Publications by authors named "David C Markel"

100 Publications

Factors That Influence Time to Operating Room for Geriatric Hip Fractures: A Quality Improvement Initiative.

Arthroplast Today 2022 Jun 26;15:115-119. Epub 2022 Apr 26.

Ascension Providence Hospital, Southfield, MI, USA.

Background: For geriatric hip fractures, the current American College of Surgeons guideline recommends surgery within 48 hours. We sought to identify which factors delayed a patient's progression to definitive surgery at 2 associated level II trauma centers using chart abstraction.

Methods: We reviewed all geriatric patients who underwent a surgical procedure for a hip fracture. Data regarding age, length of stay, procedure, and minutes from emergency department arrival to operating room (OR) were evaluated. Chart abstraction determined if cardiac or medical clearance and an echocardiogram were obtained. For patients that entered the OR over 24 hours, a reason was identified for the delay. Analysis of variance was used to compare continuous data, and chi-squared tests were used for categorical data.

Results: Of 477 patients, 288 (60%) presented to the OR in under 24 hours, 114 (24%) between 24 and 36 hours, and 75 (16%) over 36 hours. There was a significant increase in length of stay for patients, over 36 hours. Patients presenting to the OR between 24 and 36 hours were often delayed due to facility reasons such as OR or surgeon availability while patients presenting over 36 hours were delayed due to medical comorbidities. Of all patients in the under-24-hours group, 34.7% had an echocardiogram compared with 56.1% and 69.3%, respectively. Similarly, 17.7% of patients received cardiac clearance in the under-24-hours group, compared with 31.8% and 48%, respectively.

Conclusions: The timeliness of presentation of hip fractures to the OR is a multidisciplinary effort and requires cooperation between a variety of services to increase safety and efficiency as well as to control costs.
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http://dx.doi.org/10.1016/j.artd.2022.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9062343PMC
June 2022

Attachment and Growth of Fibroblasts and Tenocytes Within a Porous Titanium Scaffold: A Bioreactor Approach.

Arthroplast Today 2022 Apr 15;14:231-236.e1. Epub 2022 Jan 15.

Wayne State University, Detroit, MI, USA.

Background: Direct attachment of tendons to metallic implants is important in orthopedics. Tissue integration depends on scaffold microstructure and composition. This study evaluated the effect of pore size of titanium on the viability and function of fibroblasts and tenocytes in a dynamic bioreactor.

Methods: Standardized Ti porous cylinders with 3 pore sizes (400, 700, and 1000 μm) were seeded with fibroblasts or tenocytes (4500 cells/μL) in silicon tubes. Cells were analyzed via alamarBlue (AB) assay in addition to scanning electron microscopy at day 7 (fibroblasts) or day 8 (tenocytes) and day 15. AB functions as a cell health indicator where functional living cells reduce the resazurin dye (blue) in the solution to resorufin (pink), and cell viability can be quantified via spectroscopy.

Results: At day 7, fibroblasts cultured on all sizes reduced AB, with significant differences noted between 400 vs 1000 μm ( = .013) and 700 vs 1000 μm ( = .001). At day 15, fibroblasts reduced AB on all sizes with a significant difference noted between 700 vs 1000 μm ( = .004). Fibroblasts on all 3 pore sizes increased AB reduction from day 7 to day 15. Tenocytes reduced AB with significant differences between the 400 vs 700 μm ( = .049) and the 400 vs 1000 μm pore sizes at day 8. In contrast, tenocyte reduction of AB decreased from day 8 to day 15. Scanning electron microscopy performed on fibroblast cylinders showed fibroblasts reached the surface of the cylinders, confirming interconnectivity.

Conclusions: While both fibroblasts and tenocytes penetrated the pores, fibroblasts preferred larger size, whereas tenocytes favored smaller size. Results are encouraging since soft-tissue attachment to a metallic scaffold is difficult but clinically desirable. Future studies could be performed in an in vivo animal model.
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http://dx.doi.org/10.1016/j.artd.2021.12.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9059072PMC
April 2022

Causes of Early Hip Revision Vary by Age and Gender: Analysis of Data From a Statewide Quality Registry.

J Arthroplasty 2022 Mar 9. Epub 2022 Mar 9.

Department of Orthopaedic Surgery, The CORE Institute, Novi, MI.

Background: While total hip arthroplasty (THA) is extremely successful, early failures do occur. The purpose of this study was to determine the cause of revision in specific patient demographic groups at 3 time points to potentially help decrease the revision risk.

Methods: Data for cases performed between 2012 and 2018 from a statewide, quality improvement arthroplasty registry were used. The database included 79,205 THA cases and 1,433 revisions with identified etiology (1,584 in total). All revisions performed at <5 years from the primary THA were reviewed. Six groups, men/women, <65, 65-75, and >75 years, were compared at revision time points <6 months, <1 year, and <5 years.

Results: There were obvious and significant differences between subgroups based on demographics and time points (P < .0001). Seven hundred and fifty-six (53%) of all revisions occurred within 6 months. The most common etiologies within 6 months (756 revisions) were fracture (316, 41.8%), dislocation/instability (194, 25.7%), and infection (98, 12.9%). At this early time point, the most common revision cause was fracture for all age/gender-stratified groups, ranging from 27.6% in young men to 60% in older women. Joint instability became the leading cause for revision after 1 year in all groups.

Conclusion: This quality improvement project demonstrated clinically meaningful differences in the reason for THA revision between gender, age, and time from surgery. Strategies based on these data should be employed by surgeons to minimize the factors that lead to revision.
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http://dx.doi.org/10.1016/j.arth.2022.03.014DOI Listing
March 2022

John N. Insall Award: MARCQI's Pain-Control Optimization Pathway (POP): Impact of Registry Data and Education on Opioid Utilization.

J Arthroplasty 2022 Jun 8;37(6S):S19-S26. Epub 2022 Mar 8.

Department of Orthopaedic Surgery, Ascension Providence Rochester Hospital, Rochester, MI.

Background: In 2019, the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) recommended an evidence-based opioid pain pathway to participating physicians and hospitals for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to determine if the education could influence and have lasting effects on the prescribing patterns for TJA patients.

Methods: Using the MARCQI database, the number of oral morphine equivalents (OMEs) prescribed at discharge were collected from January 2018 through December 2019 for all primary arthroplasty procedures. Periods compared included before and after July 2018 Michigan opioid laws as well as before and after the March 2019 MARCQI recommendations. The data compared total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, opioid-naive vs opioid-tolerant patients, individual surgeons, and MARCQI sites.

Results: The data included 84,998 TJAs: 22,774 opioid-naive THAs, 9124 opioid-tolerant THAs, 40,882 opioid-naive TKAs, and 12,218 opioid-tolerant TKAs. In all the groups and at all time periods there were a significant decrease in prescriptions (P < .001). Individual surgeons and participating sites also demonstrated decreased OMEs on discharge after the recommendations. Between the first and last months of collection, this represented an overall decrease of opioid OMEs for THA by 47.1% for opioid-naive patients and 53.4% for opioid-tolerant patients. For TKA patients, the OME decrease was 48.3% for opioid-naive patients, and 48.4% for opioid-tolerant patients.

Conclusion: The MARCQI pain control optimization pathway (POP) program has been successful in drastically reducing opioid prescribing with lasting effects, which has substantially limited the overall opioid prescription burden for patients undergoing arthroplasty.
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http://dx.doi.org/10.1016/j.arth.2022.02.109DOI Listing
June 2022

Mark Coventry Award: Efficacy of Saline Wash Plus Antibiotics Doped Polyvinyl Alcohol (PVA) Composite (PVA-VAN/TOB-P) in a Mouse Pouch Infection Model.

J Arthroplasty 2022 Jun 3;37(6S):S4-S11. Epub 2022 Mar 3.

Ascension Providence Hospital Orthopedic Research Laboratory, Southfield, MI; Virotech Co., Inc., Troy, MI.

Background: The efficacy of saline irrigation for treatment of periprosthetic infection (PJI) is limited by the presence of contaminated medical devices. This study evaluated treatment efficacy of locally placed polyvinyl alcohol (PVA)/bioceramic composite doped with vancomycin (PVA-VAN-P) or vancomycin and tobramycin (PVA-VAN/TOB-P) after saline irrigation in a mouse pouch infection model.

Methods: Sutures were implanted into air pouches of BALB/cJ mice, then inoculated with Staphylococcus aureus. Mice were randomized into 6 groups (n = 6 each): (1) no bacteria; (2) bacteria without saline wash; (3) saline wash only; (4) saline wash + PVA-P; (5) saline wash + PVA-VAN-P, and (6) saline wash + PVA-VAN/TOB-P. After 7 days, pouches were washed with saline alone or with additional injection of 0.2 mL of the composites. Sacrifice occurred 14 days after the washout. Histology was performed on the pouch tissues and bacteria cultures on the washout fluid.

Results: Bacterial culture (optical density) showed that infection persisted after saline irrigation (0.10 ± 0.14) but was effectively eradicated by the addition of PVA-VAN-P (0.05 ± 0.09) and PVA-VAN/TOB-P (0.002 ± 0.003, P < .05). These effects were confirmed by histology. Importantly, no residues of the PVA-P were detected in either the pouch washouts or pouch tissues.

Conclusion: PJI is common and problematic, and few innovations have changed clinical practice and/or outcome. Our data confirmed that the effect of saline irrigation was very limited in the presence of contaminated sutures. PVA-VAN/TOB-P was biodegradable, biocompatible, and effective in eradicating bacterial retention after saline irrigation. Application of PVA-VAN/TOB-P after saline irrigation could be an option for treatment of PJI and should be evaluated in future PJI animal models.
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http://dx.doi.org/10.1016/j.arth.2022.02.098DOI Listing
June 2022

The Effects of Depression and Anxiety on 90-day Readmission Rates After Total Hip and Knee Arthroplasty.

Arthroplast Today 2021 Aug 18;10:175-179. Epub 2021 Aug 18.

Section of Orthopaedic Surgery, Ascension Providence Hospital and The Core Institute, Novi, MI, USA.

Background: Patients undergoing total joint arthroplasty have higher rates of anxiety, depression or anxiety and depression than the general population and higher costs of care, which lead to higher levels of postoperative dissatisfaction and readmission rates. We evaluated the readmission rates of patients undergoing total hip or knee arthroplasty with diagnoses of anxiety, depression, or both.

Methods: Our hospital's prospectively collected data from Michigan's statewide total joint database were reviewed from 2013 to 2018. Rates of anxiety, depression or anxiety and depression were determined based on preoperative anxiolytic or antidepressant medications using National Drug Codes.

Results: A total of 4107 cases were included. Of which 4.28% had a readmission within the 90-day global period, and 12% had a history of depression or anxiety or both. For the entire cohort, those on anxiolytic medication were 153% more likely to be readmitted than those not on medication ( = .017). When comparing total hip arthroplasty (THA) or total knee arthroplasty (TKA), patients taking anxiolytic medication and undergoing TKA were 120% more likely to undergo readmission within 90 days ( = .021). Patients on depression medication alone were not at increased risk of readmission in the TKA cohort ( = .991). For THA, neither diagnosis appeared a risk factor for readmission ( = .852).

Conclusions: Patients with depression, anxiety, or both undergoing TKA were at a statistically significant risk of readmission within 90 days compared with patients without these diagnoses. Anxiety and depression were both risk factors for readmission, but anxiety appeared to have a more significant impact. Patients undergoing THA on the other hand did not appear to share this risk profile.
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http://dx.doi.org/10.1016/j.artd.2021.06.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8379358PMC
August 2021

Impacts of compacting methods on the delivery of erythromycin and vancomycin from calcium polyphosphate hydrogel matrices.

J Biomed Mater Res B Appl Biomater 2022 02 24;110(2):412-421. Epub 2021 Jul 24.

Department of Biomedical Engineering, Wayne State University, Detroit, Michigan, USA.

Designing hydrogels for controlled drug delivery remains a big challenge. We developed a calcium polyphosphate hydrogel (CPP) as matrix for delivery of vancomycin (VCM) and erythromycin (EM) by unique ionic binding and physical wrapping. In this continuing study, we investigated if gel discs prepared by mechanical compaction (at 3000 psi pressure, C-discs) is superior to that of discs prepared by regular manual compaction (M-discs) for the release of VCM and EM (10 wt.%). Data demonstrated a significant reduction of burst release of VCM and EM in C-discs (1.8% and 5%, respectively) as compared to that from M-discs within 72 hr (55% and 60%, respectively, p < 0.05). In addition, C-discs significantly extended the VCM release (1500 hr) and EM (800 hr) as compared to M-discs (160 and 96 hr, respectively, p < 0.05). The VCM released from C-discs retained its bactericidal activity much longer (1500 hr) than that from M-discs (700 hr, p < 0.05). Raman Spectroscopy indicated an ionic bond of both VCM and EM with fully hydrated polyphosphate chains of CPP hydrogel matrix for both M-discs and C-discs. Micro CT showed that C-discs had much denser microstructures and less number/depth of microcracks as a result of high pressure. We propose that CPP hydrogel represents an excellent tool for the controllable and sustained delivery of VCM and EM. Extensive experiments are currently underway to evaluate the potential impacts of the modification of compaction techniques, other antibiotics, gel concentrations on the drug release, degradation behavior and infection control both in vitro and in vivo.
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http://dx.doi.org/10.1002/jbm.b.34917DOI Listing
February 2022

FiberWire vs FiberTape: Comparison of Bacterial Adherence in a Murine Air Pouch Wound Model.

Orthop J Sports Med 2020 Dec 15;8(12):2325967120964480. Epub 2020 Dec 15.

Ascension Providence Health System, Southfield, Michigan, USA.

Background: For high-tensile strength sutures, past research has largely focused on mechanical properties or bacterial adherence across various manufacturers.

Purpose: This study investigated high-tensile strength sutures with different shapes but otherwise identical composition. The purpose was to evaluate the differences between high-tensile strength suture wire and suture tape relative to bacterial adherence and bacterial retention after washout.

Study Design: Controlled laboratory study.

Methods: Sutures were implanted in dorsal air pouches of 72 BALB/cJ mice. Experimental pouches were inoculated with ; no bacteria were used in the control conditions. The mice were randomized into 3 groups: group 1 underwent suture extraction 7 days after implantation; group 2 underwent an irrigation procedure, followed by immediate suture extraction on day 7; and group 3 underwent an irrigation procedure on day 7, with delayed suture extraction on day 14 after implantation. The sutures were evaluated using confocal microscopy; electron microscopy; and spectrophotometry, through which optical density, as measured by the amount of scattered light, is directly correlated with the number of bacteria. Histological assessment was performed on the pouches.

Results: Optical density (mean ± SD) was significantly higher for FiberTape sutures than for FiberWire sutures, respectively, at the 2-hour time point for all groups (group 1, 0.0550 ± 0.0081 vs 0.0162 ± 0.006 [ = .0054]; group 2, 0.0225 ± 0.0049 vs 0.0056 ± 0.0006 [ = .0045]; group 3, 0.055 ± 0.0222 vs 0.0043 ± 0.0005 [ = .0103]). Additionally, groups 2 and 3 showed statistically significant results at the 4-hour time points (group 2, 0.0384 ± 0.0087 vs 0.0145 ± 0.0042 [ = .0280]; group 3, 0.0532 ± 0.0159 vs 0.0101 ± 0.0025 [ = .0058]). The wash fluid also demonstrated significantly greater optical density for the FiberTape than the FiberWire sutures, respectively, at the 2-hour time point for all groups (group 1, 0.1657 ± 0.0319 vs 0.0317 ± 0.008 [ = .0063]; group 2, 0.0522 ± 0.0156 vs 0.0127 ± 0.0022 [ = .0219]; group 3, 0.1707 ± 0.0205 vs 0.0191 ± 0.0053 [ < .0001]). No bacterial growth occurred in the control conditions. Histological assessment revealed only mild inflammation in the control groups as compared with more severe responses in the experimental groups at all time points.

Conclusion: FiberTape was associated with increased bacterial adhesion as well as retention as compared with FiberWire in an in vivo murine wound model.

Clinical Relevance: This study demonstrates that suture design influences the occurrence of and ability to clear surgical infection and must be considered when selecting high-tensile strength sutures in a clinical setting.
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http://dx.doi.org/10.1177/2325967120964480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745592PMC
December 2020

Risk factors for manipulation under anaesthesia after total knee arthroplasty.

Bone Joint J 2020 Jun;102-B(6_Supple_A):66-72

Ascension Providence Hospital Orthopaedic Residency, Novi, Michigan, USA.

Aims: Postoperative range of movement (ROM) is an important measure of successful and satisfying total knee arthroplasty (TKA). Reduced postoperative ROM may be evident in up to 20% of all TKAs and negatively affects satisfaction. To improve ROM, manipulation under anaesthesia (MUA) may be performed. Historically, a limited ROM preoperatively was used as the key harbinger of the postoperative ROM. However, comorbidities may also be useful in predicting postoperative stiffness. The goal was to assess preoperative comorbidities in patients undergoing TKA relative to incidence of postoperative MUA. The hope is to forecast those who may be at increased risk and determine if MUA is an effective form of treatment.

Methods: Prospectively collected data of TKAs performed at our institution's two hospitals from August 2014 to August 2018 were evaluated for incidence of MUA. Comorbid conditions, risk factors, implant component design and fixation method (cemented vs cementless), and discharge disposition were analyzed. Overall, 3,556 TKAs met the inclusion criteria. Of those, 164 underwent MUA.

Results: Patients with increased age and body mass index (BMI) had decreased likelihood of MUA. For every one-year increase in age, the likelihood of MUA decreased by 4%. Similarly, for every one-unit increase in BMI the likelihood of MUA decreased by 6%. There were no differences in incidence of MUA between component type/design or fixation method. Current or former smokers were more likely to have no MUA. Surprisingly, patients discharged to home health service or skilled nursing facility were approximately 40% and 70% less likely than those discharged home with outpatient therapy to be in the MUA group. MUA was effective, with a mean increased ROM of 32.81° (SD 19.85°; -15° to 90°).

Conclusion: Younger, thinner patients had highest incidence of MUA. Effect of discharge disposition on rate of MUA was an important finding and may influence surgeons' decisions. Interestingly, use of cement and component design (constraint) did not impact incidence of MUA. Level of Evidence II: Prospective cohort study. Cite this article: 2020;102-B(6 Supple A):66-72.
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http://dx.doi.org/10.1302/0301-620X.102B6.BJJ-2019-1580.R1DOI Listing
June 2020

Use of a Mandatory Clinical Decision Unit Reduces Readmission Rates following Total Joint Arthroplasty.

J Knee Surg 2021 Jul 6;34(9):924-929. Epub 2020 Jan 6.

Medical School, Wayne State University, Detroit, Michigan.

Readmission penalties have encouraged the implementation of protocols to reduce readmission rates. We hypothesized that by keeping postoperative patients, who return to the emergency department (ED) in a clinical decision unit (CDU) until being evaluated by the orthopaedic team, there would be a reduction in the readmission rate after total joint arthroplasty (TJA) at our institution. Our institution mandated the use of the CDU for all potential orthopaedic TJA readmissions. A retrospective review of prospectively collected data was performed on 365 patients who presented to the ED after either total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients presenting in the year prior to the implementation of the CDU program were compared with patients presenting in the year after implementation. Demographics, length of stay, comorbidities, and 30-day readmission rates were recorded. Additionally, a financial analysis was performed. Overall, for THA and TKA, there were a combined 141 ED visits prior to the implementation of the CDU program and 224 afterward; of these, 40 were readmitted before the CDU program and only 13 were readmitted afterward ( < 0.01). The financial analysis found that the overall 90-day cost for patients in the postoperative period was nearly $800 lower on average ( = 0.027) post-CDU implementation.During the first year of the CDU project at our institution, we significantly reduced the readmission rates following TJA and demonstrated significant cost saving. This is a Level III, prognostic study.
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http://dx.doi.org/10.1055/s-0039-3402053DOI Listing
July 2021

Bone morphology of the proximal femoral canal: ethnicity related differences and the influence on cementless tapered wedge stem designs.

Hip Int 2021 Jul 23;31(4):482-491. Epub 2019 Dec 23.

The CORE Institute, Wayne State University and Providence Hospital, Detroit, MI, USA.

Background: Differences in proximal femoral morphology between ethnicities may have implications on the design of cementless tapered wedge stems. This study analyses the differences in Asian and Caucasian bone morphology as well as the related fit of various cementless tapered wedge stem designs.

Methods: A computed tomography database and modelling software was used to retrospectively analyse a total of 1345 femora. Ethnicity related comparisons as well as the fit of the stem designs were analysed.

Results: Statistically significant differences between canal shape of Caucasian and Japanese as well as non-Japanese Asians were observed. The fit of the stems within the femoral canal was highly dependent on the respective stem shape.

Conclusions: The shape differences in stem designs had a larger influence on the fit within the femoral canal than the differences in ethnicity related to bone morphology.
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http://dx.doi.org/10.1177/1120700019895458DOI Listing
July 2021

Preparation of electrospun nanofibers with desired microstructures using a programmed three-dimensional (3D) nanofiber collector.

Mater Sci Eng C Mater Biol Appl 2020 Jan 10;106:110188. Epub 2019 Sep 10.

Department of Biomedical Engineering, Wayne State University, Detroit, MI 48201, USA; Department of Orthopedics, Providence Hospital and Medical Center, Southfield, MI 48075, USA; John D. Dingle VA Medical Center, Detroit, MI 48202, USA. Electronic address:

The traditional electrospinning process produces dense two-dimensional (2D) nanofiber (NF) sheets that limit cell infiltration and proliferation. Our previous study demonstrated that 3D NF sheets could be formed on an NF collector surface mounted with multiple movable needles through the corona discharge. In this study, we developed a programmed electrospun 3D NF collector. It can precisely control the moving speed of NF collector during electrospinning; thereby fabricating 3D NFs with desired microstructures (pore size, pore volume, and interconnectivity). Four types of polycaprolactone (PCL) 3D NF matrices with different microstructures can be obtained concurrently on the NF collector surface, which are set by different forward moving speed of the NF collector device: NF-zero (no move, as control), NF-low (0.085 mm/min), NF-mid (0.158 mm/min) and NF-high (0.232 mm/min). A linear increase of the NF sheet thickness (from 0.21 mm to 0.91 mm) was recorded with accelerating collector movement. Quantitative analysis using scanning electron microscopy (SEM), micro-computed tomography (μ-CT), and confocal laser scanning microscopy (CLSM) showed a monotonic increase of pore size and porosity with the increase of collector moving speeds. The collector movement also impacted the crystallinity and mechanical properties of the NFs. When prepared at high collector speed, the NFs showed improved proliferation and differentiation (p < .05) of pre-osteoblastic MC3T3 cells compared to the NFs from the static collector. A programmed NF collector device allows for the reproducible, precise and continuous fabrication of 3D NFs with tailorable geometry and microstructures. This simple, controllable, one-step process could promote the clinical translation of electrospun NFs in tissue engineering and regenerative medicine.
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http://dx.doi.org/10.1016/j.msec.2019.110188DOI Listing
January 2020

Long-Term Sustainability of a Quality Initiative Program on Transfusion Rates in Total Joint Arthroplasty: A Follow-Up Study.

J Arthroplasty 2020 02 30;35(2):340-346. Epub 2019 Aug 30.

Section of Orthopaedic Surgery, Ascension Providence Hospital, Novi, MI; Detroit Medical Center/Wayne State University Orthopedic Residency Program, Detroit, MI; The Core Institute, Novi, MI.

Background: There are significant variations in transfusion rates among institutions performing total joint arthroplasty. We previously demonstrated that implementation of an educational program to increase awareness of the American Association of Blood Banks' transfusion guidelines led to an immediate decrease in transfusion rates at our facilities. It remained unclear how this initiative would endure over time. We report the long-term success and sustainability of this quality program.

Methods: We reviewed the Michigan Arthroplasty Collaborative Quality Initiative data from 2012 through 2017 of all patients undergoing primary hip and knee arthroplasty at our institutions for preoperative and postoperative hemoglobin level, transfusion status, and number of units transfused and transfusions outside of protocol to identify changes surrounding our blood transfusion educational initiative. We calculated the transfusions prevented and cost implications over the course of the study.

Results: We identified 6645 primary hip and knee arthroplasty patients. There was a significant decrease in transfusion rate and overall transfusions in each group when compared to pre-education values. Subgroup analysis of TKA and THA independently showed significant decreases in both transfusion rate and overall transfusions. Over the final 3 years of the study, only 2 patients were transfused outside of the American Association of Blood Banks protocol. We estimate prevention of 519 transfusions over the study period.

Conclusion: Application of this quality initiative was an effective means of identifying opportunities for quality improvement. The program was easily initiated, had significant early impact, and has been shown to be sustainable.
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http://dx.doi.org/10.1016/j.arth.2019.08.056DOI Listing
February 2020

Early Results of a Modern Uncemented Total Knee Arthroplasty System.

Orthopedics 2019 Nov 12;42(6):355-360. Epub 2019 Sep 12.

Historically, cementless total knees were associated with early failure, which made cemented total knee arthroplasty the gold standard. Manufacturers have introduced newer uncemented technologies that provide good initial stability and use highly porous substrates for bony in-growth. The authors hypothesized that the implants would have equivalent 90-day clinical and economic outcomes. Prospectively collected data on 252 uncemented knees in the Michigan Arthroplasty Registry Collaborative Quality Initiative database were reviewed. Ninety-day outcomes, demographics, length of stay, complications, emergency department visits, readmissions, and financial data were compared with those of an age-matched group of cemented knees. Uncemented knees had shorter length of stay (1.58 vs 1.87 days; P<.01), were more frequently discharged home (90.48% vs 68.75%; P<.0001), and used less home care (6.35% vs 19.14%; P<.0001) or extended care facilities (2.78% vs 11.72%; P=.0001). More uncemented knees had "no complications." Moreover, there were no re-operations in uncemented knees, compared with 19 reoperations in cemented knees. Uncemented knees were better than age-matched counterparts for Knee injury and Osteoarthritis Outcome Score (63.69 vs 47.10, n=85 and n=43, P<.0001) and Patient-Reported Outcomes Measurement Information System (PROMIS) T-Physical and T-Mental scores (44.12 vs 39.45, P<.0001; 51.84 vs 47.82, P=.0018). Cemented cases were more expensive overall, and surgical ($6806.43 vs $5710.78; P<.01) and total hospital ($8347.65 vs $7016.11; P<.01) costs were higher. The 90-day readmission and hospital outpatient costs were not significantly different between designs. Uncemented total knee arthroplasty, when using modern technologies, is successful and economically viable for an at-risk bundle. The results of this study should alleviate fears of increased cost, early failure, complications, or poor outcomes with the use of a modern uncemented total knee arthroplasty. [Orthopedics. 2019; 42(6):355-360.].
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http://dx.doi.org/10.3928/01477447-20190906-04DOI Listing
November 2019

Blood metal levels, leucocyte profiles, and cytokine profiles in patients with a modular dual-mobility hip prosthesis: early results from a prospective cohort study.

Bone Joint J 2019 09;101-B(9):1035-1041

Department of Biomedical Engineering, Wayne State University, Detroit, Michigan, USA.

Aims: The aim of this study was to evaluate blood metal ion levels, leucocyte profiles, and serum cytokines in patients with a total hip arthroplasty (THA) involving modular dual-mobility components.

Patients And Methods: A total of 39 patients were recruited, with clinical follow-up of up to two years. Outcome was assessed using the Harris Hip Score (HHS, the 12-Item Short-Form Health Survey (SF-12), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a visual analogue scale (VAS) for pain. Blood concentrations of cobalt (Co), chromium (Cr), and serum cytokines were measured. Subpopulations of leucocytes were analyzed by flow cytometry.

Results: The clinical performance was good. Blood Co levels (ref 1.0 µg/l) were mildly elevated in seven patients at three months, and two patients at two years' follow-up. The preoperative Cr levels were normal except for one patient with a detectable Cr (1.2 µg/l). Cr levels were detectable in three patients at three months, two patients at one year, and three patients at two years' follow-up. No patients had symptoms suggestive of failure. Although flow cytometry showed constant circulating leucocyte profiles, there was a significant reduction of serum interleukin (IL)-4, IL-5, and interferon gamma (IFNγ) postoperatively compared with the preoperative levels (p < 0.05).

Conclusion: These results suggest that THA using modular dual-mobility components is safe. This allows an opportunity to use a large femoral head and a thick polyethylene bearing surface, which is especially useful in revision procedures or high-risk situations when added stability is required. Cite this article: 2019;101-B:1035-1041.
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http://dx.doi.org/10.1302/0301-620X.101B9.BJJ-2019-0377.R2DOI Listing
September 2019

Characterization of Pulmonary Emboli in Total Joint Arthroplasty Patients Compared to General Medical Patients.

J Knee Surg 2020 Dec 9;33(12):1232-1237. Epub 2019 Jul 9.

Department of Orthopaedic Surgery, Detroit Medical Center/Providence Hospital Orthopaedic Surgery Residency Program, Detroit, Michigan.

Pulmonary emboli (PEs) occur in medical and postoperative total joint arthroplasty (TJA) patients. These are different patient populations, yet both undergo identical diagnosis and treatment regardless of PEs size and quantity. To date, there has been no analysis of the location, size, and quantity of emboli that occur postoperatively in TJA compared with general medical patients. We hypothesized TJA patients would have different size and distribution of PEs per event compared with medical patients. A retrospective chart review was conducted of patients who underwent total hip or knee arthroplasty in comparison to general medical patients at our institution from 2006 to 2011 with a PE diagnosis. Medical co-morbidities, sex, age, procedure, postoperative day, size, and location of PE using spiral computed tomography were recorded using a novel mapping scheme. Embolus size was defined based on blockage level in the pulmonary arterial tree. Of the 4,178 TJA patients reviewed, 51 were diagnosed with a PE. A total of 67% of TJA patients were women, yet women represented 90% ( = 46) of TJA PE patients ( < 0.0001). Medical patients had an equal distribution of men and women with PEs. Orthopaedic patients averaged more (4.0 vs. 2.2,  < 0.0001) and smaller PEs compared with medical patients ( < 0.0001). In conclusion, women undergoing TJA had significantly higher risk of developing PE compared with male arthroplasty or medical patients. Differences were observed in size and distribution of PEs between medical and TJA patients, which suggest a different nature of embolic phenomenon.
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http://dx.doi.org/10.1055/s-0039-1693417DOI Listing
December 2020

Comparing the release of erythromycin and vancomycin from calcium polyphosphate hydrogel using different drug loading methods.

J Biomed Mater Res B Appl Biomater 2020 02 9;108(2):475-483. Epub 2019 May 9.

Department of Biomedical Engineering, Wayne State University, Detroit, Michigan.

Calcium polyphosphate (CPP) hydrogel is used to load erythromycin (EM) and vancomycin (VCM) by means of two loading methods: they are either added directly to the formed CPP hydrogel (Gel Mixture method) or mixed with CPP powders, followed by the formation of CPP-antibiotic hydrogel (Powder Mixture method). The release of loaded antibiotics from CPP hydrogel is measured up to 48 hr. Compared to Powder Mixture method, Gel Mixture method significantly reduced the burst release of embedded antibiotics. A significant change in CPP hydrogel Raman characteristic peaks is observed only in Gel Mixture method, indicating a close interaction between embedded antibiotics with CPP hydrogel matrix. In contrast, a similarity between characteristic peaks of CPP hydrogel and Powder Mixture method shows that antibiotic incorporation does not interfere with CPP gel formation, resulting in no ionic interaction between antibiotic and polyphosphate chains. Rheometer analysis further confirms that the hydrophobic nature of EM impacts the viscoelastic properties of CPP hydrogel, whereas the hydrophilic VCM exhibits a higher loading efficiency. The potential application of CPP hydrogel as a ceramic matrix for sustained drug release warrants further investigation.
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http://dx.doi.org/10.1002/jbm.b.34404DOI Listing
February 2020

The Effect of Ambient Temperature and Implantation Time on the Material Properties of Two Viscosity-Differing Cements Using American Society of Testing and Materials Methodology.

J Knee Surg 2020 Jun 2;33(6):560-564. Epub 2019 May 2.

Department of Orthopaedic Surgery, Detroit Medical Center, Providence Hospital Orthopedic Surgery Residency Program, Detroit, Michigan.

Ambient temperature and time to implantation can affect the material properties of polymethylmethacrylate bone cement, and cement intrusion depth has been shown to affect implant fixation. The purpose of this study was to examine the effects of ambient temperature and time to implantation on depth of intrusion, and the effect of ambient temperature on setting time. Two types of cements were evaluated: cement A (Simplex P,medium Q7 viscosity) and cement B (Palacos R, high viscosity). Dough, working and setting times were determined, as well as intrusion depth, at different temperatures per American Society of Testing and Materials (ASTM) protocol F451. A vacuum mixer was used in a temperature- and humidity-controlled environment at 60, 65, and 70°F. At each temperature, the cement was placed into an intrusion mold at 0, 50, and 100% of working time. Increasing ambient temperature resulted in a significant decrease in dough and working and setting times for both cements ( = 0.038 - < 0.001). At each working time point and temperature, cement A showed significantly more intrusion than cement B ( = 0.044 - < 0.001). There was no effect of temperature on intrusion depth regardless of working time to implantation for either cement with the exception of cement B when comparing 60 versus 70°F at 0% working time ( = 0.004). Both cements showed a significant decrease in intrusion as time to implantation increased ( < 0.001). In conclusion, there are large inherent differences in properties of commercially available cements, and these properties are affected by such variables as time to implantation and ambient temperatures. An understanding of these properties may aid the surgeon in optimizing surgical outcomes.
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http://dx.doi.org/10.1055/s-0039-1681090DOI Listing
June 2020

Does Suture Type Influence Bacterial Retention and Biofilm Formation After Irrigation in a Mouse Model?

Clin Orthop Relat Res 2019 01;477(1):116-126

D. C. Markel, C. Bergum, B. Wu, T. Bou-Akl, Department of Orthopedics, Providence Park Hospital, Southfield, MI, USA W. Ren, Department of Biomedical Engineering, Wayne State University, Detroit, MI, USA.

Background: Irrigation and débridement are frequently utilized in the management of surgical infections, but even with aggressive débridement, it is difficult to remove all the suture material from the tissues and retained suture material may harbor bacteria and/or biofilm. The degree to which barbed or braided sutures may differentially influence the risk of infection has not been defined in a well-controlled animal model.

Questions/purposes: We compared braided and barbed monofilament sutures after irrigation of an infected mouse air pouch model to determine whether the suture type influenced the effectiveness of the irrigation. After irrigation of infected pouches, sutures were compared for (1) bacterial adherence and bacterial retention; (2) qualitative and quantitative pouch thickness and cellular density; and (3) quantitative biofilm formation.

Methods: Soft tissue air pouches were created on the backs of 60 female, mature 10-week-old BALB/cJ mice by sequentially introducing air into the subcutaneous tissue and allowing the pouch to mature. The pouches were inoculated with Staphylococcus aureus and braided or barbed monofilament sutures were implanted. Pouch irrigation was performed Day 7 after suture implantation. Suture segments were collected before and after irrigation. After euthanasia on Day 14, pouch tissues with residual suture segments were collected for analysis: microbiologic analysis done using optical density as a measure of the concentration of bacteria in the culture (the larger concentration indicates higher number of bacteria) and histologic evaluation of the pouch tissues were semiquantitative, whereas environmental scanning electron microscopy (ESEM) and confocal analyses of the biofilm and bacteria on the sutures were qualitative.

Results: Histologic evaluation of pouch tissue showed all groups had inflammatory responses. Quantitatively microbiology showed no difference in bacterial number calculated from the optical density (OD) values between the two suture materials at any time point in the irrigation group. In the no-irrigation group, for the Day 7 time point, mean (± SD) OD was greater in the barbed than the OD in the braided sutures (0.52 ± 0.12 versus 0.37 ± 0.16, mean difference 0.43 [95% confidence interval, 0.08-0.13]; p = 0.007). Qualitatively, ESEM showed more bacterial retention by braided sutures before and after irrigation. Confocal imaging of the sutures demonstrated penetration of biofilm into the interstices of braided sutures and less adhesion in barbed monofilament sutures. The quantification of the biomass showed no differences between groups at all time points (before-irrigation biomass was 11.2 ± 9.3 for braided versus 5.2 ± 4.7 for barbed sutures, p = 0.196; and after-irrigation biomass was 7.2 ± 7.5 for braided versus 3.3 ± 4.3 for barbed suture, p = 0.259).

Conclusions: All sutures can retain bacteria and biofilm, but it is rarely possible to remove all suture material at the time of irrigation to treat infection. After an irrigation procedure, qualitatively braided sutures appeared to harbor more bacteria and to retain more biofilm than barbed monofilaments.

Clinical Relevance: When saline irrigation was used to simulate infection treatment in an infected mouse air pouch model, bacteria/biofilm was not completely eliminated from either braided or barbed monofilament sutures. The irrigation appeared to clear more bacteria and biofilm from the monofilament despite having barbs. Unfortunately, current technologies do not allow direct quantitative comparisons of biofilm retention. Clinicians should be aware that in the face of infection, any retained sutures may harbor bacteria despite irrigation.
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http://dx.doi.org/10.1097/CORR.0000000000000391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6345317PMC
January 2019

The Michigan Arthroplasty Registry Collaborative Quality Initiative Experience: Improving the Quality of Care in Michigan.

J Bone Joint Surg Am 2018 Nov;100(22):e143

Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan.

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a regional quality improvement effort that is focused on hip and knee arthroplasty. From its inception in 2012, MARCQI has grown to include data from 66 hospitals and surgery centers, and contains over 209,000 fully abstracted cases in its database. Using high-quality risk-standardized outcomes data, MARCQI drives quality improvement through a collaborative and nonpunitive structure. Quality improvement initiatives have included transfusion reduction, infection prevention, venous thromboembolism reduction, and reduction of discharge to nursing homes. In addition, MARCQI focuses on postmarket surveillance of implants by computing revision-risk estimates based on the cases that were registered prior to the end of 2016. This paper describes the impact of MARCQI on the quality of hip and knee arthroplasty care in the state of Michigan since its inception in 2012, and it briefly summarizes the recently released 5-year report.
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http://dx.doi.org/10.2106/JBJS.18.00239DOI Listing
November 2018

Isolated Tibial Component Failure in Total Knee Arthroplasty: A Case Series Evaluating Inflammatory Response versus Mechanical Failure.

J Knee Surg 2019 Jul 10;32(7):659-666. Epub 2018 Jul 10.

Department of Orthopaedic Surgery, St. John-Providence Hospital, Southfield, Michigan.

Total knee prostheses are routinely redesigned to improve performance, longevity, and to closer mimic the native kinematics of the knee. Despite continued improvements, all knee implants, even those with proven design features, have failures. We identified a cohort of patients with isolated tibial component failures that occurred in a popular and successful knee system. Our purpose was to (1) characterize the observed radiographic failure pattern; (2) investigate the biologic response that may have contributed to the failure; and (3) to determine if the failure mechanism was of a biological or a mechanical nature. Twenty-one knees from 19 patients met the inclusion criteria of isolated tibial component failure in a single knee implant system. Radiographs from the primary and revision knee surgery were analyzed for implant positioning and the failure pattern. Inflammatory biomarkers interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α were available in 16/21 knees and peripheral CD14/16 monocytes were measured in 14 of the aforementioned 16 knee revisions. Serum CD3, CD4, and CD19 were measured in 10 of the aforementioned 14 knees. Additionally, white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were measured to rule out infection as a cause of the cytokine upregulation. Radiographic findings demonstrated that all of the 21 tibial components were implanted in either neutral or 2 to 3 degrees varus in the coronal plane, and none of the revisions was implanted in valgus. All tibias showed obvious radiographic loosening and the implant failed into varus. The inflammatory biomarkers IL-1β, IL-6, and TNF-α were negative. WBC, ESR, and CRP were normal. Serum CD3, CD4, and CD19 flow cytometry analyses were found to be in the normal range. Peripheral CD14/16 and total CD16 monocytes measurements were consistent with previous findings of patients with osteoarthritis, rather than particulate-induced inflammatory loosening. The findings support the implant failure observed in our study occurred by a different mechanism than the wear debris-induced aseptic loosening. We believe that a mechanical failure can occur based on our findings. The loosening, collapse, and debonding from the cement may have been related to the implantation technique, stresses due to favorable rotational freedoms of the implant, or patient characteristics/behavior. Continued exploration into implant failure mechanisms and particularly into the biologic response associated with failure is ongoing.
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http://dx.doi.org/10.1055/s-0038-1666831DOI Listing
July 2019

Relationship of Blood Metal Ion Levels and Leukocyte Profiles in Patients With Articular Surface Replacement Metal-on-Metal Hip Replacement.

Orthopedics 2018 May 30;41(3):e424-e431. Epub 2018 Apr 30.

The purpose of this study was to compare blood leukocyte profiles and metal ion concentrations between hip resurfacing arthroplasty (articular surface replacement) patients with and without revision. A total of 25 articular surface replacement patients were recruited (10 with stable implants and 15 undergoing revision). Blood concentrations of chromium (Cr) and cobalt (Co) were measured. Flow cytometry was used to quantify the subpopulations of leukocytes, including CD14 monocytes, CD16 monocytes, CD3 T-lymphocytes, CD19 B-lymphocytes, CD4 helper T-cells, and CD45RA memory vs naïve T-cells. Patients undergoing revision had higher blood Co (mean, 10.85 µg/L) and Cr (mean, 3.19 µg/L) levels than patients with stable implants (mean Co, 3.06 µg/L; mean Cr, 1.07 µg/L) (P<.05). The number of CD4 helper T-cells was higher in patients with stable implants (mean, 842±311 cells/µL) than in patients undergoing revision (mean, 591±208 cells/µL) (P<.05). There was a significant association between total metal ion levels (Co+Cr) and the number of CD14 monocytes (P=.045) and inflammatory CD16 monocytes (P=.046). The authors observed that the increase in blood metal ions was associated with an increase in CD16 monocytes. They believe that continued analysis of blood leukocyte profiles may be helpful in defining differences among failed articular surface replacement, stable articular surface replacement, and failed metal-on-polyethylene implants. [Orthopedics. 2018; 41(3):e424-e431.].
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http://dx.doi.org/10.3928/01477447-20180409-02DOI Listing
May 2018

Comparison of in vitro biocompatibility of silicone and polymethyl methacrylate during the curing phase of polymerization.

J Biomed Mater Res B Appl Biomater 2018 10 26;106(7):2693-2699. Epub 2018 Feb 26.

Department of Biomedical Engineering, Wayne State University, Detroit, Michigan.

Adverse events have been reported with acrylic bone cements. However, current test standards for acrylic materials fail to characterize the potentially harmful monomers released during the curing stage. In clinical applications, materials are implanted into the human body during this phase. Silicone may be a safer alternative to acrylic cements. Silicone is used in medical applications for its biocompatibility and stability characteristics. Previously, no study has been completed which compares silicone to acrylic cements. In this study, both materials were injected into the cell medium during the curing process which more accurately reflects clinical use of material. Initially, cell cultures followed ASTM standard F813-07 which fails to capture the effects of monomer released during curing. Subsequently, a modified cell culture method was employed which evaluated cytotoxicity while the materials cured. The objective of this study was to capture toxicity data during curing phase. Thus, the test method employed measured and excluded the impact of the exothermic reaction temperature of polymethyl methacrylate (PMMA) on cell growth. The concentration of PMMA monomer was measured at 1 and 24 h after injecting PMMA into culture plates in a manner consistent with established cell growth methodologies. Our results indicate current in vitro cytotoxicity assays recommended by ASTM standards are unable to reveal the real cytotoxic effect caused by methyl methacrylate monomers during polymerization. Our modified experiment can more accurately illustrate the true nature of the toxicity of materials and improve assay results. In these tests, silicone based elastomeric polymers showed excellent cytocompatibility. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2693-2699, 2018.
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http://dx.doi.org/10.1002/jbm.b.34086DOI Listing
October 2018

Setting mechanism of a new injectable Dicalcium Phosphate Dihydrate (DCPD) forming cement.

J Mech Behav Biomed Mater 2018 03 4;79:226-234. Epub 2018 Jan 4.

Department of Orthopedics, Providence Hospital, 16001W Nine Mile Rd, Southfield, MI 48075, USA.

We previously described the gelation mechanism of calcium polyphosphate (CPP) in the presence of water. In this study, we developed novel and injectable poly-dicalcium phosphate dihydrate (P-DCPD) forming cement by the reaction of acidic CPP gel with alkali tetracalcium phosphate (TTCP). The setting reaction mechanism of P-DCPD is due to the intermolecular interaction between CPP gel and TTCP that was supported by XRD, AFM, Raman spectra analysis and SEM. The setting mechanism of P-DCPD is completely different from the classical calcium phosphate cement (CPC) that achieves crystallization by monophosphates reaction. P-DCPD represents a new type of poly-CPCs with significant advantages, including strong mechanical strength, excellent cohesion and easy of handling. More extensive experiments are currently underway to further evaluate the performance of P-DCPD cements, including biocompatibility, degradation behavior and bone defect hearing efficacy, among others.
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http://dx.doi.org/10.1016/j.jmbbm.2017.12.032DOI Listing
March 2018

Release of vancomycin and tobramycin from polymethylmethacrylate cements impregnated with calcium polyphosphate hydrogel.

J Biomed Mater Res B Appl Biomater 2018 11 28;106(8):2827-2840. Epub 2017 Dec 28.

Department of Orthopaedics, Shanghai 6th Peoples Hospital, Shanghai, China.

The influence of calcium polyphosphate (CPP) gel incorporation on the release of vancomycin and tobramycin from polymethyl methacrylate (PMMA) cement (Simplex P, SP) has been studied. Adding 10% CPP gel to SP led to a much lower burst release of vancomycin and considerably extended release of both vancomycin and tobramycin up to 24 weeks. Antibiotics released from this new material retain their bactericidal activity for up to 15 weeks. The improvement in the antibiotic release is mainly due to the molecular interactions of antibiotics with embedded CPP polyphosphate chains as confirmed by Raman spectroscopy analysis. The inclusion of CPP hydrogel also increased the SP surface roughness and pore sizes, leading to a higher release rate of antibiotics. The new material is biocompatible and has similar handling properties and mechanical strength as compared to SP cements. We believe that incorporating CPP gel provides a better and usable drug carrier for PMMA cement. © 2017 The Authors Journal of Biomedical Materials Research Part B: Applied Biomaterials Published by Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2827-2840, 2018.
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http://dx.doi.org/10.1002/jbm.b.34063DOI Listing
November 2018

Quality Initiative Programs Can Decrease Total Joint Arthroplasty Transfusion Rates-A Multicenter Study Using the MARCQI Total Joint Registry Database.

J Arthroplasty 2017 11 13;32(11):3292-3297. Epub 2017 Jun 13.

Department of Orthopaedic Surgery, University of Michigan Health System, A. Alfred Taubman Health Care Center, Ann Arbor, Michigan.

Background: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) noted wide variability between member hospitals in blood transfusion rates after primary total hip and knee arthroplasty (THA and TKA). Blood transfusion has substantial risks and accepted recommendations exist to guide transfusion practices. MARCQI began an initiative to decrease unnecessary transfusions by identifying/reporting outliers, discussing conservative transfusion practices, and recommending transfusion guidelines. There was a later recommendation to consider intraoperative use of tranexamic acid.

Methods: All MARCQI-registered unilateral TKA and THA cases from the 28 member hospitals (pre-November 2013) were included. For 3 time periods (before November 13, 2013; November 13, 2013, to November 12, 2014; and after November 12, 2014), we calculated average risk and range of transfusion, transfusion with nadir hemoglobin >8 g/dL, mean length of stay, and 90-day risk of discharge to nursing home, readmission, deep infection, and emergency department visits.

Results: For THA, risk and range of transfusion decreased over the 3 time periods: 12.6% (2.5%-36.2%), 7.6% (2.2%-23.8%), and 4.5% (0.7%-14.4%); for TKA, 6.3% (1.3%-15.6%), 3.1% (0%-12.5%), and 1.3% (0%-7.4%). Decreases were also noted for transfusion with a nadir hemoglobin >8 g/dL with a near elimination of "unnecessary" transfusions. There was no evidence of increase in length of stay, discharge to nursing home, readmission, deep infection, or emergency department visits.

Conclusion: A simple intervention can decrease unnecessary blood transfusions during and after elective primary unilateral THA or TKA. A collaborative registry can be used effectively to improve the quality of patient care and set a new benchmark for transfusion.
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http://dx.doi.org/10.1016/j.arth.2017.06.009DOI Listing
November 2017

Corona Discharge: A Novel Approach To Fabricate Three-Dimensional Electrospun Nanofibers for Bone Tissue Engineering.

ACS Biomater Sci Eng 2017 Jun 1;3(6):1146-1153. Epub 2017 May 1.

Department of Biomedical Engineering, Wayne State University, Detroit, Michigan 48201, United States.

The electrospinning process produces dense two-dimensional (2D) nanofiber (NF) sheets with small pore size that limits cell infiltration and proliferation. This study aims to fabricate three-dimensional (3D) NF sheets by designing a NF collector mounted with multiple movable needles. The corona discharge effect leads to continuous deposition of 3D polycaprolactone (PCL) NF matrices on the surface of the NF collector. The increase of the pore size, pore volume, and pore interconnectivity of the formed 3D NF sheet was confirmed by scanning electron microscopy, 3D confocal laser scanning microscopy, and micro-computerized tomography, respectively. An increased crystallinity of 3D NFs was observed by thermal and rheological analysis. Furthermore, cell growth on the 3D NF matrices was evaluated using murine pre-osteoblastic MC3T3 cells. When compared with 2D NF matrices, 3D NF matrices demonstrated enhanced cell infiltration, proliferation, and differentiation. We believe that a corona discharge-based NF collector design represents a promising approach to fabricate 3D NF matrices with desirable geometry, and microstructure. This simple, controllable, one-step process may help move forward the clinical translation of electrospun NFs in regenerative medicine.
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http://dx.doi.org/10.1021/acsbiomaterials.7b00061DOI Listing
June 2017

How Do Preoperative Medications Influence Outcomes After Total Joint Arthroplasty?

J Arthroplasty 2017 09 27;32(9S):S259-S262. Epub 2017 Apr 27.

Wayne State University-Detroit Medical Center Orthopaedic Surgery Residency Program, Detroit, Michigan; Department of Orthopaedic Research, Providence-Providence Park Hospital, Southfield, Michigan; The CORE Institute, Southfield, Michigan.

Background: Recent health care policy changes require hospitals and physicians to demonstrate improved quality. In 2012, a prospective database was formed with the Blue Cross and Blue Shield of Michigan to improve quality of care. The purpose of this study was to analyze patient preoperative medication as predictors of outcomes after total joint arthroplasty.

Methods: Data were collected on patient's preoperative medications from 2012 to 2015 using a total joint arthroplasty database. Medications were categorized as antiplatelet, antimicrobial, anticoagulant, narcotic, steroid, insulin, or oral diabetes medication. Outcomes included hospital length of stay (LOS), discharge disposition/destination, and 90-day readmission. Univariate and multivariate regression analyses were performed.

Results: A total of 3959 patients were studied. Eighty percent (3163 patients) were discharged home. The remainder (795) went to an extended-care facility (ECF). Patients discharged to an ECF were taking more medications (1.13 vs 0.80 in total knee arthroplasty; 1.18 vs 0.83 in total hip arthroplasty; P <.001). Patients who were readmitted took more medications (1.0 vs 0.85; P <.01). There were more discharges to an ECF in narcotic, steroid, and diabetes medication users. Patients taking anticoagulants, narcotics, insulin, and antiplatelets had greater readmission rates. There was a significant correlation between the number of medications and an increased LOS.

Conclusion: Patients taking more medications were more frequently discharged to an ECF and had increased LOS and readmission rates. Narcotics and diabetic medications had the greatest influence. Category and quantity of preoperative medications can be used as predictors of outcomes after arthroplasty surgery.
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http://dx.doi.org/10.1016/j.arth.2017.04.031DOI Listing
September 2017
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