David S. Casper

Periprosthetic Joint Infection Increases the Risk of One-Year Mortality

BACKGROUND Periprosthetic joint infection continues to potentially complicate an otherwise successful joint replacement. The treatment of this infection often requires multiple surgical procedures associated with increased complications and morbidity. This study examined the relationship between periprosthetic joint infection and mortality and aimed to determine the effect of periprosthetic joint infection on mortality and any predictors of mortality in patients with periprosthetic joint infection. METHODS Four hundred and thirty-six patients with at least one surgical intervention secondary to confirmed periprosthetic joint infection were compared with 2342 patients undergoing revision arthroplasty for aseptic failure. The incidence of mortality at thirty days, ninety days, one year, two years, and five years after surgery was assessed. Multivariate analysis was used to assess periprosthetic joint infection as an independent predictor of mortality. In the periprosthetic joint infection population, variables investigated as potential risk factors for mortality were evaluated. RESULTS Mortality was significantly greater (p < 0.001) in patients with periprosthetic joint infection compared with those undergoing aseptic revision arthroplasty at ninety days (3.7% versus 0.8%), one year (10.6% versus 2.0%), two years (13.6% versus 3.9%), and five years (25.9% versus 12.9%). After controlling for age, sex, ethnicity, number of procedures, involved joint, body mass index, and Charlson Comorbidity Index, revision arthroplasty for periprosthetic joint infection was associated with a fivefold increase in mortality compared with revision arthroplasty for aseptic failures. In the periprosthetic joint infection population, independent predictors of mortality included increasing age, higher Charlson Comorbidity Index, history of stroke, polymicrobial infections, and cardiac disease. CONCLUSIONS Although it is well known that periprosthetic joint infection is a devastating complication that severely limits joint function and is consistently difficult to eradicate, surgeons must also be cognizant of the systemic impact of periprosthetic joint infection and its major influence on fatal outcome in patients.

Operating room traffic is a major concern during total joint arthroplasty.

BackgroundPeriprosthetic joint infection (PJI) is a challenging complication associated with total joint arthroplasty (TJA). Traffic in the operating room (OR) increases bacterial counts in the OR, and may lead to increased rates of infection.Question/purposesOur purposes were to (1) define the incidence of door opening during primary and revision TJA, providing a comparison between the two types of procedures, and (2) identify the causes of door opening in order to develop a strategy to reduce traffic in the operating room.MethodsAn observer collected data during 80 primary and 36 revision TJAs. Surgeries were performed under vertical, laminar flow. Operating room personnel were unaware of the observer, thus removing bias from traffic. The observer documented the number, reason, and personnel involved in the event of a door opening from time of tray opening to closure of the surgical site.ResultsThe average operating time for primary and revision procedures was 92 and 161 minutes, respectively. Average door openings were 60 in primary cases and 135 in revisions, yielding per minute rates of 0.65 and 0.84, respectively. The circulating nurse and surgical implant representatives constituted the majority of OR traffic.ConclusionsTraffic in the OR is a major concern during TJA. Revision cases demonstrated a particularly high rate of traffic. Implementation of strategies, such as storage of instruments and components in the operating room and education of OR personnel, is required to reduce door openings in the OR.

Morphology of the proximal femur differs widely with age and sex: Relevance to design and selection of femoral prostheses

The ability of uncemented femoral stems to osseointegrate properly depends largely on their fit in the proximal femur. We evaluated the topography of the proximal femur and determined differences based on age and sex. Retrospectively, anteroposterior radiographs from 312 (168 male, 144 female) pre‐operative total hip arthroplasty (THA) patients (age of 21–85 years) were collected. Radiographic measurements were taken at 10 mm intervals along the length of the femur. Variables including canal flare index (CFI) and cortical index (CI) were calculated. Data were binned into three age groups and separated by sex for comparison. Measurements showed that CFI decreased with age for both sexes; however, females demonstrated a greater decrease. Decrease in flare occurred primarily on the lateral side. CI also decreased with age, the most pronounced drop occurring in older females. A clear difference exists between male and female proximal femoral geometry. This decrease is most likely attributed to the loss of cortical bone. The medial component likely demonstrates less loss of flare due to strong compressive forces that are transmitted through this portion of the femur. These results demonstrate the necessity of considering age and sex when selecting a proper prosthesis.

Periprosthetic joint infection: are patients with multiple prosthetic joints at risk?

Patients who present with a periprosthetic joint infection in a single joint may have multiple prosthetic joints. The risk of these patients developing a subsequent infection in another prosthetic joint is unknown. Our purposes were (1) to identify the risk of developing a subsequent infection in another prosthetic joint and (2) to describe the time span and organism profile to the second prosthetic infection. We retrospectively identified 55 patients with periprosthetic joint infection who had another prosthetic joint in place at the time of presentation. Of the 55 patients, 11 (20%) developed a periprosthetic joint infection in a second joint. The type of organism was the same as the first infection in 4 (36%) of 11 patients. The time to developing a second infection averaged 2.0 years (range, 0-6.9 years).

A prospective analysis of glove perforation in primary and revision total hip and total knee arthroplasty.

Literature in regard to glove perforation rates in revision total joint arthroplasty (TJA) is scarce. Our purpose was to determine the incidence of perforation in revision TJA. Gloves from all scrubbed personnel were tested based on the American Society for Testing and Materials. A total of 3863 gloves were collected from 58 primary and 36 revision arthroplasty cases. Surgeons had a 3.7% outer-glove perforation rate in primary TJA compared with 8.9% in revision TJA. When both gloves were perforated, the outer-glove perforation was recognized intraoperatively 100% of the time, and the inner-glove perforation was noted only 19% of the time. The surgeon has the highest rate of glove perforation. Outer-glove perforations should prompt careful inspection of the inner glove.

Descriptive Analysis of Associated Factors for Urgent Versus Nonurgent Inpatient Spine Transfers to a Tertiary Care Hospital.

Patients with spine-associated symptoms are transferred regularly to higher levels of care for operative intervention. It is unclear what factors lead to the transfer of patients with spine pathology to level I care facilities, and which transfers are indicated. All patients with isolated spinal pathology who were transferred from 2011 to 2015 were reviewed. Patients were divided into urgent transfers, defined as anyone who required operative intervention, and nonurgent transfers. Two hundred twenty-seven patients were transferred for isolated spinal pathology over 51 months; 109 (48.0%) patients required urgent intervention and 118 (52.0%) patients required nonurgent care. No significant differences were found between groups in terms of private insurance, age, sex, race, or Charlson comorbidity index. The urgent group was less likely to have a traumatic chief complaint (57.8% vs 78.0%, P = .001). More than half of all spine patients who were transferred to a tertiary care center required minimal intervention.

Reply to Letter to the Editor: Operating Room Traffic is a Major Concern During Total Joint Arthroplasty

We are grateful to Drs. Banerjee and Kheiran for carefully reading our article [1]. They made excellent points that deserve clarification. Regarding a breakdown of the openings for each TKA and THA for primary and revision procedures, the data are as follows: the average operating room times for primary TKA and THA were 109 and 93 minutes, respectively. Average door openings were 58 in primary TKA cases and 62 in primary THA cases, yielding per minute rates of 0.53 and 0.67, respectively. The average operating room times for revision TKA and revision THA were 160 minutes and 161 minutes respectively. Door openings averaged 132 in revision TKA cases and 138 in revision THA cases, yielding per minute rates of 0.83 and 0.86, respectively.