Browsing by Author "Ziemba-Davis, Mary"
Now showing 1 - 10 of 20
Results Per Page
Sort Options
Item The AAHKS Clinical Research Award: Extended Oral Antibiotics Prevent Periprosthetic Joint Infection in High-Risk Cases: 3855 Patients With 1-Year Follow-Up(Elsevier, 2021) Kheir, Michael M.; Dilley, Julian E.; Ziemba-Davis, Mary; Meneghini, R. Michael; Orthopaedic Surgery, School of MedicineBackground: Surgical and host factors predispose patients to periprosthetic joint infection (PJI) after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). While surgical factors are modifiable, host factors can be challenging, and there are limited data demonstrating that preoperative patient optimization decreases risk of PJI. The goal of this study was to evaluate whether extended oral antibiotic prophylaxis reduces the one-year infection rate in high-risk patients. Methods: A total of 3855 consecutive primary THAs and TKAs performed between 2011 and 2019 at a suburban academic hospital with modern perioperative and infection-prevention protocols were retrospectively reviewed. Beginning in January 2015, a 7-day oral antibiotic prophylaxis protocol was implemented after discharge for patients at high risk for PJI. The percentage of high-risk patients diagnosed with PJI within 1 year was compared between groups that did and did not receive extended antibiotic prophylaxis. Univariate and logistic regression analyses were performed, with P ≤ .05 denoting statistical significance. Results: Overall 1-year infection rates were 2.26% and 0.85% after THA and TKA, respectively. High-risk patients with extended antibiotic prophylaxis had a significantly lower rate of PJI than high-risk patients without extended antibiotic prophylaxis (0.89% vs 2.64%, respectively; P < .001). There was no difference in the infection rate between high-risk patients who received antibiotics and low-risk patients (0.89% vs 1.29%, respectively; P = .348) with numbers available. Conclusion: Extended postoperative oral antibiotic prophylaxis for 7 days led to a statistically significant and clinically meaningful reduction in 1-year infection rates of patients at high risk for infection. In fact, the PJI rate in high-risk patients who received antibiotics was less than the rate seen in low-risk patients. Thus, extended oral antibiotic prophylaxis may be a simple measure to effectively counteract poor host factors. Moreover, the findings of this study may mitigate the incentive to select healthier patients in outcome-based reimbursement models. Further study with a multicenter randomized control trial is needed to further validate this protocol.Item Anterior communicating artery complex aneurysms: anatomic characteristics as predictors of surgical outcome in 300 cases(Elsevier, 2018) Bohnstedt, Bradley N.; Conger, Andrew R.; Edwards, John; Ziemba-Davis, Mary; Edwards, Gary; Brom, Jacqueline; Shah, Kushal; Cohen-Gadol, Aaron A.; Neurological Surgery, School of MedicineOBJECTIVE Anterior communicating artery (ACoA) complex aneurysms are challenging to treat microsurgically. The authors report their experience with microsurgical treatment of ACoA aneurysms and examine the anatomic characteristics of these aneurysms as predictors of outcome. METHODS The authors queried their institution’s aneurysm database for records of consecutive patients treated for ACoA aneurysms via microsurgical clip ligation. Data included patient demographics and clinical/radiographic presentation characteristics as well as operative techniques. Glasgow outcome scores (GOS) at hospital discharge and 6-month as well as 1-year follow-up were analyzed. RESULTS Of 319 ACoA aneurysms that underwent treatment, 259 were ruptured and 60 were unruptured. Average GOS at 1-year follow-up for all patients was 4.6. Average GOS for patients with ruptured aneurysms correlated with Hunt and Hess grade at presentation, presence of frontal hemorrhages, and need for multiple clips during surgery. Notably, 142 (44.5%) of aneurysms originated mainly from the ACoA artery; 12 (3.8%) primarily from the A1 branch; 3 (0.9%) from the A2 branch; and 162 (50.8%) from the A1/A2 junction. Aneurysm projection was superior in 118 (37%), inferior in 106 (33.2%), anterior in 88 (27.6%), and posterior in 7 (2.2%). Patients with aneurysms originating from the A1 segment had worse outcomes. Posteriorly-projecting aneurysms were more likely to be unruptured and larger than other aneurysm configurations. CONCLUSIONS The aneurysm’s exact location in relation to the adjacent neurovascular structures is potentially predictive of outcomes in the microsurgical treatment of ACoA aneurysms.Item Complications and Outcomes Associated with Two-Stage Treatment of Periprosthetic Total Knee Infection(2022-07-22) Thomas, Jacob; Ziemba-Davis, Mary; Meneghini, R. MichaelBackground and Hypothesis: Periprosthetic joint infection (PJI) is treated with implant resection, debridement, and component reimplantation after infection eradication. Treatment consists of either a single surgery or two-stage surgery with intravenous antibiotic therapy between stages. We replicated a recent study which concluded two-stage treatment is associated with high morbidity, hypothesizing that complication rates would be similar, but that morbidity is not always conclusively a consequence of two-stage treatment for PJI Project Methods: Prospectively documented data on all primary and revision knees undergoing two-stage treatment for PJI by a single surgeon were retrospectively reviewed. Surgical complications were quantified for the interstage and post-reimplantation periods. Chi-squared tests were used to compare current findings to published findings. Results: Patient demographics and comorbidities were equivalent in the two studies (p ≥ .137). More complex infections characterized the current study as evidenced by significantly more polymicrobial infections (p < .001) and greater use of static spacers due to bone loss (p = .002). Nonetheless, only 1.5% of cases in the current study did not undergo component reimplantation compared to 7.8% in the comparison study (p = .129). There were no differences in the number of additional interstage and post-reimplantation septic surgeries (p ≥ .492). Using a proposed system which penalizes additional operations required to eradicate infection, treatment success rates at minimum one year follow-up were 64% and 71%, respectively (p = .473). Without these penalties, treatment success in the current study was 95.6% (equivalent proportion not available for comparison study). All-cause mortality was statistically equivalent in the two studies (15.6 versus 7.6%, p = .144) but no deaths from PJI were observed in the current study (unknown for comparison study). Potential Impact: Study findings suggest that morbidity attributed to two-stage treatment reflect the inherent complexity of this patient group, and not the two-stage treatment itself.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 Do Antibiotic Intramedullary Dowels Assist in Eradicating Infection in Two-Stage Resection for Septic Total Knee Arthroplasty?(Elsevier, 2019) Zielinski, Matthew R.; Ziemba-Davis, Mary; Warth, Lucian C.; Keyes, Brian J.; Meneghini, R. Michael; Orthopaedic Surgery, School of MedicineBackground Evidence suggests approximately 40% of intramedullary (IM) canals are culture positive at resection for infected knee arthroplasty. While commonly utilized, no clinical data on the efficacy of antibiotic-eluding IM dowels exist. We quantified treatment success with and without the use of antibiotic-eluding IM dowels in two-stage treatment of periprosthetic knee infection using static and articulating antibiotic cement spacers. Methods 109 consecutive patients who underwent two-stage treatment for periprosthetic knee infection were reviewed. Treatment failure, defined as repeat resection before reimplantation or recurrent infection within 6 months of reimplantation, was evaluated based on spacer type and use of IM dowels, accounting for infection type and systemic host and local extremity grade. Results After exclusions for confounds, articulating spacers without IM dowels were used in 49 (57.7%) cases, articulating spacers with IM dowels in 14 cases (16.5%), and static spacers with IM dowels in 22 (25.9%) cases. Treatment success regardless of infection classification was 85.7% for articulating spacers with IM dowels, 89.8% for articulating spacers without IM dowels, and 68.2% for static spacers with IM dowels (P = .074). In chronically infected poor hosts with compromised extremities, treatment success remained highest in patients with articulating spacers with (90.9%) or without (92.9%) IM dowels compared with static spacers with IM dowels (68.4%) (P = .061). Conclusion Findings suggest that the use of IM dowels did not enhance infection eradication above and beyond that observed for articulating spacers alone, including in the worst cases involving chronically infected poor hosts with compromised extremities.Item Do Medial Pivot Kinematics Correlate With Patient-Reported Outcomes After Total Knee Arthroplasty?(Elsevier, 2017) Warth, Lucian C.; Ishmael, Marshall K.; Deckard, Evan R.; Ziemba-Davis, Mary; Meneghini, R. Michael; Department of Orthopaedic Surgery, IU School of MedicineBackground Many total knee arthroplasty (TKA) implants are designed to facilitate a medial pivot kinematic pattern. The purpose of this study was to determine whether intraoperative medial pivot kinematic patterns are associated with improved patient outcomes. Methods A retrospective review of consecutive primary TKAs was performed. Sensor-embedded tibial trials determined kinematic patterns intraoperatively. The center of rotation (COR) was identified from 0° to 90° and from 0° to terminal flexion, and designated medial-pivot or non-medial pivot based on accepted criteria. Patient-reported outcomes were measured preoperatively and at minimum one-year follow-up. Results The analysis cohort consisted of 141 TKAs. Mean age and median BMI were 63.7 years and 33.8 kg/m2, respectively. Forty-percent of TKAs demonstrated a medial pivot kinematic pattern intraoperatively. A medial pivot pattern was more common with posterior cruciate-retaining (CR) and posterior cruciate-substituting/anterior lipped (CS) implants when compared to posterior stabilized (PS) TKAs (P ≤.0150). Regardless of bearing type, minimum one-year Knee Society scores and UCLA activity level did not significantly differ based on medial vs non-medial pivot patterns (P ≥.292). For patients with posterior cruciate-sacrificing implants, there were trends for greater median improvement in Knee Society objective (46 vs 31.5 points, P =.057) and satisfaction (23 vs 14 points, P =.067) scores in medial pivot knees. Conclusion A medial pivot pattern may not significantly govern clinical success after TKA based on intraoperative kinematics and modern outcome measures. Further research is warranted to determine if a particular kinematic pattern promotes optimal clinical outcomes.Item A Dual-Pivot Pattern Simulating Native Knee Kinematics Optimizes Functional Outcomes After Total Knee Arthroplasty(Elsevier, 2017) Meneghini, R. Michael; Deckard, Evan R.; Ishmael, Marshall K.; Ziemba-Davis, Mary; Department of Orthopaedic Surgery, IU School of MedicineBackground Kinematics after total knee arthroplasty (TKA) have been studied for decades; however, few studies have correlated kinematic patterns to patient reported outcomes. The purpose of this study was to determine if a pattern of lateral pivot motion in early flexion and medial pivot motion in high flexion, simulating native knee kinematics, produces superior clinical outcomes. A second study objective was to determine if a specific kinematic pattern throughout the various ranges of flexion produces superior function and patient satisfaction. Methods 120 consecutive TKAs were performed using sensor embedded tibial trials to record intraoperative knee kinematics through the full range of motion. Established criteria were used to identify lateral (L) or medial (M) pivot kinematic patterns based on the center of rotation within three flexion zones -- 0 to 45° (early flexion), 45 to 90° (mid flexion) and 90° to terminal flexion (late flexion). Knee Society Scores, pain scores, and patient satisfaction were analysed in relationship to kinematic patterns. Results Knee Society function scores were significantly higher in TKAs with early lateral pivot/late medial pivot intraoperative kinematics compared to all other kinematic patterns (p = 0.018) at minimum one-year follow-up. There was a greater decrease in the proportion of patients with early lateral/late medial pivot kinematics who reported that their knee never feels normal (p = 0.011). Higher mean function scores at minimum one-year follow-up (p < 0.001) and improvement from preoperative baseline (p = 0.008) were observed in patients with the most ideal “LLM” kinematic pattern (lateral pivot 0 to 45o and 45 to 90o; medial pivot beyond 90o) compared to those with the least ideal “MLL” kinematic pattern. All patients with the optimal “LLM” kinematic pattern compared to none of those with the “MLL” kinematic pattern reported that they were very satisfied with their TKA (p = 0.003). Conclusion Patients who exhibited an early flexion lateral pivot kinematic pattern accompanied by medial pivot motion in later flexion, as measured intraoperatively, reported higher functional outcome scores along with higher overall patient satisfaction. Replicating the dual-pivot kinematic pattern observed in native knees may improve function and satisfaction after TKA. Further study is warranted to explore a correlation with in-vivo kinematic patterns.Item Internet Promotion of Direct Anterior Approach Total Hip Arthroplasty by Members of the American Association of Hip and Knee Surgeons(Elsevier, 2017) Shofoluwe, Ademola; Naveen, Neal; Inabathula, Avinash; Ziemba-Davis, Mary; Meneghini, R. Michael; Callaghan, John J.; Warth, Lucian C.; Department of Orthopaedic Surgery, School of MedicineIntroduction The Direct Anterior approach (DAA) in total hip arthroplasty (THA) is of significant interest to both patients and surgeons, largely due to intense marketing. This study addressed the question, ‘What is the level of promotion of DAA THA on the internet by American Association of Hip and Knee Surgeons (AAHKS) members?’ Methods An internet search was performed to identify surgeon-specific websites for each member of the AAHKS using the members’ full name and a previously published set of criteria. Each website was evaluated utilizing a questionnaire to systematically identify claims made regarding proposed DAA specific risks, benefits, as well as the presence/absence of supporting data. Results We identified 1,855 qualified websites. The DAA was referenced on 22.8% (423/1,855) of these websites. Claims regarding DAA specific benefits included; less invasive/muscle sparing (46.3%), quicker recovery (45.2%), decreased pain (28.1%), decreased hospital stay (22.0%), and decreased dislocation risk (16.3%). Potential DAA risks including lateral femoral cutaneous nerve injury, peri-prosthetic/greater trochanteric fracture, and wound complication/hematoma were addressed on only 4.7%, 3.1%, and 1.7% of websites, respectively. Supporting peer-reviewed literature was identified on only 3.6% of DAA websites. Conclusions Over one fifth of AAHKS members promoted the DAA on the internet. Member websites claimed DAA benefits such as faster recovery and decreased pain approximately nine times more frequently than any potential risk of the procedure (p < 0.001). While AAHKS policy does not regulate member marketing, it is the responsibility of all orthopaedic surgeons to disseminate accurate, validated information concerning the procedures we perform.Item Is Manipulation Under Anesthesia Effective in Improving Patient Reported Outcomes After Total Knee Arthroplasty? A Matched Cohort Analysis.(2019-12) Ciesielski, Alex; Holder, Erik; Deckard, Evan; Ziemba-Davis, Mary; Meneghini, R MichaelIntroduction: Manipulation under anesthesia (MUA) after total knee arthroplasty (TKA) is considered effective for postoperative stiffness, but strong scientific justification is lacking. This study compared outcomes in two matched cohorts: patients who met criteria and underwent MUA and patients who met criteria but did not undergo MUA. Methods: MUA (experimental) cases had ≤ 90° flexion 4-weeks postoperatively and underwent MUA surgery within 12 weeks of the index TKA. Control cases had ≤ 90° flexion 4-weeks postoperatively and did not undergo MUA. The latter group was alternatively treated with aggressive flexion exercises, frequent follow-up, and pain control modalities per surgeon discretion. 42 MUAs performed by three surgeons between 2011 and 2017 at the same center using the same standardized clinical and rehabilitation protocols were retrospectively reviewed. Six MUAs were excluded for potential confounds. The remaining 36 MUA cases were matched one-to one on sex (p= 1.00), age (p=0.893), race (p=0.938), BMI (p=0.069), and implant manufacturer (p= 1.00) to 36 control cases. Outcome variables included amount of improvement in flexion from preoperative baseline to latest follow-up and standardized PROMS. Covariates potentially affecting outcomes were taken into account. Results: Overall MUA incidence during the time period was 1.9%. Experimental and control groups did not differ on preoperative fibromyalgia, depression, and narcotic use; or intraoperative analgesia (p≥0.084). Four control patients and no experimental patients had inflammatory disease (p=0.054), and six of the former compared to none of the latter had lumbar spine pain or disease (p=0.025). Flexion data are provided in Table 1. Mean pre-primary TKA flexion was significantly greater in experimental patients (112.4 vs. 98.6°, p=0.002). On average, between pre-primary surgery and latest follow-up, experimental patients lost 10.7° of flexion compared to a gain of 12.7° by control patients (p<0.001). Pre-primary to latest follow-up improvement in pain walking on level ground (-3.3 and -4.7 points, p=0.190) and climbing stairs (-3.7 vs. -5.1, p=0.192) did not significantly differ between experimental and control patients respectively. As shown in Figure 1, prior to primary surgery experimental and control patients had similar activity levels (p=0.624). At latest follow-up, however, control patients were significantly more active than experimental patients (Figure 1, p=0.009). Figure 2 shows the proportions of patients in each group who reported their knee never feels normal prior to primary surgery (p=0.580) and at latest follow-up (p=0.0004). Surgery significantly improved this metric for control but not experimental patients. At latest follow-up 88.6% of control patients and 50% of experimental patients were satisfied or very satisfied with their knee surgery (p=0.001). Conclusion: Patients with ≤ 90° flexion 4-weeks after TKA who underwent MUA had significantly worse flexion and PROM scores than matched control patients who did not undergo MUA. These findings question the effectiveness of MUA as a legitimate treatment for postoperative TKA stiffness.Item Is Operative Diagnosis for Aseptic Revision Total Hip Arthroplasty Related to Patient Reported Outcomes?(2018-07) Holder, Erik; Ciesielski, Alex; Ziemba-Davis, Mary; Meneghini, R. MichaelBackground and Hypothesis: Component loosening and instability are the leading causes of revision total hip arthroplasty (THA). The purpose of this study was to compare patient-reported outcomes after revision THA based on failure etiology. We hypothesized that outcomes would differ based on reason for revision. Project Methods: 187 consecutive revision THAs performed between 2010 and 2017 were retrospectively reviewed. Prospectively collected preoperative and minimum one-year Hip Disability and Osteoarthritis Outcome Score/HOOS Jr., UCLA Activity Level, WOMAC Index, and patient satisfaction were assessed based on failure etiology. Demographic variables and covariates were accounted for including sex, age, BMI, ASA classification, heart disease, lumbar spine pathology, narcotic use, fibromyalgia, depression, and autoimmune arthritis. Results: Latest UCLA activity level did not differ based on failure etiology (p=0.381). However, the degree of improvement in activity level was higher (p= 0.04) in patients revised for loosening, instability, and infection compared to ALTR and polyethylene wear. HOOS Jr (p=0.949) and WOMAC total (p=0.147) scores did not differ based on failure etiology at latest follow-up, although patients revised for loosening had greater WOMAC improvement compared to all other groups except polyethylene wear (p=0.016). Satisfaction did not vary based on failure etiology (p=0.365), and demographic and covariates were unrelated to outcomes (p³0.165). Conclusion and Potential Impact: We observed that patient-reported outcomes following revision THA vary based on revision reason and activity level improvement is mitigated patients revised for ALTR and poly wear. These findings may help surgeons and patients alike set expectations for recovery following revision THA.