Category Archives: Hip

Diabetes and the Heightened Risk of Periprosthetic Joint Infection

Diabetes woman ready for morning run along the coastDr. Stickney, a Kirkland orthopedic surgeon, is an expert in joint replacementsports medicine, and more.

Diabetes is prevalent not just in the U.S., it affects millions of people worldwide and is one of the leading causes of disability. Its direct effects on postoperative care can impact both the patient and an already strained healthcare system. In the world of orthopedic surgery specifically, little has been documented about a diabetic patient’s incidence of infection after undergoing total knee or total hip arthroplasty.

A recent investigation by researchers at the University of Utah looked at data of type-1 and type-2 diabetes mellitus patients and the incidence of periprosthetic joint infection. By looking at historical, statewide data of more than 75,000 patients undergoing knee or hip arthroplasty between 1996 and 2013, researchers were able to identify 1,668 patients with type-1 diabetes and another 18,186 patients with type-2 diabetes, providing a strong sample size. The researchers hypothesized that arthroplasty patients with type-1 diabetes were at greater risk for infection than those with type-2 diabetes.

While age and sex were found to be insignificant factors contributing to infection rates, the study did find that the frequency of periprosthetic joint infection in non-diabetic patients was 2.6% compared with 4.3% infection rates across all diabetic patients. Looking more specifically at the differences in infection rates between the two types of diabetes, patients with type-1 diabetes were at a 1.8 times greater rate of infection than patients with type-2 diabetes (7% compared to 4%, respectively).

Diabetes-related complications indicated a greater risk of periprosthetic joint infection; these include peripheral circulatory disorders, ketoacidosis, neurological manifestations, renal manifestations, or ophthalmic manifestations, hyperosmolarity (common in type-2 diabetes, where the body tries to rid itself of excess blood sugar via urination), and coma. The odds of infection increased with each added complication, and diabetes patients with more than four of these complications put them at nine times more risk. Weight also plays a role; overweight and obese type-2 diabetes patients, as well as underweight type-1 diabetes patients were also at greater risk for periprosthetic joint infection when compared with the general population.

Findings suggest it may be important to look at the length of time patients have had diabetes, factor in a patient’s diabetes type, and understand a patient’s number of diabetes-related complications prior to any joint replacement surgery. This information can help patients to make a more informed decision and help healthcare providers better manage risk.

If you have chronic health conditions and would like to learn more about how to avoid post-surgical complications related to TKA or THA, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Should There Be Strict BMI Cutoffs for TKA and THA?

happy senior couple hiking on the mountainDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

Recently we posted a blog about candidacy for and outcomes of Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) in morbidly obese patients who underwent pre-operative weight loss. Operating on obese patients for TKA and THA continues to be a hot button topic of risk versus reward in surgical outcomes.

Two well-respected orthopedic authorities, recently faced off to have a deeper conversation about whether or not orthopedic surgeons should have strict BMI cutoffs for performing primary TKA or THA. Benjamin F. Ricciardi, MD engaged Thomas K. Fehring, MD, from OrthoCarolina and Nicholas Giori, MD and PhD, a Stanford University professor, to face off. Highlights are summarized below.

Q: To what degree does the evidence support a strict BMI cutoff to determine eligibility for primary TKA and THA?

Dr. Fehring noted many Americans (35%) are obese and the association between patients with a BMI above 40 and surgical complications/infection is irrefutable. He recommends looking at big data such as Medicare or Veterans Affairs, meta-analysis, and position statements by specialty medical societies. All findings to date underscore the need to have a strict cutoff, but Dr. Fehring noted it’s important to develop weight loss strategies for patients prior to arthroplasty. 

Dr. Giori agreed that obesity is undeniably related to complications, but BMI is a weak risk factor compared to others that are commonly accepted (such as heart and metabolic disorders).

Q: Given the expansion of strict BMI cutoffs at the administrative level, how should safety (non-maleficence) be balanced against access to care?

Dr. Giori said that while BMI cutoffs are well-intended, the ones currently used have the effect of arbitrarily rationing care without medical justification. Also, he feels it disproportionately affects minorities, women and patients in low socio-economic classes. In his opinion, the decision should be based on joint decision making between the doctor and the patient. Risk adjustments in payment models (for doctors’ compensation) would help in the future.

Dr. Fehring agreed with many of the points, but at a certain point the risk outweighs the benefit, and attempting to operate on all patients regardless of BMI becomes dangerous. Keeping his “do no harm” obligation in mind, Dr. Fehring stated a BMI cutoff of 40 as a reasonable goal for patient safety.

Q: If a patient with morbid obesity is to undergo arthroplasty, what steps should be taken before surgery to make hip or knee arthroplasty safer?

Dr. Fehring recommended the patient be in the best possible health they can be prior to elective surgery to avoid complications. An optimization program, factoring in body weight, blood glucose control, serum albumin, and smoking status are part of his clinic’s protocol; patients get tools to meet and stick to set goals before getting surgery. It’s not just about treating the knee or hip; it’s about treating the whole patient as well, he said.

Dr. Giori recognized that optimization programs can help and his clinic also offers one, but the best that can be done regarding obesity is encouragement and education, and referring the patient to a structured weight-reduction program. On the flipside, the patient should do his or her best to lose weight to get below a given BMI threshold. From there, doctor and patient can create a shared decision-making plan that may or may not involve surgery.

If you’d like to discuss weight concerns prior to your total knee or hip replacement surgery, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

After One Joint Wears Out, Will More Go?

Hip, back and spinal problems in young ages.Here’s a question I’m often asked by patients: “If one of my joints has worn out, how likely are the others to go?” A recent publication from the Osteoarthritis Initiative (OAI) lends some insights into this question. The study, found in the Aug. 12, 2019 issue of Clinical Orthopaedics and Related Research, is the first of its kind. The likelihood of undergoing a 2nd Arthroplasty (Joint replacement) after hip or knee replacement had not previously been evaluated.

The authors prospectively asked two questions: “What is the likelihood of second Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA) after primary TKA or THA?” and “What risk factors are associated with undergoing addition joint replacement. The study identified 332 patients who underwent primary TKA and another 132 who underwent THA across five OAI-participating centers in the U.S., who hadn’t previously had a THA or TKA. The patients were followed for 8 years after their primary joint replacement.

  • The incidence of contralateral (opposite Knee) TKA after primary TKA was 40%
  • The incidence of THA after any TKA was 13%
  • The incidence of contralateral (opposite) THA after primary THA was 8%
  • The incidence of any TKA after primary THA was 32%

As for the second question in the study: Risk factors for undergoing contralateral TKA were younger age and a loss of medial joint space with a varus angulation, or bow leg deformity.

The conclusion is clear: Patients who underwent TKA or THA for osteoarthritis had a relatively high rate of subsequent joint arthroplasty. There’s no question that osteoarthritis is common and debilitating, and often it affects more than one large, weight-bearing joint.

If you need a joint replacement or want to learn more about the procedure, hip or knee replacement surgical outcomes, recovery and quality-of-life prognosis, please contact our office. We’ll help you return to your healthy, pain-free lifestyle. Dr. Stickney, a Kirkland orthopedic surgeon, is a knee and hip expert specializing in joint replacement surgery.

Can Activity Trackers Assist with Recovery After Knee or Hip Arthroplasty?

activitytrackerCommercial wrist-worn activity monitors, like those by Fitbit, the Apple Watch or Garmin, have the potential to accurately assess activity levels and have been gaining popularity in the last few years. In a 2018 study published in The Journal of Arthroplasty, researchers set out to determine if feedback from activity monitors can improve activity levels after total hip arthroplasty or total knee arthroplasty.

To conduct this study, 163 people undergoing primary total knee arthroplasty or total hip arthroplasty were randomized into two groups. Subjects in the study received an activity tracker with the step display obscured two weeks before surgery and completed patient-reported outcome measures. On the day after surgery, participants were randomized into either the “feedback group” or the “no feedback group”. The feedback group was able to view their daily step count and was given a daily step goal. Those in the no feedback group wore the device with the display obscured for two weeks after surgery and did not receive a formal step goal, but were also able to see their daily step count after those two weeks were up.

Average steps taken by both groups were monitored at one, two, and six weeks, and again at six months. At six months after surgery, subjects repeated their patient-reported outcome measures.

It turns out that the feedback group subjects had a significantly higher average daily step count by 43% in week one, 33% in week two, 21% in week six, and 17% at six months, compared to the no feedback group. Additionally, the feedback group subjects were 1.7 times more likely to achieve an average of 7,000 steps per day than the no feedback group subjects at six weeks after surgery. Six weeks after surgery, the feedback group participants were back to their pre-op activity levels (100%) and at six months, they were actually stepping more (137%). While 83% of the no feedback group participants reported they were satisfied with the results of the surgery, 90% of the feedback groups reported the same.

With mobility and physical activity being imperative to healthy aging and very helpful for recovery after total hip arthroplasty or total knee arthroplasty, incorporating an activity monitor into your post-operative rehabilitation is a great idea for health and exercise motivation.

Dr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more. Contact Dr. Stickney to return to your healthy, pain-free lifestyle.

Can Patients Who Live Alone Be Sent Home Safely After Joint Replacement?

homerecoveryAccording to a recent study published by The Journal of Bone & Joint Surgery in partnership with Wolters Kluwer, most patients who live alone can safely be discharged home from the hospital to recover after knee or hip replacement surgery.

This encouraging finding questions the firmly held belief that patients who live on their own should first be sent to an inpatient rehabilitation facility after undergoing hip or knee joint replacement surgery. “Patients living alone had a safe and manageable recovery when discharged directly home after total joint arthroplasty,” write Andrew N. Fleischman, MD, and colleagues from The Rothman Institute, Thomas Jefferson University, Philadelphia.

The study focused on 769 patients of a similar age demographic who were sent directly home after one-sided total hip or knee replacement; 138 of these patients were living alone for the first two weeks after surgery. The researchers compared complication rates and other important outcomes for patients who lived alone versus those who lived with others.

The researchers did find that patients who lived alone were more likely to spend more than one night in the hospital, had higher rates of in-home nursing care and physical therapy. But otherwise, the outcomes were very similar for patients living alone compared to those who lived with others. In both groups, the post-discharge complication rate was around eight percent. The two groups also had similar rates of “unplanned clinical events,” such as emergency department or urgent care visits. Pain relief and satisfaction scores during recovery were very alike as well.

Perhaps some of the most exciting results: up to six months after surgery, there were no significant differences in scores for joint functioning and quality of life and nearly 90 percent of patients living alone said they would choose to be discharged home directly after surgery again.

Although some patients who live alone can benefit from home health services or even an extra day in the hospital, discharge directly home for joint replacement postoperative rehabilitation may be a much more economical and comfortable choice than routinely sending them for inpatient rehabilitation – while also avoiding the believed associated risks.

Dr. Stickney, a Kirkland orthopedic surgeon, is an expert in exercise and healthjoint replacement surgerysports medicine and more. Contact Dr. Stickney and return to your healthy, pain-free lifestyle!

The Link Between Distance Running and Arthritis

marathonAlthough distance running is often associated with numerous health benefits, the impact on hip and knee joint health has been inconclusive up to this point. Long-distance running has been linked with an increased prevalence of arthritis in some studies, but others have shown an inverse association or no association at all.

In a recent study published by Journal of Bone & Joint Surgery, authors Ponzio et al. investigate hip and knee health in active marathon runners, including the prevalence of pain, arthritis and arthroplasty (joint replacement) and associated risk factors.

To conduct their research, Ponzio et al. distributed a hip and knee health survey internationally to marathon runners from 18-79 years old, divided into subgroups by age, sex BMI and physical activity level. The survey questions assessed pain, personal and family history of arthritis, surgical history, running volume, personal record time, risk factors and current running status. The results were then compared with National Center for Health Statistics’ information for a matched group of the US population who were not marathon runners.

What the authors of the study found is that while age, family history and surgical history independently predicted an increased risk for hip and knee arthritis in active marathoners, there was no correlation with running history. In the researcher’s cohort study, the arthritis rate of active marathoners was below that of the general US population.

While the authors conclude that longitudinal follow-up is needed to determine the effects of marathon running on developing future knee and hip arthritis, it’s a hopeful and encouraging finding for long-distance runners.

Dr. Stickney, a Kirkland orthopedic surgeon, is an expert in joint replacement surgerysports medicine and more. Contact Dr. Stickney and return to your healthy, pain-free lifestyle!