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Use of Antibiotic Lavage in Total Knee Replacement to Prevent Postoperative Infection

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Purpose

To determine the effectiveness of using antibiotic lavage in preventing postoperative infections in total knee replacement (TKR) patients.

Methods

Data on all patients who underwent TKR, either primary or secondary, during the period from May 2015 to April 2019 were collected. Many factors (both patient-related and surgery-related) that can increase the risk of surgical site infection (SSI) were taken into consideration to eliminate confounding factors.

Results

A total of 685 patients were identified; out of those, 232 patients received intraoperative antibiotic lavage and 453 did not. We noted that out of all 13 patients who developed SSI, only one patient (7.7%) had received antibiotic lavage, while the other 12 (92.3%) patients did not receive antibiotic lavage. However, the difference was not statistically significant (p=0.078).

Conclusion

Using intraoperative vancomycin lavage was associated with a decrease in the incidence of SSI post-TKR, but the difference was not statistically significant. However, more studies are needed in this area.

Introduction

Lower limb arthroplasty is a common surgical procedure performed on a daily basis, especially total knee replacement (TKR). In 2030, the estimated number of TKR cases in the USA will be 3.48 million [1]. The implantation of a large foreign body increases the risk of a deep surgical site infection (SSI) and emerges the need for effective perioperative strategies. Prosthetic joint infections (PJI) are one of the most feared complications in orthopedic surgery. Even with antiseptic techniques, SSI and PJI are common complications after orthopedic surgery, which might lead to unpleasant and unfavorable consequences such as a higher rate of prosthesis failure, hospitalization, and morbidity [2,3]. There are a multitude of risk factors that are attributed to the increased chance of the development of SSIs and PJIs. Most risk factors are attributed to host factors like the presence of underlying diseases such as obesity, diabetes mellitus (DM), rheumatoid arthritis, preoperative anemia, and cardiovascular diseases [4-11]. Surgical factors can also increase the risk of infection with longer operative duration and hospital stay [12-17]. Also, Minnema et al. and Wymenga et al. suggested that a high American Society of Anesthesiologists score contributes to the development of SSIs [18,19].

Infection is a devastating complication that bothers both orthopedic surgeons and patients. It can have a big impact on health care costs and length of stay; that is why many surgeons consider intraoperative antibiotic use as an important step in reducing the infection rate in TKR; however, it still remains controversial internationally [11]. The prevention of PJIs and SSIs mostly depends on controlling patients’ underlying diseases and optimizing their condition. In a study conducted on diabetic patients, it was found that regardless of the diabetes type, if the blood sugar was uncontrolled, it doubled the infection rate and led to a significant increase in surgical complications and an increase in the mortality rate [9]. Despite guideline recommendations, several studies explored the use of intraoperative antibiotics such as vancomycin, which has shown the ability to reduce the infection rate by up to 50% and was found to be highly effective in the reduction of SSIs [20,21]. However, Brown et al. showed that the use of antibiotics has no benefit over normal saline in wound irrigation [22]. For an antibiotic agent to be used during irrigation, it should possess a broad spectrum of antimicrobial activity, be used frequently, be used with pulsatile lavage systems, and be left in the wound for approximately one minute before removal [23]. In this study, we attempted to determine whether the use of antibiotic lavage in TKR can reduce postoperative infection.

Materials & Methods

Setting and study population

Approval from the institutional review board at King Saud University – College of Medicine was obtained prior to starting the study. The study was also conducted according to the principles of the Helsinki Declaration. This is a retrospective observational study conducted from May 2015 to April 2019 at King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia. We included all patients who underwent either primary or secondary TKR during the study period. All data were extracted from the KSUMC electronic database using surgical terminology codes, and patients were then subdivided into two groups: patients receiving intraoperative antibiotic lavage and patients not receiving antibiotic lavage intraoperatively.

All patients received standard antibiotic prophylaxis with 2 g of cefazolin IV 30 minutes preoperatively. The antibiotic group received a lavage consisting of 2 g of vancomycin powder diluted in 2 L of normal saline (1000 mg/1 L) and irrigation was done after the installation of the prosthesis during the cementation period for around 15 minutes prior to the closure of the capsule. The dose of vancomycin is based on the current literature, which shows a safe and minimal toxic effect of vancomycin on osteoblast replication at the cellular level with a concentration of 1000 mcg/ml or less [24]. The no-antibiotic group received 2 L of normal saline irrigation alone after the installation of the prosthesis and prior to the closure of the capsule. In the postoperative period, all patients from both groups received a standard dose of 1 g of cefazolin for three doses. Patients were followed up in the clinic from two weeks to six months after the surgery. Surgical wounds were checked in every visit, and clips and sutures were removed two weeks postoperatively.

Data collection

Many factors (both patient-related and surgery-related) can increase the risk of SSI; thus, we collected further information on demographics, the patient’s comorbidities, surgical procedural duration, antibiotic prophylaxis use pre and postoperatively, type of procedure (unilateral or bilateral TKR), and whether the patient had an intraoperative or postoperative complication and if they developed an infection.

Data analysis

The analysis was performed using Statistical Package for Social Sciences version 22.0 software (SPSS, Inc., Chicago, IL, US) to determine the demographics and the value of using vancomycin lavage intraoperatively. Categorical data were expressed using frequency and percentage. A chi-square and Fischer’s exact test were used to compare the categorical data for the two groups: those who took an antibiotic and those who did not. We assumed statistical significance when the p-value was less than 0.05.

Results

The sample size of our study was 685 and included all patients who underwent primary TKR during our set study period from May 2015 to April 2019. Those patients were divided into two groups. The groups were determined by whether they received antibiotic lavage intraoperatively or not. The number of patients who did not receive antibiotic lavage intraoperatively was 453 (66.1%), and the number of patients who received vancomycin lavage intraoperatively was 232 (33.8%). Most of our patients were female: 351 of those who did not receive antibiotics were female (77.5%), and 117 of those who did receive them were also female (50.4%) (Table 1).

Variable Value No antibiotic lavage given (n = 453) Antibiotic lavage given (n = 232) P-value OR (95% CI)
Gender Male 102 (22.5%) 115 (49.6%) 0.416 1.21 (0.76, 1.94)
Female 351 (77.48%) 117 (50.4%)
Age ≤50 years 22 (4.85%) 13 (5.6%) 0.675 0.86 (0.42, 1.74)
>50 years 431 (95.14%) 219 (94.39%)
Duration of surgery ≤120 min 99 (21.85%) 27 (11.63%) 0.001 2.12 (1.34, 3.36)
>120 min 354 (78.14%) 205 (88.36%)
DM 209 (46.13%) 92 (39.65%) <0.0001 1.97 (1.41, 2.76)
HTN 255 (56.29%) 129 (55.6 %) 0.020 1.48 (1.06, 2.07)
Hypercholesteremia 170 (37.52%) 85 (36.63 %) 0.017 1.51 (1.08, 2.11)
Smoking 5 (1.1%) 5 (2.155%) 0.662 0.76 (0.22, 2.64)
Cancer 14 (3.09%) 11 (4.74 %) 0.908 0.95 (0.42, 2.14)
RA 21 (4.63%) 18 (7.75 %) 0.610 0.84 (0.44, 1.62)
Obesity 363 (80.13%) 194 (83.62 %) 0.289 0.80 (0.52, 1.21)
Infectious diseases 23 (5.07%) 9 (3.87 %) 0.099 1.94 (0.88, 4.29)
Enteropathies 68 (15%) 42 (18.10 %) 0.451 1.18 (0.77, 1.81)
Table
1: Summary of demographic data and risk factors

BMI: body mass index, DM: diabetes mellitus, HTN: hypertension, RA: rheumatoid arthritis.

When further evaluating the efficacy of the antibiotic lavage among those who underwent TKR, we noted that using the antibiotics lavage in those who underwent TKR replacement did not significantly reduce infections postoperatively. Out of our entire sample size of 685, only 13 had infections. Twelve of those patients were among the group who did not receive antibiotics (6.18%); the remaining one was from the other group (0.43%) (p=0.078) (Table 2).

Variables No antibiotic lavage given (n = 453) Antibiotic lavage given (n = 232) P-value OR (95% CI)
Location Unilateral 364 (80.35%) 159 (68.53%) 0.308 1.27 (0.80,1.99)
Bilateral 87 (19.2%) 30 (12.93%)
Infection 12 (6.18%) 1 (0.43%) 0.078 6.29 (0.81,48.64)
Intraoperative complications 10 (2.2%) 10 (4.3%) 0.131 0.50 (0.21,1.23)
Postoperative complications 40 (8.83%) 31 (13.36%) 0.064 0.62 (0.38,1.03)
Table
2: Summary of operative data

Of all patients, 650 (94.9%) were above the age of 50, which constitutes the majority of patients in both groups, 431 (95.14%) and 219 (94.39%), respectively (p=0.675).

Discussion

This is the first study, to the best of our knowledge, in Saudi Arabia to report the effect of the use of antibiotic lavage in TKR to prevent postoperative infection. Our study found that the infection rate was 1.89% in all patients (those with and without antibiotics) and showed a non-significant decrease in the incidence of SSI post-TKR (P=0.078). A similar study done by Conroy et al. showed no benefit from the use of antibiotic solutions over normal saline [25]. On the other hand, after the administration of diluted betadine lavage, the rate of infection was reduced from 0.97% to 0.15%, with a significant difference in the rate of infection (p = 0.04). Diluted betadine 10% solutions were found to decrease postoperative infectious complications in orthopedic procedures, including postoperative infections in TKR, in other studies and in other types of surgeries, with minimal side effects [26-28]. Betadine use was found to be a safe and inexpensive choice that is present in almost all operating rooms [27] and can be cost-effective in preventing infections in TKR [29].

Other studies have achieved a drop in the rate of infection by using a high concentration of antibiotics at the time of implant insertion, even with prolonged operation times or in revision procedures [21,29]. A meta-analysis that included 15 studies in different surgical specialties showed that the use of prophylactic antibiotic lavage was found to be effective over the use of saline, water, or no irrigation in 10 studies, while the other five showed no difference [30].

According to our findings, there was no association between the comorbidities or patient-related factors and the increase in infection rate except for DM, which was controlled by multivariate analysis. This is similar to a study conducted on diabetic patients, which found that if the blood sugar was uncontrolled, it doubled the infection rate in patients after total joint arthroplasty [9].

Limitations of the study

There are a couple of weaknesses in our study. First, this is a retrospective cohort study, which is subjected to inconsistency when it comes to the process of data collection. However, the prospective nature of our data collection may have played a role in reducing recall and selection bias. Second, the small sample size of our study, which included only 685 patients.

Conclusions

Using intraoperative vancomycin lavage was associated with a decreased incidence of SSI post-TKR, but there was no statistically significant difference. The multivariate analysis, after adjusting other variables in the model, showed that only DM was independently related to the outcome. For the establishment of a gold standard in intraoperative prophylactic antibiotic lavage, we recommend that a prospective randomized control trial aiming to prevent postoperative infections be conducted. That would eliminate all questions and show the difference in costs and antibiotic use’s adverse effects.

Originally Appeared Here

Putting Your Best Foot Forward for Joint Surgery Success

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More than 1.25 million Americans will undergo knee or hip replacement surgery every year. And while most will report a dramatic improvement in their quality of life following recovery, some will experience a rougher road to recovery than others.

Joint replacement surgery can decrease pain and improve mobility. Patients can increase the success of the procedure by following expert advice during recovery.

If you or someone you care about is thinking about joint replacement surgery, experts say that there are steps you can take to make your recovery smoother and your procedure even more successful.

“The best thing for a good outcome after elective joint replacement surgery is to be informed and prepared,” says Dr. Elizabeth Desmond, orthopedic surgeon at Dignity Health Sierra Nevada Memorial Hospital. “It is important to have a good understanding and reasonable expectations of your operative and post-operative course.”

Dr. Desmond says the key is to ask questions early on in the process.

“You should ask how long you will be in the hospital (some joint replacements are done as an outpatient, others with a very short hospital stay),” she explains. “You should also have a discussion about pain management and you should have your home set up ahead of time for your needs, including having any needed assistive devices available.”

Dr. Desmond says patients should approach the pain management conversation with the goal of minimizing their use of opiate medications as much as possible. And regarding the home set up, she recommends minimizing stair use and planning ahead to ensure needed items are within each.

Recommended assistive devices may include a walker, a shower chair, a raised toilet seat, a bedside commode, or anything else your physician believes may be useful during your recovery.

Once your joint replacement surgery is complete and you’re back home, it’s important to remember that the work has only just begun. How you rehabilitate your joint will help to determine how your recovery goes and how successful your procedure ultimately is.

“The repeated goal at all stages is rehabilitation,” Dr. Desmond says. “The reason patients choose to have joint replacement is due to pain and a loss of function. The best way to ensure a good outcome is to participate in therapy/rehab and follow the specific activity restrictions and recommendations you have been given.”

While it may seem counterintuitive, Dr. Desmond says it is important to begin moving and walking as soon as possible after joint and hip replacement surgery.

“There will be some pain and discomfort, but delaying your rehab only makes recovery longer and more difficult,” she explains.

For the first couple days after surgery, Dr. Desmond says patients should focus on adequately controlling their pain (ideally a combination of non-narcotic and narcotic pain medications) and working with their physical therapist.

Then, one to two weeks following surgery, the focus should be on progressing with physical therapy rehabilitation.

“Do your assigned exercises as prescribed and wean off of narcotic pain medications,” Dr. Desmond says. “Ideally at this point you should stop taking narcotic pain medication if possible.”

One to two months out from surgery, the focus should continue to be strengthening the joint through rehabilitation with physical therapy.

“If you were given any specific activity or motion restrictions, these should be coming to an end at 6-8 weeks, which will make your rehab progress even better,” Dr. Desmond explains.

Throughout your recovery, you should keep an eye on your incision and the joint itself. Infections can happen and should be treated quickly.

The most common signs of infection are fevers, chills, night sweats, redness, increasing swelling, discharge or a foul smell around the wound.

Another complication that is infrequent but would need to be addressed quickly is a blood clot or pulmonary embolism, which may cause leg swelling, calf pain/cramping/soreness, shortness of breath, chest pain that worsens when you take a deep breath or cough, rapid breathing, or rapid pulse. Immediately contact your doctor if those symptoms are present.

In general, Dr. Desmond says patients should expect to be gradually improving following joint replacement surgery.

“There will be days that are worse than others, but the trajectory should be that of improvement,” she says. “Any changes that worsen and do not improve with rest or elevation should be reported and evaluated.”

If you are fortunate enough to have a spouse, family member of friend around to help you recover following joint surgery, they can help to increase the success of your procedure too.

“Having someone present is very important,” Dr. Desmond says. “The patient will need help with many basic tasks, from transportation, prescription pick up, changing dressings, food preparation, etc. The partner can help to ensure that the patient is taking all of the prescribed medications at the appropriate intervals and is aware of any signs of common complications.”

Finally, Dr. Desmond wants people to know that in general, joint replacement surgery is very successful in addressing issues of joint pain and decreased mobility.

“The important thing to remember is that the improvement will not happen all at once,” she says. “Most patients will take at least three months to return to their basic, daily, non-strenuous activities. Full recovery and strength can take up to six to 12 months. In the end, the vast majority of patients have a significant improvement in their quality of life.”

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Can Metformin Lower Need for Joint Replacement in Diabetes?

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Metformin may help reduce risk for total joint replacement in patients with type 2 diabetes (T2D), data suggest.


Dr Changhai Ding

Over a 24-month follow-up period, metformin use was associated with a 30% decrease in the risk of total knee and hip replacements, according to Changhai Ding, MBBS, MMed, MD, associate director of the Menzies Institute for Medical Research at the University of Tasmania in Hobart, Australia, and colleagues.

“Randomized controlled clinical trials in patients with osteoarthritis are warranted to determine whether metformin is effective in decreasing the need for joint replacement,” wrote the investigators.

Their findings were published online December 19 in the Canadian Medical Association Journal.

Low Doses Beneficial

The investigators identified patients diagnosed with T2D from 2000 to 2012 in the Taiwan National Health Insurance Research Database and compared those who used metformin with those who did not. They used prescription time-distribution matching and propensity-score matching to balance potential confounders between users and nonusers.

The study included 20,347 metformin-treated participants and 20,347 nonusers. The mean age at baseline was 63 years, and 49.8% of participants were women. Metformin users tended to have more severe diabetes. Common comorbidities in the cohort included hypertension and hyperlipidemia, but only about 16% in both groups had osteoarthritis. At baseline, participants also used various analgesics, as well as other diabetes drugs ranging from sulfonylureas to insulin.

Compared with nonusers, metformin users had had a 30% lower risk of total knee or hip replacement (adjusted hazard ratio [HR], 0.70). The incidence of total knee replacement among metformin nonusers and users was 4.15 per 10,000 person-months and 2.96 per 10,000 person-months, respectively. The incidence of total hip replacement was 0.83 per 10,000 person-months in nonusers and 0.44 per 10,000 person-months in users.

By joint type, the adjusted HR was 0.71 for total knee replacement and 0.61 for total hip replacement among metformin users.

The effect was observed at daily doses of less than 1 g, as well as daily doses of 1 g or more. “This suggests that metformin at a lower dosage could have effects on osteoarthritis,” Ding told Medscape Medical News. “Metformin is a safe, well-tolerated oral medication, even at higher but routinely used dosages. Therefore, for initial clinical trials, we still recommend the efficacy of metformin at routine dosages on knee osteoarthritis. If the effects are confirmed, we may explore whether a lower dosage of metformin is effective.”

Similar results emerged from propensity-score matching analyses and sensitivity analyses of 10,163 participants in each treatment group using inverse probability-of-treatment weighting and competing risk regression.

The biological mechanisms linking metformin and osteoarthritis have yet to be clarified, Ding explained. “Multiple mechanisms may be involved, including anti-inflammation, sustaining adenosine 5′-monophosphate-activated protein kinase activity in chondrocytes and dorsal root ganglia, and regulating metabolism.”

A previous study suggested an association between metformin and reduced annual loss of medial cartilage volume, and another found an association between metformin and reduced joint replacement surgery, said Ding. But another study reported no significant association between metformin use and osteoarthritis risk in patients with T2D. Recently, a retrospective cohort study by Li et al found that metformin users with diabetes had a 19% lower risk for total knee replacement than nonusers.

Ding’s group has begun a randomized clinical trial to see whether metformin can alleviate tibiofemoral cartilage volume loss in overweight patients with osteoarthritis.

No Uniform Indications

Commenting on the current findings for Medscape, Grace Hsiao-Wei Lo, MD, an assistant professor of immunology, allergy, and rheumatology at Baylor College of Medicine in Houston, Texas, called the observational study “thought-provoking.” She had concerns about the way it was conducted, however, including the potentially problematic features of the small percentage of the T2D cohort who had osteoarthritis. Another concern was the fact that the investigators only examined metformin, although patients used various other diabetic and analgesic drugs that might have had an effect. Metformin’s effect on osteoarthritis may result partly from its modest weight-loss effects, said Lo, who was not involved in the study.



Dr Grace Hsiao-Wei Lo

“Another issue with the study is that there is no set indication of the need for total knee or hip replacement. Each surgeon has a different standard,” she added. “And there’s lots of evidence that replacements are largely dependent not on need but on the interest of participants. “So, it’s not necessarily that a patient needs total joint replacement, it’s that they want it.”

Observational studies like this one are a long way from getting us to the prescribing of metformin specifically to prevent or mitigate osteoarthritis, David T. Felson, MD, MPH, a rheumatology researcher and a professor of medicine at Boston University, Boston, Massachusetts, told Medscape. Felson was not involved in the study.



Dr David Felson

“The drug’s mechanisms in osteoarthritis are still unclear. Its effect may be related to adenosine 5′-monophosphate-activated protein kinase activity,” he said. “The drug has pleiotropic effects and is safely used to treat other diseases such as polycystic ovarian syndrome. It may have antisenescence properties, since it’s been shown to extend life a bit in animals.” That said, Felson added, “Like statins, it’s not going be added to the drinking water anytime soon!”

This study was supported by the National Natural Science Foundation of China, Guangzhou Science and Technology Program, Guangdong Basic and Applied Basic Research Foundation, and Wu Jieping Medical Foundation Program. Ding, Lo, and Felson reported no competing interests.

CMAJ. Published online December 19, 2022. Full text.

Diana Swift is a freelance medical journalist based in Toronto, Ontario, Canada.

For more news, follow Medscape on  Facebook,   Twitter,   Instagram, and  YouTube.


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Patients with late-stage knee OA incur high costs for nonoperative treatments before total knee arthroplasty

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In the year before total knee arthroplasty (TKA), patients incur considerable costs for nonoperative treatments and other procedures for osteoarthritis (OA) – raising questions about the value of those procedures, reports a study in The Journal of Bone & Joint Surgery. The journal is published in the Lippincott portfolio in partnership with Wolters Kluwer.

The study shows “substantial variation in the type and cost of nonoperative procedures for patients with late-stage knee OA prior to TKA,” according to the report by Eric L. Smith, MD, of New England Baptist Hospital, Boston, and colleagues.

Estimated costs of $2.4 billion over 3 years for nonoperative procedures before TKA

Using nationwide commercial insurance databases, the researchers analyzed claims for nearly 24,500 patients who underwent primary TKA in 2018 and 2019. The study examined the types and costs of nonoperative procedures in the months leading up to TKA.

Average costs for nonoperative procedures in the year before TKA were $1,355 per patient. Knee imaging studies were the most common procedure overall, performed in about 96% of patients. Intra-articular steroid injections were the most frequent treatment procedure, performed in 54%. Bracing was the least common nonoperative treatment, performed in approximately 8% of patients.

Intra-articular injection of hyaluronic acid, excluding professional administration fees, was the most costly procedure: performed in about 13% of patients, it made up 10% of total costs. By comparison, steroid injections were performed in more than half of patients, but accounted to just over 1% of costs. Physical therapy was used in about 27% of patients and accounted for about 17% of costs.

Most patients underwent at least two nonoperative treatments, while more than one-third underwent three or more. Costs increased with time between diagnosis and surgery, exceeding $2,000 in patients with a 12-month duration before undergoing TKA.

Women had higher total costs for nonoperative treatment, with the greatest differences in physical therapy and prescription of nonsteroidal anti-inflammatory drugs. Men had higher costs for opioids. Procedures and costs also varied by region, with the Northeast region having the highest average cost ($1,740).

TKA is a highly effective and cost-efficient treatment for knee OA. The researchers note that decisions about TKA can be “extremely complicated,” involving factors related to patients, providers, and insurers. For example, insurers may require some period of nonoperative treatment before authorizing coverage for TKA. With the national focus on reducing costs while delivering high-value care, the requirement of nonoperative treatment in the months before TKA warrants evaluation.

Extrapolated to the 600,000 TKAs performed each year in the United States, the total costs of nonoperative treatment are estimated at $2.4 billion over a 3-year period and are likely to increase in the future. The authors point out some limitations of their study, mainly related to the use of insurance claims data.

“For patients who eventually undergo TKA, the cost-effectiveness of these nonoperative treatments right before TKA needs to be carefully considered as the health-care system transitions toward a value-based model,” Dr. Smith and coauthors conclude. They also note that some nonoperative treatments – for example, intra-articular steroid or hyaluronic acid injections or bracing – do not have strong evidence of effectiveness. The researchers call for further studies focusing on the benefits of nonoperative treatments at different stages of knee OA.

Source:

Journal reference:

Nin, D.Z., et al. (2022) Costs of Nonoperative Procedures for Knee Osteoarthritis in the Year Prior to Primary Total Knee Arthroplasty. The Journal of Bone and Joint Surgery. doi.org/10.2106/JBJS.21.01415.

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A Road to Recovery After Knee Surgery: 6 Tips to Follow

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Recovery from knee surgery can be full of ups and downs, but there are steps you can take to make the process as smooth as possible.

We find that patients who know what to expect and are proactive in their recovery tend to do better overall. With that in mind, here are six tips to follow in your recovery after knee surgery.

1. Get Plenty of Rest

Get_Plenty_of_Rest.png

Most people know that getting a good night’s sleep is essential for feeling rested and alert the next day, but few realize just how important it is for recovering from surgery. This doesn’t mean you have to stay in bed all day – although you should take it easy for the first few days – it does mean getting enough sleep at night and taking periodic naps during the day.

Good rest is crucial for healing because it gives your body the time it needs to repair the damage from surgery. When you’re well-rested, you’ll also have more energy for physical therapy and other essential activities for recovery. The recovery timelines for patients who get adequate rest are usually shorter than for those who don’t. So, make sure to get your ZZZs.

2. Eat a Nutritious Diet

As with sleep, eating a nutritious diet is vital for everyone but especially crucial for people recovering from surgery. A healthy diet will give your body the nutrients it needs to heal properly and fight infection. It’s also essential to avoid constipation, which can be a problem after surgery due to pain medication and inactivity.

Eat_a_Nutritious_Diet.png

To stay on top of your nutrition, eat plenty of fruits, vegetables, and whole grains. These foods are packed with vitamins, minerals, and fiber that will help keep your digestive system moving and your body healthy. It would help if you also drank plenty of water to stay hydrated.

3. Stay Active

It may seem counterintuitive, but staying active is vital for recovery after knee surgery. Of course, you shouldn’t overdo it – too much activity can delay healing – but getting some gentle exercise will help keep your joints mobile and prevent stiffness. Physical therapy is a great way to get the proper exercise for your needs.

Walking is another excellent way to stay active while recovering from knee surgery. Just be sure to start slowly and increase your distance gradually. If walking is painful or makes your incision feel uncomfortable, stop and rest until the pain subsides. As long as you listen to your body, staying active will speed up your recovery.

4. Follow Your Physical Therapy Regimen

Physical therapy is essential to recovering from knee surgery, but it’s important to follow your therapist’s recommendations. Depending on the surgery you had, you may need to start physical therapy a week after your procedure. This may seem like a lot, but getting the rehabilitation process started early is vital.

Your physical therapist will design a customized exercise program that gradually increases in intensity as you heal. Sticking to this program even when you feel like you can do more is essential. Pushing yourself too hard can delay healing and lead to setbacks. Trust your therapist and follow their guidelines for a successful recovery.

5. Use Pain Medication as Directed

Recovering knee surgery can be painful, but taking pain medication only as directed is essential. Taking too much medication can be dangerous and make it difficult to gauge your level of activity. It’s vital to listen to your body and rest when necessary, even if that means taking a little extra medication.

Of course, you shouldn’t suffer unnecessarily. Talk to your doctor or surgeon about adjusting your medication regimen if your pain is severe or persistent. It’s also important to let them know if you have any concerns about the side effects of your medication. In most cases, the benefits of pain relief outweigh the risks, but it’s always best to err on the side of caution.

6. Be Patient

Recovery from knee surgery takes time, so it’s essential to be patient and realistic about your expectations. Depending on the procedure, it may be several months before you’re back to your old self. And even then, you may have some lingering stiffness or pain. It’s important to listen to your body and take things slowly to avoid setbacks.

If you’re having trouble staying positive, talk to your doctor or surgeon about ways to cope with the frustration of a long recovery. In the meantime, focus on following your rehabilitation program and taking care of yourself. The better you take care of yourself now, the sooner you’ll be back to your old self.

Following these tips will help you have a successful recovery after knee surgery. However, every patient is different, so talk to your surgeon about what you should expect during your recovery process. Just remember to listen to your body and take things one day at a time – before you know it, you’ll be back on your feet again.

Originally Appeared Here

New laser surface modification process with silver provides antimicrobial defense to titanium orthopedic devices

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Process to create nanostructures on implant surfaces also enhances bone cells’ attachment

WEST LAFAYETTE, Ind. – A patent-pending process developed by Purdue University engineers could improve the quality of life for the more than 6 million people who undergo orthopedic and trauma surgery annually, according to a paper published in Langmuir: The ACS Journal of Fundamental Interface Science.

Infection is a major complication when rods, plates, screws and other devices are embedded into people during procedures like joint replacement surgery and spinal fusion surgery. Most infections occur because the devices’ titanium implant surfaces have poor antibacterial and osteoinductive properties; osteoinduction is the process that prompts bone formation.

Rahim Rahimi, a Purdue University assistant professor in the School of Materials Engineering, has created a process that immobilizes silver onto the implant surfaces of titanium orthopedic devices to improve antibacterial properties and cellular integration. The process can be implemented onto many currently utilized metal implant surfaces.

The antibacterial efficacy of laser-nanotextured titanium surfaces with laser-immobilized silver was tested against both gram-positive (Staphylococcus aureus) and gram-negative (Escherichia coli) bacteria. The surfaces were observed to have efficient and stable antimicrobial properties for more than six days. The laser-nanotextured titanium surfaces also provided a 2.5-fold increase in osseointegration properties as compared to the pristine titanium implant surface.

“The first step of the two-step process creates a hierarchical nanostructure onto the titanium implant surface to enhance the bone cells’ attachment,” Rahimi said. “The second step immobilizes silver with antibacterial properties onto the titanium implant surface.

“The technology allows us to not only immobilize antibacterial silver compounds onto the surface of the titanium implants but also provide a unique surface nanotexturing that allows better settle attachment mineralization.

“These unique characteristics will allow improving implant outcomes, including less risk of infection and fewer complications like device failure.”

Rahimi said the traditional method to address infections caused by implanted orthopedic devices often utilizes antibiotics or other surface modifications that have their own associated complications.

“Long-term antibacterial protection is not possible with these traditional drug coatings because a large portion of the loaded drug is released in a short time,” Rahimi said. “There also is often a mixture of microbes that are found in implant-associated infection; it is essential to choose a bactericidal agent that covers a broad spectrum.”

Rahimi disclosed the innovation to the Purdue Research Foundation Office of Technology Commercialization, which has applied for a patent on the intellectual property. Industry partners seeking to further develop this innovation should contact Patrick Finnerty, pwfinnerty@prf.org, about reference number 2022-RAHI-69768.

Rahimi said the next steps to develop the laser process to texturize and immobilize silver onto orthopedic devices are to implement it onto standard orthopedic fixtures, validate the technology to get approval from the U.S. Food and Drug Administration, and license it to companies working in the orthopedic sector.

Rahimi’s research was funded by Purdue’s School of Materials Engineering.

About Purdue University

Purdue University is a top public research institution developing practical solutions to today’s toughest challenges. Ranked in each of the last five years as one of the 10 Most Innovative universities in the United States by U.S. News & World Report, Purdue delivers world-changing research and out-of-this-world discovery. Committed to hands-on and online, real-world learning, Purdue offers a transformative education to all. Committed to affordability and accessibility, Purdue has frozen tuition and most fees at 2012-13 levels, enabling more students than ever to graduate debt-free. See how Purdue never stops in the persistent pursuit of the next giant leap at https://stories.purdue.edu.

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The Purdue Research Foundation Office of Technology Commercialization operates one of the most comprehensive technology transfer programs among leading research universities in the U.S. Services provided by this office support the economic development initiatives of Purdue University and benefit the university’s academic activities through commercializing, licensing and protecting Purdue intellectual property. In fiscal year 2021, the office reported 159 deals finalized with 236 technologies signed, 394 disclosures received and 187 issued U.S. patents. The office is managed by the Purdue Research Foundation, which received the 2019 Innovation and Economic Prosperity Universities Award for Place from the Association of Public and Land-grant Universities. In 2020, IPWatchdog Institute ranked Purdue third nationally in startup creation and in the top 20 for patents. The Purdue Research Foundation is a private, nonprofit foundation created to advance the mission of Purdue University. Contact otcip@prf.org for more information.

Writer: Steve Martin, sgmartin@prf.org

Source: Rahim Rahimi, rrahimi@purdue.edu

ABSTRACT

Laser-Assisted Nanotexturing and Silver Immobilization on Titanium Implant Surfaces to Enhance Bone Cell Mineralization and Antimicrobial Properties

Vidhya Selvamani, Sachin Kadian, David A. Detwiler, Amin Zareei, Ian Woodhouse, Zhimin Qi, Samuel Peana, Alejandro M. Alcaraz, Haiyan Wang, Rahim Rahimi

Despite the great advancement and wide use of Titanium (Ti) and Ti-based alloys in different orthopedic implants, device-related infections remain the major complication in modern orthopedic and trauma surgery. Most of these infections are often caused by both poor antibacterial and osteoinductive properties of the implant surface. Here, we have demonstrated a facile two-step laser nanotexturing and immobilization of silver onto the titanium implants to improve both cellular integration and antibacterial properties of Ti surfaces. The required threshold laser processing power for effective nanotexturing and osseointegration was systematically determined by the level of osteoblast cells mineralized on the laser nanotextured Ti (LN-Ti) surfaces using a Neodymium-doped yttrium aluminum garnet laser (Nd-YAG, wavelength of 1.06 μm). Laser processing powers above 24 W resulted in the formation of hierarchical nanoporous structures (average pore 190 nm) on the Ti surface with a 2.5-fold increase in osseointegration as compared to the pristine Ti surface. Immobilization of silver nanoparticles onto the LN-Ti surface was conducted by dip coating in an aqueous silver ionic solution and subsequently converted to silver nanoparticles (AgNPs) by using a low power laser-assisted photocatalytic reduction process. Structural and surface morphology analysis via XRD and SEM revealed a uniform distribution of Ag and the formation of an AgTi-alloy interface on the Ti surface. The antibacterial efficacy of the LN-Ti with laser immobilized silver (LN-Ti/LI-Ag) was tested against both gram-positive (Staphylococcus aureus) and gram-negative (Escherichia coli) bacteria. The LN-Ti/LI-Ag surface was observed to have efficient and stable antimicrobial properties for over 6 days. In addition, it was found that the LN-Ti/LI-Ag maintained a cytocompatibility and bone cell mineralization property similar to the LN-Ti surface. The differential toxicity of the LN-Ti/LI-Ag between bacterial and cellular species qualifies this approach as a promising candidate for novel rapid surface modification of biomedical metal implants.

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Novel Imaging Technique Reveals Excellent Biologic Fixation in Cementless Knee Replacement

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Newswise — Cementless knee replacement, an alternative approach to the traditional surgery in which bone cement is used, is gaining interest among orthopedic surgeons. Using a novel MRI technique, researchers at Hospital for Special Surgery (HSS) found that a cementless implant demonstrated excellent biologic fixation, and even improved fixation of implant components in some areas in the joint, compared to the standard cemented implant.

HSS hip and knee surgeon Geoffrey Westrich, MD, and colleagues in the HSS Radiology Department used an advanced imaging technique known as “multi-acquisition variable-resonance image combination selective MRI” to assess fixation in patients who had a cementless knee replacement compared to those whose implant was affixed with bone cement.

“The purpose of our study was to quantify and compare the fixation of uncemented versus cemented knee replacement components,” said Dr. Westrich, lead investigator. “At an average patient follow-up of 16 months, our study demonstrated robust fixation of the cementless knee replacement components, with results comparable to the cemented total knee replacements. And while there was no clinically significant difference regarding overall fixation in the knee, there were some component areas in which cementless fixation appeared to be superior.” The study was published in the October edition of the journal Arthroplasty Today.  

The HSS researchers performed MRIs in 20 patients who had a cementless knee replacement. A matched control group of 20 patients with a cemented knee replacement was also evaluated. The images were reviewed by a fellowship-trained musculoskeletal radiologist specializing in the interpretation of joint replacement MRI, including more than 20 years of experience in assessing bony fixation of knee replacement components.

In a traditional knee replacement, implant components are secured in the joint using bone cement. It’s a tried-and-true technique that has worked well for decades. But eventually, over time, the cement may start to loosen from the bone and/or the implant. This loosening is the leading cause of revision surgery, in which a patient needs a second knee replacement.

“With the cementless prosthesis, the components are press fit into place for biologic fixation, which basically means that the bone will grow into the implant,” explains Dr. Westrich, who believes a well-designed cementless implant will make loosening over time less likely. This could enable a total knee replacement to last much longer, a particular concern for younger patients.

“Overall, traditional knee replacement offers excellent outcomes and longevity,” he says. “However, younger patients generally put more demands on their joint, causing more wear and tear and potential loosening. The cemented knee implant used in a traditional joint replacement usually lasts 15 to 20 years.”

Cementless implants have been used successfully in total hip replacement surgery for many years. It has been much more challenging to develop a cementless prosthesis that would work well in the knee because of its particular anatomy, Dr. Westrich explains.

“Early generation cementless implants had numerous design flaws resulting in loosening and poor survivorship compared to cemented knee replacements,” he says. “More contemporary cementless knee components such as those used in our study utilize highly porous surfaces to promote biologic fixation of the prosthesis. This should improve outcomes.”

Candidates for the cementless procedure are generally patients under age 70 with good bone quality to promote biologic fixation. In addition to younger patients, Dr. Westrich notes that the cementless implant may prove to be a good option for very overweight patients who tend to put more stress on their joint replacement.

“While our study found that early fixation of cementless total knee components are comparable, if not superior, to cemented total knee replacement, further study with a larger number of patients over a lengthier time period is needed to assess long-term durability and fixation.”

Disclosure: Research support received from Stryker Corporation. 

 


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Preparing for Joint Replacement Surgery

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Contact friends and family for support. You may need help bathing, using the toilet, cooking meals, doing laundry or housework, shopping, going to your doctor’s office, and exercising for several weeks. Contact family members or friends ahead of time to make the necessary arrangements. If you don’t have someone to help you at home, ask your doctor about home caregivers. There are various support networks that can provide emotional support and, in many areas, there are also businesses that offer in-home support.

Get your home ready for your recovery. Store frequently used items such as cleaning supplies, food, remote controls, medications, and reading materials in easy-to-reach locations. Avoid very high or very low shelves as these may require you to use a step stool or kneel.

Plan for meals. Make and freeze meals or stock up on frozen dinners before surgery so that meal preparation is easier and requires less effort. You should plan on making enough meals for at least one week.

Check the safety of your home to prevent falls or tripping. Move long electrical and telephone cords against the wall, remove rugs, and place a non-skid mat in your bathtub. You may want to prepare a bed on the ground level of your home so you can avoid climbing stairs. Have an elevated chair or high-seated chair with arms in every room if possible.

A little time spent getting your home ready before your surgery can make a big difference in your recovery. Some ideas to get started, include:

  • Stock up on toilet paper, shampoo, toothpaste, medications, and other personal items
  • Put a chair in your shower
  • Get a hand-held shower head
  • Get a raised toilet seat
  • Get a shower sponge with a long handle
  • Put handrails in the shower and next to the toilet
  • Install nightlights throughout the house
  • Wash all your towels, linens, and dirty clothes
  • Place loose clothing and pajamas in upper drawers or closets
  • Reachers and grabbers will come in handy
  • To keep your hands free for balance, consider using a walker basket, hip-pouch, small backpack, or an apron with large pockets to hold things you’ll want nearby
  • Rent/buy/borrow plenty of books, movies, music, and puzzles
  • Call your local post office to request that mail be left at your front door instead of in your mailbox

Originally Appeared Here

The Challenge of Knee OA and the Potential of Manual Therapy

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Knee osteoarthritis is a major public health problem that primarily
affects the elderly. Almost 10 percent of the United States population
suffers from symptomatic knee osteoarthritis by the age of 60. In fact,
OA is prevalent worldwide, especially with an increasingly aging
society. It is one of the leading causes of pain and dysfunction in the
joints among the aging population. Despite this, there are no approved
interventions that ameliorate structural progression of this disorder. Continue reading on digital


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Originally Appeared Here

Prior Diagnosis of COVID Has No Increased Complications in Total Joint Arthroplasty

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Introduction

Although a substantial portion of the United States population has been infected with and recovered from Coronavirus Disease-19 (COVID-19), many patients may have persistent symptoms and complications from disease-driven respiratory disease, arrhythmias, and venous thromboembolism (VTE). With institutions resuming elective total joint arthroplasties (TJA), it is unclear whether a prior resolved diagnosis of COVID has any implications on postoperative outcomes.

Methods

All elective TJA performed in 2021 at our institution were retrospectively reviewed and a history of prior COVID+ result recorded. Baseline demographics, days from prior COVID+ result to surgery date, preoperative methicillin-resistant Staphylococcus aureus (MRSA) nares colonization, and laboratory markers were obtained to determine baseline characteristics. Postoperative estimated blood loss (EBL), length of stay (LOS), rate of revision surgery, and discharge destination were compared between groups. Perioperative and postoperative rates of VTE, urinary tract infection (UTI), pneumonia, postoperative oxygen supplementation, cardiac arrhythmia, renal disease, sepsis, and periprosthetic joint infections within six months of surgery were recorded.

Results

Of the 155 elective TJA performed in 2021, 24 patients had a prior COVID+ diagnosis with a mean of 253 days from positive result to surgery date. There were no significant differences in baseline demographics, comorbidities, and preoperative lab markers between groups. Surgeries on patients with a prior COVID+ had a significantly higher EBL (260 vs 175cc), but postoperative outcomes of VTE, UTI, pneumonia, oxygen supplementation requirement, nares MRSA+, cardiac disease, and infection rates between groups were similar. Bivariate logistic regression revealed increased days from COVID+ diagnosis (>6 months) to surgery date were associated with a shorter LOS.

Conclusion

Although a prior COVID+ diagnosis had increased intraoperative blood loss, there were no significant differences in respiratory, infectious, cardiac, and thromboembolic complications up to six months after elective TJA. This study suggests that asymptomatic C+ patients receiving elective TJA do not require more aggressive prophylactic anticoagulation or antibiotic regimens to prevent VTE or perioperative infections. As institutions around the nation resume pre-COVID rates of arthroplasty surgeries, a prior diagnosis of COVID appears to have no effects on postoperative complications.

Introduction

Due to the COVID-19 nonessential procedure restriction, there was a large decrease in orthopedic procedures during the pandemic. One study estimated that approximately 30,000 primary and 3000 revision hip and knee arthroplasty procedures were canceled each week throughout the COVID-19 nonessential procedure restrictions [1]. As cases resumed, multiple studies have explored the short-term effects of COVID-19 on the perioperative morbidity and mortality of various orthopedic surgeries. A 2020 study by Kayani et al. demonstrated an increased length of hospital stay, more critical care admissions, higher risk of perioperative complications, and increased mortality in COVID-19-positive (C+) patients undergoing hip fracture surgery compared to COVID-19-negative (C-) patients [2]. These results were consistent with other orthopedic surgical outcomes of femur neck and ankle fracture surgeries [3,4].

Several notable complications that were tightly bound to the COVID-19 virus were the increased risk of venous thromboembolism, atrial fibrillation, as well as respiratory issues inherent to the virus. As recently assessed by Forlenza et al., the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) was significantly higher in COVID-19 patients undergoing total joint arthroplasty (TJA), owing to the hypercoagulability associated with the inflammatory state [5]. Additionally, the study determined a temporal relationship between COVID-19 diagnosis and TJA, with an increased risk of DVT and PE in patients who were diagnosed with COVID-19 one month prior to their operation versus two or three months. This temporalizing trend was also witnessed when assessing the post-operative risk for pneumonia between C+ and C- patients [6,7]. Likewise, a study exploring the complication rates in C+ patients after hip fracture repair demonstrated an increased risk of post-operative atrial fibrillation compared to C- patients [7].

Notably, a rare yet significant complication of joint replacement is the risk of infection of the prosthesis which is a common cause of joint replacement revision. While minimal data has been presented regarding the risk of prosthetic joint infection, previous studies have demonstrated no significant risk of infection in TJA [6,8]. Additionally, the imposed restriction during the COVID-19 pandemic significantly hindered the ability of patients to seek adequate and continuous rehabilitation post-operatively which led to overall worse patient-reported outcomes [9]. Lastly, while the length of hospital stay (LOS) for surgical orthopedic patients has decreased in hopes of limiting the risk of COVID-19 infection, there was a significant increase in LOS in a previous study in C+ hip fracture patients compared to C- patients secondary to increased risk for complications as well as slower rehabilitation and dependence on oxygen supplementation.

While the short-term effects of a recent COVID-19 diagnosis on post-operative outcome have been explored, the effects of a previous C+ diagnosis and recovery on the outcomes of an orthopedic procedure and, more specifically, total joint arthroplasties, remains unclear. As the COVID-19 virus becomes increasingly more ubiquitous, it is important to gain an understanding regarding the complications or lack thereof that previously infected patients may face in future TJA procedures. For this reason, the objective of this study is to establish the complication risks of previous COVID-19-positivity on the postoperative outcomes of total joint arthroplasty.

This study aims to identify any significant differences in prosthetic joint infections, DVT and PE incidence, post-operative oxygen requirement, estimated blood loss (EBL), and LOS between prior asymptomatic C+ and C- patients undergoing TJA.

Materials & Methods

All elective TJA performed in 2021 at our institution were retrospectively reviewed and a history of prior PCR C+ result recorded. The study protocol was reviewed and approved by the University of California, Irvine Institutional Review Board. Baseline demographics, days from prior C+ result to the surgery date, preoperative methicillin-resistant Staphylococcus aureus (MRSA) nares colonization, and preoperative laboratory markers were obtained to determine baseline characteristics between groups.

All patients received standardized preoperative optimization including weight control and medical co-management when indicated. Within 72 hours prior to surgery, all asymptomatic patients received a COVID test to ensure no active infection or spread of infection through asymptomatic carriers. Patients with C+ results were rescheduled at least four weeks after the last C+ test and retested to ensure negative COVID test 72 hours prior to new surgical date. On the date of surgery, all patients were tested for MRSA Nares in the preoperative area. Patients were then prepped and draped in a standardized fashion including preoperative shaving with electrical clippers as needed and scrub with chlorhexidine gluconate for skin antisepsis. Preoperative prophylaxis included weight-based antibiotic dosing of Ancef, or Vancomycin and Gentamycin for those with penicillin allergies, or for those with a positive MRSA colonization. Of note, the approaches used for the hip procedure were entirely anterior approaches while the approach for knee arthroplasty was the medial parapatellar approach. Postoperatively, patients received two doses of cefazolin 2 grams for 24 hours per standard protocol. Post-surgical venous thromboembolism (VTE) chemoprophylaxis consisted of aspirin 81 mg twice daily for six weeks with the addition of Sequential Compression Devices (SCDs) or compression stockings for patients without any prior history of a DVT. Patients with a history of atrial fibrillation were resumed on their home oral anticoagulant (Apixaban or Rivaroxaban) on postoperative day 1 without aspirin. Patients who were unable to take home oral anticoagulant or aspirin were given daily Lovenox 40 mg injections for six weeks for VTE chemoprophylaxis.

Postoperative estimated blood loss (EBL), length of stay (LOS), rate of revision surgery, and discharge destination were compared between groups. Perioperative and postoperative rates of VTE, urinary tract infection (UTI), pneumonia, postoperative oxygen supplementation, new cardiac arrhythmia, renal disease, sepsis, and periprosthetic joint infections within six months of surgery were recorded. Patients who required any supplemental oxygenation, including nasal cannula or oxygen mask, and patients who required blood transfusion(s) were recorded. Periprosthetic joint infection (PJI) was determined using the updated 2018 criteria for periprosthetic infections including the presence of a sinus tract or two positive cultures with the same pathogen comprising the major criteria, and elevated C-reactive protein (CRP), D-dimer, erythrocyte sedimentation rate (ESR), synovial WBC, Leukocyte esterase, alpha-defensin, synovial polymorphonuclear leukocyte (PMN), synovial CRP comprising minor criteria [10].

Analysis was performed using the SPSS Statistical Tool. Chi-squared tests were used to determine the relationship between prior COVID+ results with postoperative EBL, LOS, rate of revision surgery, discharge destination, rates of VTE, UTI, pneumonia, postoperative oxygen supplementation, cardiac arrhythmia, renal disease, sepsis, and periprosthetic joint infections within six months of surgery. Bivariate logistic regression analysis controlling for baseline demographics was used to determine the relationship between COVID+ diagnosis and association with postoperative complications. Additionally, days from prior C+ diagnosis to surgical date were compared between groups for effects on increased EBL and LOS. Multivariate linear regression was performed to identify COVID positivity as an independent risk factor for postoperative outcomes.

Results

Of the 155 elective TJA performed in 2021, 24 patients had a prior C+ diagnosis with a mean of 253 days from positive result to surgery date. Of note, the 155 TJA consisted of 93 (60%) knee and 62 (40%) hip arthroplasty. There were no significant differences in comorbidities, BMI, type of postoperative chemical VTE prophylaxis, and WBC/INR preoperative lab markers between groups (Table 1). Although C+ patients had a significantly higher preoperative Hb level, C+ patients were more likely to be males. There were no statistically significant differences with regard to performing surgeon, type of arthroplasty (hip or knee), ASA classification, and smoking status between the two groups.

Demographic Variable +COVID-19 (n = 24) -COVID-19 (n = 131) p
Age, mean ± SD 66.8 ± 9.5 68.0 ± 10.6 0.593
Sex     <0.001
                  Male, n (%) 18 (75.0) 46 (35.1)  
                  Female, n (%) 6 (25.0) 85 (64.9)  
BMI, mean ± SD 31.9 ± 5.3 30.4 ± 7.0 0.315
Days From COVID-19+ To Surgery, mean ± SD 253.5 ± 189.3 — —
Diabetes, n (%) 9 (37.5) 40 (30.5) 0.485
Postoperative Blood Thinner     0.490
                   ASA, n (%) 21 (87.5) 110 (84.6)  
                   Lovenox, n (%) 0 (0) 7 (5.4)  
                  Xarelto/Eliquis, n (%) 3 (12.5) 10 (7.7)  
                  Multiple, n (%) 0 (0) 3 (2.3)  
Preoperative Nares MRSA+, n (%) 2 (8.3) 2 (1.5) 0.114
Preoperative Laboratory Values      
                  WBC, mean ± SD 6.4 ± 1.8 7.3 ± 2.4 0.076
                  INR, mean ± SD 1.0 ± 0.1 1.1 ± 0.3 0.265
                  Hb, mean ± SD 14.0 ± 1.5 12.8 ± 2.1 0.006
 
Table
1: Demographics

BMI, body mass index; ASA, aspirin; MRSA, methicillin-resistance staphylococcus aureus; WBC, white blood cell; INR, international normalized ratio; Hb, hemoglobin

Surgeries on patients with a prior COVID+ had a significantly higher EBL (260 vs 175cc), but postoperative outcomes of VTE, UTI, pneumonia, oxygen supplementation requirement, nares MRSA+, cardiac disease, and infection rates between groups were similar (Tables 2, 3). Of note, no patients within the study required a blood transfusion. Bivariate logistic regression revealed increased days from COVID+ diagnosis (>6 months) to surgery date was associated with a shorter LOS (Table 4). Last, multivariate analysis (Table 5) demonstrated that prior COVID+ diagnosis was associated with greater EBL, and a COVID+ diagnosis cutoff of one year ago was also associated with significantly shorter LOS.

Postoperative Complication +COVID-19 (n = 24) -COVID-19 (n = 131) p
EBL (mL), mean ± SD 258.3 ± 124.8 175.4 ± 177.9 0.030
PE, n (%) 0 (0) 1 (0.8) 1.000
UTI, n (%) 0 (0) 5 (3.8) 1.000
Postoperative Bleeding or Hematoma, n (%) 0 (0) 5 (3.8) 1.000
Pneumonia, n (%) 0 (0) 1 (0.8) 1.000
Postoperative Nasal Cannula/Oxygen Requirement in Hospital, n (%) 4 (16.7) 7 (5.3) 0.069
Renal Failure, n (%) 0 (0) 3 (2.3) 1.000
Sepsis, n (%) 0 (0) 1 (0.8) 1.000
Cardiac Arrhythmia, n (%) 0 (0) 6 (4.6) 0.591
Periprosthetic Joint Infection, n (%) 0 (0) 4 (3.1) 1.000
Revision Joint Surgery, n (%) 1 (4.2) 3 (2.3) 0.493
Revision for Infection, n (%) 1 (4.2) 3 (2.3) 0.493
Length of Stay, mean ± SD 2.6 ± 1.2 2.5 ± 1.6 0.802
Discharge Destination     0.206
Home, n (%) 18 (75.0) 114 (87.0)  
Rehabilitation, n (%) 6 (25.0) 17 (13.0)  
 
Table
2: Postoperative Complications

EBL, estimated blood loss; PE, pulmonary embolism; UTI, urinary tract infection.

Postoperative Complication OR 95% CI p
PE 0.000 (0.000, 0.000) 0.998
UTI 0.000 (0.000, 0.000) 0.998
Postoperative Bleeding/Hematoma 0.000 (0.000, 0.000) 0.998
Pneumonia 0.000 (0.000, 0.000) 0.998
Postoperative Nasal Cannula/Oxygen Requirement in Hospital 3.543 (0.950, 13.211) 0.060
Renal Failure 0.000 (0.000, 0.000) 0.998
Sepsis 0.000 (0.000, 0.000) 0.998
Cardiac Arrhythmia 0.000 (0.000, 0.000) 0.998
Periprosthetic Joint Infection 0.000 (0.000, 0.000) 0.998
Revision Joint Surgery 1.855 (0.185, 18.620) 0.599
Revision for Infection 1.855 (0.185, 18.620) 0.599
Discharge to Rehabilitation 2.235 (0.778, 6.421) 0.135
 
Table
3: Bivariate Logistic Regression for COVID-19 Positivity and Postoperative Complications

PE, pulmonary embolism; UTI, urinary tract infection.

Postoperative Complication USC B 95% CI p
EBL      
                COVID-19+ 82.913 (7.908, 157.919) 0.030
                Days From COVID-19+ To Surgery -0.170 (-0.451, 0.112) 0.225
                COVID-19+ Cutoff 3 Months -14.737 (-147.610, 118.136) 0.820
                COVID-19+ Cutoff 6 Months -28.571 (-137.427, 80.284) 0.592
                COVID-19+ Cutoff 1 Year -87.500 (-195.381, 20.381) 0.107
Length of Stay      
                COVID-19+ 0.087 (-0.597, 0.772) 0.802
                Days From COVID-19+ To Surgery -0.003 (-0.006, -0.001) 0.006
                COVID-19+ Cutoff 3 Months -1.032 (-2.241, 0.178) 0.091
                COVID-19+ Cutoff 6 Months -1.229 (-2.144, -0.313) 0.011
                COVID-19+ Cutoff 1 Year -1.437 (-2.352, -0.523) 0.004
 
Table
4: Bivariate Linear Regression for COVID-19 Positivity and Postoperative Complications

Having a history of COVID positivity was associated with significantly greater EBL. As the number of days from COVID-19+ increases, the hospital length of stay decreases. If COVID-19 positivity >6 months or >1 year away from a current hospital stay, LOS significantly decreased.

EBL, estimated blood loss; USC B, unstandardized coefficient B.

Perioperative Variables USC B 95% CI p
EBL      
              COVID-19+ 78.607 (9.328, 147.887) 0.027
              Age -1.344 (-3.713, 1.025) 0.263
              Female Sex -65.317 (-123.139, 7.495) 0.065
              BMI -2.137 (-6.476, 2.203) 0.331
              Diabetes -49.504 (-106.745, 7.736) 0.089
              ASA Perioperative Blood Thinner -72.002 (-141.647, 2.173) 0.076
              INR 0.346 (-108.647, 109.338) 0.995
              Hg -6.301 (-22.296, 9.695) 0.437
Length of Stay      
             COVID-19+ Cutoff 1 Year -1.703 (-3.167, -0.240) 0.026
             Age 0.034 (-0.018, 0.086) 0.177
             Female Sex -0.041 (-1.514, 1.433) 0.953
             BMI 0.052 (-0.050, 0.155) 0.290
             Diabetes 0.171 (-1.439, 1.781) 0.822
             ASA Perioperative Blood Thinner -1.333 (-3.355, 0.689) 0.178
             INR -1.910 (-13.301, 9.480) 0.723
             Hg -0.316 (-0.878, 0.246) 0.246
 
Table
5: Multivariate Linear Regression for COVID-19 Positivity and Estimated Blood Loss

In a multivariate model, COVID-19 positivity was associated with much greater EBL while female sex and ASA use were preoperatively associated with decreased EBL. A COVID-19+ cut-off of 1 year ago was associated with significantly shorter LOS.

EBL, estimated blood loss; BMI, body mass index; ASA, aspirin; INR, international normalized ratio; Hg, hemoglobin; USC B, unstandardized coefficient B.

Discussion

As the number of TJA performed increases to pre-pandemic rates nationwide, the population of asymptomatic prior C+ patients receiving TJA will increase. Although prior studies have demonstrated higher rates of cardiopulmonary complications, thromboembolic disease, renal injury, and urinary tract infections in postoperative COVID+ patients one month from joint arthroplasty, our study focuses on whether a preoperative resolved asymptomatic COVID+ diagnosis increases the risks for complications and outcomes [6]. Preoperative risk stratification for elective TJA is an important component of perioperative planning and medical optimization in an effort to reduce healthcare costs and decrease preventable complications [11]. As institutions implement COVID testing protocols to prevent the active perioperative spread of COVID in TJA, it is still unknown whether asymptomatic patients have an increased hypercoagulable inflammatory state that may perhaps warrant a prolonged prophylactic course of antibiotics or chemical DVT prophylaxis not routinely prescribed [12]. In this study, we demonstrate preliminary results of a prior COVID+ diagnosis having no increased rates of respiratory, infectious, cardiac, and thromboembolic complications up to six months after elective TJA with the standard postoperative protocol.

While other studies focus on the effects of a new COVID diagnosis during the perioperative period, our study is the first to our knowledge to examine the effects of a prior asymptomatic PCR COVID+ diagnosis > at least 3 months prior to the surgical date. Our average COVID+ diagnosis of ~250 days prior to surgery is relevant for healthcare providers stratifying a rising number of asymptomatic COVID+ elderly patients who have never undergone stresses of surgery post COVID. There are conflicting studies reporting on the prolonged duration of increased DVT, cardiac abnormalities, and PE rates in COVID patients after inoculation, and our study aims to demonstrate asymptomatic patients, >6 months since the last positive PCR test, have no increased risks of UTI, PJI, PE, DVT, and cardiac arrhythmias after joint arthroplasty [13]. Many of our patients had delayed procedures due to positive testing, and they are at increased risk for thromboembolism due to worsened arthritis and reduced mobility during the self-isolation period [14]. Despite theories on increased coagulopathy in prior positive patients, our findings of no increased risks for thromboembolic disease suggest more aggressive prophylactic anticoagulation regimens may not be necessary and otherwise increase the risk for hematoma formation [6,15]. While many of our patients were limited in formal therapy sessions due to pandemic restrictions, our patients were given supplemental standardized home therapy programs to encourage active recovery and mobility.

Although effects of prior COVID diagnosis on respiratory complications have been seen in prior literature, there are no studies correlating PCR COVID diagnosis to either increased MRSA nares colonization or supplemental oxygen requirements in arthroplasty patients. MRSA nares colonization is a known risk factor for periprosthetic joint infections, and prior reports indicate increased MRSA colonization during the COVID pandemic [16]. Our study indicates prior PCR COVID diagnosis had no increased risk for MRSA colonization despite theories on the decreased nasal immune response to respiratory co-pathogens after COVID infection [17]. Our overall low MRSA nares rate may reflect institutionalized trends of mask-wearing, physical distancing, reducing crowds, and hand hygiene used to prevent the spread of respiratory infections. In fact, our COVID patients had no increased leukocytosis or risk for overall UTI, pneumonia, or PJI complications. Low infection rates suggest no overall compromise to the immune function combined with the possible efficacy of current social distancing trends. Our C+ patients not only had no increased rates of MRSA nares colonization and postoperative infections, but they had no increased rates of postoperative oxygen supplementation requirements during their inpatient stay and at physical therapy sessions. Preventing atelectasis is an important postoperative goal to reduce further postoperative hypoxemia that may lead to arrhythmias, myocardial ischemia, and cognitive dysfunction [18]. Prior COVID+ PCR had no effects on post ambulatory breathing oxygenation and no increased rates of nasal cannula use that would indicate reduced respiratory function.

While comorbidities between groups were similar, this study had a higher percentage of males who were COVID+ and subsequently preoperative Hb was higher in the C+ group due to the greater percentages of males [19]. C+ was a significant risk factor for increased EBL intraoperative, which may reflect C+ coagulopathy and loss of antithrombotic mechanisms from imbalances between coagulation and inflammation [12]. While there were no increased postoperative hematomas, INR levels, or postoperative blood transfusions seen in the C+ group, surgeons should strive to obtain meticulous hemostasis and be aware that C+ may increase surgical blood loss. Although discharge destination and LOS were similar between C+ and C-, hospital LOS was inversely related to the number of days from C+ diagnosis to surgical date. COVID-19 positivity >6 months or >1 year away from surgery significantly decreased overall LOS, which may suggest faster recovery and less need for inpatient monitoring. It is possible that our C+ patients with increased EBL combined with inflammatory post-surgical stresses experienced greater physiologic demand postoperatively that required longer inpatient recovery [20]. The findings from this study have important insight for future arthroplasty centers as the surgical community begins to recover from the Covid-19 pandemic, which has caused widespread and numerous delays in surgical care.

There are several limitations to this study. Despite our preliminary findings, suggesting that elective joint replacement surgery is safe in patients with a history of COVID-19, the study is not well powered to detect differences in in-hospital complications, especially for rarer complications such as pulmonary emboli. Additionally, more research is needed in larger samples to confirm the robustness of this finding, as well as to investigate longer-term outcomes. Our cohort of C+ patients may not represent the true spectrum of the disease of all prior C+ patients as our population undergoing elective joint replacement were medically cleared and self-selected to undergo TJA. It is possible that our C+ patients were on the healthier side of the COVID spectrum as sicker patients are more likely to not be medically optimized for elective surgery and be at higher risk of perioperative complications. Since a C+ diagnosis is not randomized and our findings reflect a retrospective review, our results must be viewed as associations and a larger sample size is needed to detect the possible variability in outcomes associated with the various increasing strains of COVID.

Conclusions

Although a prior COVID+ diagnosis had increased intraoperative blood loss, there were no significant differences in respiratory, infectious, cardiac, and thromboembolic complications up to six months after elective TJA. Increased time from C+ diagnosis to surgical date predicted less EBL and shorter LOS, which may reflect a possible improved recovery in C- compared to C+ patients. This study suggests that asymptomatic C+ patients receiving elective TJA do not require more aggressive prophylactic anticoagulation or antibiotic regimens to prevent VTE or perioperative infections. As institutions around the nation resume pre-COVID rates of arthroplasty surgeries, the effect of prior diagnosis of COVID should be further investigated across a larger sample size to determine the true effect of a prior diagnosis on overall outcomes.


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