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Chronic kidney disease increases prosthetic joint infection rates after TJA

Patients with stage 1, 2 or 3 chronic kidney disease may have a higher rate of prosthetic joint injection after total joint arthroplasty, according to study results.

Researchers retrospectively reviewed electronic medical records for 377 patients with stage 1 to 2 kidney disease with 402 patients who had stage 3 chronic kidney disease. All patients underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) between 2004 and 2011.

Patients with stage 3 chronic kidney disease had a greater rate of overall mortality compared with patients with stage 1 to 2 chronic kidney disease, according to the researchers.

When adjusted for comorbid disease, the researchers found no significant increases in joint infection, readmission or early revision between patients with stage 1 to 2 chronic kidney disease compared with patients with stage 3 chronic kidney disease.

Compared with patients with end-stage renal disease, dialysis and kidney transplant, overall incidence of infection was high but much less in chronic kidney disease patients.

In a subgroup analysis, the significant difference in mortality rate persisted between the stage 1 to 2 group vs. the stage 3 group in patients who had undergone THA, but not in patients who had undergone TKA, according to the researchers. 
Study results showed a slightly lower rate of 90-day readmission in patients with stage 1 to 2 chronic kidney disease who underwent TKA than in patients with stage 3 chronic kidney disease, whereas 90-day readmission was slightly higher in the THA subgroup.

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Higher baseline expectations for TJR improved health-related quality of life, satisfaction

Health-related quality of life and satisfaction improved among patients who had higher expectations for total joint replacement at baseline compared with patients who had lower expectations, according to study results.

Researchers recruited 892 patients preparing for total joint replacement (TJR) of the knee or hip due to primary osteoarthritis. Before surgery and for 12 months afterward, patients completed questionnaires with five questions about expectations before surgery; an item to measure satisfaction; WOMAC and SF-12; and questions about sociodemographic information. The researchers performed general linear models and logistic regression analysis to determine the association of patients’ expectations at baseline with satisfaction and changes in health-related quality of life (HRQoL) 12 months after surgery.

Study results showed larger improvements in HRQoL at 12 months among patients who had higher pain relief or ability to walk expectations. WOMAC and SF-12 physical component summary domains also improved more among patients with high expectations regarding the ability to walk, interact with other and psychological wellbeing expectations, according to the researchers.
Patients with very high expectations on the SF-12 physical component summary regarding their ability to walk and with high or very high pain relief expectations on SF-12 mental component summary experienced better improvement compared with patients with low expectations, the researchers found.

The researchers also found patients who had high or very high daily activities expectations were more likely to be satisfied.

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Older patients still fastest-growing demographic for TKA

Despite total knee arthroplasty becoming more prevalent in patients younger than 65 years of age, the main demographic of growth is still among patients older than 65, according to recent study data.

Researchers compared 1999 to 2008 U.S. census data for individuals 18 to 44 years old, 45 to 64 years old, and 65 years and older and the number of total knee arthroplasties (TKAs) performed annually in each age group. Per-capita incidence rates were calculated, and the growth rate in all demographics was determined.

Approximately 305,000 TKAs were performed beyond the number predicted by population growth alone in 2008. Patients older than 65 years of age represented the largest growing cohort, as 151,000 recorded TKA procedures and a per-capita growth rate from 5.2 to 9.1 procedures per 1,000 individuals was observed. Per-capita growth rate also increased from 1.4 to 3.3 procedures per 1,000 individuals among patients 45 to 64 years old.

TKAs were found to have increased 234% during the span of this study, from 264,000 in 1999 and approximately 616,000 in 2008, with fewer than 48,000 of the additional procedures able to be explained by population increase, according to the researchers.

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TKA provides excellent outcomes after lower-extremity amputation

Although total knee arthroplasty is rare after lower-extremity amputation, it can provide excellent functional and clinical outcomes, according to study results.

Researchers reviewed 13 primary total knee arthroplasties (TKAs) in 12 patients with prior lower-extremity amputation, among which 12 TKAs were performed on the contralateral side of the amputated limb and one was performed on the ipsilateral side. Using clinical examinations and patient surveys, the researchers calculated preoperative and postoperative Knee Society scores. The study’s primary endpoint was failure, which was defined as revision for any reason. Average clinical follow-up occurred at 6.8 years.

The researchers observed improvement in Knee Society scores from 30.4 preoperatively to 88.5 following TKA with a prior contralateral amputation.

At final follow-up, radiographic evidence of aseptic loosening of the tibial components was observed in 23.1% of patients, and the researchers recommended augmentation of tibial fixation with a stem during TKA after contralateral amputation.

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Regular physical activity improved patient satisfaction after TKA

Patients who participated in regular physical activity after undergoing total knee arthroplasty experienced improved satisfaction with their outcomes, according to study results.

Researchers evaluated physical activity profiles of 369 patients before and after total knee arthroplasty (TKA) using a questionnaire that contained the University of California — Los Angeles activity scale and types of sports activities. Using subgroup comparisons and partial correlation analyses, the researchers assessed the associations of socio-demographic features and postoperative functional outcomes with the physical activity levels, as well as the effects of regular physical activity on patient satisfaction with replaced knees.

Both before and after TKA, study results showed the three most common sports activities were walking, swimming and bicycling. Although the mean activity level remained similar after TKA, the frequency of moderate activity levels and moderate types of physical activities increased, according to the researchers.

The researchers also found higher postoperative activity levels reported by patients with higher postoperative function scores. However, socio-demographic factors were not associated with activity level. Overall, greater patient satisfaction was associated with regular physical activity.

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Prior TKR or revision THR causes increased periprosthetic fractures

Periprosthetic fractures are especially common in patients with prior total knee replacement or revision total hip replacement a decade after primary total hip replacement, according to study results.

Researchers identified 58,521 Medicare beneficiaries who had elective primary total hip replacement (THR) for non-fracture diagnoses between July 1995 and June 1996 and followed them using Medicare Part A claims data through 2008. Using ICD-9 codes, researchers identified periprosthetic femoral fractures occurring from 2006 to 2008. The incidence density method was used to calculate the annual incidence of periprosthetic femoral fractures, and Cox proportional hazards models were used to identify risk factors for periprosthetic fracture. The risk of hospitalization during the subsequent year was also calculated.

Overall, 55% of patients who had elective primary THR between July 1995 and June 1996 survived until January 2006, with 0.7% of these patients developing a periprosthetic femoral fracture between 2006 and 2008. The researchers found an annual incidence of periprosthetic fractures of 26 per 10,000 person-years among these individuals.

According to Cox proportional hazards models, patients had a greater risk of periprosthetic fracture after having a total knee replacement or a revision total hip replacement between the primary THR and 2006. The researchers found a three-fold higher risk of hospitalization in the subsequent year among THR patients who sustained periprosthetic femoral fracture compared with patients without fractures.

“These data will help clinicians as they portray to patients and their families the long-term concerns associated with living with a hip implant,” the researchers wrote. “The message is that periprosthetic fractures are relatively rare, though more frequent in patients with multiple implants. Further, these fractures are typically associated with the need for considerable subsequent medical care, as they are accompanied by a much greater risk hospitalization in the subsequent year than experienced by THR recipients who did not have hip fracture.”

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Comparable readmission rates found for inpatient and outpatient TJA

Patients undergoing outpatient total joint arthroplasty had readmission rates, number of emergency room visits and patient satisfaction outcomes comparable patients who underwent inpatient procedures, according to a presenter at the American Academy of Orthopaedic Surgeons Annual Meeting.

“There has been a recent demand in outpatient total joint arthroplasty [TJA] stemming from better protocols, pain management and physical therapy,” Walter B. Beaver Jr., MD, medical director at OrthoCarolina in Charlotte, N.C., said. “The big question is, are there safety concerns with outpatient TJA? And more recently, there are concerns about penalties for readmission.”

According to Beaver and his colleagues, under the Patient Care and Affordability Act, Medicare is focusing on 30-day readmission rates for certain diagnoses and is penalizing hospitals financially for readmissions in this timeframe. “In 2015, [CMS is] probably going to include total hip and total knee arthroplasty in the penalties for readmission, and the penalties may be a maximum of 3%,” Beaver said.

Study inclusion criteria

Beaver and his colleagues sought to determine whether outpatient or inpatient TJA influenced hospital readmission rates during the 30-day postoperative period. They completed telephone surveys with 235 patients, including 137 outpatients and 98 inpatients who underwent TJA at the same institution between September 2010 and May 2011. One surgeon performed all of the outpatient TJAs, and two surgeons who performed the inpatient TJAs, which included hospital stays with a minimum of 2 days.

Criteria for outpatient TJA included a body mass index of less than 40 kg/m2 and no active cardiopulmonary issues, sleep apnea, or history of deep venous thrombosis or pulmonary embolus. Patients also had to live less than 1 hour from the hospital and have good family support.

Readmission rates were 5.7% for inpatient TJA vs. 10.1% for outpatient TJA. “At our cohort size, there was no statistical significance seen,” Beaver said.

When researchers included emergency room visits with readmissions, 6.7% of inpatients and 12.4% of outpatients required unplanned medical care after hospital discharge; again, according to Beaver, this difference was not statistically significant.

Readmission rates

Researchers observed no statistically significant differences between the two groups for readmission during the first 4 postoperative days or when stratified by joint: In the inpatient group, seven total knee arthroplasty (TKA) patients and no total hip arthroplasty (THA) patients were readmitted during the 30-day postoperative period, and in the outpatient group, 16 TKA patients and one THA patient were readmitted.

Both patient groups reported high patient satisfaction, with no statistically significant difference between the two groups.

“There was no statistical difference when looking at 30-day hospital readmission rate and patient satisfaction,” Beaver said. “However, there was a higher readmission rate for the outpatient surgery group, which was clinically meaningful. This may have financial implications due to higher readmission rates for the outpatient group. Implications could affect bundled payments in the future, and this is especially true for total knee arthroplasty.”

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Hepatitis C infection did not affect outcomes after total hip arthroplasty

Clinical and patient-reported outcomes following total hip arthroplasty in patients with chronic hepatitis C were comparable to outcomes of patients without the infection at a mean 6-year follow-up, according to a presenter at the American Academy of Orthopaedic Surgeons Annual Meeting.

“Hepatitis C can affect approximately 3% of orthopedic patients, many of whom undergo total joint arthroplasty,” said Samik Banerjee, MBBS, MS, MRCS (Glasg), of the Department of Orthopaedic Surgery and Center for Joint Preservation and Replacement at the Rubin Institute for Advanced Orthopedics and Sinai Hospital of Baltimore. “However, there has been a paucity of reports on the outcomes of primary total hip arthroplasty in patients with hepatitis C.”

Similar implant survivorship

Banerjee and his colleagues compared the clinical and patient-reported outcomes of 49 patients (54 hips) who underwent primary total hip arthroplasty (THA) to a matched cohort of 148 THAs in patients without hepatitis C. All patients underwent THA during 2002 to 2011. Patients with hepatitis C included 10 women and 39 men who had a mean age of 57 years. Mean follow-up was 6 years, and the underlying cause of hip disease was end-stage osteoarthritis in 49 hips and avascular necrosis in five. Patients were matched according to age, gender, body mass index, cause of hip disease and mean follow-up duration.

Overall implant survivorship was statistically similar between the groups: 98% in the patients with hepatitis C and 98.5% in the matched control group. “The hepatitis C group had one aseptic revision, while the matched cohort had two revisions during this period,” Banerjee said during his presentation.

Researchers also found no difference between the groups in the postoperative Harris hip score, with an improvement to a mean of 89 points in the patients with hepatitis C and an improvement to a mean of 90 points in the comparison group.

Superficial infection, hematoma

Banerjee and colleagues also reported no significant differences in the complication rate between the groups, but in the hepatitis C group, he and his colleagues found a superficial infection and two wound hematoma cases. Furthermore, they found no differences in the SF-36 physical and mental component scores or UCLA activity scores. Postoperative radiographic evaluation revealed no component malalignment, symptomatic progressive radiolucencies, change in component position or implant subsidence.

“From our study, we can agree [with previously published data] that there is no difference in aseptic implant survivorship, activity levels or functional outcomes after THA,” Banerjee said. “We believe that a prior history of chronic hepatitis C alone may not predict inferior clinical outcomes, and we also believe more prospective studies are necessary to better evaluate these outcomes.”

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Multidisciplinary treatment can help with pain after TKA or THA

Multidisciplinary pain treatment has been shown in a recent study to one way to aid patients following total knee arthroplasty and total hip arthroplasty procedures.

In the study, investigators found that multidisciplinary pain treatment (MPT) “has beneficial short-term and mid-term effects on subjective pain intensity, physical capability and depression levels in patients with persistent pain after joint arthroplasty,” lead author Christian Merle, MD, MSc, and colleagues, wrote.

Merle and colleagues conducted a retrospective study that followed 40 patients (mean age 62 years) with persistent unexplained pain following total knee arthroplasty (TKA) or total hip arthroplasty (THA) that previous treatments were unable to rectify. The procedures were performed between April 2007 and April 2010.

The evaluations, which were done before MPT, after 3 weeks of MPT and at 32 months mean follow-up, focused on the patients’ pain intensity, physical capability and psychological status, according to the study.

All the scores used showed a significant improvement at the completion of MPT over the baseline pain scores. At 32 months’ follow-up, pain intensity, physical capability and depression levels deteriorated slightly, but were significantly better than at baseline.

The results showed 79% of the 34 patients available for final follow-up reported a reduction in pain on the Numeric Rating Scale of 0.5 to 5.0 points. All patients reported pre-MPT NSAID use, 41% of patients continued to use NSAIDs and15% of them reported using opioids after 32 months.

Because MPT helps to alleviate unexplained pain following TKA and THA, Merle and colleagues noted in the study it may help patients avoid exploratory revision surgery.

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Study: Good results seen with algorithmic approach in treatment of hip instability

Hip instability can be successfully managed using a six-part algorithm that helps surgeons identify and treat variations in instability, according to a presenter at the Current Concepts in Joint Replacement Winter Meeting, here.

“Our conclusion, then, is this demonstrates a six-part algorithm for treating an unstable hip,” Wayne G. Paprosky, MD, said. “We think it is probably one of the most successful series of its size. We are now advocating the use of tripolar constrained liners where possible, especially in these type III abductor deficiencies.”

Paprosky and colleagues performed a retrospective analysis of 77 consecutive hip arthroplasties that were revised due to instability, according to the abstract. They identified six variations of instability and placed patients in numbered from one to six based on the etiology of the instability, which included acetabular component malposition, femoral component malposition, abductor deficiency, impingement, late wear, or “unclear etiology.”

Once the instability was identified, type I and II instabilities were treated with component revision, type III and VI instabilities were treated with a constrained liner, type IV instabilities were treated by removing the impingement and type V was treated with a liner change.

The success rate was 84.4% for all treatments of instability. When treatment for type III abductor insufficiencies were removed, which accounted for 8 of 12 revisions in the study, the success rate was 92%, according to the abstract.

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