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Infection After Total Knee Arthroplasty: Does Timing of Pre-operative Antibiotics Matter?

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Journal of Clinical Orthopaedics | Vol 9 | Issue 1 |  January-June 2024 | page: 17-21 | Timothy J Walden, Max L Willinger, Jamie C Heimroth, Adam Strigenz2, Alain Sherman, Jonathan R Danoff

DOI: https://doi.org/10.13107/jcorth.2024.v09i01.624

Author: Timothy J Walden [1,2,3], Max L Willinger [1,2,3], Jamie C Heimroth [1,2,3], Adam Strigenz2, Alain Sherman [1], Jonathan R Danoff [1,2,3]

[1] Northwell Orthopedics, New Hyde Park, New York, USA,
[2] North Shore University Hospital, New York, USA,
[3] Zucker School of Medicine, Hempstead, New York, USA.

Address of Correspondence

Dr. Jonathan R. Danoff,
270-05 76th Ave, New Hyde Park, NY 11040,
E-mail: jdanoff@northwell.edu

Abstract

Background: Since the 2003 NIH consensus statement, the use of prophylactic antibiotics in total knee arthroplasty (TKA) has been the standard of care. Some studies recommend antibiotic administration within 1 h of skin incision, but no specific time frame has been delineated. The objective of this study was to determine if timing of pre-operative antibiotics is associated with post-operative infection after TKA.
Materials and Methods: An institutional database from a multi-center health-care system was queried with ICD-10 codes and reviewed for patients undergoing primary TKA between March 2020 and December 2020. The rate of superficial surgical site infection (SSI) and periprosthetic joint infection (PJI) was compared with pre-operative antibiotic timing. PJIs were defined based on 2018 MSIS criteria and superficial SSIs were other infections that did not meet MSIS criteria. Antibiotic timing was separated into 15-min cohorts from 0 min before skin incision to over 45 min before incision. Further comparison between patients who received antibiotics within 30 min of incision with those who received antibiotics greater than 30 min prior was performed.
Results: Of the 2511 patients who underwent primary TKA, 19 were found to have post-operative infections. There were 7 SSIs, and 12 PJIs, 16 of the post-operative infections occurred when patients received antibiotics <30 min before incision. There was no significant difference in SSIs or PJIs between each 15-min time interval of antibiotic administration (P = 0.45) or between the 30-min time intervals (P = 0.09).
Conclusion: Our study demonstrates no difference in post-operative infection based on pre-operative antibiotic timing. As long as antibiotics are given within 60 min of incision, preferentially 30–60 min before incision, their timing does not have a significant effect on post-operative infection following TKA.
Keywords: Pre-operative antibiotics, periprosthetic joint infection, superficial skin infection, total knee arthroplasty, complications

References

1. Premkumar A, Kolin DA, Farley KX, Wilson JM, McLawhorn AS, Cross MB, et al. Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty 2021;36:1484-9.e3.
2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780-5.
3. Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, American Academy of Orthopaedic Surgeons, American Association of Critical Care Nurses, American Association of Nurse Anesthetists, et al. Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004;38:1706-15.
4. de Jonge SW, Gans SL, Atema JJ, Solomkin JS, Dellinger PE, Boermeester MA. Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of surgical site infection. Medicine 2017;96:e6903.
5. Parvizi J, Tan TL, Goswami K, Higuera C, della Valle C, Chen AF, et al. The 2018 definition of periprosthetic hip and knee infection: An evidence-based and validated criteria. J Arthroplasty 2018;33:1309-14.e2.
6. Parvizi J, Gehrke T, Chen AF. Proceedings of the international consensus on periprosthetic joint infection. Bone Joint J 2013;95-B:1450-2.
7. Allegranzi B, Bischoff P, de Jonge S, Kubilay NZ, Zayed B, Gomes SM, et al. New WHO recommendations on preoperative measures for surgical site infection prevention: An evidence-based global perspective. Lancet Infect Dis 2016;16:e276-87.
8. Berríos-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784-91. Erratum in: JAMA Surg 2017;152:803.
9. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281-6.
10. Steinberg JP, Braun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ, et al. Timing of antimicrobial prophylaxis and the risk of surgical site infections: Results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg 2009;250:10-6.
11. van Kasteren ME, Manniën J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: Timely administration is the most important factor. Clin Infect Dis 2007;44:921-7.
12. Wu CT, Chen IL, Wang JW, Ko JY, Wang CJ, Lee CH. Surgical site infection after total knee arthroplasty: Risk factors in patients with timely administration of systemic prophylactic antibiotics. J Arthroplasty 2016;31:1568-73.
13. Badge H, Churches T, Xuan W, Naylor JM, Harris IA. Timing and duration of antibiotic prophylaxis is associated with the risk of infection after hip and knee arthroplasty. Bone Jt Open 2022;3:252-60.
14. American Academy of Orthopaedic Surgeons. Information Statement: Recommendations for the Use of Intravenous Antibiotic Prophylaxis in Primary Total Joint Arthroplasty. Available from: https://www.aaos.org/about/papers/advistmt/1027.asp

How to Cite this article: Walden TJ, Willinger ML, Heimroth JC, Strigenz A, Sherman A, Danoff JR. Infection After Total Knee Arthroplasty: Does Timing of Pre-operative Antibiotics Matter? Journal of Clinical Orthopaedics 2024;January-June:9(1):17-21.

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What is Associated with the Greatest Effect on Lengths of Stay after Total Knee Arthroplasty: The Hospital, the Surgeon, or the Patient

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Journal of Clinical Orthopaedics | Vol 8 | Issue 2 |  Jul-Dec 2023 | page: 07-11 | Max Willinger, Peter Gold, Luke Garbarino, Hiba Anis, Nipun Sodhi, Jonathan R Danoff

DOI: https://doi.org/10.13107/jcorth.2023.v08i02.580

Author: Max Willinger [1], Peter Gold [1], Luke Garbarino [1], Hiba Anis [2], Nipun Sodhi [1], Jonathan R Danoff [3]

[1] Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York, USA,
[2] Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA,
[3] Department of Orthopedic Surgery, North Shore University Hospital, Manhasset, New York, USA.

Address of Correspondence
Dr. Max Willinger,
Department of Orthopedic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York, USA.
E-mail: max.willinger1@gmail.com

Abstract

Introduction: Patient-, hospital-, and surgeon-related factors are each associated with the variable nature of length of stay (LOS) after total knee arthroplasty (TKA). However, there is a paucity of literature regarding these intertwined relationships. This study aimed to determine if the hospital, the surgeon, or the patient has the greatest association with LOS after TKA.
Materials and Methods: A total of 11,402 patients were identified from a multicenter prospectively collected institutional database between January 01, 2017, and April 01, 2019. Surgeons and hospitals were subdivided into three groups: (1) low volume (<10 and <100 cases, respectively), (2) intermediate volume (10–150 and 100–400 cases, respectively), and (3) high volume (>150 and >400 cases, respectively). Patient demographics, comorbidities, hospital academic status, and LOS were identified. Univariate and multivariate analyses were performed to compare hospital-, surgeon-, and patient-related factors.
Results: Neither hospital (P = 0.173) volume nor surgeon (P = 0.413) volume were significantly associated with LOS in multivariate analyses while controlling for patient-, surgeon-, and hospital-related factors. Patient medical factors including diabetes (P < 0.001), congestive heart failure (P < 0.001), peripheral vascular disease (P < 0.001), chronic kidney disease (P < 0.001), chronic obstructive pulmonary disease (P < 0.001), and anemia (P < 0.033), as well as academic teaching hospitals (P < 0.001) were associated with a significant increase in hospital LOS.
Conclusion: Patient’s chronic medical conditions and hospital status as an academic teaching hospital were found to be the most important associated risk factors on post-operative hospital LOS after TKA. This study directs the focus onto pre-operative optimization and patient selection and helps demonstrate where to best allocate resources to successfully decrease LOS.
Keywords: Lengths of stay, Total knee arthroplasty, Pre-operative optimization, Complications, High volume surgeon.

References

1. Hoffmann JD, Kusnezov NA, Dunn JC, Zarkadis NJ, Goodman GP, Berger RA. The shift to same-day outpatient joint arthroplasty: A systematic review. J Arthroplasty 2018;33:1265-74.
2. Burn E, Edwards CJ, Murray DW, Silman A, Cooper C, Arden NK, et al. Trends and determinants of length of stay and hospital reimbursement following knee and hip replacement: Evidence from linked primary care and NHS hospital records from 1997 to 2014. BMJ Open 2018;8:e019146.
3. Kreder HJ, Grosso P, Williams JI, Jaglal S, Axcell T, Wal EK, et al. Provider volume and other predictors of outcome after total knee arthroplasty: A population study in Ontario. Can J Surg 2003;46:15-22.
4. Styron JF, Koroukian SM, Klika AK, Barsoum WK. Patient vs provider characteristics impacting hospital lengths of stay after total knee or hip arthroplasty. J Arthroplasty 2011;26:1418- 26.e1.
5. Yasunaga H, Tsuchiya K, Matsuyama Y, Ohe K. Analysis of factors affecting operating time, postoperative complications, and length of stay for total knee arthroplasty: Nationwide web-based survey. J Orthop Sci 2009;14:10-6.
6. Piuzzi NS, Strnad GJ, Sakr Esa WA, Barsoum WK, Bloomfield MR, Brooks PJ, et al. The main predictors of length of stay after total knee arthroplasty: Patient-related or procedure-related risk factors. J Bone Joint Surg Am 2019;101:1093.
7. Bozic KJ, Maselli J, Pekow PS, Lindenauer PK, Vail TP, Auerbach AD. The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery. J Bone Joint Surg Am 2010;92:2643-52.
8. Prohaska MG, Keeney BJ, Beg HA, Swarup I, Moschetti WE, Kantor SR, et al. Preoperative body mass index and physical function are associated with length of stay and facility discharge after total knee arthroplasty. Knee 2017;24:634-40.
9. Winemaker M, Petruccelli D, Kabali C, de Beer J. Not all total joint replacement patients are created equal: Preoperative factors and length of stay in hospital. Can J Surg 2015;58:160-6.
10. Martino J, Peterson B, Thompson S, Cook JL, Aggarwal A. Day of week and surgery location effects on stay length and cost for total joint arthroplasty: Academic versus orthopaedic-specific hospital. J Knee Surg 2018;31:815-21.
11. Pamilo KJ, Peltola M, Paloneva J, Makela K, Hakkinen U, Remes V. Hospital volume affects outcome after total knee arthroplasty. Acta Orthop 2015;86:41-7.
12. Lavernia CJ, Guzman JF. Relationship of surgical volume to short-term mortality, morbidity, and hospital charges in arthroplasty. J Arthroplasty 1995;10:133-40.
13. Hervey SL, Purves HR, Guller U, Toth AP, Vail TP, Pietrobon R. Provider volume of total knee arthroplasties and patient outcomes in the HCUP-nationwide inpatient sample. J Bone Joint Surg Am 2003;85:1775-83.

How to Cite this article: Willinger M, Gold P, Garbarino L, Anis H, Sodhi N, Danoff JR. What is associated with the Greatest Effect on Lengths of Stay after Total Knee Arthroplasty: The Hospital, the Surgeon, or the patient. Journal of Clinical Orthopaedics 2023:8(2);07-11.

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Ultrasonic Bone Scalpel and Its Role In Spine Surgeries : An Article Review

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Journal of Clinical Orthopaedics | Vol 7 | Issue 1 |  Jan-Jun 2022 | page: 20-27| TausifAhmed Shikalgar, Priyank Patel, Abhay Nene, Shubhanshu Bhaladhare, Sanjay Puri, Manojkumar Gaddiker

DOI:10.13107/jcorth.2022.v07i01.461

Author: TausifAhmed Shikalgar [1], Priyank Patel [1], Abhay Nene [1], Shubhanshu Bhaladhare [1], Sanjay Puri [1], Manojkumar Gaddiker [1]

[1] Department of Orthopaedics, Lilavati Hospital and Research Centre, Bandra (W), Mumbai 400050, India

 

Address of Correspondence
Dr. Tausif Ahmed Shikalgar,
Fellow Spine Surgery, Under Dr. Abhay Nene, Lilavati Hospital and Research Centre, Bandra (W), Mumbai – 400 050, Maharashtra, India.
E-mail: Dr.tausifahmedshikalgar@gmail.com

Abstract

The past few decades have seen tremendous improvement in the field of spine surgery. Spine surgery involves a number of procedures from simple laminectomy to deformity correction. This requires high surgical skills and care, which is achieved by a number of instruments, which, in turn, protect surgeons from committing complications. Recent advancements in spine surgery include ultrasonic bone scalpel, which cut bone accurately and precisely. It is a unique surgical device which offers a controlled osteotomy which slices the hard bone while the soft tissues remain largely unaffected. The major benefits of using this modern instrument are the soft-tissue sparing, controlled cutting, reduced bleeding, and thereby increasing the effectiveness. The aim of this article is to summarize its uses in current practice of spine surgeons and to focus on its advantages and complications associated with uses of this device.

Keywords: Ultrasonic bone scalpel, spine surgery, complications, safety, osteotomy

References

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How to Cite this article: Shikalgar TA, Patel P, Nene A, Bhaladhare S, Puri S, Gaddikeri M. Ultrasonic Bone Scalpel and its Role in Spine Surgeries: An Article Review. Journal of Clinical Orthopaedics Jan-Jun 2022;7(1):20-27.

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