Browsing by Author "Buller, Leonard T."
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Item Complications and Outcomes Associated with Two-Stage Treatment of Periprosthetic Total Knee Infection(2024-04-19) Thomas, Jacob; Ziemba-Davis, Mary; Buller, Leonard T.; Meneghini, R. MichaelBackground: Chronic periprosthetic joint infection (PJI) has been traditionally treated with two-stage revision. However, single-stage treatment is gaining popularity based on claims of decreased morbidity and mortality. This study sought to evaluate whether two-stage treatment for chronic knee PJI is associated with high morbidity and complication rates compared to existing literature. Methods: Prospectively collected data on all two-stage knee revisions were retrospectively reviewed (n=97). Modern perioperative optimization protocols were implemented during the interstage and post-reimplantation periods. Surgical complications were quantified for interstage and post-reimplantation periods. Chi-squared tests compared current findings to published data. Results: Patient sex and age were equivalent, with more current smokers in the present study (P=.001) and more renal failure (P=.002) in the comparison study. Infection complexity in the current study is indicated by 84% late chronic infections in compromised (McPherson) hosts (70%) with 14% polymicrobial infections (unknown for comparison). One percent of cases in the current study did not undergo component reimplantation compared to 8.2% in the comparison study (P=.015). There were no differences in interstage and post-reimplantation septic surgeries (P=.566). Within a year of reimplantation, 9% versus 29% underwent septic reoperation (P=.0002). Using a proposed system from the comparison study penalizing additional operations required to eradicate infection, treatment success rates at minimum one-year follow-up were 56% (current study) and 51% (comparison study) (P=.412). Without these penalties, treatment success in the current study was 64% (unknown for comparison). All-cause mortality rates were the same in both samples (13.4%); however, 9/13 deaths in the current study were unrelated to PJI (unknown for comparison). No patients in the current sample died within the first postoperative year compared to 6.7% in the comparison (P=.024). Conclusion: Study data suggest morbidity attributed to two-stage treatment for PJI reflects the inherent complexity of this patient group, and not the two-stage treatment itself.Item Is There Benefit in Keeping Early Discharge Patients Overnight After Total Joint Arthroplasty?(Elsevier, 2020-07-16) Kraus, Kent R.; Buller, Leonard T.; Caccavallo, Peter; Ziemba-Davis, Mary; Meneghini, R. Michael; Orthopaedic Surgery, School of MedicineIntroduction: In recent years, cost containment relative to patent safety and quality of care for total joint arthroplasty (TJA) has been a key focus for the Centers for Medicare and Medicaid Services (CMS) spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA. TJA outpatients receive few, if any, medical interventions prior to discharge, but the type and quantity of medical interventions provided for TJA patients who stay overnight in the hospital is unknown. This study quantified the nature, frequency, and outcome of interventions occurring overnight after primary TJA. Methods: 1,725 consecutive primary unilateral TJAs performed between 2012 and 2017 by a single surgeon in a rapid-discharge program, managed by a perioperative internal medicine specialist, were reviewed. Medical records were examined for diagnostic tests, treatments, and procedures performed, results of interventions, and all-cause readmissions. Recorded interventions included any that varied from the preoperative treatment plan, were beyond standard-of-care, and could not be completed at home. Results: 759 patients were discharged on postoperative day one. 84% (641/759) received no medical interventions during their overnight hospital stay. Twelve (1.6%) received diagnostic tests, 90 (11.9%) received treatments, and 29 (3.8%) received procedures. 92% (11/12) of diagnostic tests were negative, 66% of 100 treatments in 90 patients were intravenous fluids for oliguria or hypotension, and all procedures were in/out catheterizations for urinary retention. 90-day all cause readmission rates were similar in patients who received (2.5%) and did not receive (3.3%) a clinical intervention. Conclusion: The majority of patients received no overnight interventions, suggesting unnecessary costly hospitalization. The most common issues addressed were oliguria, urinary retention, and hypotension. Protocols to prevent these conditions would facilitate outpatient TJA, improve patient safety, and reduce costs.Item Patients With Previous COVID-19 Infection Can Safely Undergo Primary Total Joint Arthroplasty(Elsevier, 2023) Rosas, Samuel; Pollock, David C.; Roche, Martin W.; Najafi, Farideh; Hollingsworth, Neusha; Buller, Leonard T.; Krueger, Chad A.; Orthopaedic Surgery, School of MedicineBackground: The COVID-19 virus is believed to increase the risk of diffusing intravascular coagulation. Total joint arthroplasty (TJA) is one of the most common elective surgeries and is also associated with a temporarily increased risk of venous thromboembolism (VTE). However, the influence of a history of COVID-19 infection on perioperative outcomes following TJA remains unknown. Therefore, this study sought to determine what effect a history of COVID-19 infection had on outcomes following primary TJA. Methods: A retrospective case-control study using the national database was performed to identify all patients who had a history of COVID-19 and had undergone TJA, between 2019 and 2020. Patients who had a history of both were 1:1 matched to those who did not have a history of COVID-19, and 90-day outcomes were compared. A total of 661 TKA and 635 THA patients who had a history of COVID-19 were 1:1 matched to controls. There were no differences in demographics and comorbidities between the propensity-matched pairs in both TKAs and THAs studied. Previous COVID-19 diagnosis was noted in 28.3% of patients 5 days within TJA and in 78.6%, 90 days before TJA. Results: Patients who had a previous diagnosis of COVID-19 had a higher risk of pneumonia during the postoperative period for both THA and TKA (6.9% versus 3.5%, P < .001 and 2.27% versus 1.21%, P = .04, respectively). Mean lengths of stay were also greater for those with a previous COVID-19 infection in both cohorts (TKA: 3.12 versus 2.57, P = .027, THA: 4.52 versus 3.62, P < .001). Other postoperative outcomes were similar between the 2 groups. Conclusion: COVID-19 infection history does not appear to increase the risk of VTE following primary TJA, but appears to increase the risk of pneumonia in addition to lengths of stay postoperatively. Individual risk factors should be discussed with patients, to set reasonable expectations regarding perioperative outcomes.Item Safety of Same and Next Day Discharge Following Revision Hip and Knee Arthroplasty Using Modern Perioperative Protocols(Elsevier, 2020-07-29) Buller, Leonard T.; Hubbard, Trey; Ziemba-Davis, Mary; Deckard, Evan R.; Meneghini, R. Michael; Orthopaedic Surgery, School of MedicineIntroduction: Advances in perioperative care have enabled early discharge and outpatient primary total joint arthroplasty (TJA). However, the safety of early discharge after revision TJA (rTJA) remains unknown and the COVID-19 pandemic will force decreased hospitalization. This study compared 90-day outcomes in patients undergoing aseptic rTJA discharged the same or next day (early) to those discharged two or three days postoperatively (later). Methods: 530 aseptic rTJAs performed at a single tertiary referral center (12/5/2011-12/30/2019) were identified. Early and later discharge patients were matched as closely as possible on procedure type, sex, ASA-PS classification, age, and BMI. All patients were optimized using modern perioperative protocols. The rate of 90-day ED visits and hospital admissions was compared between groups. Results: 183 early discharge rTJAs (54 hips, 129 knees) in 178 patients were matched to 183 later discharge rTJAs (71 hips, 112 knees) in 165 patients. 62% of the sample was female, with an overall average age and BMI of 63±9.9 (range: 18-92) years and 32±6.9 (range: 18-58) kg/m2. There was no statistical difference in 90-day ED visit rates between early (6/178, 3.4%) and later (11/165, 6.7%) discharge patients (p=0.214). 90-day hospital admission rates for early (7/178, 3.9%) and later (4/165, 2.4%) did not differ (p=0.545) Conclusions: Using modern perioperative protocols and with appropriate patient selection, early discharge following aseptic rTJA does not increase 90-day readmissions or ED visits. As hospital inpatient capacity remains limited due to COVID-19, select rTJA patients may discharge home the same or next day to preserve hospital beds and resources for more critical medically related illness.Item Same-Day Discharge Following Aseptic Revision and Conversion Total Joint Arthroplasty: A Single-Institution Experience(Elsevier, 2022-09-20) Deans, Christopher F.; Buller, Leonard T.; Ziemba-Davis, Mary; Meneghini, R. Michael; Orthopaedic Surgery, School of MedicineBackground: With hospital inpatient capacity increasingly limited and primary total joint arthroplasty (TJA) rapidly transitioning to outpatient settings, the feasibility of outpatient aseptic revision and conversion TJA (rTJA) has been considered. Before the widespread adoption of outpatient rTJA, guidelines must be established to prevent patient harm. To this end, this study describes our initial experience with same-day-discharge (SDD) aseptic rTJA. Methods: All aseptic rTJAs performed between May 8, 2015, and December 30, 2021, were retrospectively reviewed. Revision indications, patient selection criteria, and outcomes including SDD success rate, predischarge complications, all-cause emergency department visits, inpatient readmissions, and unplanned clinic encounters within 90 days of surgery were recorded. Results: Thirty-five SDD aseptic rTJAs were performed. Conversion total hip arthroplasty (55.0%) and instability (27.3%) were the most common indications for hip revision. Instability (50%) and conversion total knee arthroplasty (20.8%) were most common for knee revision. SDD was achieved in 97% (34/35) of cases. One hip patient failed SDD due to persistent hypoxia requiring an overnight hospital stay and also underwent closed reduction for dislocation in the emergency department within 90 days of discharge. Two additional patients had unplanned clinic encounters within 90 days of the index procedure. There were no hospital readmissions or reoperations within 90 days. Conclusions: Our initial experience suggests SDD aseptic rTJA can be safe and effective when modern perioperative outpatient protocols and surgical techniques are implemented. Future studies should further define patient selection criteria to optimize outcomes and minimize complications in this population.Item Tibial baseplate position and posterior cruciate ligament status impact patient-reported outcomes in conforming dual-pivot bearing total knee arthroplasty(Elsevier, 2021-10-04) Madden, Joseph A.; Arnold, Payton K.; Buller, Leonard T.; Deckard, Evan R.; Meneghini, R. Michael; Orthopaedic Surgery, School of MedicineBackground: In an effort to optimize clinical outcomes and enhance stability, ultracongruent bearings have been increasingly used in primary total knee arthroplasty (TKA). The importance of the posterior cruciate ligament (PCL) and optimal sagittal tibial baseplate position in ultracongruent bearing TKA remains unknown. This study sought to determine whether these modifiable, surgical-technique-dependent variables meaningfully impact patient-reported outcome measures. Methods: A total of 759 primary TKAs of the same dual-pivot design performed using a consistent surgical technique between January 2016 and April 2019 were retrospectively reviewed. PCL status was recorded, and anteroposterior (AP) tibial baseplate position and posterior tibial slope were measured by two independent blinded raters. Patient-reported outcomes related to pain, function, satisfaction, and activity level were analyzed in relationship to PCL status, posterior tibial slope, and AP tibial baseplate position, in addition to other pertinent covariates. Results: Median age and body mass index of the cohort were 68.3 years and 33.4 kg/m2, respectively, with 73% being female. In multivariate analysis, partial or full release of the PCL was predictive of a knee "always" feeling normal (odds ratio 1.42, P = .041). Furthermore, tibial baseplate position closer to the middle of the tibia was associated with greater improvements in pain with level walking, pain while climbing stairs, and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement total scores (P ≤ .079). Conclusion: In congruent dual-pivot bearing TKA, partially or fully releasing the PCL and AP tibial baseplate position closer to the middle of the tibia may provide greater improvement in pain and function scores at minimum 1-year follow-up.Item Time Required for Planned and Unplanned Episodes of Care in Septic Two-Stage Revision Hip and Knee Arthroplasty(Elsevier, 2022-04) Hulsman, Luci A.; Ziemba-Davis, Mary; Hicks, Shelly A.; Meneghini, R. Michael; Buller, Leonard T.; Orthopaedic Surgery, School of MedicineBackground Septic revision total hip (rTHA) and knee (rTKA) arthroplasty requires more effort but is reimbursed less than primary procedures per minute of intraoperative time. This study quantified planned and unplanned work performed by the surgical team for septic 2-stage revision surgeries during the entire episode-of-care “reimbursement window” and compared that time to allowable reimbursement amounts. Methods Between October 2010 and December 2020 all unilateral septic 2-stage rTHA and rTKA procedures performed by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. Impromptu patient inquiries and treatments after discharge, but within the episode of care, involving the surgeon/surgeon team constituted unplanned work. Planned and unplanned work minutes were summed and divided by the number of patients reviewed to obtain average minutes of work per patient. Results Sixty-eight hips and 64 knees were included. For 2-stage rTHA and rTKA the average time per patient for planned care was 1728 and 1716 minutes and for unplanned care was 339 and 237 minutes. Compared to the Centers for Medicare and Medicaid Services’ allowable reimbursement times, an additional 799 and 887 minutes of uncompensated time was required to care for 2-stage rTHA and rTKA patients. Conclusion Two-stage revision procedures are substantially more complex than primary procedures. Financially disincentivizing surgeons to care for these patients reduces access to care when high-quality care is most needed. These findings support increasing the allowable times for 2-stage septic revision cases.Item Total Joint Arthroplasty and Sleep: The State of the Evidence(Elsevier, 2024-04-24) Pettit, Robert J.; Gregory, Brandon; Stahl, Stephanie; Buller, Leonard T.; Deans, Christopher; Medicine, School of MedicineBackground: As the number of total hip and knee arthroplasties (TJA) performed increases, there is heightened interest in perioperative optimization to improve outcomes. Sleep is perhaps one of the least understood perioperative factors that affects TJA outcomes. The purpose of this article is to review the current body of knowledge regarding sleep and TJA and the tools available to optimize sleep perioperatively. Methods: A manual search was performed using PubMed for articles with information about sleep in the perioperative period. Articles were selected that examined: sleep and pain in the perioperative period; the effect of surgery on sleep postoperatively; the relationship between sleep and TJA outcomes; risk factors for perioperative sleep disturbance; the effect of anesthesia on sleep; and the efficacy of interventions to optimize sleep perioperatively. Results: Sleep and pain are intimately associated; poor sleep is associated with increased pain sensitivity. Enhanced sleep is associated with improved surgical outcomes, although transient sleep disturbances are normal postoperatively. Risk factors for perioperative sleep disturbance include increasing age, pre-existing sleep disorders, medical comorbidities, and type of anesthesia used. Interventions to improve sleep include optimizing medical comorbidities preoperatively, increasing sleep time perioperatively, appropriating sleep hygiene, using cognitive behavioral therapy, utilizing meditation and mindfulness interventions, and using pharmacologic sleep aids. Conclusions: Sleep is one of many factors that affect TJA. As we better understand the interplay between sleep, risk factors for suboptimal sleep, and interventions that can be used to optimize sleep, we will be able to provide better care and improved outcomes for patients.Item What Are the Benefits of Hip Resurfacing in Appropriate Patients? A Retrospective, Propensity Score-Matched Analysis(Sage, 2020-12) McLawhorn, Alexander S.; Buller, Leonard T.; Blevins, Jason L.; Lee, Yuo Yu; Su, Edwin P.; Orthopaedic Surgery, School of MedicineBackground: Hip arthritis is one of the major causes of disability worldwide. Hip resurfacing arthroplasty (HRA) has emerged in recent years as an alternative to total hip arthroplasty (THA), but complications of HRA have limited the patient population to younger male patients with primary osteoarthritis and large hip anatomy. How the functional benefits of HRA in this population compare with those of THA is not entirely clear. Questions/purposes: The primary aim of this study was to determine whether there were differences in hip disability and patient satisfaction with surgery between these two groups at 2 years after surgery, using patient-reported outcome measures (PROMs) and subjective measures of patient satisfaction. Additionally, we sought to determine whether there were differences in post-operative discharge disposition, revision rates, or adverse events. Methods: We searched an institutional database to identify patients undergoing unilateral HRA or THA between January 2007 and July 2011 who met today's recommended criteria for HRA: younger male patients with large-enough hip anatomy to make surgery viable (a femoral head of at least 48 mm in HRA patients and, in THA patients, an acetabular shell size of 54 mm, the minimum outer shell size that could accommodate a femoral head component of 48 mm; for matching purposes, acetabular shell size in THA was used as a surrogate for the femoral head size used in HRA). We used propensity score matching to control for potentially confounding pre-operative variables and administered the Hip Disability and Osteoarthritis Outcome Score (HOOS) survey, including its subdomains, at the 2-year mark. We also assessed differences between groups in Lower Extremity Activity Scale scores, 12-item Short Form Health Survey results, and answers regarding satisfaction with surgery. We calculated minimal detectable change, minimum clinically important change, and substantial clinical benefit using anchor-based techniques for multiple outcome measures. Results: There were 251 patients in each group. HRA patients scored significantly higher than THA patients on the 2-year HOOS sports and recreation (92 versus 87, respectively) and on rates of overall satisfaction (94% versus 89%, respectively). The HRA group also had a greater chance of achieving minimum clinically important change (18.75 points) in the HOOS sports and recreation subdomains than the THA group (97% versus 91%). No significant difference was found in 6-month adverse event rates. HRA patients also had a significantly shorter mean hospital stay, a higher rate of discharge to home, and a lower incidence of a "significant" limp after surgery. Conclusion: HRA may provide a functional benefit in sports and recreation and greater satisfaction in patients who meet the current criteria for HRA. Because these benefits may be small, pre-operative counseling should focus on balancing the possible functional benefits against the longer-term risks associated with metal-on-metal bearings.