Mitch Winemaker

Total Joint Arthroplasty and Preoperative Low Back Pain

Lower extremity osteoarthritis with concomitant low-back pain (LBP) may obscure a clinicians ability to properly evaluate the status of hip or knee osteoarthritis and subsequent total joint arthroplasty (TJA) candidacy. A prospective cohort study was conducted to determine prevalence and severity of preoperative LBP among TJA patients, and the effect of TJA on alleviating LBP. Preoperative moderate to worst imaginable LBP pain on the Oswestry Disability Index (ODI) was significantly higher among hips compared to knees (28.8% vs. 16.1%, P < 0.0001). Compared to knees, hips also saw significant ODI improvement from preoperative to one-year postoperative. TJA candidates with considerable preoperative LBP should be counselled that TJA outcome may be impaired by the coexistence of spine disease, and that residual spine pain may continue following otherwise successful TJA.

Continuous Infusion of Bupivacaine Following Total Knee Arthroplasty: A Randomized Control Trial Pilot Study

An RCT pilot-study was conducted to assess efficacy of a 48-h continuous local infiltration of intra-articular bupivacaine (0.5% at 2 cc/h) versus placebo (0.5% saline at 2 cc/h) in decreasing PCA morphine consumption following TKA. Secondary outcomes included 48-h VAS pain, opioid side effects, length of stay, and knee function scores up to 1-year postoperatively. Of 67 randomized patients, 49 completed the trial including 24 bupivacaine, and 25 placebo patients. Mean 48-h PCA morphine consumption did not differ significantly between treatment (39 mg ± 27.1) and placebo groups (53 mg ± 30.4) (P = .137). The intervention did not improve pain scores, or any other outcome studied. Given study results we would conclude that analgesia outcomes with a multimodal analgesia regimen are not significantly improved by adding 48 h of 0.5% bupivacaine infiltration at 2 cc/h.

Preoperative Knee Stiffness and Total Knee Arthroplasty Outcomes

A retrospective case-control study was conducted to evaluate 1-year total knee arthroplasty (TKA) outcomes among preoperative stiff knees, range of motion (ROM) 80° or less, compared with nonstiff preoperative knees, ROM 100° or greater. A total of 134 stiff knee cases were compared with a matched cohort of 134 non-stiff knee controls. Knee Society Score and Oxford Knee Score change scores from baseline to 1 year were similar between the groups. Stiff knees experienced a significantly greater mean improvement in ROM from baseline to 1 year (30.8° ± 18.8°) as compared with nonstiff knees (1.1° ± 12.8°) (P < .0001). Although ultimate ROM of a TKA can be restricted secondary to preoperative stiffness, improvements in outcomes and ROM are not affected. We conclude that progression of stiffness should not in and of itself lead to earlier intervention of TKA in most cases.

Preoperative Predictors of Pain Catastrophizing, Anxiety, and Depression in Patients Undergoing Total Joint Arthroplasty

BACKGROUND The relationship between pain catastrophizing and emotional disorders including anxiety and depression in osteoarthritic patients undergoing total joint arthroplasty (TJA) is an emerging area of study. The purpose of this study was to examine the association of these factors with preoperative patient characteristics. METHODS A prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale (PCS) and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Preoperative measures included visual analog pain scale (VAS), Harris Hip and Knee Society scores, Oxford Score, and Kellgren-Lawrence grade. Logistic and quantile regression were used to assess the relationship between preoperative characteristics and PCS or HADS, adjusting for covariate effects. RESULTS We recruited 463 TJA patients. VAS pain (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.04-1.45) and Oxford (OR 1.13; 95% CI 1.07-1.20) were significant predictors for PCS and its subdomains excluding rumination. Oxford was the only significant predictor for abnormal HADS-A (OR 1.10; 95% CI 1.04-1.17). VAS pain (OR 1.27; 95% CI 1.02-1.52) and Oxford (OR 1.09; 95% CI 1.01-1.17) were significant predictors for abnormal HADS-D. The quantile regression showed similar patterns of association, with female gender, younger age, and higher ASA also associated with HADS-A. CONCLUSION The most important predictor of catastrophizing, anxiety and/or depression in TJA patients is preoperative pain and poor subjective function. At-risk patients include those with increased pain and generally good clinical function, as well as younger women with significant comorbidities. Such patients should be identified and targeted psychological therapy implemented preoperatively to optimize coping strategies and adaptive behavior to mitigate potential for inferior TJA outcomes including pain and patient dissatisfaction.

Clinical Outcomes of Primary Total Joint Arthroplasty Among Nonagenarian Patients

A retrospective cohort study and a comparative literature review were undertaken to determine outcomes and survival/mortality rates among nonagenarian patients who underwent total joint arthroplasty (TJA). Thirty-nine patients who underwent TJA (14 hips, 25 knees) aged 90+ years were identified from a database of 9817 primary TJA cases performed at one hospital between 1998 and 2010. Findings were compared to synthesized data from relevant published literature review (LR). The mean age was 91.3 (±1.4) years, 79.5% were rated by the American Society of Anesthetists as 3+. Medical complication rate was 25.6% vs 36.2% for LR cases (P = .219). Perioperative death rate was 2.6% vs 2.1% among LR cases (P = 1.000). At 3.8-year follow-up, mortality rate was 59% (LR, 58.2%; 5.1 years), with a mean age of 95.2 (±3.5) years at death (LR, 96.3 ± 3.4). Excellent clinical outcomes were achieved. Primary TJA remains a viable and effective procedure in nonagenarian patients.

Antibiotic Prophylaxis for Dental Procedures at Risk of Causing Bacteremia Among Post-Total Joint Arthroplasty Patients: A Survey of Canadian Orthopaedic Surgeons and Dental Surgeons

To elicit current practice and attitudes toward use of antibiotic-prophylaxis among TJA patients prior to dental procedures, a cross-sectional survey of practicing Canadian orthopaedic (OS) and dental surgeons (DS) was undertaken. Of respondents, 77% of OS and 71% of DS routinely prescribe antibiotic-prophylaxis, but while 63% of OS advocate lifelong use, only 22% of DS choose to do so (P<0.0001). Both groups nonetheless recognize the importance of treatment within 2-years post-TJA as per AAOS/ADA guidelines. However, greater duration of practice pointed to potential inadequacy of these guidelines based on reported experience with late-hematogenous infection post-TJA. While discrepancies in attitude toward antibiotic-prophylaxis between surgeon groups remain, both groups agreed that the evidence to support decision making regarding antibiotic-prophylaxis for TJA patients undergoing dental procedures remains inadequate.

Staged bilateral total knee arthroplasty: does history dictate the future?

A retrospective cohort study of 668 staged bilateral TKA patients was conducted to determine first-side versus second-side subjective and objective outcomes. Improvement in patient perceived function, measured by one-year Oxford Score (OKS) was defined by a minimal clinically important difference of >5 points in OKS. Results indicate that patients who had a minimal clinically important improvement (MCII) on the first-side have a significantly greater chance of maintaining or improving benefit with second-side TKA (OR 3.2; 95% CI 1.63-6.22; P=0.000). Of those with no clinical improvement (NCI), 71.4% achieved MCII on the second-side, while 28.6% remained NCI (P=0.000). Patients who do not initially benefit from first-side TKA should not be denied second-side staged-TKA as they still have a significant chance of achieving an MCII.

The impact of acute perioperative myocardial infarction on clinical outcomes after total joint replacement

Background:Improvements in perioperative care have markedly decreased mortality after total joint replacement. Acute myocardial infarct (MI) is the most common clinically significant complication after total joint replacement (TJR) and the most common cause of 30-day mortality after TJR, which remains a concern especially in light of an older population with advanced comorbidities. In spite of this, little evidence exists in regard to its effect on TJR functional outcomes. Methods:To assess the potential impact, if any, of acute MI on the clinical outcomes of patients undergoing primary TJR, a matched cohort study of MI and non-MI patients was conducted to determine 1-year Oxford, Harris Hip and Knee Society score outcomes. Results:Of 12,739 primary TJR patients identified over a 9-year period, 0.9% (114; 95% CI, 0.75-1.1) experienced a perioperative MI. A greater proportion of MI than non-MI patients had ≥1 cardiac risk factor (P=0.001) and an American Society for Anesthesiologist (ASA) 4 status (P=0.037). Length of hospital stay was longer for MI cases (MI=11.5±9.8 vs. Non-MI=5.4±2.7, P<0.0001), with 70% requiring intensive care unit or cardiac care unit stays (P<0.0001). One-year outcome scores were similar among groups (P>0.05). One-year cardiac mortality rate was 6.1% compared to 0 non-MI deaths (P<0.0001). Conclusions:While functional outcomes of MI after TJR are equivalent to non-MI, 1-year mortality remains high, and targeted cardiac screening and long-term monitoring for this patient population should be implemented.

Dental hygiene in maintaining a healthy joint replacement: a survey of Canadian total joint replacement patients

Background:Dental procedures and their role in prosthetic joint infections remain controversial. Recent literature shows that total joint replacement in patients with good oral hygiene are less like to develop an prosthetic joint infection. The purpose of this study was to assess dental hygiene practices and knowledge of its importance in maintaining joint health among patients who have had a total joint replacement, and to understand, based on patient report, the extent to which current clinical practice guidelines have been adopted into everyday practice. Methods:A cross-sectional survey study of dental hygiene practices was conducted on patients who have had total joint replacement presenting for their 6 wk postoperative follow-up. We hypothesized that patients would have good dental hygiene habits, but limited knowledge of oral hygiene and prosthetic joint infection risk. Responses were analyzed using descriptive statistics and benchmarked against population data from the Oral Health Module of the Canadian Health Measures Survey (CHMS). Results:The study cohort included 453 patients (mean age 65.9±9.9 yr) with total joint replacements. Our findings demonstrated that although 86% had a cleaning within 12 mo, 5% did not visit a dentist. While 95% brush and 46% floss daily, 4% did not brush and 21% did not floss which is comparable to CHMS population data. Only 49% had been informed of dental hygiene in reducing prosthetic joint infection risk. Conclusions:Patients who have had total joint replacement practice good dental hygiene overall; however, communication regarding its importance in preventing prosthetic joint infection remains inconsistent. Healthcare practitioners must uniformly educate patients who have total joint replacement on the importance of good dental hygiene in maintaining joint health.

Shape-matching: “measure with a micrometer, mark with a chalk-line, and cut with an axe” still holds true with modern 3D-templating

Background:Shape-matching technology provides preoperative three-dimensional templating of total knee arthroplasty (TKA) placement to restore optimal kinematics for the native prearthritic knee. Despite an accurate preoperative plan to construct cutting jigs for placement of the femoral and tibial implants in a TKA, it is hypothesized that the actual implementation or reproduction of this placement of implants remains suboptimal. Methods:A retrospective radiographic review of 67 primary unilateral TKAs performed using the OtisMed™ (OM, Stryker, Kalamazoo, MI) shape-matching technology was conducted to determine how closely the computer-generated OM preoperative plan resembled the postoperative femoral and tibial implant position in both the coronal and sagittal planes. Results:Preoperative and postoperative measurements were correlated in the coronal (r=0.407, P=0.001), but not the sagittal plane (r=−0.124, P=0.329). Postoperative coronal alignment differed from the preoperative plan more than 3° in 33.3% of cases, while sagittal alignment differed more than 3° in 56.3% of cases. Conclusions:A significant number of cases did not achieve precise placement of the implants per the OM plan, most notably in the sagittal plane. While these differences are noteworthy, the limiting factor still remains our ability to precisely execute the plan.