This chapter presents a case scenario of a 70-year-old gentleman who presents to orthopedic specialists' clinic for a preoperative appointment. He is scheduled to undergo a total knee arthroplasty (TKA) for debilitating multicompartmental osteoarthritis. Thromboembolic disease – specifically pulmonary embolism and deep vein thrombosis (DVT) – was once a common and morbid complication following TKA. Ongoing research has endeavored to determine the optimal prophylactic regimen to prevent thromboembolism following TKA. Acetylsalicylic acid may be the more appropriate option in patients at higher risk of bleeding or wound complications. Color doppler-compression ultrasound has emerged as the most sensitive and specific diagnostic modality to detect DVT, particularly after orthopedic surgery. The duration of required prophylaxis is a common inquiry posed by both patients and orthopedic surgeons. The chapter provides recommendations for implementing evidence-based practice in the clinical setting.

BACKGROUND:Prosthetic joint infections (PJI) can be devastating postoperative complications after total joint replacement (TJR). The role of decolonization of Staphylococcus aureus carriers prior to surgery still remains unclear, and the most recent guidelines do not state a formal recommendation for such strategy. Our purpose was to seek further evidence supporting preoperative screening and S aureus decolonization in patients undergoing TJR. METHODS:This was a quasiexperimental quality improvement study comparing a 5-year baseline of deep and organ-space PJIs (2005- 2010) to a 1-year intervention period (May 2015 to July 2016). The intervention consisted of nasal and throat screening for S aureus preoperatively and decolonization of carriers over 5 days prior to surgery. RESULTS:Prior to the intervention, we identified 42 deep and/or organ-space PJIs in 8,505 patients undergoing TJR (0.5%). S aureus was the causal microorganism in 28 of 42 (66.6%) cases. During the intervention, 22.5% (424 of 1,883) of patients were S aureus carriers. The PJI rate was similar overall (0.4%, 7 of 1,883; odds ratio, 0.75; 95% confidence interval, 0.34-1.67; P = .58), but there was a significant reduction in S aureus PJI to only 1 case during the intervention (odds ratio, 0.15; 95% confidence interval, 0.004-0.94; P = .039). CONCLUSIONS:Active screening for S aureus and decolonization of carriers prior to TJR was associated with a reduction in PJI due to S aureus, but no changes in overall PJI rates were observed.

The relationship between pain catastrophising and emotional disorders including anxiety and depression in patients with osteoarthritis (OA) undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between pain catastrophising, anxiety, depression and preoperative patient characteristics.A prospective cohort study of preoperative TJR patients at one centre over 12-months was conducted. We examined association between catastrophising, anxiety, depression and preoperative patient characteristics including demographics, pain and function. Pain catastrophising was assessed using the Pain Catastrophising Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D). Patient perceived level of hip/knee pain was measured using a visual analogue (VAS) pain scale. Patient perception of function was measured using the Oxford Score. Preoperative radiographic grading of OA was determined using the Kellgren and...

Background: The diagnosis and treatment of prosthetic joint infection (PJI) remains challenging. In 2013, both the Infectious Diseases Society of America (IDSA) guidelines and an international consensus’ recommendation on PJI were published, providing a consistent approach to PJI management. We undertook a study to compare outcomes of PJI managed in accordance with IDSA versus those managed outside of the same. Methods: This retrospective cohort study of a consecutive series of patients who had total joint replacement (TJR) with subsequent deep PJI was undertaken to determine historical clinical variation relative to recently established management guidelines. All operations were completed at one arthroplasty center over a 5-year period predating IDSA guideline development. Results: Of 8505 patients who had TJR, 267 (3.1%) were diagnosed with subsequent PJI. Of these, 42/8505 (0.5%) had culture positive deep PJI, with 38/42 (90.5%) managed surgically. The odds of treatment failure among cases not managed in accordance with IDSA were 11 times greater as compared to guideline-accordant cases (OR 11, 95%CI 1.84-65.7; P=0.006). This difference was most pronounced among those who had irrigation and debridement. We could not demonstrate any significant difference in treatment success or failure for one-stage or two-stage exchange. Conclusions: Surgical management of PJI in accordance with existing guidelines can optimize success of PJI treatment. In particular, aggressive surgical treatment (including prosthesis removal) is likely warranted in patients who had symptoms of PJI for longer than 3 wk. In a patient in whom deviation from existing guidelines is considered, it is important for physicians to weigh the risk of inferior outcome and counsel the patient accordingly.

Background: A cross-sectional study of total knee arthroplasty (TKA) patients was conducted to determine the association of lower-extremity arterial calcification (LEAC) with acute perioperative cardiovascular events (CVEs). Methods: Regression modeling was used to examine the association of radiographic presence of LEAC and acute myocardial infarction (MI), perioperative CVE, 30-day CVE readmit, and 30-day and 1-year mortality. Results: Of 900 TKA patients, LEAC was identified in 21.1%. Of LEAC cases, 1.6% had an acute MI vs 0.1% of non-LEAC cases (P = .031). Perioperative CVE rate was 5.8% for LEAC vs 1.5% for non-LEAC (P = .002). Having LEAC was identified as a significant risk factor for a perioperative CVE (odds ratio [OR] 2.83; 95% confidence interval [CI] 1.09-7.35). Because of limited number of acute MI events, absence of 30-day CVE readmit, 30-day mortality, and few 1-year mortality events, computing OR for these was not possible. Likewise, because of small number of events (n = 3), estimates for the odds of LEAC cases having an acute MI are less reliable, yielding extremely large random errors (OR 11.37; 95% CI 0.09-597.93) and must be interpreted with caution. The OR for 1-year mortality was 1.88 (95% CI 0.17-13.20), but again with large random errors. Conclusion: Our study shows that LEAC around the knee is associated with an increased risk of having a perioperative CVE. Crude radiographic detection of LEAC around the knee has the potential to improve risk stratification for TKA patients by informing the surgeon of the need for further preoperative cardiac workup. (c) 2017 Elsevier Inc. All rights reserved.

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.

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.

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.

Background:While total joint replacement (TJR) is reserved for end-stage osteoarthritis (OA), a greater proportion of OA sufferers require nonsurgical treatment. Given the importance of primary healthcare physicians (PHCPs) in managing patients with OA, we surveyed local PHCPs to ascertain their perceptions and practice patterns regarding hip and knee OA management.Methods:A PHCP survey was developed to determine OA management practices within our region. Responses were analyzed using descriptive statistics. Response variance by practice duration (< 15 yr compared with >= 15 yr) was explored.Results:A total of 265 (34%) PHCP surveys were received. PHCPs in practice fewer than 15 yr had a significantly greater proportion of patients with hip and knee OA than those in practice for longer than 15 yr (22% compared with 17%, P < 0.0001). PHCPs agreed that radiographs are crucial in the decision for specialist referral (7/10), placing a higher value or utility on nonweightbearing radiographs for a knee OA diagnosis (87%). Mean comfort with discussing TJR indications and contraindications was 6/10 and was slightly higher than discussing postoperative-TJR course (5.7/10). Top treatments were weight loss, low-impact exercise, and oral nonsteroidal antiinflammatory drugs, with PHCPs in practice for fewer than 15 yr assigning higher value or utility to more holistic treatments.Conclusions:There is discordance in the conservative management of hip and knee OA, variability in nonsurgical management comfort level, and a knowledge gap in value and utility of plain radiographs within OA management algorithms among PHCPS. While younger PHCPs are in favor of earlier intervention and practice a more holistic symptom management approach, senior PHCPs stressed greater importance of traditional treatment. With the role of the PHCP shifting from surgical gatekeeper to patient navigator, future efforts aimed at helping facilitate this role are needed.

Introduction Knee OA is the leading cause of pain and disability and half of people with knee OA experience significant pain that hinders daily activities. In the assessment of knee OA pain, the current focus is on pain intensity and associated disability, suggesting that the assessment of one dimension will reflect the other dimensions of chronic knee OA pain adequately. However, current studies dispute this assumption by showing fair correlation between scores on unidimensional disease-specific pain questionnaires and multidimensional ones. Appropriate pain measurement is critical to guide clinical decision-making. However, iti?½s been reported that no attempt has been made to ask patients with pain about whether current outcome measures are meaningful or whether the instructions, anchors or items included in the scales are capturing their pain experience adequately. The objective of this study is to determine if people with knee osteoarthritis (OA) prefer one of three self-report pain measures addressing different pain dimensions to represent their pain experience. Secondary objectives were to examine the correlation among measures and burden of completing these measures. Method Participants attending an orthopaedic outpatient clinic aged 40 y or older having idiopathic knee OA pain, minimal pain in other body parts, fluent in English, and cognitively competent were recruited for our cross sectional study. All consenting participants completed a demographic form and three pain measures were administered in a pre-determined order. The pain measures included 1) a generic, 11-point, single-item measure (Verbal Numeric Rating Scale, VNRS, maximum score = 10) asking about average pain intensity in the study knee in the past 24 hours; 2) a disease-specific, multi-item questionnaire (Intermittent and Constant Osteoarthritis Pain Questionnaire, ICOAP, maximum score = 44) asking about intensity and consistency of pain in the study knee over the past week; and 3) a generic, multi-item questionnaire (Short-Form McGill Pain Questionnaire-2, SF-MPQ-2, maximum score = 10) asking about somatic and affective dimensions of pain in the study knee over the past week. Higher scores indicate worse pain for all measures. After completing each measure, participants were asked how the measures fit their pain experience (FIT) by rating how well the pain measure described their experience of pain by placing a horizontal mark on a 10 cm FIT visual analogue scale where 0 = i?½Does not describe my pain at alli?½ and 100 = i?½Describes my pain completelyi?½. FIT scores for the three measures were compared using Freidmani?½s nonparametric repeated measures analysis of variance test. Associations between raw scores on the three pain measures were tested using Spearman rho correlation (rs). Findings 96 participants (57 females) had a mean (SD) age of 63.8(9.4) yr. The median of FIT score for the VNRS, ICOAP and SF-MPQ-2 was 7.5, 7.4, and 7.8cm, respectively, and did not differ (I?2 (2, N = 96) = 1.288, P = 0.5). The included participants had moderate knee OA pain intensity (median (IQR) score =6(5), 23(14.5), 2.4(3) for VNRS, ICOAP and SF-MPQ-2). Scores on the three measures were similarly associated (VNRS and ICOAP: rs=0.73(0.62, 0.81); VNRS and SF-MPQ-2: rs=0.69(0.56, 0.78); ICOAP and SF-MPQ-2: rs=0.70(0.58, 0.79). Conclusion: All three pain measures describe knee OA pain experience to a similar degree and scores were only moderately correlated. Differences in the pain attributes assessed may explain the finding that no one measure represented the experience of knee OA pain better than the other measures in our study sample.

BACKGROUND:We conducted a cross-sectional study of primary total joint replacement (TJR) patients to determine predictors for prolonged length of stay (LOS) in hospital to identify patient characteristics that may inform resource allocation, accounting for patient complexity.METHODS:Preoperative demographics, medical comorbidities and acute hospital LOS from a consecutive series of primary TJR patients from an academic arthroplasty centre were abstracted. We categorized patients as LOS of 3 or fewer days, 4 days, or 5 or more days to align results with varying LOS benchmarks. To identify predictors for LOS, we used a generalized logistic regression model fitted on an LOS ternary outcome, using LOS of 3 or fewer days as a reference category.RESULTS:The sample included 1459 patients: 61.7% total knee and 38.3% total hip. Male sex was predictive of an LOS of 3 or fewer days (4 d: odds ratio [OR] 0.48, 95% confidence interval [CI] 0.364-0.631; ≥ 5 d: OR 0.57, 95% CI 0.435-0.758), as was current smoking status (4 d: OR 0.425, 95% CI 0.274-0.659; ≥ 5 d: OR 0.489, 95% CI 0.314-0.762). Strong predictors of prolonged LOS included total hip versus total knee arthroplasty, age 75 years or older, American Society of Anesthesiologists classification of 3 and 4 and number of cardiovascular comorbidities.CONCLUSION:Not all patients undergoing TJR are equal. The goal should be individual patient-focused care rather than a predetermined LOS that is not achievable for all patients. Hospital resource planning must account for patient complexity when planning future bed management.

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 (TM) (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 31 in 33.3% of cases, while sagittal alignment differed more than 31 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.

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.

Lower extremity osteoarthritis with concomitant low-back pain (LBP) may obscure a clinician's 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.

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.

Given institutional pressures to reduce hospital length of stay (LOS) we hypothesized that "failure to cope" would be a significant factor for readmission following total joint arthroplasty (TJA). A retrospective review of 4288 TJA patients was conducted to determine readmission rates and reasons for readmit within 30 days of discharge. Ninety-five patients (2.2%; 95% CI: 1.8%-2.7%) were readmitted. Leading diagnoses were surgical site infection (23.2%) and cardiovascular event (16.8%). Of readmits 5.3% (5/95) were readmitted for failure to cope, representing 0.1% of the sample. In multivariate analysis, increased age was a significant predictor of readmission (OR = 0.974, 95% CI 0.952-0.997). Contrary to our hypothesis failure to cope was not a leading diagnosis for readmission; concerns remain that early discharge may however correlate with increased readmit rates.

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.

A 42-item survey was developed and administered to determine patient perception of and satisfaction with total hip arthroplasty (THA) vs total knee arthroplasty (TKA). A total of 153 patients who had both primary THA and TKA for osteoarthritis with 1-year follow-up were identified. Survey response rate was 72%. Patients were more satisfied with THA meeting expectations for improvement in function and quality of life (P < .05), whereas pain relief expectations were equivalent. Most patients (70.9%) reported that TKA required more physiotherapy. One-year Oxford score and improvement in Oxford score from preoperative to 1 year were superior for THAs (P = .000). Despite equivalent pain relief, THAs trend toward higher satisfaction compared with TKAs. THA is more likely to “feel normal” with greater improvement in Oxford score. Recovery from TKA requires more physiotherapy and a longer time to achieve a satisfactory recovery status. Patients should be counseled accordingly.

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.

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.