readmission rates, and total global 90-day episode of care costs.

Results: Patients with a history of OUD were found to be at greater risk for 90-day venous thromboembolisms (2.38 vs. 1.07%; OR: 2.25, 95% CI: 1.86-2.73, P < .0001) compared with matched NUD patients. Specifically, OUD patients were at greater risk for both deep vein thromboses (2.13 vs. 0.87%; OR: 2.46, 95% CI: 2.00-3.03, P < .001) and pulmonary embolism (0.61 vs. 0.27%; OR: 2.24, 95% CI: 1.53-3.27, P < .0001). In addition, patients with OUD were at an increased risk for 90-day readmission (28.68 vs. 22.62%; OR: 1.37, 95% CI: 1.29-1.46, P < .0001) compared with controls. Primary THA patients with OUD incurred a 14.72% higher cost of care ($20,610.65 vs. $17,964.58) compared with NUD patients.

Conclusion: These findings demonstrate that primary THA patients with a history of OUD are at greater risks for thromboembolic complications, readmissions, and higher costs of care in the 90-day postoperative period.
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http://dx.doi.org/10.1016/j.arth.2020.02.014DOI Listing
June 2020

Are We Treating Similar Patients? Hospital Volume and the Difference in Patient Populations for Total Knee Arthroplasty.

J Arthroplasty 2020 06 1;35(6S):S97-S100. Epub 2020 Feb 1.

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH.

Background: Early findings of superior total knee arthroplasty (TKA) outcomes at high volume centers have been thought to have led to distinct referral patterns. However, the effect of these selective referral processes has not been well assessed. Therefore, this study compared the characteristics of primary TKA patients at high, intermediate, and low volume hospitals.

Methods: A total of 12,541 primary TKA patients were stratified into risk groups based on age (>65 years), body mass index (>40), and Charlson Comorbidity Index (≥4). Hospitals were classified as low, intermediate, or high volume based on mean annual TKA volumes (<250, 250-499, and >500). Multivariate logistic regression models evaluated the relationship between baseline patient characteristics and hospital volume.

Results: There was a greater percentage of high risk patients at high volume (19%, n = 853) compared to those at intermediate (16%, n = 899) or low volume (17%, n = 444) hospitals (P < .001). Patients with a body mass index >40 were more likely to be treated at high compared to intermediate (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.6, P < .001) and low volume centers (OR 1.4, 95% CI 1.2-1.7, P < .001). Patients with Charlson Comorbidity Index scores ≥4 were also more likely be treated at high compared to intermediate (OR 1.5, 95% CI 1.3-1.6, P < .001) or low (OR 1.2, 95% CI 1.0-1.4, P = .002) volume centers.

Conclusion: This study found that TKA patients at high volume centers have significantly different baseline characteristics compared to those at lower volume centers. This study highlights the importance of considering hospital volume status and the associated disparity in the preoperative risk of patients when comparing primary TKA outcomes between centers.
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http://dx.doi.org/10.1016/j.arth.2020.01.075DOI Listing
June 2020

The treatment of periprosthetic joint infection: safety and efficacy of two stage versus one stage exchange arthroplasty.

Expert Rev Med Devices 2020 Mar 2;17(3):245-252. Epub 2020 Mar 2.

Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL, USA.

: Periprosthetic joint infection (PJI) remains one of the most dreaded and challenging complications in adult reconstruction. While primary total joint arthroplasty is one of the most successful surgeries in medicine, revisions secondary to infections do not hold as well. As the number of primary procedures increases, so will infections. In North America, two-stage exchange arthroplasty is the standard of care for patients with PJI, especially when the presentation is greater than 4 weeks after the index procedure. However, it is not necessarily the best option for all patients, particularly when compared to one-stage arthroplasty.: The aim of this review is to analyze the indications, safety, and efficacy of two-stage exchange arthroplasty for the treatment of PJI and to compare the results reported 10 years ago with the ones of recent publications and those of one-stage arthroplasty.: Two-stage exchange arthroplasty is a safe and efficacious treatment particularly suited for recalcitrant infections, resistant organisms, and patients with certain host factors that make it more difficult to eradicate infection. However, one-stage arthroplasty might be well suited as well for infections caused by susceptible organisms and patients with minimal or no comorbidities or those unable to undergo two surgeries.
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http://dx.doi.org/10.1080/17434440.2020.1733971DOI Listing
March 2020

The Utility of Serum d-Dimer for the Diagnosis of Periprosthetic Joint Infection in Revision Total Hip and Knee Arthroplasty.

J Arthroplasty 2020 06 23;35(6):1692-1695. Epub 2020 Jan 23.

Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL.

Background: There is scarce and contradicting evidence supporting the use of serum d-dimer for the diagnosis of periprosthetic joint infection in revision total hip (THA) and knee (TKA) arthroplasty. Therefore, the purpose of this study is to test the accuracy of serum d-dimer against the 2013 International Consensus Meeting (ICM) criteria.

Methods: A retrospective review was performed on a consecutive series of 172 revision THA/TKA surgeries performed by 3 fellowship-trained surgeons at a single institution (August 2017 to May 2019) and that had d-dimer performed during their preoperative workup. Of this cohort, 111 (42 THAs/69 TKAs) cases had complete 2013 ICM criteria tests and were included in the final analysis. Septic and aseptic revisions were categorized per 2013 ICM criteria ("gold standard") and compared against serum d-dimer using an established threshold (850 ng/mL). Sensitivity, specificity, likelihood ratios, and positive/negative predictive values were determined. Independent t-tests, Fisher's exact tests, chi-squared tests, and receiver operating characteristic curve analysis were performed.

Results: There was no statistically significant difference in baseline demographics between septic and aseptic cases per 2013 ICM criteria. When compared to ICM criteria, d-dimer demonstrated high sensitivity (95.9%) and negative predictive value (90.9%) but low specificity (32.3%), positive predictive value (52.8%), and overall, poor accuracy (61%) to diagnose periprosthetic joint infection. Positive likelihood ratio was 1.42 while negative likelihood ratio was 0.13. The area under the curve (AUC) was 0.742.

Conclusion: Serum d-dimer has poor accuracy to discriminate between septic and aseptic cases using a described threshold in the setting of revision THA and TKA.
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http://dx.doi.org/10.1016/j.arth.2020.01.034DOI Listing
June 2020