Revisiting INR Targets Prior to TKA
An elevated International Normalized Ratio (INR)—a standardized gauge for how long it takes blood to clot—is rarely a good sign when someone is about to undergo an elective orthopaedic procedure. This is especially true for larger surgeries such as total hip or knee arthroplasty, in which there are already concerns about perioperative bleeding. Excessive surgery-related blood loss can lead to wound complications, increased length of hospital stay, and higher mortality rates. But what precisely constitutes an “elevated” INR? While some recommendations suggest that elective procedures be performed only when a patient’s INR is ≤1.5, the evidence supporting this recommendation, especially in the setting of total knee arthroplasty (TKA), is sparse at best.
In the March 20, 2019 issue of The Journal, Rudasill et al. use the National Surgical Quality Improvement Program (NSQIP) database to help define what “elevated” should mean in the context of TKA. They evaluated data from >21,000 patients who underwent a TKA between 2010 and 2016 and who also had an INR level reported within one day before their joint replacement. They stratified these patients based on their INR levels (≤1, >1 to 1.25, >1.25 to 1.5, and >1.5). Using multivariate regression analysis to adjust for patient demographics and comorbidities, the authors found a progressively increasing risk of bleeding requiring transfusion for each group with an INR >1 (odds ratios of 1.19, 1.29 and 2.02, respectively). Relative to patients with an INR of ≤1, Rudasill et al. also found a significantly increased risk of infection in TKA patients with an INR >1.5 (odds ratio 5.34), and an increased risk of mortality within 30 days of surgery among patients with an INR >1.25 to 1.5 (odds ratio 3.37). Lastly, rates of readmission and the length of stay were significantly increased in patients with an INR >1.25.
While there are certainly weaknesses inherent in using the NSQIP dataset, this study is the first to carefully evaluate the impact of slight INR elevations on post-TKA morbidity and mortality. While I was not surprised that increasing INR levels were associated with increased bleeding events, I was impressed by the profound differences in length of stay, infection, and mortality between patients with an INR ≤1 and those with an INR >1.25. I agree with the authors’ conclusion that “current guidelines for a target INR of <1.5 should be reconsidered for patients undergoing TKA.” Further, based on the risks highlighted in this study, prospective or propensity matched cohort studies should be performed to help determine whether anyone with an INR >1 should undergo a TKA.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
What’s New in Reconstructive Knee Surgery 2019
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries. This month, Michael J. Taunton, MD, author of the January 16, 2019 “What’s New in Adult Reconstructive Knee Surgery,” selected the five most compelling findings from among the more than 100 noteworthy studies summarized in the article.
Cementless vs Cemented TKA Fixation
—A matched case-control study of 400 primary total knee arthroplasties (TKAs) found that cementless TKAs had a 0.5% rate of aseptic loosening over a mean follow-up of 2.5 years, while cemented TKAs had an aseptic loosening rate of 2.5%.1
TKA Component Size in Obese Patients
—Among 35 revision-TKA patients with a varus collapse of the tibia, 29 weighed >200 lbs. Fehring et al. found that patients with implants at the small end of the range of the manufacturer’s tibial size offering and with >5° of preoperative varus were at increased risk of tibial-component failure.2
Outpatient TKA
—A retrospective multivariate analysis of >4,300 patients who underwent outpatient TKA and >128,900 patients who underwent inpatient TKA found that, within 1 year, those who had outpatient procedures were more likely to experience a tibial and/or femoral component revision due to a noninfectious cause, irrigation and debridement, explantation of the prosthesis, and stiffness requiring manipulation under anesthesia.
Infection Prevention
—In a randomized trial of patients undergoing TKA, one group received 15 mg/kg of systemic intravenous vancomycin, and a second group received intraosseous regional administration of 500 mg vancomycin into the tibia. Mean tissue concentrations of the antibiotic were 34.4 mg/g in the intraosseous group and 6.1 mg/g in the intravenous group, suggesting that intraosseous administration provides a significantly higher tissue concentration of that antibiotic. 3
TKA Anesthesia Protocol
—A retrospective review of 156 consecutive patients who underwent primary TKA found that procedures performed with mepivacaine spinal anesthesia led to fewer episodes of urinary catheterization and shorter mean length of stay compared with procedures performed with bupivacaine spinal anesthesia.4
References
- Miller AJ, Stimac JD, Smith LS, Feher AW, Yakkanti MR, Malkani AL. Results of cemented vs cementless primary total knee arthroplasty using the same implant design. J Arthroplasty.2018 Apr;33(4):1089-93. Epub 2017 Dec
- Fehring TK, Fehring KA, Anderson LA, Otero JE, Springer BD. Catastrophic varus collapse of the tibia in obese total knee arthroplasty. J Arthroplasty.2017 May;32(5):1625-9. Epub 2017 Jan 30.
- Chin SJ, Moore GA, Zhang M, Clarke HD, Spangehl MJ, Young SW. The AAHKS Clinical Research Award: intraosseous regional prophylaxis provides higher tissue concentrations in high BMI patients in total knee arthroplasty: a randomized trial. J Arthroplasty.2018 Jul;33(7S):S13-8. Epub 2018 Mar 15.
- Mahan MC, Jildeh TR, Tenbrunsel TN, Davis JJ. Mepivacaine spinal anesthesia facilitates rapid recovery in total knee arthroplasty compared to bupivacaine. J Arthroplasty.2018 Jun;33(6):1699-704. Epub 2018 Jan 16.
Routine Diagnostic Tests for Periprosthetic Joint Infection Demonstrate a High False-Negative Rate
What’s New in Musculoskeletal Basic Science 2018
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Matthew J. Allen, VetMB, PhD, author of the December 5, 2018 Specialty Update on Musculoskeletal Basic Science, focuses on the five most compelling findings from among the more than 60 noteworthy studies summarized in the article.
Gene Editing in Orthopaedics
–Gene-editing tools such as CRISPR-Cas9 have great potential as a means of introducing therapeutic genes into mesenchymal stem cells that can then be targeted to tissues in vivo. These researchers1 reported on genetically modified stem cells that have the potential to differentiate into chondrocytes encoding a natural inhibitor of interleukin-1, providing an opportunity for localized release of immunomodulatory factors.
Managing Orthopaedic Infections
–A novel study2 in which transmission electron microscopy was used to identify viable bacteria deep within the canalicular structure of cortical bone, remote from the site of an infected implant, suggests that effective debridement requires the removal of not just necrotic tissue, but also of adjacent, apparently unaffected bone.
Computational Modeling of Human Movement
–This report3 presented a human musculoskeletal model that provided extremely accurate predictions of ground reaction forces during simulated walking and squatting. As similar models are developed and validated, surgeons will have improved tools for evaluating patients, planning surgery, and making decisions about which procedure/implant is most appropriate for an individual patient.
Sex-Related Differences
–This report4 demonstrated sexually dimorphic regulation of gene-expression profiles in bone marrow osteoprogenitor cells that could partly explain clinical observations in sex differences in peak bone mass, bone remodeling, and immunomodulation.
Biological Enhancement of Ligament Healing
–Among several basic science papers focused on the optimal healing and durable fixation of tendons and ligaments, this notable work5 reported on the translation of bridge-enhanced ligament repair for the anterior cruciate ligament.
References
- Brunger JM, Zutshi A, Willard VP, Gersbach CA, Guilak F. CRISPR/Cas9 editing of murine induced pluripotent stem cells for engineering inflammation-resistant tissues. Arthritis Rheumatol.2017 May;69(5):1111-21. Epub 2017 Mar 31.
- de Mesy Bentley KL, Trombetta R, Nishitani K, Bello-Irizarry SN, Ninomiya M, Zhang L, Chung HL, McGrath JL, Daiss JL, Awad HA, Kates SL, Schwarz EM. Evidence of Staphylococcus aureus deformation, proliferation, and migration in canaliculi of live cortical bone in murine models of osteomyelitis. J Bone Miner Res.2017 May;32(5):985-90. Epub 2017 Jan 26.
- Jung Y, Koo YJ, Koo S. Simultaneous estimation of ground reaction force and knee contact force during walking and squatting. Int J Precis Eng Manuf.2017;18(9):1263-8.
- Kot A, Zhong ZA, Zhang H, Lay YE, Lane NE, Yao W. Sex dimorphic regulation of osteoprogenitor progesterone in bone stromal cells. J Mol Endocrinol.2017 Nov;59(4):351-63. Epub 2017 Sep 4.
- Perrone GS, Proffen BL, Kiapour AM, Sieker JT, Fleming BC, Murray MM. Bench-to-bedside: bridge-enhanced anterior cruciate ligament repair. J Orthop Res.2017 Dec;35(12):2606-12. Epub 2017 Jul 9.
Physical Parameters Beyond BMI Affect TKA Outcomes
It is well established that obese patients who undergo total joint arthroplasty have increased risks of complications and infections. But what about folks who are not obese, but are just generally large? Do they also have increased post-arthroplasty complications, compared to their smaller counterparts? That is the question Christensen et al. explored in a registry-based study in the November 7, 2018 edition of JBJS.
In addition to BMI, the authors examined 3 other physical parameters—body surface area, body mass, and height—to determine whether these less-studied characteristics (all contributing to “bigness”) were associated with an increased rate of various adverse outcomes, including mechanical failure and infection, after primary total knee arthroplasty (TKA). They evaluated data from more than 22,000 TKAs performed at a single institution and found that the risk of any revision procedure or revision for a mechanical failure was directly associated with every 1 standard deviation increase in BMI (Hazard Ratio [HR], 1.19 and 1.15, respectively), body surface area (HR, 1.37 and 1.35, respectively), body mass (HR, 1.30 and 1.27, respectively), and height (HR, 1.22 and 1.23, respectively). In this study, 1 standard deviation was equivalent to 6.3 kg/m2 for BMI, 0.3 m2 for body surface area, 20 kg for body mass, and 10.5 cm for height.
These findings, while not all that surprising, are enlightening nonetheless. The study shows that increasing height has a greater negative impact on TKA outcomes than previously thought. While I spend a lot of time counseling patients with high BMIs about the increased risks of undergoing a TKA (and while such patients can take certain actions to lower their BMI prior to surgery), I do not spend nearly as much time counseling patients who are much taller than normal about their increased risks (and height is not a modifiable risk factor). Nor do I spend much time thinking about a patient’s overall body mass or body surface area in addition to their BMI. This study will remind me not to overlook these less commonly examined physical parameters when discussing TKA with patients in the future.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
JBJS 100: Shoulder Impingement and Distraction Osteogenesis
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Anterior Acromioplasty for Chronic Impingement Syndrome in the Shoulder
C S Neer: JBJS, 1972 January; 54 (1): 41
For many years after its publication, this 1972 JBJS article changed the treatment approach for patients with shoulder disability. But more recently, arthroscopy and magnetic resonance imaging arthrography have identified other painful non-impingement shoulder conditions. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete rotator cuff tear, and performing aggressive rehabilitation prior to corrective surgery.
Use of the Ilizarov Technique for Treatment of Non-union of the Tibia Associated with Infection
G K Dendrinos, S Kontos, E Lyritsis: JBJS, 1995 June; 77 (6): 835
This case series described a technique of bone transport with bridging achieved by distraction osteogenesis. The defects averaged 6 cm, the mean duration of treatment was 10 months, and the mean time to union was 6 months. More recent research has focused on augmenting the osteogenic potential of tissues in the distraction gap with substances such as bone morphogenetic protein, platelet-rich plasma, and mesenchymal stem cells.
JBJS 100: Infection Prevention and Hip Replacement Rates
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Prevention of Infection in Treatment of 1,025 Open Fractures of Long Bones
R B Gustilo and J T Anderson: JBJS, 1976 June; 58 (4): 453
While “best practices” for managing open long-bone fractures have changed since this landmark study was published, the Gustilo-Anderson classification still correlates well with the risk of infection in patients with comorbid medical illnesses and other complications. It remains widely accepted for research and training purposes, and it provides commonly used basic language for communicating about open fractures.
Rates and Outcomes of Primary and Revision Total Hip Replacement in the US Medicare Population
N N Mahomed, J A Barrett, J N Katz, C B Phillips, E Losina, R A Lew, E Guadagnoli, W H Harris, R Poss, J A Baron: JBJS, 2003 January; 85 (1): 27
Analyzing Medicare claims data between July 1, 1995 and June 30, 1996, the authors of this prognostic study claimed it was “the first population-based study of the rates of revision total hip replacement and its short-term outcomes.” In the last 10 years alone, more than 5,000 studies on revision THA have been published in PubMed-indexed journals, including this 2012 JBJS study, which examined THA revision risk in the same Medicare cohort over 12 years.
JBJS 100: Pavlik Harness and the Infected TKA
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal constituted Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered activity on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are the first two:
- Congenital Dislocation of the Hip
PL Ramsey, S Lasser, GD MacEwen: JBJS, 1976 Oct; 58 (7): 1000
The introduction of the Pavlik harness revolutionized the treatment of congenital dislocation of the hip in infants. The concept of the “safe zone” was introduced in this article. - Two-Stage Reimplantation for the Salvage of Infected Total Knee Arthroplasty
J N Insall, F M Thompson, B D Brause: JBJS, 1983 Jan; 65 (8): 1087
This was the first paper to show that a specific reimplantion protocol (debridement of the soft tissues and removal of the prosthesis and all cement, six weeks of parenteral antibiotics, and implantation of a new total knee) could provide predictable results in managing this difficult problem.
What’s New in Musculoskeletal Basic Science 2017
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Matthew J. Allen, VetMB, PhD, author of the December 6, 2017 Specialty Update on Musculoskeletal Basic Science, summarized the five most compelling findings from among the more than 60 noteworthy studies summarized in the article.
Cartilage Repair
–Deriving induced pluripotent stem cells (iPSCs) from peripheral blood cells1 rather than from dermal fibroblasts obviates the need for in vitro expansion. This method may also serve to boost interest in the use of commercial cell-based therapies with defined potency that are available off-the-shelf and don’t require separate cell-harvesting procedures.
–The FDA recommends that large-animal models be used to corroborate basic-science findings from small-animal models. Recent work has demonstrated the efficacy of insulin-like growth factor (IGF)-1 in supporting mechanically competent repair tissue following chondrocyte implantation in a pig model.2
Infection
–Infection, especially from organisms that have developed antimicrobial resistance and/or that produce biofilms, continues to pose a challenging problem for orthopaedic surgeons. To provide a more rational and stratified approach to managing these complex cases, Getzlaf et al. recommend the use of a multidisciplinary approach in which patient-specific information about individual microorganisms is combined with detailed understandings of the vulnerabilities of candidate bacterial species.3
Aseptic Loosening
–There is a resurgence of interest in the role of subclinical infection in the etiopathogenesis of aseptic loosening. At the same time, molecular diagnostic methods for microbial infection are moving forward.4 Such methods may serve to highlight the relevance of subclinical microbial contamination as a cause of aseptic loosening.
Cartilage Imaging
–While the goal of cartilage imaging is to develop tools that are fast, inexpensive, sensitive, accurate, and noninvasive, there is growing interest in the use of more direct, invasive techniques such as optical coherence tomography (OCT),5 which could be used in vivo at the time of surgery to analyze cartilage damage.
References
- Li Y, Liu T, Van Halm-Lutterodt N, Chen J, Su Q, Hai Y. Reprogramming of blood cells into induced pluripotent stem cells as a new cell source for cartilage repair. Stem Cell Res Ther.2016 Feb 17;7:31.
- Meppelink AM, Zhao X, Griffin DJ, Erali R, Gill TJ, Bonassar LJ, Redmond RW,Randolph MA. Hyaline articular matrix formed by dynamic self-regenerating cartilage and hydrogels. Tissue Eng Part A.2016 Jul;22(13-14):962-70. Epub 2016 Jul 7.
- Getzlaf MA, Lewallen EA, Kremers HM, Jones DL, Bonin CA, Dudakovic A,Thaler R, Cohen RC, Lewallen DG, van Wijnen AJ. Multi-disciplinary antimicrobial strategies for improving orthopaedic implants to prevent prosthetic joint infections in hip and knee. J Orthop Res.2016 Feb;34(2):177-86. Epub 2015 Dec 29.
- Palmer MP, Melton-Kreft R, Nistico L, Hiller NL, Kim LH, Altman GT, Altman DT, Sotereanos NG, Hu FZ, De Meo PJ, Ehrlich GD. Polymerase chain reaction-electrospray-time-of-flight mass spectrometry versus culture for bacterial detection in septic arthritis and osteoarthritis. Genet Test Mol Biomarkers.2016 Dec;20(12):721-31. Epub 2016 Oct 17.
- Novakofski KD, Pownder SL, Koff MF, Williams RM, Potter HG, Fortier LA. High-resolution methods for diagnosing cartilage damage in vivo. 2016 Jan;7(1):39-51.
Fructosamine Bests HbA1c for Preop Glycemic Screening
Patients with diabetes have an increased risk of postoperative complications following total joint arthroplasty (TJA). Additionally, perioperative hyperglycemia has been identified as a common and independent risk factor for periprosthetic joint infection, even among patients without diabetes. Therefore, knowing a patient’s glycemic status prior to surgery is very helpful.
In the November 15, 2017 edition of The Journal of Bone & Joint Surgery, Shohat et al. demonstrate that serum fructosamine, a measure of glycemic control obtainable via a simple and inexpensive blood test, is a good predictor of adverse outcomes among TJA patients—whether or not they have diabetes.
Researchers screened 829 patients undergoing TJA for serum fructosamine and HbA1c—a common measure, levels of which <7% are typically considered good glycemic control. Patients with fructosamine levels ≥292 µmol/L had a significantly higher risk of postoperative deep infection, readmission, and reoperation, while HbA1c levels ≥7% showed no significant correlations with any of those three adverse outcomes. Among the 51 patients who had fructosamine levels ≥292 µmol/L, 39% did not have HbA1c levels ≥7%, and 35% did not have diabetes.
In addition to being more predictive of postsurgical complications than HbA1c, fructosamine is also a more practical measurement. A high HbA1c level during preop screening could mean postponing surgery for 2 to 3 months, while the patient waits to see whether HbA1c levels come down. Fructosamine levels, on the other hand, change within 14 to 21 days, so patients could be reassessed for glycemic control after only 2 or 3 weeks.
While conceding that the ≥292 µmol/L threshold for fructosamine suggested in this study should not be etched in stone, the authors conclude that “fructosamine could serve as the screening marker of choice” for presurgical glycemic assessment. However, because the study did not examine whether correcting fructosamine levels leads to reduced postoperative complications, a prospective clinical trial to answer that question is needed.
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