The Journal of arthroplasty
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Multicenter Study
Revision of unicompartmental arthroplasty to total knee arthroplasty: not always a slam dunk!
As the number of UKA performed in the world continues to increase, so will the number of failures. A better understanding of the outcomes after revision UKAto TKA is warranted. The objective of this study is to report the outcomes of modern UKA revised to TKA in three US centers. ⋯ In the present series, the re-revision rate after revision TKA from UKA was 4.5 % at an average of 75 months or 1.2 revisions per 100 observed component years. Compared to published individual institution and national registry data, re-revision of a failed UKA is equivalent to revision rates of primary TKA and substantially better than re-revision rates of revision TKA. These data should be used to counsel patients undergoing revision UKA to TKA.
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Randomized Controlled Trial
Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial.
Controlling postoperative pain and nausea after total joint arthroplasty remains an important challenge. We conducted a prospective, randomized controlled trial with 120 patients to determine if the addition of perioperative dexamethasone to a multimodal regimen improves antiemetic and analgesic control, enhances mobility, and shortens hospital length of stay after total hip and knee arthroplasty. ⋯ A second, 24-hour postoperative dose of 10mg intravenous dexamethasone provided significant additional pain and nausea control and further reduced length of stay (P<0.05). No adverse events were detected with the administration of the intraoperative and/or postoperative dexamethasone.
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Revision total knee arthroplasty (TKA) has been associated with an increased risk of perioperative blood loss. Tranexamic acid (TXA) has been proven to be safe and effective in preventing blood loss in primary TKA. The purpose of this study was to evaluate the effect of TXA on blood loss and transfusion rates in revision TKA. ⋯ A total of 178 patients did not receive TXA while 246 patients received one intraoperative dose of 20mg/kg of TXA given prior to tourniquet release. There was a significant reduction in hemoglobin loss (42±16g/L vs 38±15g/L, P=0.005), transfusion rates (30.3% vs 16.7%, P=0.001) and average amount transfused (1.1±1.9units vs 0.5±1.1units, P=0.001) in the TXA group. There was no significant difference in recorded major adverse events with the administration of TXA.
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Staphylococcus decolonization prior to surgery is used to prevent surgical site infections (SSIs) after total joint arthroplasty (TJA). To determine if current treatment protocols result in successful decolonization of methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA), 106 consecutive patients were screened for nasal MSSA/MRSA colonization pre-operatively and on the day of surgery. Colonized patients used intranasal mupirocin twice a day and chlorhexidine showers daily 5 days prior to surgery. ⋯ On the day of surgery, 3 joints (2.8%) who underwent decolonization were positive for MSSA colonization and 0 joints were positive for MRSA colonization. The reduction in MSSA colonization was significant (P<0.001), while the eradication of MRSA colonization approached statistical significance (P=0.063). Current decolonization protocols using intranasal mupirocin and chlorhexidine washes are effective for reducing MRSA/MSSA colonization.
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The Patient Protection and Affordable Care Act contains a number of provision for improving the delivery of healthcare in the United States, among the most impactful of which may be the call for modifications in the packaging of and payment for care that is bundled into episodes. The move away from fee for service payment models to payment for coordinated care delivered as comprehensive episodes is heralded as having great potential to enhance quality and reduce cost, thereby increasing the value of the care delivered. This effort builds on the prior experience around delivering care for arthroplasty under the Acute Care Episode Project and offers extensions and opportunities to modify the experience moving forward. ⋯ This fundamental shift in payment for care offers both considerable risk and tremendous opportunity for physicians. Acquiring an understanding of the recent experience and the determinants of future success will best position orthopaedic surgeons to thrive in this new environment. Although this will remain a dynamic exercise for some time, early experience may enhance the chances for long term success, and physicians can rightfully lead the care delivery redesign process.