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Spinal anesthesia tied to increased opioid use after hip surgery

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Spinal anesthesia is increasingly being used instead of general anesthesia to improve patient comfort and reduce opioid use, but it could be having the opposite effect on hip fracture patients, according to research published June 13 in Annals of Internal Medicine.

“In our study, patients who got spinal anesthesia did get fewer opioids in the operating room, but they ended up having more pain, and more prescription pain medication use after surgery,” said lead author Mark Neuman, MD, anesthesiologist and past-chair of the Penn Medicine Opioid Task Force, said. “While our study can’t determine conclusively whether this was due to the spinal anesthesia itself or the fact that fewer opioids were given up front, this is a result that should make people examine some of the assumptions informing current care pathways.”

To confirm whether assumptions about spinal anesthesia and reduced pain were accurate, researchers at the University of Pennsylvania in Philadelphia examined 1,600 patients who underwent hip fracture surgery between 2016 and 2021. About half of enrollees had spinal anesthesia and the other half had general anesthesia, with each patient asked to assess their pain levels at varying intervals and outline their prescription painkiller use after surgery.

Overall, patients rated their worst pain the day after surgery. Spinal anesthesia patients indicated slightly higher levels of their worst pain, averaging 7.9 out of 10 compared to 7.6 among those who had general anesthesia, according to the study.

Spinal anesthesia patients were 33 percent more likely than general anesthesia patients to have taken prescription painkillers about two months after surgery, according to the study. No significant difference in prescription painkiller use was noted at six and 12 months after surgery, but researchers said the results are still reason to be wary.

“Even though the 180- and 365-day findings are not statistically significant, the 60-day finding is still concerning, since there could be medication-related harms like respiratory depression or over-sedation that could still occur over the short term,” Dr. Neuman said.

Researchers aim to conduct another study comparing the effects of spinal anesthesia and general anesthesia on total hip replacements.

Originally Appeared Here

Useful Health Tips for People With Chronic Hip Issues

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Do you suffer from chronic hip issues? If so, you know how frustrating and debilitating this problem can be. There are many things that you can do to help manage your condition and improve your quality of life. This blog post will discuss some useful health tips for people with chronic hip issues. It will also provide a list of resources that can help you find additional information and support.

1. Hip replacement surgery

If you are suffering from chronic hip pain, you may be considering hip replacement surgery. This is a major operation and should not be undertaken lightly. However, it can be an effective treatment for many people with hip problems. If you are considering this option, be sure to discuss it with your doctor and get all the information you can about the risks and benefits. When you undergo the patient journey for hip replacement surgery, you will first meet with your doctor to discuss the procedure. They will then complete a pre-operative assessment to make sure that you are a good candidate for surgery. Once you have been cleared for surgery, you will be scheduled for the procedure.

2. Physical therapy

Another option that you may want to consider is physical therapy. This can be an effective treatment for many people with hip problems. Physical therapy can help to improve range of motion, flexibility, and strength. It can also help to reduce pain and inflammation. If you are considering this option, be sure to discuss it with your doctor. They will be able to refer you to a physical therapist who can help you develop a treatment plan that is right for you.

Physical therapy usually begins with a few sessions of evaluation and education. During these sessions, your therapist will assess your condition and develop a treatment plan. They will also teach you some exercises that you can do at home to help improve your condition.

3. Pain medication

Another option that you may want to consider is pain medication. There are many different types of pain medications available, and your doctor will be able to prescribe the one that is right for you. Pain medication can help to reduce pain and inflammation. It can also help to improve the range of motion and function. If you are considering this option, be sure to discuss it with your doctor. They will be able to determine if this is the best treatment for you. Sometimes, pain medication is used in combination with other treatments, such as physical therapy.

4. Alternative treatments

There are also many alternative treatments that you may want to consider. These include acupuncture, chiropractic care, and massage therapy. These treatments can help to reduce pain and improve function. If you are considering any of these options, be sure to discuss them with your doctor. They will be able to determine if this is the best treatment for you. While these treatments can be effective, it is important to remember that they should not be used as a replacement for medical care.

5. Light exercise

Next, one of the best things that you can do for your chronic hip issues is to stay active. Light exercise can help to improve range of motion, flexibility, and strength. It can also help to reduce pain and inflammation. If you are not sure how to get started, there are many resources available that can help you. The important thing is to find an activity that you enjoy and stick with it. You can do some research online or talk to your doctor about what options are available. Also, be sure to check with your insurance company to see if they cover any of the costs associated with these activities.

6. Lose weight

Another thing that you can do to improve your chronic hip pain is to lose weight. If you are overweight, it can put extra pressure on your hips and joints. This can lead to pain and inflammation. Losing even a few pounds can make a big difference. If you are not sure how to get started, there are many resources available that can help you. You can talk to your doctor about a weight loss plan that is right for you. They may also be able to refer you to a dietitian or nutritionist who can help you develop a healthy eating plan.

These are just a few of the many health tips that can be useful for people with chronic hip issues. If you are suffering from this condition, be sure to talk to your doctor about all of the treatment options that are available to you. With the right treatment plan, you can improve your quality of life and manage your condition effectively. So, don’t hesitate to get the help you need. Good luck!

Originally Appeared Here

A robotic assistant for joint replacement surgery

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Are you one of the millions of silent sufferers living with chronic pain caused by arthritis or an injury to the hip or knee?

While conservative treatment options are the first line of treatment, some patients with severe disease may require hip or knee replacement surgery.

While we’re more used to human surgeons wielding the scalpel, nowadays, such surgery can be done with the help of robotic technology.

In Malaysia, over 300 patients have undergone robotic arm- assisted knee or hip replacement surgery since its introduction here in recent years.

Consultant orthopaedic, joint and arthroplasty surgeon Dr Chua Hwa Sen shares that the popularity of robotic arm-assisted knee and hip replacement surgeries is growing due to its ability to provide each patient with a surgical experience that is specifically tailored to the individual’s needs and anatomy.

With the new technology, he says surgeons are able to facilitate more accurate placement of implants, while being minimally invasive in cutting the patient.

This allows patients to experience less post-operative pain and recover faster.

He explains: “Treatment begins with CT-based 3D modelling to help surgeons view in detail each patient’s diseased anatomy prior to surgery to formulate a personalised surgical plan.

“Given that every joint is different – even more so for diseased joints, as the degree of severity varies greatly in different patients – the robot (along with pre-operative CT scans and 3D reconstruction) greatly helps surgeons plan accurately for each patient.

“The robot intraoperatively helps surgeons to seek the most ideal position and size of new joints for the patients, as well as accurately resect the bones and implant the new joints.”

Interest among the surgical community in this procedure is also increasing, with more and more surgeons showing interest in being trained for these procedures.

They merely assist

Dr Chua also assures that the robot is not doing the entire surgery and is merely assisting with the operation.

“People often think that surgeons sit back and relax when the surgery is being conducted by the robot.

“That is not true.

“The robot is a semi-active robot. Hence, the procedure is called robotic arm-assisted joint replacement.

“The surgeon is there every step of the way to expose the joints, release soft tissues, feed live movement of the joints to the robots intraoperatively to have wider combinations of data.”

He explains that the robot’s function during surgery is to enable surgeons to be precise in determining the best placement of implants within the joint.

The robot can accurately feed back data that is impossible to be detected with the naked eyes, he says, adding that it can adjust bone cuts and the degree of joint rotation as precisely as 0.1mm and 0.5 degrees respectively.

“Accuracy makes the surgery less invasive and enables us to sacrifice less healthy bone and tissues.

“‘The more we see, the more you keep’ is the key message of CT- based 3D modelling robotic arm-assisted joint replacement to our patients.”

Dr Chua notes that the robot’s accuracy reduces post-operative pain greatly, reduces the need for physical therapy, helps patients accept new joints with less effort, achieves a much better outcome, and potentially increases the longevity of the new implants.

Urging the public to be more open to technological advancements, he says the rise of robotics and artificial intelligence in healthcare is beneficial to society and should be embraced.

“Instead of being wary of it, let it assist us and improve our quality of life.”

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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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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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.

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Tips to care for an elderly person after hip replacement surgery

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A hip replacement surgery is no cakewalk. The pain and discomfort continues for a while. People, especially the older folks, need more care and love after a hip replacement surgery. Be it being a support while standing up or walking with them to the bathroom, there will be many moments when they will need you. But caring doesn’t end here. There are more ways you can help an elderly loved one who had a hip replacement surgery. Read on to find out how to make the recovery journey a smooth one.

After the hip replacement surgery, you will need to focus on special care to ensure that your loved one will recover completely.

Health Shots consulted Dr Atul Mishra, Director and Head for Orthopedics at Fortis Hospital, Noida, to know how to care for an elderly after hip replacement surgery.

Elders after hip replacement surgery need more care. Image courtesy: Shutterstock

Why is hip replacement surgery done?

Some people experience unbearable pain in and around the hip joint. Well, that’s just one of the signs that mean you need to consult a doctor. Dr Mishra explains that hip replacement surgery is done when there is osteoarthritis of the hip joint. The hip joint gets destroyed as a result of recurrent inflammation and degeneration in the joint. The bearing surface comprising the femoral head and the acceptable cup are completely destroyed. Movements of the hip become extremely painful and variable amount of deformities develop. In such cases, doctors suggest a hip replacement surgery.

Elderly people need more support after hip replacement surgery

It’s true that anyone who returns home after a surgery, needs a lot of care and love. But special care needs to be taken in the case of elderly people. The expert says that after a hip replacement surgery, they advise people, particularly the elderly ones, to walk with the help of a support like a walker or a stick for at least one month. The reason is that people in the older age group have poor muscle control, the muscle bulk and the power in the muscles are less. So, many a times it has been noticed that in spite of a stable painless joint, the muscles are unable to provide support and balance to the leg. Also, in early post-operative periods, they tend to stumble and fall. So, they will need help till the time external and internal stitches are healed and all the muscles regain their power. All this takes around three to four weeks’ time.

Tips to care for an elderly, who had a hip replacement surgery

• Your loved one needs a regular psychological support that the surgery has been done, and everything is going to be fine.

• Getting them out of the bed after surgery can be difficult at times. You will have to help your loved one in negotiating him or her out of the bed. You’ll have to provide support so that the elderly family member can move around in the room and go to the washroom.

caring for elderly
Provide support to your elderly family member after surgery. Image courtesy: Shutterstock

• Adequate hydration is needed. At least 1.5 to two liters of water needs to be taken every day.

• Proper diet is to be taken in early post-operative period. It should be a protein-rich diet, which can be easily digested. It has to be given so as to maintain the nutritional status. Adequate nutritional status in the post-operative period prevents fall of hemoglobin. It maintains the nutrition level and helps in healing of the surgical wound.

• You have to see that the dressing is not soiled by urine or by any other thing. If there is any deformity or any soakage in form of blood or any other fluid in and around the dressing area, you have to report it to a doctor.

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Exactech Total Knee Failure Resulted in Revision Surgery, Lawsuit Alleges

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Safran indicates she underwent left knee replacement surgery in 2014, at which time she was implanted with an Exactech Optetrak Comprehensive Total Knee System. However, in May 2022, an MRI detected signs of debris in her right knee, and a CT scan found osteolysis occurring around the Exactech total knee implant.

After experiencing worsening pain and instability, Safran underwent right knee replacement revision surgery to remove the failed Exactech Total Knee implant. The lawsuit claims Exactech knew there were problems with the implants for years, but failed to warn patients or the medical community.

“Defendants, however, ignored reports of early failures of their Optetrak Device and failed to promptly investigate the cause of such failures or issue any communications or warnings to orthopedic surgeons and other healthcare providers,” Safran’s lawsuit states. “Before the date of Plaintiff’s initial knee replacement surgery, Defendants knew or should have known that the Optetrak Device was defective and unreasonably dangerous to patients, that the product had an unacceptable failure and complication rate, and that the product had a greater propensity to undergo substantial early polyethylene wear, component loosening and/or other failure causing serious complications including tissue damage, osteolysis, and other injuries as well as the need for revision surgery in patients.”

Exactech Knee Implant Failure Lawsuits

Safran’s claim joins dozens of Exactech knee lawsuits now being pursued in the federal court system, each involving similar allegations that the manufacturer knew or should have known about high failure rates associated with its implants long before doctors and patients were warned about the problems.

At least as early as 2017, lawsuits over Exactech knee implants indicated there were alarming rates of adverse event reports being submitted to the FDA involving premature knee replacement revision surgery, which resulted in what some said was a “silent” Exactech recall when the company began slowly and quietly replacing the tibial trays of some Optetrak models.

In November, the U.S. Judicial Panel on Multidistrict Litigation (JPML) centralized all Exactech lawsuits in an MDL, or multidistrict litigation, and transferred the claims to U.S. District Judge Nicholas G. Garaufis in the Eastern District of New York, to coordinated discovery into common issues in the claims, avoid conflicting pretrial schedules and to serve the convenience of common witnesses and parties involved lawsuits that were spread out throughout the federal court system.

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AAOS Updates Clinical Practice Guideline for Surgical Management of Osteoarthritis of the Knee

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ROSEMONT, Ill., Jan. 10, 2023 /PRNewswire/ — The American Academy of Orthopaedic Surgeons (AAOS) issued an update to the Clinical Practice Guideline (CPG) for Surgical Management of Osteoarthritis of the Knee, which replaces the previous edition released in 2015. This CPG provides two new evidence-based recommendations and updates to 19 of the 38 recommendations. In addition to providing guidelines for specific surgical techniques and procedures for knee osteoarthritis (OA), the CPG also highlights important lifestyle considerations including diabetes, BMI and opioid use, all of which can play a role in surgical outcomes and complications.

OA is the most common form of arthritis in the knee and can have a severe impact on activity levels. This degenerative “wear and tear” typically occurs in people 50 years of age and older and is often associated with joint pain, stiffness and difficulty with purposeful movement. Surgical interventions, such as arthroplasty for symptomatic OA of the knee, is performed to relieve pain and restore function.

“We want to do everything possible to help our patients undergoing knee OA surgery experience favorable functional outcomes while reducing the risk of operative and postoperative complications, including pain or reoperation,” said Ajay Srivastava, MD, FAAOS, co-chair of the clinical practice guideline workgroup and member of the AAOS Committee on Evidence-Based Quality and Value. “Updates to this CPG include a rigorous systematic process, resulting in a guide that provides physicians with the information needed for shared decision-making with their patients.”

Highlights of the CPG include:

  • A strong recommendation that the optimization of perioperative glucose control (<126mg/dl) after total knee arthroplasty should be attempted in diabetic and non-diabetic patients with HgbA1C <6.5, as hyperglycemia can lead to less favorable postoperative outcomes and higher complication rates.
  • A strong recommendation showing that there is no difference in postoperative functional scores between patients with a BMI less than 30 and obese patients (BMI 30-39.9); however, there may be an increased risk of complications of surgical site infections in morbidly obese patients (BMI greater than 40).
  • A strong recommendation that there is no difference between patellar surfacing (kneecap replacement) or non-patellar resurfacing in TKA.
  • A new strong recommendation stating that there is no difference in composite/functional outcomes or complications between kinematic or mechanical alignment principles in TKA.

“A total knee replacement with kinematic alignment often incorporates a technological aspect such as a robot or a custom jig, which can potentially add cost to the surgery,” said Dr. Srivastava. “Therefore, if the current evidence demonstrates no difference in outcomes, the extra cost might not be necessary.”

The updated CPG continues to recommend multimodal pain management techniques and ways to reduce opioid intake including a new recommendation of moderate strength focused on counseling patients to avoid opioids prior to their TKA. Studies have shown a decrease in postoperative functional scores and increased pain scores and complications when opioids are taken prior to surgery. Additionally, a strong recommendation for peripheral nerve blockades for TKA can lead to decreased postoperative pain and opioid requirements with no difference in complications or outcomes, and a strong recommendation for periarticular local infiltrations used in TKA also lead to decreased postoperative pain.

“New evidence demonstrates the effectiveness of both pain management techniques, especially when used together, to decrease postoperative pain without increasing complications,” said Jonathan Godin, MD, FAAOS, co-chair of the clinical practice guideline workgroup and member of the AAOS Committee on Evidence-Based Quality and Value. “However, if a surgical facility isn’t able to perform a peripheral nerve blockade, I’d still encourage the use of an injection with local anesthetic around the knee capsule to decrease postoperative pain.”

The use of robotics in TKA and unicompartmental knee arthroplasty are included in the CPG as new options and demonstrate no significant difference in function, outcomes, or complications in the short term between robotic-assisted and conventional surgery.

“What remains to be seen is the granular, midterm or long-term data pertaining to the use of robotics for these arthroplasty procedures,” said Dr. Godin. “In five years, the next work group will have access to midterm outcomes, and it will be very interesting to see if this continues to hold true or not.”

This CPG was prepared by the AAOS Surgical Management of Osteoarthritis of the Knee Guideline physician work group (clinical experts) with the assistance of the AAOS Clinical Quality and Value (CQV) Department (methodologists).

CPGs are not meant to be stand-alone documents, but rather serve as a point of reference and educational tool for both healthcare professionals managing patients knee OA and orthopaedic surgeons. CPGs recommend accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol for treatment or diagnosis. Patient care and treatment should always be based on a clinician’s independent medical judgment, giving the individual patient’s specific clinical circumstances.

The full Clinical Practice Guideline for Surgical Management of Osteoarthritis of the Knee is intended for reference by orthopaedic surgeons and other physicians, and available through AAOS’ OrthoGuidelines website and free mobile app. For more information on the development process for AAOS clinical practice guidelines, please view the Clinical Practice Guideline Methodology.

About the AAOS
With more than 38,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level to best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal health care issues and it leads the health care discussion on advancing quality.

SOURCE American Academy of Orthopaedic Surgeons

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Robotics Procedure Helping People Recover From Joint Replacement Surgery

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Tulsa Bone and Joint’s Union Pines Surgery Center is now the first ambulatory surgery center in Oklahoma to have the Mako SmartRobotics technology.

With the Mako SmartRobotics system, surgeons can better see how surgeries like a knee replacement will impact the entire body.

“What the Mako allows us to do, the way I explain it to my patients, is it allows us to know the consequences of the bony cuts we’re going to make, before we actually make them,” said Dr. Scott Reid, an Orthopedic Surgeon.

This data can help surgeons decide the best course of action for each patient, because everyone does not react the same way.

This is especially helpful in situations where the result can be hard to predict.

“The problem with soft tissue releases is that they’re not very predictable,” said Reid. “You may think when you’re in the operating room that you’ve balanced the knee really well, ultimately that may not actually be the case.”

Finding potential problems earlier, can change the recovery process, and the lives, of patients.

“One outlier, if we have one patient out of 100 that has a poor outcome because we didn’t get the implants in exactly the way they needed to be, that’s a big burden to that patient and we want to try to eliminate those as much as possible,” said Reid. “But there’s a big cost to the system.”

Reid says this technology has been in hospitals for nearly a decade, but using the Mako at Tulsa Bone and Joint’s surgery center can benefit more patients.

“Now, I think we’ve got every insurance contract that we have, to include Medicare and all the other subsidiaries of Medicare, we have the technology available to them now,” said Reid.

He’s excited about the future of this technology and the number of people it can help in the future.

“If we can use this technology to provide a more consistent outcome to our patients, ultimately that’s what we’re looking for,” said Reid.

The first two knee replacements using this surgery were performed successfully last Thursday.


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