Jourdan M. Cancienne

Does Timing of Previous Intra-Articular Steroid Injection Affect the Post-Operative Rate of Infection in Total Knee Arthroplasty?

Intra-articular steroid injections are widely used for symptomatic relief of knee osteoarthritis. This study used a national database to determine if there is an association between preoperative intra-articular knee injection at various time intervals prior to ipsilateral TKA and infection. The incidence of infection within 3 months (2.6%, OR 2.0 [1.6-2.5], P < 0.0001) and 6 months (3.41%, OR 1.5 [1.2-1.8], P < 0.0001) after TKA within 3 months of knee injection was significantly higher than our control cohort. There was no significant difference in patients who underwent TKA more than 3 months after injection. Ipsilateral knee injection within three months prior to TKA is associated with a significant increase in infection.

The Timing of Total Hip Arthroplasty After Intraarticular Hip Injection Affects Postoperative Infection Risk

BACKGROUND The data regarding any association between preoperative intraarticular steroid injection and risk ofperiprosthetic joint infection (PJI) after total hip arthroplasty (THA) are conflicting. The goal of the present study is to evaluate the association of preoperative intraarticular hip injection before THA on the incidence of postoperative PJI. METHODS A national database was queried for patients who underwent THA and those patients who underwent prior ipsilateral hip injection. Three cohorts were created: THA within 3 months of ipsilateral hip injection (n = 829), THA between 3 and 6 months after ipsilateral hip injection (n= 1379), and THA between 6 and 12months after ipsilateral hip injection (n=1160). A control group of THAwithout prior injectionwas created for comparison purposes (n=31,229). The rate of postoperative infectionwas compared between injection cohorts and controls. RESULTS The incidence of infection after THA at 3 months (2.41%; odds ratio, 1.9; P = .004) and 6 months (3.74%; odds ratio, 1.5; P < .019) was significantly higher in the patients who underwent hip injection within 3months before THA comparedwith controls. Therewas no significant difference in infection rates in patients who underwent THA between 3 and 6months or 6 and 12months after ipsilateral hip injection compared with controls. CONCLUSIONS The present study demonstrates a significant increase in PJI in patients who underwent intraarticular hip injection within 3 months before THA. This association was not noted when THA was more than 3 months after injection.

Tobacco Use Is Associated With Increased Complications After Anterior Cruciate Ligament Reconstruction

Background: The use of tobacco is a well-established cause of preventable morbidity and mortality. There have been few studies examining the effect of tobacco use on outcomes and complications after arthroscopic knee procedures such as anterior cruciate ligament (ACL) reconstruction. Purpose: To investigate the relationship between tobacco use and rates of postoperative infection, venous thromboembolism (VTE), arthrofibrosis, and subsequent ACL reconstruction after primary ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A national insurance database was queried for patients who underwent arthroscopic-assisted ACL reconstruction using Current Procedural Terminology code 29888. Patients underage for tobacco use in all regions of the United States (age <20 years), those with prior ACL reconstruction, and those with the following concomitant procedures were excluded: open cruciate or collateral ligament reconstruction, open or arthroscopic cartilage procedures, patellar stabilization, extra-articular ligamentous reconstruction, and posterior cruciate ligament reconstruction. Tobacco use and non–tobacco use cohorts were queried using International Classification of Diseases–9th Revision coding. The non–tobacco use patients were then matched to the patients with coded tobacco use by age, sex, obesity, diabetes, meniscal repair, and meniscectomy. Complications within 90 days postoperatively were assessed for both cohorts, including infection, VTE, arthrofibrosis, and subsequent ipsilateral or contralateral ACL reconstruction after the index procedure. Results: A total of 13,358 patients who underwent ACL reconstruction met inclusion and exclusion criteria, including 1659 patients with documented tobacco use and 11,699 matched controls. The incidence of infection was significantly higher in patients who use tobacco (2.0%) versus matched controls (0.9%; odds ratio [OR], 2.3; P < .0001). The rate of VTE was also significantly higher in patients who use tobacco (1.0%) compared with matched controls (0.5%; OR, 1.9; P = .035). The rate of subsequent ACL reconstruction was significantly higher in the tobacco use cohort (12.6%) compared with matched controls (7.8%; OR, 1.7; P < .0001). There was no significant difference in the rate of postoperative stiffness after ACL reconstruction between patients who use tobacco (2.0%) and matched controls (2.3%; OR, 0.9; P = .656). Conclusion: ACL reconstruction in patients who use tobacco is associated with significantly increased rates of infection, VTE, and subsequent ACL reconstruction compared with controls. There was no association between tobacco use and postoperative arthrofibrosis after primary ACL reconstruction.

Complications of Primary Total Knee Arthroplasty Among Patients With Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, and Osteoarthritis.

Background:Although several studies have reported outcomes of primary total knee arthroplasty (TKA) in patients with rheumatoid arthritis, very little has been reported on the outcomes of this procedure in patients with other inflammatory arthritides. Methods:This study used a national database to evaluate 90-day postoperative complication rates, readmission rates, and revision rates after TKA in patients with inflammatory arthritis. Patients with rheumatoid arthritis (n = 153,531), psoriatic arthritis (n = 7,918), and ankylosing spondylitis (n = 4,575) were compared with patients with osteoarthritis (n = 1,751,938) who underwent TKA from 2005 to 2012. Results:The rates of systemic complications, infection, revision, and 90-day readmission after TKA in patients with different types of inflammatory arthritis were significantly higher than those in control patients with osteoarthritis (P < 0.0001). No differences were found in the rates of systemic or local complications, revision, or readmission among the types of inflammatory arthritis. Conclusion:Inflammatory arthritis is associated with increased rates of perioperative complications, revision, and 90-day readmission after primary TKA. Level of Evidence:Level III.

Applications of Local Antibiotics in Orthopedic Trauma

Local antibiotics have a role in orthopedic trauma for both infection prophylaxis and treatment. They provide the advantage of high local antibiotic concentration without excessive systemic levels. Nonabsorbable polymethylmethacrylate (PMMA) is a popular antibiotic carrier, but absorbable options including bone graft, bone graft substitutes, and polymers have gained acceptance. Simple aqueous antibiotic solutions continue to be investigated and appear to be clinically effective. For established infections, such as osteomyelitis, a combination of surgical debridement with local and systemic antibiotics seems to represent the most effective treatment at this time. Further investigation of more effective local antibiotic utilization is ongoing.

Incidence of Manipulation Under Anesthesia or Lysis of Adhesions After Arthroscopic Knee Surgery

Background: Arthrofibrosis after knee arthroscopy is a challenging complication. Previous studies reporting incidences of manipulation under anesthesia (MUA) or lysis of adhesions (LOA) after knee arthroscopy are limited by confounders such as small sample size and regional sampling bias. Purpose: To investigate the incidence of MUA or LOA after common arthroscopic knee procedures. Study Design: Descriptive epidemiology study. Methods: A national insurance database was retrospectively queried for arthroscopic knee procedures from 2007 to 2011. The incidence of postoperative MUA and LOA within 3 and 6 months postoperatively was determined for each of 13 common arthroscopic knee surgeries, including ligamentous reconstructive procedures, cartilage restoration procedures, and meniscal procedures. Results: A total of 330,714 unique patients who underwent knee arthroscopy were included in the study. The overall incidence of MUA was 0.06% to 6.00% by 3 months and 0.11% to 8.00% by 6 months postoperatively. The incidence of LOA was somewhat less, ranging from 0.04% to 4.00% by 3 months and 0.06% to 6.00% by 6 months postoperatively. Isolated arthroscopic partial meniscectomy had the lowest incidence of postoperative MUA and LOA, while multiligament reconstructions and meniscal transplants had the highest incidences. Conclusion: The overall incidence of MUA and LOA after arthroscopic knee procedures is low but rises significantly as the number of concomitant procedures or complexity of the procedures increases. This information may be useful in counseling patients on the likelihood of MUA or LOA based on the type of arthroscopic knee procedure that is planned.

Morbid Obesity and Lumbar Fusion in Patients Older Than 65 Years: Complications, Readmissions, Costs, and Length of Stay

Study Design. Retrospective database review. Objective. The aim of this study was to determine how both morbid obesity (body mass index [BMI] ≥40) and obesity (BMI 30–39.9) modify 90-day complication rates and 30-day readmission rates following 1- to 2-level, primary, lumbar spinal fusion surgery for degenerative pathology in an elderly population. Summary of Background Data. In the United States, both obese and elderly patients are known to have increased risk of complication, yet both demographics are increasingly undergoing elective lumbar spine surgery. Methods. Medicare data from 2005 to 2012 were queried for patients who underwent primary 1- to 2-level posterolateral lumbar fusion for degenerative pathology. Elderly patients undergoing elective surgery were selected and separated into three cohorts: morbidly obese (BMI ≥40; n = 2594), obese (BMI ≥30, < 40] (n = 5534), and nonobese controls (n = 48,210). Each pathologic cohort was matched to a unique subcohort from the control population. Ninety-day medical and surgical complication rates, 30-day readmission rates, length of stay (LOS), and hospital costs were then compared. Results. Both morbidly obese and obese patients had significantly higher odds of experiencing any one major medical complication (odds ratio [OR] 1.79; P < 0.0001 and OR 1.32; P < 0.0001, respectively). Wound infection (OR 3.71; P < 0.0001 and OR 2.22; P < 0.0001) and dehiscence (OR 3.80; P < 0.0001 and OR 2.59; P < 0.0001) rates were increased in morbidly obese and obese patients, respectively. Thirty-day readmissions, length of stay, and in-hospital costs were increased, with patients with morbid obesity incurring charges almost

The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients.

8000 greater than controls. Conclusion. Patients with both obesity and morbid obesity are at significantly increased risk of major medical complications, wound complications, and 30-day readmissions. Additionally, both groups of patients have significantly increased LOS and hospital costs. Both obese and morbidly obese patients should be appropriately counseled of these risks and must be carefully selected to reduce postoperative morbidity. Level of Evidence: 3

Is Hepatitis C Infection Associated With a Higher Risk of Complications After Total Shoulder Arthroplasty

BACKGROUND The goal of this study was to employ a national database to evaluate the association of preoperative injection before shoulder arthroscopy and arthroplasty with the incidence of postoperative infection. METHODS A national database of Medicare patients was queried for patients who underwent shoulder arthroscopy or arthroplasty after ipsilateral shoulder injection. Three arthroscopy cohorts were created: arthroscopy within 3 months of injection (n = 3625), arthroscopy between 3 and 12 months after injection (n = 7069), and matched control arthroscopy without prior injection (n = 186,678). Three arthroplasty cohorts were created: arthroplasty within 3 months of injection (n = 636), arthroplasty between 3 and 12 months after injection (n = 1573), and matched control arthroplasty (n = 6211). Infection rates within 3 and 6 months postoperatively were assessed. RESULTS The incidence of infection after arthroscopy at 3 months (0.7%; odds ratio [OR], 2.2; P < .0001) and 6 months (1.1%; OR, 1.6; P = .003) was significantly higher in patients who underwent injection within 3 months before arthroscopy compared with controls. The incidence of infection after arthroplasty at 3 months (3.0%; OR, 2.0; P = .007) and 6 months (4.6%; OR, 2.0; P = .001) was significantly higher in patients who underwent injection within 3 months before arthroplasty compared with controls. CONCLUSIONS There was a significant increase in postoperative infection in Medicare patients who underwent injection within 3 months before shoulder arthroscopy and arthroplasty. This association was not noted when shoulder arthroscopy or arthroplasty occurred >3 months after injection.

Preoperative epidural injections are associated with increased risk of infection after single-level lumbar decompression.

BackgroundDespite recent advances in the treatment of hepatitis C, it is estimated that nearly 4 million Americans have a chronic form of the disease. Although research in lower-extremity arthroplasty suggests patients with hepatitis C are at risk for increased complications, including postoperative bleeding, acute postoperative infection, and general medical complications, no similar studies have investigated this question in patients undergoing total shoulder arthroplasty (TSA).Questions/purposesWe asked whether there is an increased risk of postoperative complications after TSA among patients who have hepatitis C, and if so, what complications in particular seem more likely to occur in this population?MethodsPatients who underwent TSA, including anatomic or reverse TSA, were identified in the PearlDiver database using ICD-9 procedure codes. This is a for-fee insurance patient-records database that contains more than 100 million individual patient records from 2005 to 2012. The Medicare data in the database are the complete 100% Medicare Standard Analytical File indexed to allow for patient tracking with time. Patients with hepatitis C who underwent shoulder arthroplasty then were identified using ICD-9 codes. Patients with hepatitis B coinfection or HIV were excluded. A control cohort of patients without hepatitis C who underwent TSA was created and matched to the study cohort based on age, sex, obesity, and diabetes mellitus. A total of 1466 patients with hepatitis C and 21,502 control patients were included. The two cohorts were statistically similar in terms of sex (53% females in study and control groups), age (nearly ½ of each cohort younger than 65 years), obesity (approximately 17% of each cohort were obese), diabetes (approximately 40% of each cohort had diabetes), and followup of each cohort occurred throughout the length of the database from 2005 to 2012. Postoperative complications were assessed using ICD-9 and Current Procedural Terminology codes and compared between cohorts.ResultsPatients with hepatitis C, when compared with matched control subjects, had greater odds of infection within 3 months (odds ratio [OR], 1.7; 95% CI, 1.1–2.6; p = 0.015), 6 months (OR, 1.7; CI, 1.3–2.4; p = 0.001), and 1 year (OR, 2.1; CI, 1.7–2.7; p < 0.001); revision TSA within 1 year (OR, 1.5; CI, 1.1–2.9; p = 0.008) and 2 years (OR, 1.6; CI, 1.2–2.0; p = 0.001), dislocation within 1 year (OR, 1.6; CI, 1.2–2.2; p < 0.001); postoperative fracture within 1 year (OR, 1.8; CI, 1.2–2.6; p = 0.002); systemic or medical complications within 3 months (OR, 1.3; CI, 1.0–1.6; p = 0.022); and blood transfusion within 3 months (OR, 1.7; CI, 1.4–1.9; p < 0.001).ConclusionsHepatitis C is associated with an increased risk for complications after TSA, including infection, dislocation, fracture, revision TSA, systemic complications, and blood transfusion compared with matched control subjects. Although this study is able to identify increased odds of complications in patients with hepatitis C, the mechanism by which these occur is likely not solely related to the virus, and is more likely related to a higher degree of case complexity in addition to other postoperative socioeconomic factors.Level of EvidenceLevel III, therapeutic study.