JAAOS, Volume 25, No. 12

Venous Thromboembolism Prophylaxis in Total Hip Arthroplasty and Total Knee Arthroplasty Patients: From Guidelines to Practice

Venous thromboembolism (VTE) prophylaxis is recommended for all patients undergoing total hip arthroplasty or total knee arthroplasty. The selection of an appropriate prophylaxis regimen represents a balance between efficacy and safety. To help orthopaedic surgeons select an appropriate VTE prophylaxis regimen for their patients, the American Academy of Orthopaedic Surgeons and the American College of Chest Physicians have developed guidelines. These guidelines do not recommend an optimal regimen, however. Rather, an individualized prophylaxis regimen that balances efficacy and safety is recommended for each patient, based on various risk factors. Because of a paucity of data and a lack of adequately powered head-to-head trials, implementing these guidelines can be challenging for the orthopaedic surgeon. Knowledge of the prophylaxis options and the VTE risk factors is paramount for developing an effective VTE prophylaxis algorithm for the surgeon’s practice.

      • Subspecialty:
      • Hip

    Diagnostic Injections About the Shoulder

    Injections about the shoulder serve diagnostic as well as therapeutic purposes. Diagnosis of shoulder conditions, such as rotator cuff tears, acromioclavicular joint pathology, subacromial impingement or anterolateral pain syndrome, glenohumeral joint pathology, suprascapular nerve entrapment, and biceps tendon pathologies, is often complicated by concomitant conditions with overlapping symptoms and by inconclusive physical examination and imaging results. Injections of anesthetic agents can often help clinicians locate the source of pain. However, technique and accuracy of needle placement can vary by route. Accuracy is often improved with the use of ultrasonography guidance, although studies differ on the benefits of guided versus unguided injection.

        • Subspecialty:
        • Shoulder

      Screening for Infection Before Revision Hip Arthroplasty: A Meta-analysis of Likelihood Ratios of Erythrocyte Sedimentation Rate and Serum C-reactive Protein Levels

      Introduction: Diagnosing periprosthetic joint infection (PJI) before revision hip arthroplasty is critical to ensure effective treatment of patients undergoing surgery for reasons other than infection. The main objective of our study is to determine whether the erythrocyte sedimentation rate (ESR) and the serum C-reactive protein (CRP) level are sufficient to use for testing to rule out infection in patients undergoing revision hip surgery.

      Methods: We performed a systematic review of the literature in the MEDLINE, Ovid, and Embase databases. We included studies in which the investigators used the ESR (>30 mm/h) and serum CRP level (>10 mg/L) for the diagnosis of PJI of the hip. We obtained meta-estimates of sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR−).

      Results: From 511 articles, we analyzed 12 studies in which the investigators reported data on 2,736 patients. Sensitivity and specificity for the ESR were 0.860 (95% confidence interval [CI], 0.825 to 0.890) and 0.723 (95% CI, 0.704 to 0.742), respectively, and for the CRP level were 0.869 (95% CI, 0.835 to 0.899) and 0.786 (95% CI, 0.769 to 0.803), respectively. For the ESR, LR+ was 3.42 (95% CI, 2.55 to 4.59) and LR− was 0.22 (95% CI, 0.12 to 0.41). For the CRP level, LR+ was 4.18 (95% CI, 3.42 to 5.11) and LR− was 0.20 (95% CI, 0.12 to 0.32).

      Discussion: With a low pretest probability of PJI, a negative test result for either the ESR or CRP level is enough to rule out infection before revision hip arthroplasty.

      Level of Evidence: III

          • Subspecialty:
          • Hip

        Sex-specific Outcomes and Predictors of Concussion Recovery

        Introduction: Sports-related concussion (SRC) is a substantial concern in collegiate athletics. Some studies of SRC that make comparisons by sex are limited by sample size, follow-up duration, or referral bias. Sex-specific predictors of occurrence and recovery are uncertain.

        Methods: A 15-year retrospective cohort study identified 1,200 Columbia University varsity athletes (822 male [68.5%], 378 female [31.5%]) at risk of collegiate SRC.

        Results: A total of 228 athletes experienced at least one collegiate concussion, including 88 female athletes (23.3% of female athletes) and 140 male athletes (17.0% of male athletes) (P = 0.01); follow-up data were available on 97.8% of these athletes. Postconcussion symptoms were similar by sex, with the exception of sleep disturbance (29.3% of male athletes versus 42.0% of female athletes; P = 0.048) and memory impairment (43.6% of male athletes versus 30.7% of female athletes; P = 0.052), although the latter difference was not statistically significant. Risk factors for collegiate concussion included female sex (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1 to 2.0) or precollegiate concussion (OR, 2.9; 95% CI, 2.2 to 3.9). Prolonged recovery was predicted by the presence of eight or more postconcussion symptoms for all athletes (OR, 3.77; 95% CI, 1.68 to 8.46) and for female athletes only (OR, 8.24; 95% CI, 1.58 to 43.0); this finding was not statistically significant for male athletes.

        Discussion: Female athletes were more likely than male athletes to experience concussion. Increasing numbers of prior concussions predicted recurrence. Although most postconcussion symptoms were highly intercorrelated, the total number of symptoms predicted a prolonged recovery period.

        Conclusion: This study confirms sex-based differences in SRCs. Longitudinal studies of collegiate cohorts should attempt to limit follow-up bias and offer opportunities to clarify determinants of SRC.

            • Subspecialty:
            • Sports Injuries

          Complication Rates After Total Hip and Knee Arthroplasty in Patients With Hepatitis C Compared With Matched Control Patients

          Background: A paucity of data exists regarding long-term outcomes among patients with hepatitis C who undergo total hip arthroplasty (THA) and total knee arthroplasty (TKA).

          Methods: We queried a database for patients with hepatitis C who underwent THA and TKA. We then identified their rates of several postoperative complications and compared them with the same rates among mutually exclusive matched control cohorts.

          Results: Patients with hepatitis C who underwent THA and TKA had higher rates of infection, aseptic revision surgery, medical complications, and blood transfusion compared with matched control patients.

          Discussion: Our findings suggest that patients with hepatitis C who undergo THA and TKA are at increased risk of experiencing several postoperative complications, which could mean a substantial increase in the cost of care.

          Conclusions: Further research is needed to establish quantifiable associations between hepatitis C and postoperative complications among patients with the disease who undergo total joint arthroplasty.

              • Subspecialty:
              • Knee

              • Hip

            Variables Affecting Return to Work After Spinal Surgery in a Non-workers’ Compensation Population: A Retrospective Cohort Study

            Introduction: Return-to-work (RTW) outcomes following spine surgery are critical information for patients aspiring to return to employment following surgical correction. Among patients receiving workers’ compensation (WC), spinal surgery has been repeatedly linked to poor RTW rates. However, among patients not receiving WC, the percentage of patients who return to employment is unclear.

            Methods: We conducted a retrospective cohort study of 326 non-WC patients who underwent spinal surgery at two institutions. We determined RTW status and analyzed potential predictors of RTW status.

            Results: Preoperative work status was the only markedly positive predictor of RTW status; patients who were working prior to their surgery were more likely to return to work after surgery. Patients with at least one comorbidity were less likely to return to employment. All other sociodemographic, surgery-related, and complication variables did not reach statistical significance. However, smoking status, short fusion, and cervical fusion were clinically relevant predictors of a negative RTW status.

            Discussion: Among non-WC patients, employment before surgery was a positive predictor for RTW status. For patients with a positive comorbidity status, a lower likelihood of returning to employment is predicted. Randomized trials are needed to fully explore the effect of predictor variables on RTW status among non-WC patients.

            Conclusions: Patients not receiving WC who underwent spinal surgery had a high chance of returning to employment within 1 year if they had been working at least 3 months before the date of surgery.

                • Subspecialty:
                • Back

                • Spine

              Stemless Prosthesis for Total Shoulder Arthroplasty

              The fourth generation of humeral components currently are being used in anatomic shoulder arthroplasty. Anatomic shoulder arthroplasty implants have evolved to better re-create anatomy, improve fixation, preserve bone, and facilitate revision surgery. Most of the design changes for shoulder arthroplasty implants have centered on the humeral stem, with a transition to shorter, metaphyseal humeral stems. Many of these humeral component design changes may be beneficial; however, long-term studies are necessary to determine if the results of anatomic shoulder arthroplasty with the use of newer humeral components can match those of anatomic shoulder arthroplasty with the use of older humeral components.

                  • Subspecialty:
                  • Shoulder