Highlights of Papers on Adult Reconstruction Knee Topics, Part 1
Risk of PJI in a TJA Patient with a History of Septic Arthritis in the Same Joint
If a patient has total joint arthroplasty (TJA) in a joint previously treated for septic arthritis, is the patient at higher risk for periprosthetic joint infection (PJI)?
That’s the question researchers from Cleveland Clinic and the University of Utah sought to answer, specifically looking to identify the incidence of PJI and risk factors for PJI in TJA patients with a history of treatment for native joint septic arthritis.
They included 62 patients who had undergone primary hip or knee replacement between January 2000 and December 2016 and who had a resolved infection in the same joint prior to surgery. Five patients (8%) developed a PJI at mean follow-up of 4.4 years. Only cigarette smoking had a statistically significant increased risk of PJI.
Although not statistically significant, PJI risk increased in patients with:
- Prior native joint septic arthritis in the knee compared with the hip
- Prior native joint septic arthritis caused by Staphylococcus aureus
- A diagnosis of diabetes mellitus
- Worse American Society of Anesthesiologists status
- Increasing Charlson comorbidity index adjusted for age
Sultan A, George J, Samuel LT, Faour M, Pelt CE, Anderson M, Klika A. Higuera Rueda CA Total Joint Arthroplasty in Patients with History of Treated Same-Joint Septic Arthritis: A Multicenter Investigation of Incidence and Risk Factors for Periprosthetic Joint Infection (Paper 013). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Sultan A, Mahmood B, Samuel LT, George J, Faour M, Pelt CE, Anderson MB, Klika AK. Higuera CA. Patients with a History of Treated Septic Arthritis are at High Risk of Periprosthetic Joint Infection after Total Joint Arthroplasty. Clin Orthop Relat Res. 2019 Mar 14. doi: 10.1097/CORR.0000000000000688. [Epub ahead of print].
Failures in Revision Total Knee Arthroplasty
Between 2005 and 2015, surgeon at Mayo Clinic performed more than 1800 aseptic revision total knee arthroplasty (TKA) procedures for aseptic loosening, instability, polyethylene wear and osteolysis, and periprosthetic fracture, with implant survivorship of 95% at 2 years, 90% at 5 years, and 81% at 10 years.
A total of 184 re-revision TKAs were performed during the study period. What went wrong with those knees?
According to researchers from Mayo Clinic, re-revision TKA was performed for:
- Aseptic loosening, 33%
- Infection, 23%
- Instability, 20%
- Periprosthetic fracture, 5%
- Extensor mechanism disruption, 5%
- Polyethylene wear, 2%
- Other reasons, 12%
The first 3 causes accounted for nearly three quarters of failed revision TKAs. The researchers said that improvements in implants that focus on reducing the risk of aseptic loosening, infection, and instability are needed.
Goldman A, Berry DJ, Abdel MP. Why are Contemporary Revision Total Knee Arthroplasties Failing? (Paper 091). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Isolated Polyethylene Exchange in TKA May Be Effective After All
Isolated polyethylene exchange (IPE) following total knee arthroplasty patients is an acceptable treatment for aseptic indications, with a 5-year reoperation rate similar to the reoperation rate for revision TKA overall, according to a study from the University of Utah.
The researchers included 155 IPEs performed between September 2000 and April 2014, 122 for aseptic indications and 33 for septic indications. Isolated polyethylene exchange was performed in aseptic knees for:
- polyethylene wear
- Patella fracture
- Patellar resurfacing
- Patellar maltracking
- Extensor mechanism failure
- Custom polyethylene for correction of valgus deformity
At 5 years, the cumulative reoperation rates were 41% for septic knees due to persistent infection and 12% for aseptic knees.
Duensing I, Pelt CE, Anderson M, Erickson J, Gililland J, Peters CL. Revisiting the Role of Isolated Polyethylene Exchange in Total Knee Arthroplasty (Paper 094). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
The Case for Not Revising the Patella in Revision TKA
A single-surgeon review indicates that revision of a resurfaced patella is unnecessary in patients undergoing aseptic revision total knee arthroplasty (TKA), unless the patella is loose, severely worn, or severely maltracking.
In a group of 121 patients (130 knees), the following revisions were performed:
- Both components, 51 knees
- Femur only, 6 knees
- Tibia only, 3 knees
- Polyethylene revision only, 70 knees
Five patients had a mismatch between a retained non-oval patella and new trochlear groove and 10 patients had patella polyethylene cold flow or wear.Even with the few mismatches and wear, no reoperations were performed on the patellas, nor were any of them at risk for failing, at a minimum follow-up of 5 years (range, 5 to 9 years). Sunrise view radiographs showed tilt beyond 10° in 6 patellas, but none were subluxed.
Dalury DF, Chapman DM. Ignore the Patella in Revision Total Knee Surgery (Paper 095). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
Rethinking Extended-Release Opioids as a Preemptive Analgesic before TKA
Routine administration of extended-release opioids right before primary total knee arthroplasty (TKA) does not appear to have the intended effect of reducing pain postoperatively and may, in fact, hinder recovery in the hospital, according to a study from Columbia University Medical Center in New York.
Extended-release opioids are often included – without good supporting data – in preemptive multimodal analgesia protocols implemented in the preoperative holding area prior to TKA, along with non-opioid analgesics such as acetaminophen and non-steroidal anti-inflammatory drugs.
In November 2017, surgeons at Columbia University Medical Center stopped using extended-release oxycodone in their preemptive multimodal analgesia protocol; the rest of the protocol remained the same. They compared outcomes – pain scores, opioid consumption, and ambulation distance with a physical therapist – in 153 patients pre-protocol change and 154 patients post-protocol change, finding worse outcomes in the pre-protocol change patients who had received extended-release oxycodone before surgery.
The pre-protocol change patients had higher pain scores on POD0, POD1, and POD2 and consumed more morphine equivalents while in the hospital than patients who had not received long-acting oxycodone before TKA surgery. What’s more, the oxycodone group could not walk as far as the non-oxycodone group on POD0, POD1, and POD2.
The researchers said that based on these findings, surgeons should rethink routine use of extended-release opioids as part of a preemptive multimodal analgesia protocol.
Cooper HJ, Lakra A, Maniker R, Hickermell TR, Shah RP, Geller JA. Preemptive Analgesia with Extended-Release Oxycodone is Associated with More Pain following Total Knee Arthroplasty (Paper 165). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
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