THIS WEEK'S ARTICLES
Reducing Surgical Site Infections in Total Joints - Sponsored Content
How Young Is Too Young for Total Knee Arthroplasty?
Researchers call for criteria aimed at selecting appropriate candidates for the procedure.
Knee replacement patients younger than age 60 have similar joint pain and disability as their older counterparts, but also possess more risk factors for surgical complications, according to new research published in The Journal of Bone & Joint Surgery.
The study's authors assessed the relationship between age and the appropriateness of undergoing total knee arthroplasty among 2,037 patients, 25% of whom were younger than 60 years. During pre-op consultations and on pre-procedure questionnaires, the younger patients reported worse knee symptoms and higher use of arthritis therapies than the older patients did. The younger patients had higher rates of severe obesity, were more likely to smoke, and were more interested in a post-op return to exercise or playing sports.
The older patients in the study had less demanding expectations, focusing on outcomes that would improve their quality of life, such as the ability to straighten their leg or walk up and down stairs.
After pre-op evaluations, surgeons recommended knee replacements for 73.6% of patients overall. The breakdown of recommendations by age was 52.2% of patients younger than 50 years, 71% of patients 50 to 59 years old and 75.4% of patients 60 years or older.
"Surgeons have to balance the patient's clinical need and willingness to undergo the procedure with the risks for complications and revision," says study coauthor Gillian A. Hawker, MD, MSc, a professor of medicine at the University of Toronto. "When they considered all of these factors, they were just as likely to offer surgery to younger people."
There has been a significant upswing in younger individuals suffering more severe knee pain or worse joint function than in older people, say the study's authors, who note knee replacement procedures are increasing at the highest rate among patients younger than 60 years. "Incorporation of appropriateness criteria into decision-making may facilitate consideration of total knee replacement benefits and risks in a growing population of young, obese individuals with knee osteoarthritis," they write.
Five Things Sterile Processing Needs to Service a Total Joints Program
Maintain efficient and effective instrument care even when your volume doubles.
Three years ago, Knoxville (Tenn.) Orthopaedic Surgery Center launched a comprehensive total joints program, adding two new ORs and 150 instrument trays. There was an issue, however: It couldn't expand the footprint of its sterile processing department because every square foot of new real estate was allocated for precious clinical space.
The center was able to make it work, however. Here's how its SPD continues to run lean and mean while reprocessing instruments for 10,000 procedures annually.
Perpetual flow. Case carts full of soiled instruments are delivered to the decontamination room after every case, as opposed to "batching" them by waiting until several carts are ready for transport. "The sporadic arrival of carts leads to backups and delays while the reprocessing techs prioritize the multiple instrument sets for reprocessing," says Jennifer Parrott, RN, the facility's OR clinical manager and sterile processing department manager. "A constant flow of incoming instruments ultimately helps the process move along more smoothly."
Tray consolidation. The OR team worked with the reprocessing department to eliminate rarely or never-used tools from instrument trays, shaving minutes off the two-and-a-half hours it can take to reprocess a set. "We standardized our vendor sets as much as we could," explains Ms. Parrott. "Vendors worked with us to fit instruments into one tray instead of two when possible."
Staggered starts. When the facility's total joints service line launched, the starting time for one reprocessing tech's first shift moved from 6 a.m. to 4 a.m. The earlier start time enables techs to get autoclaves started and tested, load instruments leftover from the previous shift into the washer, and ensure trays needed for the day's first case are reprocessed and ready for the first case of the day at 6:45 a.m. A second tech starts at 9 a.m. when instruments from the first cases of the day arrive for reprocessing. A third tech starts at 1 p.m. to reprocess instruments needed for afternoon cases while getting as many sets as possible ready for the next morning.
Outside assistance. The facility contracts with a company that visits monthly to sharpen instruments, remove burrs, tighten screws and replace damaged instruments in its mobile, truck-based instrument lab. They also disassemble instruments and thoroughly clean them, which extends the life of those instruments while reducing surgeons' frustration when damaged instruments show up in ORs.
Constant communication. Ms. Parrott is always calling, texting or emailing colleagues, surgeons and staff, as well as product reps who supply the instrument trays. "You can't be successful without being in contact with all of them," she says. "The communication must be consistent and effective, and we always find new ways to improve it."
The scope of reprocessing instruments for a busy total joints facility is enormous, but with the right equipment, staff and effective communication, the operation can continue to run smoothly even when volumes increase but room to work does not.
Reducing Surgical Site Infections in Total Joints
Four ways your care team can combat SSIs.
Surgical site infections (SSIs) are always top of mind for any OR team as they implement procedures and employ strategies for patient safety. Whether you're doing total joint procedures today or plan to add them in the future, it's important for your staff to have the tools and knowledge available to them to help prevent, diagnose and treat surgical site infections.
SSIs are expected to increase by an alarming 198% by 2023 for knee and hip replacements, and the cost to the healthcare system for knee and shoulder infections is projected to reach $1.62 billion.1 Today, surgical site infections contribute to the most common reasons that knee and hip surgeries require a second visit to the OR for revisions.2
Clearly, a focus on SSIs and ways to reduce them is of critical importance in total joint procedures and it's equally critical that your staff is armed with the best resources to help reduce SSIs. Here are four ways to help reduce SSIs.
Begin with the skin. About 80% of skin flora occurs on the outer skin layers.2 In fact, one square centimeter of skin can host as many as 10 million aerobic bacteria, a leading cause of healthcare-acquired infections.1 A single-use skin prep applicator can help reduce skin flora by moving the clinician's hand away from the patient's skin for a more aseptic technique (this does not apply to the swabstick format). A proprietary tinting process also allows the clinician to see the prepped area more clearly.
Tables take cover. Are you covering your tables and stands? The Association of periOperative Registered Nurses (AORN) guidelines state that the sterile field – including tables – should be covered if not being used immediately.3 You can help significantly reduce the risk for contamination by covering even just portions of the sterile field that are not in active use.3
The American Journal of Infection Control recently published a study stating that covering sterile tables reduced bacterial contaminations at four and eight hours. The study also suggested that covered tables reduce the amount of bioburden that can collect on unused instruments.4
Beware the colonies. Research suggests that the risk of SSI increases up to nine times due to nasal colonization of Staphylococcus aureus, presenting a big challenge in surgical settings.5 Pre-op testing for MRSA is not always included at surgical facilities, but some proactive clinicians have modified their pre-op protocol to treat every surgical patient with a nasal iodine-saturated swab, often with favorable results.6 Nasal swab tests allow clinicians to detect and identify MRSA for better prevention and control. Scalable instrument models fit into a wide variety of testing environments, including surgery centers that are usually challenged for space.
Dress for success. Not all orthopedic surgical gowns are created equal. High-quality surgical gowns should meet or exceed testing standards of the American National Standards Institute and the Association for the Advancement of Medical Instrumentation, and they should be certified to meet AAMI level 3 standards for all critical zones. When selecting a gown, be sure to choose one that's resistant to tears, punctures, strikethrough and fiber strains — and also is comfortable for your staff to use every day.
Note: For more information on SSI prevention and products that help reduce infections in total joints, please go to visit the McKesson orthopedics webpage.
1. Kurtz SM, Lau E,Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012; 27(8) (suppl):61-5.e1.
2. Readmission Rates, Causes, and Costs Following Total Joint Arthroplasty in US Medicare Population, W. Murphy, P. Lane, B. Lin, T. Cheng, D. Terry, S. Murphy; Bozic KJ, Kurtz SM, Lau E, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010; 468(1):45-51.
3. AORN Guidelines for Perioperative Practice, 2018 Edition
4. Markel, et al. Covering the instrument table decreases bioburden: An evaluation of environmental quality indicators, American Journal of Infection Control, 2018
5. Price CS, Williams A, Philips G, Dayton M, Smith W, Morgan S. Staphylococcus aureus nasal colonization in preoperative orthopaedic outpatients. Clin Orthop Relat Res. 2008; 466(11):2842-2847.
6. Outpatient Surgery Magazine, 2018
7. Melissa S. Schmidt, MSN, RN, CNL, CPAN, CAPA, PACU.; VandenBergh MF, Yzerman EP, van Belkum A, Boelens HA, Sijmons M, Verbrugh HA. Follow-up of Staphylococcus aureus nasal carriage after 8 years: redefining the persistent carrier state. J Clin Microbiol.1999; 37:3133-3140.
Why Are Women More Likely to Develop Knee Osteoarthritis?
Study suggests early intervention and tissue transplants could quell the pain.
Knee osteoarthritis is more common in women than in men, and researchers have found that it could have something to do with meniscus tissue. Specifically, a newly published study says genetic differences in the meniscus found in roughly 50% of women increases their risk of developing osteoarthritis as compared with men and other women.
Knee osteoarthritis, the most common joint problem, affects an estimated 250 million people worldwide, including 14% of women 60 years of age and older. Just a small tear in the meniscus, which is often caused by a sports injury, can increase the risk of osteoarthritis later in life, even if the damaged tissue is removed. Lack of use can also lead to deconditioning of the meniscus and increase arthritis risk.
During the study, Adetola Adesida, PhD, a professor in the department of surgery at the University of Alberta in Edmonton, and his team conducted experiments that simulated the damage that can occur to the meniscus due to lack of exercise. Their research suggests that a possible blood test could help to identify patients who have the high-risk gene, which could allow for early interventions. "We've uncovered the mechanisms that lead to this higher response, and we are hoping to develop drugs to target those pathways and block those responses," says Dr. Adesida.
The research team also developed bioengineered meniscus tissue grown from cells that have been removed from the damaged menisci of otherwise healthy individuals. Their hope is that in the future, damaged tissue can be replaced through transplant, preventing the development of knee osteoarthritis. "The goal is really to be able to use a patient's own cells to make a new meniscus for them," says Dr. Adesida.
New Guideline for Hip and Knee Replacement Patients with Rheumatic Diseases
Important new information about medication management and infection control is included.
The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) have updated the guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty.
The updated version of the organizations' 2017 joint guideline on the topic, downloadable here, includes recommendations for patients with systemic lupus erythematosus, spondyloarthritis, juvenile idiopathic arthritis, rheumatoid arthritis and other forms of inflammatory arthritis. Lists of medications patients should continue to take through surgery, along with those to withhold prior to surgery, are also provided.
Patients with rheumatic diseases such as rheumatoid arthritis or psoriatic arthritis face substantially higher risk for adverse events, particularly infections, after total hip and total knee replacements, says Susan M. Goodman, MD, attending rheumatologist at the Hospital for Special Surgery in New York City and co-principal investigator of the guideline.
"Some risk factors for infection, such as disease severity or overall disability, are not modifiable, but immunosuppressing medications used to treat rheumatic musculoskeletal diseases are an accessible target where perioperative management may decrease risk," says Dr. Goodman. "New data and medications have become available since our last guideline in 2017, so we felt it was important to update our recommendations."
That new data led the researchers to recommend withholding biologic medications in patients with inflammatory arthritis, withholding medication for a dosing cycle prior to surgery and scheduling the surgery after that dose is due. They provide the example of a patient who takes their medication every four weeks; that patient should withhold a dose of medication and schedule surgery on the fifth week after their last dose, say the authors.
The new guideline also recommends that providers continue treating patients who have severe systemic lupus erythematosus with biologics, but to withhold them in less severe cases where risk of organ damage is low. The guideline recommends shortening the gap between the last dose of JAK inhibitors and surgery from seven to three days to avoid early flares.
The updated guideline includes recently introduced immunosuppressive medications anafrolumab and voclosporin, which are used for treatment of systemic lupus erythematosus, but notes that peer-reviewed data regarding their use in the perioperative period does not yet exist. Because the drugs increase the risk of infection, the guideline says their use in patients with severe systemic lupus erythematosus should be reviewed by the treating rheumatologist in consideration of surgery.
The full manuscript of the guideline has been submitted for journal peer review, with an expectation of joint publication in rheumatology and surgical journals this summer.