Perioperative Outcomes of Hemiarthroplasty Versus Total Hip Arthroplasty for Geriatric Hip Fracture: The Importance of Studying Matched Populations.

BACKGROUND: Geriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. As prior database studies comparing these have not used propensity matching, which is a robust statistical method of controlling for potentially confounding variables, unmatched and matched methodologies are contrasted in the present study. METHODS: Patients aged ≥70 years who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts. RESULTS: In total, 15,558 patients (14,403 HA and 1155 THA) were evaluated. Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, P < .001). Of note, although readmissions were similar for the two groups, patients undergoing THA had a 5.4% greater rate of perioperative readmission due to dislocation. CONCLUSION: Geriatric patients undergoing HA and THA for hip fracture were compared with and without propensity matching. Once matching was performed, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among the THA group. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Abnormally High, as Well as Low, Preoperative Platelet Counts Correlate With Adverse Outcomes and Readmissions After Elective Total Knee Arthroplasty.

BACKGROUND: Laboratory studies are routinely performed as a part of the preoperative workup for a total knee arthroplasty (TKA). The ramifications of abnormal preoperative platelet counts remain uncharacterized in large, multicenter patient populations. METHODS: Patients who underwent elective primary TKA were identified in the 2011-2015 National Surgical Quality Improvement Program database. Risk of 30-day postoperative complications was calculated as a function of preoperative platelet counts. Patients were characterized as having a normal platelet count, abnormally low platelet count, and abnormally high platelet count based on relative risk calculations. Univariate and multivariate analyses were performed to associate abnormal platelet counts with patient demographics, operative variables, 30-day postoperative complications, and readmissions. RESULTS: In total, 140,073 patients who underwent elective TKA were identified. Using the relative risk threshold of 1.5 for any adverse event, abnormally low and abnormally high platelet count thresholds were set at ≤116,000/mL and ≥492,000/mL, respectively. Multivariate analyses revealed low platelet counts to be associated with higher rates of any, major, and minor adverse events and longer length of stay. Analogously, high platelet counts were associated with higher rates of any and minor adverse events and longer length of stay. CONCLUSION: The present study employed a large patient sample size and showed that elective TKA patients with abnormally high, as well as low, platelet counts are at increased risk of postoperative adverse outcomes. Focused attention needs to be paid to TKA patients with preoperative abnormal platelet counts for optimization and postoperative care. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Dialysis Patients Undergoing Total Knee Arthroplasty Have Significantly Increased Odds of Perioperative Adverse Events Independent of Demographic and Comorbidity Factors.

BACKGROUND: The prevalence of dialysis-dependent patients is growing, and an increasing number of these patients are being considered for total knee arthroplasty (TKA). Studies assessing the preoperative risk associated with TKA in this population are limited to institutional cohorts with small sample sizes or national inpatient databases that lack follow-up data. METHODS: The 2006-2015 National Surgical Quality Improvement Program databases were queried for adult patients undergoing elective TKA. Differences in 30-day any/severe/minor adverse event, need for reoperation, readmission, and mortality were compared for dialysis-dependent and nondialysis TKA patients using risk-adjusted logistic regression. To account for the smaller number of dialysis patients and variations in study populations, coarsened exact matching was used. The proportion of adverse events that occurred before vs after discharge was also assessed. RESULTS: In total, 250 dialysis-dependent patients and 163,560 nondialysis patients met inclusion criteria. After controlling for patient demographics (age, sex, body mass index, functional status) and overall health (American Society of Anesthesiologists class), matched analysis revealed dialysis-dependent patients to be significantly more likely to experience any adverse event (odds ratio = 2.01; 95% confidence interval [CI], 1.34-3.02; P = .001), severe adverse event (odds ratio = 2.49; 95% CI, 1.61-3.84; P < .001), reoperation (odds ratio = 2.38; 95% CI, 1.19-4.75; P = .014), readmission (odds ratio = 2.32; 95% CI, 1.47-3.66; P = .001), and mortality (odds ratio = 6.71; 95% CI, 2.99-22.50; P = .002). The majority of adverse outcomes occurred postdischarge. CONCLUSION: Independent of patient demographics and overall health (American Society of Anesthesiologists), patients undergoing dialysis before TKA are significantly more likely to experience 30-day adverse outcomes than matched nondialysis cohorts. Preoperative evaluation of bone health status and management of medical treatment are warranted in this fragile population. Cautious surgical planning, patient counseling, and heightened surveillance are necessitated throughout their perioperative period and postoperative recovery plans may need to be different from nondialysis counterparts. Furthermore, hospitals and physicians must take these increased risks into account when working on bundle payment reimbursement strategies and resource allocation. LEVEL OF EVIDENCE: 3.

Association Between Social Media Activity and Ratings on Physician Review Websites Among Orthopaedic Surgeons With an Active Online Media Presence.

Background: Social media has the potential to play a substantial role in the decision-making of patients when choosing a physician for care. Purpose: The purpose of this study was to determine whether an association exists between physician social media activity and patient satisfaction ratings on physician review websites (PRWs) as well as number of reviews. It was hypothesized that there would be a significant association between physician social media utilization and patient satisfaction ratings. Study Design: Cross-sectional study. Methods: The American Orthopaedic Society for Sports Medicine database was queried for the complete membership list. The online media profile and level of activity of the members were evaluated, and an online media presence score was calculated. The surgeons with the approximately top 10% of online media presence scores were compiled to assess the relationship between social media usage (Twitter, Instagram, YouTube, and Facebook) and patient satisfaction ratings on the Google Reviews, Healthgrades, and Vitals PRWs. Bivariate analysis was performed to compare demographic variables and level of online presence. Results: A total of 325 surgeons were included in the analysis. The most common platform used was Facebook (88.3%). There was no significant relationship between active social media use and overall ratings on any of the PRWs. Active Twitter use was associated with a greater number of ratings on all review websites, a greater number of comments on Google Reviews and Healthgrades, and shorter patient-reported clinic wait times on Healthgrades. Active Instagram use was associated with a greater number of comments on Vitals. No relationships were observed for YouTube or Facebook. Conclusion: For the included sports medicine surgeons who were most active on social media, no significant relationships were found between social media use and overall ratings on PRWs. Of all the platforms assessed, active use of Twitter was the only significant predictor of more reviews on PRWs. Thus, when deciding which form of social media engagement to prioritize in building one's practice, Twitter may serve as a relatively low-demand, high-reward option.

Lateral Patellofemoral Ligament Reconstruction With Semitendinosus Allograft in the Setting of Previous Lateral Release.

The lateral patellofemoral ligament acts to resist medial displacement of the patella. When medial subluxation occurs, it usually has an iatrogenic cause such as prior lateral release, an over-tightened medial patellofemoral ligament reconstruction, or detachment of the vastus lateralis from the patella. The justification for lateral retinacular release has historically been to address extensor mechanism issues such as imbalance of the mechanism due to increased retinacular tension. We present a Technical Note on the treatment of chronic medial patellar instability due to a previous lateral retinacular release using a soft-tissue reconstruction approach with a semitendinosus allograft.

Predictors and Sequelae of Postoperative Delirium in a Geriatric Patient Population With Hip Fracture.

INTRODUCTION: Postoperative delirium is common for patients with hip fracture. Predictors of postoperative delirium and its association with preexisting dementia and adverse postoperative outcomes in a geriatric hip fracture population were assessed. METHODS: Patients with hip fracture aged 60 years and older were identified in the 2016 and 2017 National Surgical Quality Improvement Program Procedure Targeted Databases. Independent risk factors of postoperative delirium were identified. Associations with mortality, readmission, and revision surgery were evaluated using moderation and mediation analysis. RESULTS: Of 18,754 patients with hip fracture, 30.2% had preoperative dementia, 18.8% had postoperative delirium, and 8.3% had both preoperative dementia and postoperative delirium. Independent predictors of postoperative delirium were as follows: older age, male sex, higher American Society of Anesthesiologists score, dependent functional status, nongeneral anesthesia, preoperative diabetes, bleeding disorder, and preoperative dementia. Preoperative dementia and postoperative delirium each had an independent correlation with 30-day mortality (odds ratios = 2.06 and 1.92, respectively, with P < 0.001 for both). However, when both were present, those with preoperative dementia and postoperative delirium had an even higher odds of mortality based on moderation analysis (odds ratio = 2.25, P < 0.001). Readmissions and reoperations were significantly correlated with postoperative delirium, but not with preoperative dementia. The combination of preoperative dementia and postoperative delirium, however, did have compounding effects. Furthermore, a significant proportion of the total effect of preoperative dementia on mortality and readmission was accounted for by the development of postoperative delirium based on mediation analysis (medeff: 7%, P < 0.001 and medeff: 35%, P < 0.001). DISCUSSION: Postoperative delirium is a potentially preventable postoperative adverse outcome that was seen in 18.8% of 18,754 patients with hip fracture. Those with preoperative dementia seem to be a particularly at-risk subpopulation. Quality improvement initiatives to minimize postoperative delirium in this hip fracture population should be considered and optimized.

Incidence, predictors, and timing of post-operative stroke following elective total hip arthroplasty and total knee arthroplasty.

BACKGROUND: Postoperative stroke is a rare but potentially devastating complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of the current study was to determine the incidence, independent risk factors, and timing of stroke following THA and TKA utilizing the National Surgical Quality Improvement (NSQIP) database. METHODS: Patients who underwent elective primary THA and TKA were identified in the 2005-2016 NSQIP database. Thirty-day postoperative strokes were identified, timing was characterized, and an incidence curve was created. Multivariate analyses determined the independent predictors of these strokes. RESULTS: Of 333,117 patients identified, 286 (0.09%) experienced a stroke. Given that THA vs TKA was not a univariate predictor of stroke, the two procedures were considered together. The majority (65%) of strokes occurred before discharge. Of the strokes observed, 25% occurred by postoperative day one, 50% by postoperative day two, and 75% by postoperative day nine. Independent risk factors for postoperative stroke were: age (60-69 years old odds ratio [OR] = 4.2; 70-79 years old OR = 8.1; ≤80 years old OR = 16.1), higher American Society of Anesthesiologists (ASA) score (ASA≥3 OR = 1.7), and smoking [OR = 1.6). CONCLUSION: The incidence of stroke after THA/TKA was low at 0.09%, with the majority occurring prior to discharge and half occurring by postoperative day two. Patients who were older, sicker, or who were smokers were at greater risk of postoperative stroke. These findings can be used to council patients and to optimize patient care. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

Cardiac Complications Related to Spine Surgery: Timing, Risk Factors, and Clinical Effect.

INTRODUCTION: Large cohort studies evaluating cardiac complications in patients undergoing spine surgery are lacking. The purpose of this study was to determine the incidence, timing, risk factors, and effect of cardiac complications in spine surgery by using a national database, the American College of Surgeons National Surgical Quality Improvement Program. METHODS: Patients who underwent spine surgery in the 2005 to 2012 National Surgical Quality Improvement Program database were identified. The primary outcome was an occurrence of cardiac arrest or myocardial infarction during the operation or the 30-day postoperative period. Risk factors for development of cardiac complications were identified using multivariate regression. The postoperative length of stay, 30-day readmission, and mortality were compared between patients who did and did not experience a cardiac complication. RESULTS: A total of 30,339 patients who underwent spine surgery were identified. The incidence of cardiac complications was 0.34% (95% confidence interval [CI], 0.27% to 0.40%). Of the cases in which a cardiac complication developed, 30% were diagnosed after discharge. Risk factors for the development of cardiac complications were greater age (most notably ≥80 years, relative risk [RR] = 5.53; 95% CI = 2.28 to 13.43; P < 0.001), insulin-dependent diabetes (RR = 2.58; 95% CI = 1.51 to 4.41; P = 0.002), preoperative anemia (RR = 2.46; 95% CI = 1.62 to 3.76; P < 0.001), and history of cardiac disorders and treatments (RR = 1.88; 95% CI = 1.16 to 3.07; P = 0.011). Development of a cardiac complication before discharge was associated with a greater length of stay (7.9 versus 2.6 days; P < 0.001), and a cardiac complication after discharge was associated with increased 30-day readmission (RR = 12.32; 95% CI = 8.17 to 18.59; P < 0.001). Development of a cardiac complication any time during the operation or 30-day postoperative period was associated with increased mortality (RR = 113.83; 95% CI = 58.72 to 220.68; P < 0.001). DISCUSSION: Perioperative cardiac complications were diagnosed in approximately 1 in 300 patients undergoing spine surgery. High-risk patients should be medically optimized and closely monitored through the perioperative period. LEVEL OF EVIDENCE: Level III.