Chronic Warfarin Anticoagulation in Hip Fracture Patients Delays Surgery and Is Associated With Increased Risk of Postoperative Complications: A Multicenter Propensity-Score-Matched Analysis.

OBJECTIVE: To evaluate the effect of warfarin on blood transfusion and postoperative complications in a low-energy hip fracture population compared with a non-anticoagulated comparison group. DESIGN: Multicenter Retrospective Cohort. SETTING: Three Urban Level I Academic Trauma Centers. PATIENTS: Acute, low-energy, native hip fractures in patients 55 years of age or older on chronic warfarin anticoagulation, propensity score matched 1:2 to non-anticoagulated hip fracture patients meeting all other inclusion criteria. MAIN OUTCOME MEASUREMENTS: Transfusion and postoperative complication rates. RESULTS: Two hundred ten anticoagulated hip fracture patients were matched to 420 nonanticoagulated patients. A higher proportion of patients required blood transfusion in the warfarin cohort (52.4% vs. 43.3%, P < 0.001), attributable mostly to the subgroup of patients undergoing arthroplasty. Warfarin patients had higher incidence of overall 90-day complications (47% vs. 38%, P = 0.039) and readmissions (31.4% vs. 8.9%, P < 0.001). Day of surgery international normalized ratio (INR) did not influence transfusions or complications among warfarin patients. Warfarin patients undergoing surgery within 24 hours had no difference in transfusions and had fewer complications compared with those undergoing surgery after 24 hours. On multivariable logistic regression analysis, warfarin use and day of surgery INR were not predictors of transfusion or complications. CONCLUSIONS: Patients on warfarin experienced longer time to surgery and higher incidence of overall transfusion and postoperative complications within 90 days of surgery. However, warfarin use and day of surgery INR was not independently associated with transfusions or complications. The reason for poorer outcomes in warfarin patients remains a topic of further investigation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Characterization of Infraspinatus Tendon Anatomy: The Soft-Tissue Portion of Remplissage.

PURPOSE: To characterize the morphology of the infraspinatus (IS) tendon and evaluate the bony anatomy of the humeral head (HH) to determine if there is a correlation between HH measurements and the amount of available IS tendon. METHODS: The superior-inferior width as well as the medial-lateral (M-L) length of the inferior and superior portions of the IS tendon were measured in 15 human cadaveric shoulders. Three measurements were then obtained for each corresponding humeral head: (1) anterior to posterior (A-P) distance, (2) midcoronal humeral head distance (MCHH), and (3) M-L distance. Pearson correlation coefficients (R) of tendon measurements relative to HH measurements were determined. RESULTS: The mean ± SD HH measurements were 44.3 ± 3.3 mm for A-P, 49.3 ± 3.4 mm at the MCHH, and 52.2 ± 3.4 mm in the M-L plane. The mean M-L length of the superior portion of the IS tendon was significantly different from the inferior portion (42.4 vs 31.0 mm, P < .0001). The mean ± SD width of the IS tendon was 19.4 ± 3.0mm. There was a statistically significant correlation (R = 0.58) between the M-L length of the superior IS tendon relative to the M-L HH distance (P < .05) and the A-P HH distance (P < .05). CONCLUSIONS: The superior M-L IS tendon length was significantly greater than the inferior M-L length. The M-L HH and the AP HH distances were significantly correlated to the M-L length of the superior portion of the IS tendon. These relationships may provide an estimation of the length of available IS tendon to help guide the management of Hill-Sachs lesions (HSLs). CLINICAL RELEVANCE: Knowledge of the available IS length can help optimize the management of HSLs following anterior shoulder dislocation. If IS tendon M-L length is less than HSL M-L length, then remplissage may result in capsulomyodesis rather than tenodesis. Placement of the superior anchor in a position that is as superior as possible within the HSL defect will maximize the opportunity for IS tenodesis.

Clavicle nonunion: plate and graft type do not affect healing rates-a single surgeon experience with 71 cases.

BACKGROUND: Clavicle nonunions often result after nonoperative treatment for the acute fracture. Those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. The aims of the present study were to (1) determine healing rates of clavicle nonunions after plate osteosynthesis using either a conventional or locked plate, (2) compare iliac crest bone graft vs. bone morphogenetic protein on nonunion healing, and (3) identify risk factors for the development of a recalcitrant nonunion. METHODS: We performed a retrospective analysis of a prospectively collected database of 78 clavicle nonunions treated with open reduction and plate fixation with or without graft augmentation by a single surgeon over 25 years. Seventy-one patients over the age of 18 with at least 12 months of follow-up comprised the study group. We analyzed healing rates after the index clavicle nonunion surgery comparing plate type and graft technique as well as identifying risk factors for developing a recalcitrant nonunion. RESULTS: A total of 62 patients (87.3%) healed after their index nonunion surgery at our institution. Three patients (4.2%) required additional surgery but healed, and 6 patients (8.5%) remain un-united; these 9 patients (12.7%) were defined as recalcitrant. There was no statistically significant difference in healing rates between plate type (P = .633) or type of bone graft (P = .157). There were no identifiable risk factors for the development of a recalcitrant nonunion. CONCLUSIONS: Plate fixation of clavicle nonunions remains a successful method of treatment. The type of plate or the method of bone graft did not produce different results. There were no demographic, patient, or injury characteristics associated with the development of a recalcitrant nonunion.

Fascia Iliaca Regional Anesthesia in Hip Fracture Patients Revisited: Which Fractures and Surgical Procedures Benefit Most?

OBJECTIVES: Perioperative fascia iliaca regional anesthesia (FIRA) decreases pain in hip fracture patients. The purpose of this study is to determine which hip fracture types and surgical procedures benefit most. DESIGN: Prospective observational study compared with a retrospective historical control. PATIENTS/PARTICIPANTS: Patients older than 60 years who received perioperative FIRA were compared with a historical cohort not receiving FIRA. SETTING: This study was conducted at a Level 1 trauma center. MAIN OUTCOME MEASUREMENTS: The primary outcome was morphine milliequivalents (MME) consumed during the index hospitalization. Fracture pattern-specific preoperative and postoperative MME consumption and surgical procedure-specific postoperative MME consumption was compared between the FIRA and non-FIRA groups. RESULTS: A total of 949 patients were included in this study, with 194 (20.4%) patients in the prospective protocol group. There were no baseline differences between cohorts. Preoperatively, only femoral neck fracture patients receiving FIRA used fewer MME (P < 0.001). Postoperatively, femoral neck fracture patients receiving FIRA used fewer MME on postoperative day (POD) 1 (P = 0.027) and intertrochanteric fracture patients used fewer MME on POD1 and POD2 (P = 0.013; P = 0.002). Cephalomedullary nail patients receiving FIRA used fewer MME on POD1 and POD2 (P = 0.004; P = 0.003). Hip arthroplasty patients receiving FIRA used fewer MME on POD1 (P = 0.037). Percutaneous pinning and sliding hip screw patients had no significant MME reduction from FIRA. CONCLUSIONS: Preoperatively, patients with femoral neck fractures benefit most from FIRA. Postoperatively, both patients with femoral neck fractures and intertrochanteric fractures benefit from FIRA. Patients undergoing cephalomedullary nail fixation or hip arthroplasty benefit most from FIRA postoperatively. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pain Management with Early Regional Anesthesia in Geriatric Hip Fracture Patients.

BACKGROUND: Geriatric hip fracture patients are susceptible to the adverse effects of opioid-induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). DESIGN: This is a prospective observational study. SETTING: A level 1 trauma center in California. PARTICIPANTS: From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. INTERVENTION: All prospectively enrolled patients were given FIBs. For a single-shot FIB, a 30- to 40-mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. RESULTS: A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0-44.5) versus 29.5 (interquartile range = 6.0-56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0-24.0) versus 29.0 (interquartile range = 12.0-59.0) (P < .001). CONCLUSION: FIBs reduce preoperative opioid intake and have low rates of opioid-related adverse events in geriatric hip fracture patients. LEVEL OF EVIDENCE: The level of evidence was II.

A Comparison in Outcomes of Preoperative Single-shot versus Continuous Catheter Fascia Iliaca Regional Anesthesia in Geriatric Hip Fracture Patients.

BACKGROUND: Fascia iliaca nerve blocks relieve pain in geriatric hip fracture patients and can be administered via a single-shot or continuous catheter. We compared perioperative opioid consumption and pain scores between these two blocks. METHODS: We performed a prospective, observational cohort study, including geriatric hip fracture patients who received a preoperative block. We compared morphine milligram equivalent (MME) consumption and visual analog scale (VAS) pain scores between single-shot and continuous fascia iliaca blocks at multiple time points: preoperative and on postoperative (POD) day 0, 1, and 2. We compared the change in preoperative total and hourly opioid consumption before and after block placement within and between groups. Secondary outcomes included opioid related adverse events, length of stay, and readmission rates. RESULTS: 107 patients were analyzed, 66 received a single-shot and 41 a continuous block. No significant differences were found between both blocks at any time point for median MME consumption or pain scores. MME [IQR]: preoperative 20.5 [6.0,48.8] vs. 24.0 [8.8,48.0], p=0.95; POD0 6.0 [0.0,18.6] vs. 10.0 [0.0,14.0], p=0.52; POD1 12.0 [0.0,30.0] vs. 18.0 [5.0,24.0], p=0.69; POD2 6.0 [0.0,21.2] vs. 12.0 [0.0,24.0], p=0.54. VAS [IQR]: preoperative 4.0 [2.2,5.3] vs. 4.6 [3.2,5.3], p=0.34; POD0 1.3 [0.0,3.7] vs. 2.5 [0.0,3.6], p=0.73; POD1 2.9 [1.7,4.4] vs. 3.7 [1.5,4.7], p=0.59; POD2 2.4 [1.0,4.4] vs. 3.3 [1.9,4.2], p=0.18. Preoperative MME/hr significantly decreased after the block for both groups: 1.05 [0.0,2.2] to 0.0 [0.0,0.0], p < 0.001; 1.4 [0.6,3.1] to 0.0 [0.0,0.1], p < 0.001. The reduction in MME/hr between groups was not significantly different: 0.9 [0.0,1.9] vs. 1.4 [0.6,3.1], p = 0.067. We found no significant differences in secondary outcomes between groups. CONCLUSIONS: We report no differences in opioid use and pain scores between single-shot and continuous catheter fascia iliaca nerve blocks. Both blocks similarly reduce preoperative opioid consumption.

Time to Block: Early Regional Anesthesia Improves Pain Control in Geriatric Hip Fractures.

BACKGROUND: Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events. METHODS: This prospective cohort study included patients who were ≥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB. RESULTS: There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay. CONCLUSIONS: Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Healing the Index Humeral Shaft Nonunion: Risk Factors for Development of a Recalcitrant Nonunion in 125 Patients.

BACKGROUND: Humeral shaft nonunions are challenging to treat, and those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. Most studies on nonunion have evaluated the union rate independent of the number of procedures required to achieve union. The aims of the present study were (1) to compare the healing rates after the index operation for the treatment of a nonunion with conventional versus locked plating with or without graft augmentation, (2) to report the prevalence of recalcitrant nonunion, and (3) to identify risk factors that predict a recalcitrant nonunion. METHODS: We performed a retrospective analysis of a prospectively collected database of 125 humeral shaft nonunions treated with open reduction and plate fixation by a single surgeon over 25 years. Univariate and multivariate regression analyses were performed to compare healing rates by type of plate fixation and biological augmentation and to identify demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. RESULTS: One hundred and five patients (84%) had healing after the index procedure for the treatment of nonunion. Twenty patients (16.0%) required secondary procedures and were defined as having a recalcitrant nonunion. Eight of these patients (6.4% of the overall group) healed after the secondary interventions, and 12 (9.6% of the overall group) had a failure to unite. There were no significant differences in healing rates between conventional and locked plates or between the types of bone graft (autogenous or recombinant human bone morphogenetic protein). Risk factors for the development of a recalcitrant nonunion were plate fixation of the acute humeral fracture, a history of deep infection, and ≥2 prior procedures. CONCLUSIONS: Plate fixation with bone graft augmentation remains a successful method for the treatment of humeral shaft nonunions. Neither plate type nor graft type reduced the risk of a recalcitrant nonunion. Factors that predicted a recalcitrant nonunion were operative fixation of the acute fracture with a plate, a history of deep infection, and ≥2 surgical procedures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Infraspinatus Tenotomy Improves Glenoid Visualization With the Modified Judet Approach.

OBJECTIVES: To determine if the addition of an infraspinatus tenotomy to the modified Judet approach (MJA) improves glenoid visualization. METHODS: We performed an MJA on 14 human cadaveric shoulders. After exposing the glenoid, the boundary of the visualized glenoid surface was marked with a 1.8- and 2.0-mm drill bit before and after performing an infraspinatus tenotomy, respectively. The humerus was disarticulated, and the pre- and post-tenotomy drill marks were verified. The area of the entire glenoid, and each of the 4 quadrants [anterior-superior (AS), anterior-inferior (AI), posterior-superior (PS), and posterior-inferior (PI)] were analyzed using a custom image-processing program. The amount of glenoid exposure and percentage of area visualized before and after the tenotomy were compared. RESULTS: Adding an infraspinatus tenotomy to the MJA significantly increased total glenoid area (cm) exposure by 33%, P < 0.0001. Three of 4 glenoid quadrants (PS, AS, and AI) had a significant increase in glenoid visualization, with the AS quadrant having the most substantial improvement after the tenotomy (+67%), P < 0.0001. CONCLUSIONS: The results provide the percentage of glenoid fossa that can be seen using an MJA and demonstrate that visualization significantly improves after adding an infraspinatus tenotomy.