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Objective:To determine whether combinations of diagnosis and procedures codes can improve the detection of prosthetic hip and knee joint infections from administrative databases.Design:We performed a validation study of all readmissions from January 1, 2010, until December 31, 2016, following primary arthroplasty comparing the diagnosis and procedure codes obtained from an administrative database based upon the International Classification of Disease, Tenth Revision (ICD-10) to the reference standard of chart review.Setting:Four tertiary-care hospitals in Toronto, Canada, from 2010 to 2016.Participants:Individuals who had a primary arthroplasty were identified using procedure codes.Intervention:Chart review of readmissions identified the presence of a prosthetic joint infection and, if present, the surgical procedure performed.Results:Overall, 27,802 primary arthroplasties were performed. Among 8,844 readmissions over a median follow-up of 669 days (interquartile range, 256–1,249 days), a PJI was responsible for or present in 586 of 8,844 (6.6%). Diagnosis codes alone exhibited a sensitivity of 0.88 (95% CI, 0.85–0.92) and positive predictive value (PPV) of 0.78 (95% CI, 0.74–0.82) for detecting a PJI. Combining a PJI diagnosis code with procedure codes for an arthroplasty and the insertion of a peripherally inserted central catheter improved detection: sensitivity was 0.92 (95% CI, 0.88–0.94) and PPV was 0.78 (95% CI, 0.74–0.82). However, procedure codes were unable to identify the specific surgical approach to PJI treatment.Conclusions:Compared to PJI diagnosis codes, combinations of diagnosis and procedure codes improve the detection of a PJI in administrative databases.

OBJECTIVE The influence of sex on post-total knee arthroplasty (TKA) outcomes has been variable in the literature. Though sex is often reported as an averaged effect, we undertook this study to investigate whether sex modified the influence of presurgery characteristics on post-TKA knee pain. METHODS This was a prospective study with data derived from 477 TKA osteoarthritis patients (279 women, 198 men). Questionnaires were completed presurgery and at 3 months postsurgery. The association between 3-month post-TKA knee pain and presurgery covariates (body mass index, comorbidity count, symptomatic joint count, low back pain, knee pain, and depressive symptoms) was assessed by linear regression. Sex-specific effects were evaluated using interactions. RESULTS Women had significantly worse presurgery knee pain, joint count, and depressive symptoms, and worse postsurgery knee pain, than men. With simple covariate adjustment, no sex effect on pain was found. However, sex was found to moderate the effects of comorbidities (worse for women [P = 0.013]), presence of low back pain (worse for men [P = 0.003]), and depressive symptoms (worse for men [P < 0.001]) on postsurgery pain. Worse presurgery pain was associated with worse postsurgery pain similarly for women and men. CONCLUSION The influence of some patient factors on early post-TKA pain cannot be assumed to be the same for women and men; average effects may mask underlying associations. Results suggest a need to consider sex differences in understanding TKA outcomes, which may have important implications for prognostic tool development in TKA.

Topical tranexamic acid (TA) has been reported to be effective in reducing postoperative bleeding and transfusions after total knee arthroplasty (TKA). The main objective of this study was to retrospectively assess the effectiveness and safety of topical TA administration in patients undergoing simultaneous bilateral TKA.We conducted a retrospective chart review of consecutive cohorts of patients undergoing simultaneous bilateral TKA. We compared the patients who received TA with patients from a similar time frame who did not receive TA. For those who received TA, a topical concentration of 2 g per 30 mL of normal saline was used in each knee. Preoperative and postoperative hemoglobin, transfusions, length of stay (LOS) and postoperative complications were recorded for each patient until discharge. Outcome measures were analyzed using independentWe included 49 patients in our analysis: 25 who received TA and 24 who did not. There were no statistical differences in demographics between the groups. The rate of transfusion in the TA group was 4% compared with 67% in the non-TA group (Topical administration of TA in patients undergoing simultaneous bilateral TKA significantly reduced transfusions, blood loss and postoperative LOS, with no increased risk of thromboembolic events.Selon certains rapports, l'acide tranexamique (AT) topique réduirait efficacement les saignements postopératoires et le recours aux transfusions après une intervention pour prothèse totale du genou. Le principal objectif de cette étude était d'évaluer de manière rétrospective l'efficacité et l'innocuité de l'AT topique chez des patients soumis à une intervention pour prothèse totale des 2 genoux.Nous avons procédé à une analyse rétrospective des dossiers de cohortes consécutives de patients soumis à une intervention pour prothèse totale des 2 genoux. Nous avons comparé les patients ayant reçu l'AT aux patients d'une période similaire qui n'ont pas reçu l'AT. Pour ceux qui ont reçu l'AT, la concentration topique de 2 g par 30 mL de solution physiologique a été utilisée dans les 2 genoux. On a enregistré chez chaque patient les taux d'hémoglobine pré- et postopératoires, le nombre de transfusions, la durée du séjour hospitalier et les complications postopératoires jusqu'à leur congé. Les paramètres ont été analysés à l'aide du testNous avons inclus 49 patients dans notre analyse : 25 ayant reçu l'AT et 24 ne l'ayant pas reçu. Il n'y avait aucune différence statistique entre les groupes pour ce qui est des caractéristiques démographiques. Le taux de transfusions dans le groupe ayant reçu l'AT a été de 4 %, contre 67 % dans le groupe n'ayant pas reçu l'AT (L'administration topique d'AT chez des patients soumis à une intervention pour prothèse totale des 2 genoux a significativement réduit le recours aux transfusions et les pertes sanguines et a abrégé les séjours hospitaliers postopératoires, sans accroître le risque d'incidents thromboemboliques.

Summary Objective There are suggestions that the relationship between inflammation and pain in osteoarthritis (OA) may differ by sex, yet studies have been limited. We investigated whether the relationship between knee-specific OA pain and systemic inflammatory markers differs by sex. Design 196 patients scheduled for knee arthroplasty for OA were included. Questionnaires were completed and blood samples drawn pre-surgery. Questionnaire data: knee pain (WOMAC), sex, age, height, weight, comorbidities, depressive symptoms, and symptomatic joint count. Systemic inflammatory markers (cytokines IL-6, IL-8, IL-10, IL-1β and TNF-α) were measured by multiplex ELISA. A series of regression models with interaction terms between sex and ln-transformed inflammatory markers were estimated with pain score as the outcome. The adjusted relationship between pain and inflammatory markers, by sex, were presented graphically. Results Mean age was 64 years (range 43–89); females comprised 58.7% of the sample. In adjusted analyses, similar relationships between knee pain and lnIL-10 (negative: β ​= ​−1.28, 95%CI (−1.97, −0.58)) and lnTNF-α (positive: β ​= ​0.92, 95%CI (0.11, 1.76)) were found for females and males. In contrast, relationships between knee pain and lnIL-1β, lnIL-6 and lnIL-8 differed in direction for females and males. Specifically, for lnIL-1β and lnIL-8 they were positive for males, negative for females. The opposite was found with lnIL-6, negative for males, positive for females. Conclusion These findings provide some evidence of sex-specific relationships between individual inflammatory markers and knee OA pain. They expose a need for further exploration of sex-differences in this context, with potential future implications for treatment or drug development in OA.

OBJECTIVE To evaluate rates of prescription opioid use among patients with presurgical knee, hip, and spine osteoarthritis (OA) and associations between use and sociodemographic and health status characteristics. METHODS Participants were patients with presurgical, end-stage OA of the knee (n = 77), hip (n = 459), and spine (n = 168). Data were collected on current use of opioids and other pain medications, as well as measures of sociodemographic and health status variables and depression and pain (0-10 numeric rating scale). Rates of opioid use were calculated by sex, age, and surgical site. Multivariable logistic regression was used to examine associations between opioid use (sometimes/daily versus never) and other study variables. RESULTS The mean age of participants was 65.6 years; 55.5% were women, 15% of patients reported "sometimes" using opioids, and 15% reported "daily use." Use of opioids was highest among patients with spine OA (40%) and similar among patients with knee and hip OA (28% and 30%, respectively). Younger women (ages

Total joint arthroplasty can be associated with major blood loss and require subsequent blood transfusions for postoperative anemia. Measures to effectively and safely decrease blood loss and reduce the need for blood transfusions would help improve patient safety and lower health care costs. A possible pharmacological option to reduce surgical blood loss in total joint arthroplasty is the use of tranexamic acid. Abundant literature has shown that intravenous and/or topical administration of tranexamic acid is effective in reducing blood loss and blood transfusions, with no increased risk of venous thromboembolic events or other complications.

The imaging findings of periprosthetic soft tissue lesions (pseudotumours) have been typically defined in the context of newer second-generation metal-on-metal hip arthroplasty. More recently, similar findings have been described in the setting of non-metal-on-metal prostheses. Although uncommon, wear and corrosion between the metal surfaces at the head-neck ('trunnionosis') and neck-stem interfaces are the potential culprits. With modular junctions containing at least one cobalt chromium component frequently present in hip arthroplasty prostheses, the incidence of this mode of adverse wear may be higher than previously thought (irrespective of the specific bearing couple used). In the present report, we described a case of a severe adverse local tissue reaction secondary to suspected corrosion at the head-neck taper in a metal-on-polyethylene total hip arthroplasty and reviewed the literature. Knowledge of this topical entity should help radiologists facilitate early diagnosis and ensure early management of this potentially serious complication.

The efficaciousness of topical tranexamic acid use at the end of knee arthroplasty surgery to reduce blood loss and transfusion requirements has previously been shown. The aim of this study was to retrospectively assess the effectiveness of topical tranexamic acid use, comparing 155 patients undergoing hip and knee arthroplasty surgery in which tranexamic acid was routinely used, to a group of 149 patients from a similar time frame prior to the introduction of tranexamic acid use. The transfusion rate fell from 19.3% to 2.3% for hip arthroplasty patients and from 13.1% to 0% for knee arthroplasty patients; these differences were significant. We also found significant reductions in haemoglobin loss, blood loss and length of stay of 8 g/L, 244 mL and 1.0 days respectively for hip arthroplasties and 15 g/L, 527 mL and 1.2 days respectively for knee arthroplasties following the introduction of tranexamic acid.

Obesity has been identified as a risk factor for the development of hip and knee osteoarthritis (OA) and may play a role in exacerbating existing disease. Therefore, we hypothesized that obese patients would present for hip and knee replacement surgery at a younger age than nonobese patients. From our registry, we performed a cross-sectional study of 841 hip and 804 knee replacement patients. Patients were categorized by BMI ≤ 25 kg/m(2), 25.1-29.9 kg/m(2), 30-34.9 kg/m(2), and ≥ 35 kg/m(2). Linear regression modeling was used to examine the relationship between BMI and age at surgery. Hip and knee replacement patients' mean age at surgery was 7.1 and 7.9 years younger, respectively, if their BMI was ≥ 35 kg/m(2) when compared to patients with a BMI ≤ 25 kg/m(2) (P = 0.002). BMI was a significant independent (of gender, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, surgeon, and comorbidity) predictor of age at knee replacement (P < 0.05). WOMAC scores were significantly worse preoperatively in patients with a BMI ≥ 35 kg/m(2) compared to those with a BMI ≤ 25 kg/m(2) (P < 0.05). Our study indicates that obese patients, especially those with a BMI ≥ 35 kg/m(2), presented for and underwent joint replacement surgery at a younger age as compared to nonobese patients.

Background Canada lacks a prosthetic hip and knee joint infection (PJI) registry, leaving active surveillance to be orchestrated by individual hospitals, which is limited by cost and narrow scope. Administrative databases are potentially an ideal instrument for infection surveillance, but detection algorithms relying solely on PJI diagnostic codes alone have been hampered by low specificity. There is a need to develop improved strategies to efficiently and accurately identify PJIs using health administrative databases. Methods Combinations of International Classification of Disease, Tenth Revision, diagnostic and procedure codes were used to create testing cohorts among individuals treated at two institutions in Toronto, Ontario, from April 1, 2015 until March 31, 2016. These cohorts were compared with a reference standard of PJIs, which were identified by chart reviews of every individual who underwent a hip or knee revision operation at these institutions during the study period. The primary outcomes were the performance characteristics of each algorithm. Results Over the 1-year study period, there were 471 revision operations for 405 patients, of which 155 (33%) were performed for the treatment of a PJI. Of the 405 individuals, 108 (27%) had a PJI as the surgical indication; there were 57 (53%) two-stage procedures, nine (8%) single-stage procedures, 34 (31%) incision and drainage procedures with implant retention, and eight (7%) excisional arthroplasties. The combination of a revision operation code plus a PJI diagnosis code was the most robust detection method: sensitivity 0.86 (95% confidence interval, 0.79–0.91) and specificity 0.99 (0.98–1.00). Coupling codes for a revision operation and insertion of a peripherally inserted central catheter yielded a sensitivity of 0.45 (0.37–0.53) and specificity of 1.00 (0.98–1.00). PJI codes alone had a sensitivity of 1.00 (0.86–1.00) and specificity 0.50 (0.23–0.77). Conclusion The combination of a revision operation procedure code and a PJI diagnosis code is sensitive and specific for the detection of a PJI in administrative databases. This is a promising avenue for national PJI surveillance and has the potential to facilitate future research in the prevention and management of PJIs. Disclosures All authors: No reported disclosures.

Objective.The objective of this study was to identify the patient-level predictors (age, sex, body mass index, mental health, and comorbidity) for a sustained functional outcome at a minimum 1 year of followup after total hip replacement (THR).Methods.We reviewed data from our registry on 636 consecutive patients from 1998 to 2005. Demographic data and the outcome scores of the Western Ontario McMaster University Osteoarthritis Index (WOMAC) and Medical Outcomes Study Short-form 36 (SF-36) scores were extracted from the database. Longitudinal regression modeling was performed to identify the predictive factors of interest. Fourteen percent of patients were missing outcomes data at 1 year of followup.Results.The mean followup in our cohort was 3.3 years (range 1–6 yrs) and there were no revisions for aseptic loosening performed during this time. Mean clinical outcome scores were found to be relatively constant for the 6 years after surgery. Older age, year of followup, and greater comorbidity were identified as negative prognostic factors for a sustained functional outcome following THR (p < 0.05).Conclusion.Understanding of longterm surgical outcomes should be appropriately used to set realistic patient expectations of surgery.

Metabolic syndrome (MS) is a known risk factor for the development of osteoarthritis (OA). We asked whether the prevalence of MS varies across ethnicity among patients who undergo total knee arthroplasty for end-stage OA. In our population of 1460 patients undergoing primary knee arthroplasty, MS was defined as body mass index greater than 30 kg/m(2), diabetes, hypertension, and hypercholesterolemia. Among the 1334 white patients, 114 (8.5%) had MS as compared with 3 of 36 (8.3%) blacks and 18 of 90 (20%) Asians (P = .006) Adjusted analysis showed that those of Asian ethnicity had a 2.0 (95% confidence interval, 1.1-3.8; P = .03) times greater odds of MS as compared with those of other ethnicity. Metabolic syndrome is a risk factor for OA, and Asians demonstrate a greater prevalence of MS as compared with whites and blacks in this population.

We asked the question of what are the patient level predictors (age, gender, body mass index, education, ethnicity, mental health, and comorbidity) for a sustained functional benefit at a minimum of 1 year follow-up after total knee arthroplasty(TKA). Five hundred fifty-one consecutive patients were reviewed from our joint registry between the years of 1998 and 2005. Baseline demographic data and the outcome scores of the Western Ontario McMaster University Osteoarthritis Index (WOMAC) and Medical Outcomes Short-Form 36 (SF36) scores were extracted from the database. Longitudinal regression modeling was performed to identify the predictive factors of interest. We had 27% of data points missing. The mean follow-up in our cohort was 3.0 years (range 1-8 years) and there were no revisions performed during this time. Clinical outcome scores were found to be relatively constant for 3-4 years after surgery and then demonstrated a gradual decline after that. Older age, year of follow-up, greater comorbidity, and a poorer mental health state at time of surgery were identified as negative prognostic factors for a sustained functional outcome following TKR (P

PURPOSE: The present study investigated whether the conceptualization of hip and knee osteoarthritis pain implicit in the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Medical Outcomes Study Short-Form 36 (SF-36) scales is complete, or whether the addition of another scale, such as the Short-Form McGill Pain Questionnaire (MPQ-SF), provides a more complete characterization. Furthermore, the impact that mental health symptoms and catastrophizing had on these scales was investigated.METHODS: Before hip and knee arthroplasty, 200 patients completed surveys of demographic data, the WOMAC pain scale, the MPQ-SF, the SF-36 Bodily Pain scale, the Pain Catastrophizing Scale and the Hospital Anxiety and Depression Scale. Correlations between scales were calculated and linear regression modelling was used to determine the impact of mental health and catastrophizing on these three pain measures.RESULTS: A strong correlation between the WOMAC and SF-36 pain scales (r=−0.70) was found; however, both correlated only moderately with the MPQ-SF (r=0.36 and r=−0.36, respectively). Linear regression modelling showed that the Pain Catastrophizing Scale significantly predicted a greater score on all three pain scales (PCONCLUSIONS: The addition of the MPQ-SF appears to add to a more complete quantification of the pain experience in hip and knee osteoarthritis.

We asked if the use of antibiotic-laden bone cement (ALBC) decreased the deep infection rate after primary total knee arthroplasty as compared to plain bone cement. We surveyed 1625 consecutive patients for relevant covariates. Joint pain and function were assessed at baseline and at 1 year of follow-up with the Western Ontario McMaster University Osteoarthritis Index scores. The incidence of deep infection at 1-year follow-up was recorded. There were no differences in baseline covariates between groups (P > .05). We found a deep infection rate of 2.2% in the ALBC group and 3.1% in the plain bone cement group (P = .27). Adjusted analysis showed that ALBC was not predictive of a lower infection rate at 1 year (P = .84). Antibiotic-laden bone cement did not reduce the incidence of deep infection following primary total knee arthroplasty at 1-year follow-up.

We conducted meta-analysis of clinical studies of HA coated femoral stems in hip arthroplasty. After an exhaustive literature search, we abstracted relevant data on the outcomes of stem survival from aseptic loosening and Harris Hip scores. The risk ratios and mean differences with 95% confidence intervals (CI) are reported. 9 studies met our inclusion criteria for the analysis. The cumulative risk ratio for femoral stem survival from aseptic loosening was 1.0 (95% CI: 0.995 to 1.005) P = .98. The pooled mean difference for the Harris Hip scores (HHS) was 0.072 (95% CI: -0.062 to 0.206), P = .293. The results of this study demonstrate that there are no clinical benefits in the use of HA/porous coating over porous coating alone in primary hip arthroplasty.

A prospective randomized trial comparing hydroxyapatite (HA)-coated and non-HA-coated femoral total hip arthroplasty components was conducted. Sixty-one consecutive patients undergoing primary hip arthroplasty were randomized to receive an identical femoral component with or without HA. Forty-eight hips were available for review at an average of 13 years and 5 months after surgery. The only femoral stem revised was secondary to femoral fracture after mitral valve area. All femoral stems were well fixed on x-ray with no evidence of loosening. There was no statistically significant difference in the revision rates or in the Harris hip score between the HA vs non-HA-coated groups. This study suggests there is no clinical advantage to the use of a hydroxyapatite coating on the femoral component of this design for primary total hip arthroplasty.

ObjectiveThe incidence of patient-reported dissatisfaction following total joint arthroplasty can be up to 30%. Our aim was to identify the preoperative patient-level predictors of patient dissatisfaction 1 year after surgery.MethodsWe surveyed 1720 patients undergoing primary hip or knee replacement surgery. Relevant covariates including demographic data, body mass index, sex, comorbidities, and education were recorded. Joint functional status and patient quality of life were assessed at baseline and at 1-year followup with the Western Ontario McMaster University Osteoarthritis Index (WOMAC) and Medical Outcomes Study Short Form-36 (SF-36) scales, respectively. Patient satisfaction with surgery was determined with 4 survey questions at 1-year followup.ResultsThere were no significant differences in demographic data between satisfied (n = 1290) and dissatisfied patients (n = 430). Logistic regression modeling showed that a lower preoperative SF-36 Mental Health score independently predicted patient dissatisfaction with surgery, adjusted for all relevant covariates (p < 0.05). We found no correlation between patient satisfaction and WOMAC change scores at 1-year followup (p = 0.31).ConclusionPreoperative mental health is an important factor to consider when understanding patient satisfaction with surgery. Interventions to reduce psychological distress prior to surgery should be studied to determine if they may improve subjective outcomes of patients undergoing joint replacement surgery.

Our objectives were: (1) to assess the relationship between self-reported measures (Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Medical Outcomes Study Short Form-36 (SF-36)) and a performance-based timed-up-and-go (TUG) test in a hip and knee joint replacement population and (2) to determine the predictors of postoperative functional status as measured by the 12-week WOMAC and TUG scores. We surveyed 200 patients undergoing primary hip or knee replacement surgery for demographic data and outcome scores at baseline and 12-week follow-up. There was a weak correlation between preoperative TUG scores and preoperative SF-36 physical function scores (r = −0.28, p < 0.0001), SF-36 role-physical scores (r = −0.21, p = 0.0022) and WOMAC (r = 0.29, p < 0.0001) scores. The relationship was stronger between the postoperative TUG scores and WOMAC scores (r = 0.43, p < 0.0001), SF-36 physical function scores (r = −0.39, p < 0.0001) and SF-36 role-physical (r = −0.33, p < 0.0001) scores. Significant predictors for the TUG test at 12-week follow-up were age (p = 0.004) and preoperative TUG scores (p < 0.0001). Given low-to-moderate relationship between self-reported and performance-based tools, both tests are needed to assess the true level of patient disability.

Inadequate soft-tissue balancing is a major yet often underemphasized cause of failure for primary and revision total hip arthroplasty. Accordingly, contemporary cemented and cementless hip prostheses have been designed with consideration of this issue, and this has substantially increased the long-term survival of total hip replacements. Therefore, it is important for orthopaedic surgeons to be familiar with the rationale, biomechanical principles, and clinical implications associated with soft-tissue balancing of the hip as well as strategies to avoid inadequate soft-tissue balancing and systematic techniques to restore adequate soft-tissue tensioning during total hip arthroplasty.

The effect of disrupting the intraosseous fluid compartment and freezing on the mechanical stiffness of trabecular bone in intact canine femoral head specimens was investigated. Twenty-four skeletally mature dogs were divided into two groups. Twelve paired fresh femora were tested and 12 paired femora were tested after freezing at -20° C. The intact femoral head specimens were subjected to a load of physiologic magnitude, and then the stiffness of the underlying trabecular bone was determined in intact femora, in drilled femora with a disrupted intraosseous fluid compartment, and subsequently after refilling the compartment with fluid. Drilling of the femoral head and disrupting its bony fluid compartment resulted in a 40% decrease in stiffness (P

Background context Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been widely accepted as highly cost-effective procedures, spine surgery for the treatment of degenerative conditions does not share the same perception among stakeholders. In particular, the sustainability of the outcome and cost-effectiveness following lumbar spinal stenosis (LSS) surgery compared with THA/TKA remain uncertain. Purpose The purpose of the study was to estimate the lifetime incremental cost-utility ratios for decompression and decompression with fusion for focal LSS versus THA and TKA for osteoarthritis (OA) from the perspective of the provincial health insurance system (predominantly from the hospital perspective) based on long-term health status data at a median of 5 years after surgical intervention. Study design/setting An incremental cost-utility analysis from a hospital perspective was based on a single-center, retrospective longitudinal matched cohort study of prospectively collected outcomes and retrospectively collected costs. Patient sample Patients who had undergone primary one- to two-level spinal decompression with or without fusion for focal LSS were compared with a matched cohort of patients who had undergone elective THA or TKA for primary OA. Outcome measures Outcome measures included incremental cost-utility ratio (ICUR) ($/quality adjusted life year [QALY]) determined using perioperative costs (direct and indirect) and Short Form-6D (SF-6D) utility scores converted from the SF-36. Methods Patient outcomes were collected using the SF-36 survey preoperatively and annually for a minimum of 5 years. Utility was modeled over the lifetime and QALYs were determined using the median 5-year health status data. The primary outcome measure, cost per QALY gained, was calculated by estimating the mean incremental lifetime costs and QALYs for each diagnosis group after discounting costs and QALYs at 3%. Sensitivity analyses adjusting for +25% primary and revision surgery cost, +25% revision rate, upper and lower confidence interval utility score, variable inpatient rehabilitation rate for THA/TKA, and discounting at 5% were conducted to determine factors affecting the value of each type of surgery. Results At a median of 5 years (4–7 years), follow-up and revision surgery data was attained for 85%-FLSS, 80%-THA, and 75%-THA of the cohorts. The 5-year ICURs were $21,702/QALY for THA; $28,595/QALY for TKA; $12,271/QALY for spinal decompression; and $35,897/QALY for spinal decompression with fusion. The estimated lifetime ICURs using the median 5-year follow-up data were $5,682/QALY for THA; $6,489/QALY for TKA; $2,994/QALY for spinal decompression; and $10,806/QALY for spinal decompression with fusion. The overall spine (decompression alone and decompression and fusion) ICUR was $5,617/QALY. The estimated best- and worst-case lifetime ICURs varied from $1,126/QALY for the best-case (spinal decompression) to $39,323/QALY for the worst case (spinal decompression with fusion). Conclusion Surgical management of primary OA of the spine, hip, and knee results in durable cost-utility ratios that are well below accepted thresholds for cost-effectiveness. Despite a significantly higher revision rate, the overall surgical management of FLSS for those who have failed medical management results in similar median 5-year and lifetime cost-utility compared with those of THA and TKA for the treatment of OA from the limited perspective of a public health insurance system.

Treating deep infection following THA has been a challenge. While the standard treatment has remained a two-stage revision, spacer designs, incorporated antibiotics, and concentrations have varied. Since control of infection may relate to choice and concentration of antibiotics, it is important to report rates of control from various spacers.We therefore determined (1) the rate of infection control and (2) complications associated with a prefabricated, load-bearing, gentamicin-impregnated hip spacer in treating periprosthetic infections of the hip.We retrospectively reviewed 33 patients with periprosthetic THA infections treated with a prefabricated, partial load-bearing, gentamicin-impregnated hemiarthroplasty spacer. Thirty of the 33 patients underwent second stage reimplantation after a mean 15 weeks. We collected patient demographic data, laboratory values, infecting organism, size of spacer mold, antibiotic selection, complications, and infection control rates from two academic centers. Recurrent infection at last followup was determined by the presence of physical symptoms or signs or elevated serologic tests. The minimum followup was 24 months (mean, 43 months; range, 24-70 months).Twenty-eight of the 30 patients who underwent reimplantation remained infection-free at last followup: one patient became reinfected with a different organism secondary to wound problems; one became reinfected with the same organism, but was restaged with the mold used in this study, reimplanted, and subsequently remained free of infection. Two of the 33 patients had persistently elevated inflammatory markers at the completion of their first stage and were restaged with this mold; both underwent reimplantation and remained free of infection at latest followup. One of the 33 patients was satisfied and ambulatory with their spacer mold. There were no major complications.Our data supported the use of a partial load-bearing, gentamicin-impregnated hemiarthroplasty spacer in treating deep periprosthetic THA infections.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Objective.To examine differences in genes involved in fat metabolism, energy homeostasis, adipogenesis, and inflammation between endstage and early-stage knee osteoarthritis (OA) infrapatellar fat pads (IFP).Methods.Twenty-nine endstage and 5 early-stage primary OA IFP were harvested at knee surgery. Total RNA was extracted, labeled, and hybridized to whole-genome expression arrays. Unsupervised analysis of all samples using principal components analysis or 2-way hierarchical clustering showed groupings based on tissue source and disease. Statistical testing identified sets of genes that displayed differences between the 2 fat types. Western blot analysis was performed for protein expression of an identified gene of interest.Results.The 29 IFP demonstrated an elevation in the expression of adipokines such as adiponectin and leptin. A statistically significant increased expression was seen for genes of adipogenesis, such as peroxisome proliferator-activated receptor-γ (PPAR-γ), diacylglycerol acyltransferase 2 (DGAT2), cluster of differentiation (CD36), and thyroid hormone responsive spot (THRSP) in the severe OA fat pads as compared to the controls. A subset of 5 patients in the endstage OA group were consistently similar in gene expression to early OA tissue. Protein expression of PPAR-γ2 was 5.4-fold and PPAR-γ1 was 1.4-fold greater in endstage versus early OA tissue.Conclusion.Endstage OA fat pads demonstrated a significant upregulation of genes for fat metabolism and energy homeostasis and a mixed result for inflammatory cytokines.

Background: Topical application of tranexamic acid to bleeding wound surfaces reduces blood loss in patients undergoing some major surgeries, without systemic complications. The objective of the present trial was to assess the efficacy and safety of the topical application of tranexamic acid on postoperative blood loss in patients undergoing primary unilateral total knee arthroplasty with cement. Methods: In a prospective, double-blind, placebo-controlled trial, 124 patients were randomized to receive 1.5 or 3.0 g of tranexamic acid in 100 mL of normal saline solution or an equivalent volume of placebo (normal saline solution) applied into the joint for five minutes at the end of surgery. The primary outcome was blood loss calculated from the difference between the preoperative hemoglobin level and the corresponding lowest postoperative value or hemoglobin level prior to transfusion. The safety outcomes included Doppler ultrasound in all patients and measurement of plasma levels of tranexamic acid one hour after release of the tourniquet. Results: Twenty-five patients were withdrawn for various reasons; therefore, ninety-nine patients were included in the intention-to-treat analysis. The postoperative blood loss was reduced in the 1.5 and 3-g tranexamic acid groups (1295 mL [95% confidence interval, 1167 to 1422 mL] and 1208 mL [95% confidence interval, 1078 to 1339 mL], respectively) in comparison with the placebo group (1610 mL [95% confidence interval, 1480 to 1738 mL]) (p < 0.017). The postoperative hemoglobin levels were higher in the 1.5 and 3.0-g tranexamic acid groups (10.0 g/dL [95% confidence interval, 9.5 to 10.4 g/dL] and 10.1 g/dL [95% confidence interval, 9.8 to 10.5 g/dL], respectively) in comparison with the placebo group (8.6 g/dL [95% confidence interval, 8.2 to 9 g/dL]) (p < 0.017). With the numbers studied, there was no difference in the rates of deep-vein thrombosis or pulmonary embolism between the three groups. Minimal systemic absorption of tranexamic acid was observed. Conclusions: At the conclusion of a total knee arthroplasty with cement, topical application of tranexamic acid directly into the surgical wound reduced postoperative bleeding by 20% to 25%, or 300 to 400 mL, resulting in 16% to 17% higher postoperative hemoglobin levels compared with placebo, with no clinically important increase in complications being identified in the treatment groups. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Objective.We asked if patients with metabolic syndrome undergoing total knee replacement (TKR) have an increased risk for symptomatic deep vein thrombosis (DVT) at 3 months followup.Methods.We reviewed 1460 patients from our joint registry undergoing primary, unilateral TKR between 1998–2006. Demographic variables of age, sex, comorbidity, and education were retrieved. Metabolic syndrome was defined as body mass index above 30 kg/m2, diabetes, hypertension, and hypercholesterolemia. Logistic regression was used to examine the relationship of metabolic syndrome on the incidence of DVT.Results.The overall incidence of symptomatic DVT was 4.4% (65/1460). Patients with metabolic syndrome had an increased incidence of DVT compared to those without metabolic syndrome (15.5% vs 3.4%). Adjusted analysis showed that the risk of symptomatic DVT in patients with metabolic syndrome was 3.2 times [odds ratio 3.2, 95% CI (1.0,15.4), p = 0.04] the risk in those without metabolic syndrome.Conclusion.Hospital protocols developed for prophylactic anticoagulation following TKR should give special consideration to patients with metabolic syndrome.

Objective.To determine if there is a difference between male and female patients in their perceived control of osteoarthritis (OA) symptoms at the time of joint replacement surgery, as measured by the Arthritis Helplessness Index (AHI), and how this helplessness affects surgical outcomes at 1 year.Methods.From a joint replacement registry, 70 male and 70 female patients were randomly selected and matched for age, body mass index, comorbidity, procedure, and education. Patients completed the AHI prior to surgery. Functional status was assessed at baseline and 1-year followup with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Linear regression modeling was used to determine the effect of sex on predicting AHI scores. A second model was constructed to examine the effect of AHI on the 1-year WOMAC change score.Results.There were no statistically significant differences in demographic data or clinically significant differences in AHI scores between sexes. Linear regression modeling showed that female sex was a significant predictor of a greater AHI score prior to surgery (p < 0.05). Moreover, a greater AHI score was an independent predictor of a lower WOMAC change score at 1 year (p = 0.01).Conclusion.Interventions to improve control over arthritis symptoms should be studied with the goal of improving surgical outcomes.

Despite much evidence showing racial disparities in the use of surgical procedures, it is unknown whether ethnicity affects perception of surgical risk.We surveyed 1609 patients undergoing primary hip or knee replacement surgery. Relevant covariates including demographic data, body mass index (BMI), sex, comorbidities, education, and ethnicity were recorded. Pain and joint functional status were assessed at baseline and at 1-year followup with the Western Ontario McMaster University Osteoarthritis Index (WOMAC) pain and function scores. Risk perception was assessed with 3 survey questions.Non-European patients had greater functional disability and pain prior to surgery and demonstrated significantly greater perception of risk than European patients (p0.001). Independent of other covariates, non-European ethnicity was an independent predictor of a greater perception of risk (p0.05).Patient ethnicity is an important factor to consider in understanding a patient's perception of risk in joint replacement surgery.

Background We asked whether a high-flexion design implant improves patient functional outcomes or range of motion (ROM) after primary knee arthroplasty. Methods We searched the major medical databases for randomized trials and comparison observational studies comparing high-flexion and conventional knee implants. After testing for publication bias and heterogeneity, the data were aggregated by random effect modeling. We estimated the weighted mean differences of functional outcomes scores and ROM with 95% confidence intervals. Results Six studies met our inclusion criteria for review. We found no evidence of publication bias. The pooled mean difference for KSS scores was 0.144 (95% CI: − 0.018 to 0.306), p = 0.081. The pooled mean difference for the mean changes in ROM was 0.404 (95% CI: 0.139 to 0.669), p = 0.003. Conclusion High-flexion implant design improves overall ROM as compared to traditional implants but offers no clinical advantage over traditional implant designs in primary knee arthroplasty.

Increased wait times for total joint arthroplasty (TJA) are a concern nationally and provincially. Additionally, the number of patients requiring revision of their initial TJA is increasing. The purpose of this study was to evaluate the wait times and impact of waiting for revision TJA.We followed 127 revision hip arthroplasty patients (mean age 68 y) prospectively while they waited for surgery. We collected Western Ontario and McMaster Universities Osteoarthritis Index (pain, stiffness and physical function) data at the decision for surgery and at 6-month intervals until surgery.The mean wait time for surgery was 123.8 days (mean wait times for individual surgeons ranged from 7 to 213 d). Of the patients, 106 waited6 months, 12 waited 6-12 months and 9 waited12 months. Wait times evaluated up to 6 months, 6-12 months or12 months demonstrated significant increases in pain (F = 7.12, p = 0.01), with a mean change of 2.6 points when patients waited6 months. Physical disability increased (F = 4.61, p = 0.01), with a mean change of 5.1 points when the wait time was 6-12 months and 8.8 points when the wait time was12 months.Waiting6 months for revision hip arthroplasty resulted in significant increases in pain and physical disability.

We conducted meta-analysis of clinical studies of HA coated femoral stems in hip arthroplasty. After an exhaustive literature search, we abstracted relevant data on the outcomes of stem survival from aseptic loosening and Harris Hip scores. The risk ratios and mean differences with 95% confidence intervals (CI) are reported. 9 studies met our inclusion criteria for the analysis. The cumulative risk ratio for femoral stem survival from aseptic loosening was 1.0 (95% CI: 0.995 to 1.005) P = .98. The pooled mean difference for the Harris Hip scores (HHS) was 0.072 (95% CI: -0.062 to 0.206), P = .293. The results of this study demonstrate that there are no clinical benefits in the use of HA/porous coating over porous coating alone in primary hip arthroplasty.

A prospective randomized trial comparing hydroxyapatite (HA)-coated and non-HA-coated femoral total hip arthroplasty components was conducted. Sixty-one consecutive patients undergoing primary hip arthroplasty were randomized to receive an identical femoral component with or without HA. Forty-eight hips were available for review at an average of 13 years and 5 months after surgery. The only femoral stem revised was secondary to femoral fracture after mitral valve area. All femoral stems were well fixed on x-ray with no evidence of loosening. There was no statistically significant difference in the revision rates or in the Harris hip score between the HA vs non-HA-coated groups. This study suggests there is no clinical advantage to the use of a hydroxyapatite coating on the femoral component of this design for primary total hip arthroplasty.

To determine a preliminary profile of the variation in rehabilitation and home care services for patients with total joint arthroplasty (TJA) in Ontario in 2001.A cross-sectional survey was conducted of directors at the 43 regional community care access centers (CCAC).One-third (36%) of CCAC had existing care pathways, 54% had defined discharge criteria, and 32% had predetermined the length of home care services. The intensity and frequency of services provided were variable.There is a need to standardize rehabilitation protocols to maintain quality of care and contain costs.

Background contextIt is well accepted that total hip and knee arthroplasty (THA/TKA) for osteoarthritis (OA) is associated with reliable and sustained improvements in postoperative health-related quality of life (HRQoL). Although several studies have demonstrated comparable outcomes with THA/TKA after surgical intervention for lumbar spinal stenosis (LSS), the sustainability of the outcome after LSS surgery compared with THA/TKA remains uncertain.PurposeThe primary purpose of this study is to assess whether improvements in HRQoL after surgical management of focal lumbar spinal stenosis (FLSS) with or without spondylolisthesis are sustainable over the long term compared with that of THA/TKA for OA.Study designSingle-center, retrospective, longitudinal matched cohort study of prospectively collected outcomes, with a minimum of 5-year follow-up (FU).Patient samplePatients who had primary one- to two-level spinal decompression with or without instrumented fusion for FLSS and THA/TKA for primary OA.Outcome measuresPostoperative change from baseline to last FU in Short-Form 36 physical component summary (PCS) and mental component summary (MCS) scores among groups was used as the primary outcome measure.MethodsAn age, sex-matched inception cohort of primary one- to two-level spinal decompression with or without instrumented fusion for FLSS (n=99) was compared with a cohort of primary THA (n=99) and TKA (n=99) for OA and followed for a minimum of 5 years. Linear regression was used for the primary analysis.ResultsMean (percent) FUs in months were 80.5+16.04 (79%), 94.6+16.62 (92%), and 80.6+16.84 (85%) for the FLSS, THA, and TKA cohorts, respectively, with a range of 5 to 10 years for all three cohorts. The number of patients who have undergone revision including those lost to FU for the FLSS, THA, and TKA cohorts were n=20 (20.2%, same site [n=7] and adjacent segment [n=13]) requiring 27 operations, n=3 (3%, same site) requiring 5 operations, and n=8 (8.1%, same site) requiring 12 operations, respectively (p.1).ConclusionsSignificant improvements in HRQoL after surgical treatment of FLSS with or without spondylolisthesis and hip and knee OA are sustained for a mean of 7 to 8 years, with a minimum of 5-year FU. Despite a higher revision rate, patients undergoing surgery for FLSS can expect a comparable long-term average improvement in HRQoL from baseline compared with their peers undergoing TKA and to a lesser extent THA.