Risk factors for malalignment after intramedullary nail treatment of distal tibia fractures with associated fibula fractures.

PURPOSE: Malalignment of distal tibia fractures can lead to malunion/nonunion or alter the limb mechanical axis which may cause arthritis. Proposed methods to decrease malalignment include fibular fixation or multiplanar interlocking screws, however these remain controversial. This study aimed to identify factors associated with malalignment in distal tibial fractures with associated fibular shaft fractures. METHODS: A retrospective review was performed of distal tibia fractures with associated fibular shaft fractures treated with intramedullary nailing at two level one trauma centers between 2015 and 2019. Cases involving malalignment (> 5° of deviation from anatomic axis on either coronal/sagittal axis) on final follow-up (minimum three months postoperatively) were compared to those without malalignment with regard to demographics, fracture characteristics, intraoperative characteristics, and complications. RESULTS: The rate of malalignment was 13%. On multivariate analysis, multiplanar distal interlocking screw fixation (odds ratio [OR], 0.18; 95% confidence interval [CI] 0.03-0.92) was associated with a decreased rate of final malalignment, while nail diameter > 10 mm was associated with a higher rate (OR, 4.05; 95% CI 1.25-13.11). Fibular fixation was not associated with malalignment. CONCLUSION: Multiplanar distal interlocking screws may protect against malalignment. Fibula fixation does not appear associated with a decreased rate of malalignment in distal tibia fractures treated with intramedullary nails. LEVEL OF EVIDENCE: III.

Is there an increased risk for subtrochanteric stress fracture with the Femoral Neck System versus multiple cannulated screws fixation?

Purpose: This study sought to compare the risk of subtrochanteric stress-riser fractures and biomechanical stability of the Femoral Neck System (FNS) versus multiple screw fixation (MSF). Methods: Eight paired cadaveric femurs were randomly assigned to FNS or MSF. Physiologic load mimicking single leg stance at the subtrochanteric region was applied to the constructs. Results: No constructs failed in the subtrochanteric region during loading. There was no significant difference in force (P = 0.364) or loading cycles (P = 0.348) between groups. Conclusion: FNS constructs were not associated with an increased incidence of iatrogenic subtrochanteric fractures or biomechanical stability versus MSF.

Weightbearing after combined medial and lateral plate fixation of AO/OTA 41-C2 bicondylar tibial plateau fractures: a biomechanical study.

BACKGROUND: Combined medial and lateral plate fixation is recommended for complex tibial plateau fractures with medial fragments or no cortical bone contact. Although such fixation is adequate to resist forces during range of motion, it may be insufficient to support immediate postoperative weightbearing. Here, we analyzed displacement, stiffness, and fixation failure during simulated full weightbearing of bicondylar tibial plateau fractures treated with combined medial and lateral locking plate fixation. METHODS: We used 10 fresh-frozen adult human cadaveric tibias and mated femurs. Osteotomies were performed with an oscillating saw and cutting template to simulate an AO Foundation and Orthopaedic Trauma Association (AO/OTA) 41-C2 fracture (simple articular, multifragmentary metaphyseal fracture). Specimens were anatomically reduced and stabilized with combined medial and lateral locking plates (AxSOS, Stryker, Mahwah, NJ). Specimens were loaded axially to simulate 4 weeks of walking in a person weighing 70 kg. The specimens were cyclically loaded from 200 N to a maximum of 2800 N. Then, if no failure, loading continued for 200,000 cycles. We measured displacement of each bone fragment and defined fixation failure as ≥5 mm of displacement. Construct stiffness and load at failure were calculated. Categorical and continuous data were analyzed using Chi-squared and unpaired t-tests, respectively. RESULTS: Mean total displacement values after 10,000 loading cycles were as follows: lateral, 0.4 ± 0.8 mm; proximal medial, 0.3 ± 0.7 mm; distal medial, 0.3 ± 0.6 mm; and central 0.4 ± 0.5 mm. Mean stiffness of the construct was 562 ± 164 N/mm. Fixation failure occurred in 6 of 10 specimens that reached 5 mm of plastic deformation before test completion. In the failure group, the mean load at failure was 2467 ± 532 N, and the mean number of cycles before failure was 53,155. After test completion, the greatest displacement was found at the distal medial fracture site (2.3 ± 1.4 mm) and lateral fracture site (2.2 ± 1.7 mm). CONCLUSIONS: Although combined medial and lateral plate fixation of complex tibial plateau fractures provides adequate stability to allow early range of motion, immediate full weightbearing is not recommended.

Extremity fasciotomy for patients on extracorporeal membrane oxygenation is independently associated with inpatient mortality.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) maintains end-organ perfusion in critically ill patients with cardiac or respiratory failure; however, ECMO cannulation in the extremities has been associated with significant limb ischemia and risk of compartment syndrome. Current literature on ECMO and fasciotomies is limited to small single-center retrospective studies. This study aimed to (1) compare the incidence of postoperative outcomes and mortality in patients undergoing fasciotomy while on ECMO to those of non-fasciotomy ECMO patients, and (2) assess the difference in adjusted mortality risk between the two groups. HYPOTHESIS: We hypothesized that patients undergoing fasciotomy while on ECMO would have significantly higher odds of in-hospital mortality than non-fasciotomy ECMO patients after adjustment for perioperative variables. METHODS: We conducted a retrospective review of NIS from January 1st, 2012-September 30, 2015 for all hospitalizations involving ECMO and stratified them into two cohorts based on whether they underwent fasciotomy after ECMO. Patient baseline characteristics, in-hospital procedures, and postoperative outcomes were compared between the two cohorts. Logistic regression was used to assess in-hospital mortality risk between the two cohorts adjusting for age, sex, Elixhauser score, and perioperative procedures and non-fasciotomy perioperative morbidity. RESULTS: There were 7,085 estimated eligible discharges between 2012 and 2015 identified, 149 (2.1%) of which underwent fasciotomy following ECMO. One hundred and thirteen of the 149 hospitalizations (77%) in the fasciotomy cohort resulted in in-hospital mortality, compared to 3,805 of the 6,936 (55%) in the non-fasciotomy cohort. There were no differences in rates of transfusion (p=0.290), length of stay (p=0.282), or discharge disposition (p=0.126) between the two cohorts. In the logistic regression model, the fasciotomy cohort had a higher odds of in-hospital mortality than non-fasciotomy cohort (OR, 2.5; 95% CI, 1.1-5.6). DISCUSSION: Operative treatment of acute compartment syndrome for patients on ECMO therapy is associated with significantly increased mortality and morbidity. Whether fasciotomy is a marker of sickness or represents a cause-and-effect relationship is unknown and future should investigate the role of non-operative treatment of compartment syndrome on mortality in this population. LEVEL OF EVIDENCE: III; Prognostic.

Fusion versus fixation in complex comminuted C3-type tibial pilon fractures: a systematic review.

BACKGROUND: Comminuted intra-articular tibial pilon fractures can be challenging to manage, with high revision rates and poor functional outcomes. This study reviewed [1] treatment, complications, and clinical outcomes in studies of complex comminuted tibial pilon fractures (type AO43-C3); and [2] primary ankle arthrodesis as a management option for these types of complex injuries. METHODS: A systematic literature search was performed on PubMed from 1990 to 2020 to determine complications and outcomes after staged fracture fixation and primary ankle joint arthrodesis for comminuted C3-type tibial pilon fractures. The search was conducted in compliance with the PRISMA guidelines, using the following MeSH terms: "tibial pilon"/"pilon fracture"/"plafond fracture"/"distal tibial"/"43-C3"/"ankle fracture"/"ankle fusion"/"primary ankle arthrodesis"/"pilon fracture staged"/"pilon external fixation" and "pilon open reduction internal fixation." Inclusion criteria were restricted to original articles in English language on adult patients ≥18 years of age. Eligibility criteria for retrieved publications were determined using a "PICO" approach (population, intervention/exposure, comparison, outcomes). Weighted analysis was used to compare treatment groups on time to definitive treatment, follow-up time, range of motion, fracture classification, and complications. RESULTS: The systematic literature review using the defined MeSH terms yielded 72 original articles. Of these, 13 articles met the eligibility criteria based on the PICO statements, of which 8 publications investigated the outcomes of a staged fixation approach in 308 cumulative patients, and 5 articles focused on primary ankle arthrodesis in 69 cumulative patients. For staged treatment, the mean wound complication rate was 14.6%, and the malunion/nonunion rate was 9.9%. For primary arthrodesis, the mean wound complication rate was 2.9%, and the malunion/nonunion rate was 2.9%. After risk stratification for fracture type and severity, the small cumulative cohort of patients included in the primary arthrodesis publications did not provide sufficient power to determine a clinically relevant difference in complications and long-term patient outcomes compared to the staged surgical fixation group. CONCLUSIONS: At present, there is insufficient evidence in the published literature to provide guidance towards consideration of ankle arthrodesis for complex comminuted C3-type tibial pilon fractures, compared to the standard treatment by staged surgical fracture fixation.

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration.

BACKGROUND: Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery. AIM: To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients. METHODS: In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05. RESULTS: Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort. CONCLUSION: The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

Peri-incisional perfusion does not differ between running versus interrupted Allgöwer-Donati suture technique in ankle fracture surgery: a pilot randomized controlled trial of wound perfusion.

OBJECTIVES: To compare peri-incisional perfusion, perfusion impairment and wound closure time between the conventional interrupted Allgöwer-Donati (IAD) technique and a modified running Allgöwer-Donati (RAD) technique in ankle fracture surgery. DESIGN: Prospective, randomized controlled clinical trial. SETTING: Level I and II trauma centers. PATIENTS: Twenty-five healthy adults with ankle fractures (AO/OTA 44-A, 44-B, or 44-C) between November 2017 and December 2018. (Of 26 patients enrolled in this study, 1 was lost to follow-up.). INTERVENTION: Participants were randomized into the IAD or the RAD group (13 patients each). All participants were followed for at least 3 months after surgery to assess for wound complications. MAIN OUTCOME MEASUREMENTS: Skin perfusion was assessed immediately after wound closure with laser-assisted indocyanine green angiography. Wound closure time, mean incision perfusion, and mean perfusion impairment were measured and compared with analysis of variance. Alpha = 0.05. RESULTS: The RAD technique was significantly faster in terms of mean (± standard deviation) wound closure time (6.2 ±â€Š1.4 minutes) compared with the IAD technique (7.3 ±â€Š1.4 minutes) (P = 0.047). We found no differences in mean incision perfusion and mean perfusion impairment (all, P > 0.05). CONCLUSION: The IAD and RAD techniques resulted in similar peri-incisional perfusion and perfusion impairment. Closure time was significantly shorter for the RAD technique compared with the IAD technique. LEVEL OF EVIDENCE: I.

Complications and 30-Day Mortality Rate After Hip Fracture Surgery in Superobese Patients.

OBJECTIVE: Paradoxically, overweight and obesity are associated with lower odds of complications and death after hip fracture surgery. Our objective was to determine whether this "obesity paradox" extends to patients with "superobesity." In this study, we compared rates of complications and death among superobese patients with those of patients in other body mass index (BMI) categories. METHODS: Using the National Surgical Quality Improvement Program database, we identified >100,000 hip fracture surgeries performed from 2012 to 2018. Patients were categorized as underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obese (BMI 30-39.9), morbidly obese (BMI 40-49.9), or superobese (BMI ≥50). We analyzed patient characteristics, surgical characteristics, and 30-day outcomes. Using multivariate regression with normal-weight patients as the referent, we determined odds of major complications, minor complications, and death within 30 days by BMI category. RESULTS: Of 440 superobese patients, 20% had major complications, 33% had minor complications, and 5.2% died within 30 days after surgery. When comparing patients in other BMI categories with normal-weight patients, superobese patients had the highest odds of major complications [odds ratio (OR): 1.6, 95% confidence interval (CI), 1.2-2.0] but did not have significantly different odds of death (OR: 0.91, 95% CI, 0.59-1.4) or minor complications (OR: 1.2, 95% CI, 0.94-1.4). CONCLUSION: Superobese patients had significantly higher odds of major complications within 30 days after hip fracture surgery compared with all other patients. This "obesity paradox" did not apply to superobese patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a Complete Description of Levels of Evidence.

Distance Between Reproductive Structures and the Insertion Point of the Retrograde Pubic Ramus Screw.

OBJECTIVE: To identify the distance between the guidewire for a retrograde pubic ramus screw and critical reproductive structures in men and women. METHODS: Twenty hemipelves from 10 fresh-frozen cadavers (pelvis to distal femur) were studied. The mean (±SD) age was 77 ± 6 years for the 5 male cadavers and 71 ± 9 years for the 5 female cadavers. A 2.8-mm guidewire for a cannulated screw was inserted from the parasymphyseal bone using fluoroscopic guidance. The soft tissue was dissected and measurements performed by the first author. In men, we measured the closest distances from the guidewire entry point to the contralateral spermatic cord and corpus cavernosum. In women, we measured the closest distances from the guidewire entry point to the base of the clitoral body and clitoral glans. RESULTS: In male cadavers, mean distances were 8.8 ± 4.2 mm to the spermatic cord and 13 ± 6.7 mm to the corpus cavernosum. The guidewire did not penetrate these structures in any specimen. In female cadavers, mean distances were 12 ± 5.7 mm to the base of the clitoral body and 40 ± 8.2 mm to the clitoral glans. The guidewire also did not penetrate these structures. CONCLUSIONS: The contralateral spermatic cord and corpus cavernosum in men and the base of the clitoral body in women are close to the pathway of the retrograde ramus screw guidewire. Careful identification of the entry point and avoidance of multiple attempts of guidewire insertion may reduce the risk of injury to these structures.

Assessing the level of evidence in the orthopaedic literature, 2013-2018: a review of 3449 articles in leading orthopaedic journals.

BACKGROUND: In biomedical research, level of evidence (LOE) indicates the quality of a study. Recent studies evaluating orthopaedic trauma literature between 1998 and 2013 have indicated that LOE in this field has improved. The objective of this study was to determine the validity of one such study by 1) comparing our results and how they relate to more recent years of publications; and 2) assessing how our findings may be used to estimate future changes. METHODS: A total of 3449 articles published from 2013 to 2018 in The Journal of Orthopaedic Trauma (JOT); Journal of Bone and Joint Surgery, American Volume (JBJS-Am); and Clinical Orthopaedics and Related Research (CORR) were evaluated for their LOE. Articles published in JBJS-Am or CORR were classified as trauma or nontrauma studies; articles published in JOT were considered trauma studies. Articles were assigned a LOE using guidance published by JBJS-Am in 2015. RESULTS: The percentage of total high-level (level I or II) trauma and nontrauma articles published in JOT, JBJS-Am, and CORR decreased from 2013 to 2018 (trauma 23.1 to 19.2%, p = 0.190; nontrauma 28.8 to 24.9%, p = 0.037). JBJS-Am published the highest percentage of level-I trauma studies, and CORR published the lowest percentage of level-IV studies. JBJS-Am and CORR published higher percentages of level-I trauma studies and lower percentages of level-IV nontrauma studies than all trauma studies. CONCLUSIONS: Based on our results we cannot validate the findings of previous studies as we found the overall LOE of both trauma and nontrauma orthopaedic literature has decreased in recent years. JBJS-Am published a greater percentage of high-level studies than did JOT and CORR. Although the number and percentage of high-level studies published in JOT increased during the study period, it still lagged behind JBJS-Am and CORR.

Outcomes after unstable pertrochanteric femur fracture: intermediate versus long cephalomedullary nails.

PURPOSE: Optimal cephalomedullary nail (CMN) length for unstable pertrochanteric femur fractures is controversial. Long CMNs (L-CMNs) are currently recommended; however, intermediate-length CMNs (I-CMNs) may provide stable fixation without the additional surgical steps required by L-CMNs. We analyzed outcomes after unstable pertrochanteric femur fractures treated with L-CMNs or I-CMNs to determine whether functional outcomes, perioperative measures, complications, and mortality and reoperation rates differ by CMN length. METHODS: We retrospectively reviewed medical records at our institution for 100 patients who received surgical treatment for pertrochanteric femur fractures from June 2014 to June 2016. Data from 43 unstable pertrochanteric femur fractures treated with L-CMNs (n = 25) or I-CMNs (n = 18) were analyzed. We evaluated operative time, fluoroscopy time, intraoperative blood loss, blood transfusions, and perioperative complications; peri-implant fracture, malunion, reoperation, and death; and neck-shaft angle, tip-apex distance, and 6-month postoperative functional scores. We analyzed categorical data with Fisher exact tests and continuous data with Student t tests. P < 0.05 was considered significant. RESULTS: The I-CMN group had shorter operative time (68 versus 92 min; P = 0.048), shorter fluoroscopy time (72 versus 110 s; P = 0.019), and less intraoperative blood loss (80 versus 168 mL; P < 0.001) than the L-CMN group. The groups were similar in rates of blood transfusion, perioperative complications, peri-implant fracture, malunion, reoperation, and death. Six-month postoperative functional scores were similar between groups (P > 0.05). CONCLUSIONS: We found operative advantages of I-CMNs over L-CMNs with no difference in treatment outcomes. LEVEL OF EVIDENCE: Level IV, Retrospective case series study.

Biomechanical Evaluation of a New Suture Button Technique for Reduction and Stabilization of the Distal Tibiofibular Syndesmosis.

BACKGROUND: Stabilization methods for distal tibiofibular syndesmotic injuries present risk of malreduction. We compared reduction accuracy and biomechanical properties of a new syndesmotic reduction and stabilization technique using 2 suture buttons placed through a sagittal tunnel in the fibula and across the tibia just proximal to the incisura with those of the conventional method. METHODS: Syndesmotic injury was created in 18 fresh-frozen cadaveric lower leg specimens. Nine ankles were repaired with the conventional method and 9 with the new technique. Reduction for the conventional method was performed using thumb pressure under direct visualization and for the new method by tightening both suture buttons passed through the fibular and tibial tunnels. Computed tomography was used to assess reduction accuracy. Torsional resistance, fibular rotation, and fibular translation were evaluated during biomechanical testing. RESULTS: The new technique showed less lateral translation of the fibula on CT measurements after reduction (0.06 ± 0.06 mm) than the conventional method (0.26 ± 0.31 mm), P = .02. The new technique produced less fibular rotation during internal rotation after 0 cycles (new -2.4 ± 1.4 degrees; conventional -5.0 ± 1.2 degrees, P = .001), 100 cycles (new -2.1 ± 1.9 degrees; conventional -4.6 ± 1.4 degrees, P = .01), and 500 cycles (new -2.2 ± 1.6 degrees; conventional -5.3 ± 2.5 degrees, P = .01) and during external rotation after 100 cycles (new 3.9 ± 3.3 degrees; conventional 5.9 ± 3.5 degrees, P = .02) and 500 cycles (new 3.3 ± 3.2 degrees; conventional 6.3 ± 2.6 degrees, P = .03). Fixation failed in 3 specimens. CONCLUSION: The new syndesmotic reduction and fixation technique resulted in more accurate reduction of the fibula in the tibial incisura in the coronal plane and better rotational stability compared with the conventional method. CLINICAL RELEVANCE: This new technique of syndesmosis reduction and stabilization may be a reliable alternative to current methods.

Minimally Invasive Fixation for Spinopelvic Dissociation: Percutaneous Triangular Osteosynthesis with S2 Alar-Iliac and Iliosacral Screws: A Case Report.

CASE: Traumatic U- and H-type sacral fractures are often unstable, causing spinopelvic dissociation. We describe a minimally invasive approach that allows percutaneous spinopelvic fixation of unstable H-type sacral fractures using a triangular osteosynthesis construct with S2 alar-iliac screws. We present the case of a patient with traumatic lumbopelvic dissociation who underwent percutaneous S2 alar-iliac and iliosacral screw fixation. CONCLUSIONS: Combined percutaneous S2 alar-iliac and iliosacral screw fixation is a safe option for spinopelvic fixation and avoids the soft-tissue compromise of open approaches. The triangular osteosynthesis construct provides adequate pelvic anchor points to allow immediate weight-bearing.

Reducing routine laboratory tests in patients with isolated extremity fractures: a prospective safety and feasibility study in 246 patients.

BACKGROUND: Daily routine laboratory testing is unnecessary in most admitted patients. The opportunity to reduce daily laboratory testing in orthopaedic trauma patients has not been previously investigated. METHODS: A prospective observational study was performed based on a new laboratory testing reduction protocol for 12 months at two tertiary care trauma centers. Admitted patients with surgically treated isolated upper or lower extremity fractures were included (n = 246). The testing protocol consisted of a complete blood count (CBC) and basic metabolic panel (BMP) on postoperative day 2. Thereafter, tests were obtained at individual providers' discretion. Patients were followed for 30 days postoperatively. The primary outcome was number of laboratory tests reduced. Secondary outcomes included provider protocol compliance, and adverse patient outcomes. Chi-squared tests were used to compare differences in categorical variables among the cohorts. Analysis of variance tests were used for continuous variables. The relative reductions in testing utilization were calculated using our division's standard-of-care before program implementation (1 CBC and 1 BMP per patient per inpatient day). Significance was defined as P < 0.05. RESULTS: Of the 246 patients, there were 45 protocol fall outs due to provider deviation (n = 24) or medically justified necessity for additional testing (n = 21). Across all groups, a total of 778 CBC or BMP tests were avoided, amounting to a 69% reduction in testing compared to the pre-implementation baseline. Ninety-five percent of protocol group patients were safely discharged either without laboratory testing or with one set of tests obtained on postoperative day 2. There were no 30-day readmissions or reported complications associated with the new laboratory testing protocol. CONCLUSIONS: In patients with surgically treated fractures about the elbow and knee, obtaining a single set of laboratory tests on postoperative day 2 is safe and efficacious in terms of reducing inappropriate resource utilization. TRIAL REGISTRATION: retrospectively registered.

Depth of sedation as an interventional target to reduce postoperative delirium: mortality and functional outcomes of the Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients randomised clinical trial.

BACKGROUND: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. METHODS: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0-2] or lighter (OAA/S 3-5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan-Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. RESULTS: One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02-1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60-0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84-0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03-1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24-2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53-0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10-0.97; P=0.04]. CONCLUSIONS: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT00590707.

A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures.

INTRODUCTION: In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population. METHODS: In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation. RESULTS: After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival. DISCUSSION: A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Complications of pelvic and acetabular fractures in 1331 morbidly obese patients (BMI ≥ 40): a retrospective observational study from the National Trauma Data Bank.

BACKGROUND: There have been no large-scale epidemiological studies of outcomes and perioperative complications in morbidly obese trauma patients who have sustained closed pelvic ring or acetabular fractures. We examined this population and compared their rate of inpatient complications with that of control patients. METHODS: We retrospectively reviewed the records of patients treated for closed pelvic ring or acetabular fracture, aged 16-85 years, with Injury Severity Scores ≤15 from the National Trauma Data Bank Research Dataset for the years 2007 through 2010. The primary outcome of interest was rate of in-hospital complications. Secondary outcomes were length of hospital stay and discharge disposition. Unadjusted differences in complication rates were evaluated using Student t tests and Chi-squared analyses. Multiple logistic and Poisson regression were used to analyze binary outcomes and length of hospital stay, respectively, adjusting for several variables. Statistical significance was defined as p < 0.05. RESULTS: We included 46,450 patients in our study. Of these patients, 1331 (3%) were morbidly obese (body mass index ≥40) and 45,119 (97%) were used as controls. Morbidly obese patients had significantly higher odds of complication and longer hospital stay in all groups considered except those with pelvic fractures that were treated operatively. In all groups, morbidly obese patients were more likely to be discharged to a skilled nursing/rehabilitation facility compared with control patients. CONCLUSIONS: Morbidly obese patients had higher rates of complications and longer hospital stays and were more likely to be discharged to rehabilitation facilities compared with control patients after pelvic ring or acetabular fracture.

The distal femur is a reliable guide for tibial plateau fracture reduction: a study of measurements on 3D CT scans in 84 healthy knees.

BACKGROUND: Limited data have been published regarding the typical coronal dimensions of the femur and tibia and how they relate to each other. This can be used to aid in judging optimal operative reduction of tibial plateau fractures. The purpose of the present study was to quantify the width of tibial plateau in relation to the distal femur. METHODS: We reviewed 3D computed tomography (CT) scans taken between 2013 and 2016 of 42 patients (84 knees). We measured positions of the lateral tibial condyle with respect to the lateral femoral condyle (dLC) and the medial tibial condyle with respect to the medial femoral condyle (dMC) in the coronal plane. Positions of the articular edges of the lateral and medial tibia were also measured with respect to the femur (dLA and dMA). RESULTS: The mean (± standard deviation) measurements were as follows: dLC, - 0.1 ± 1.9 mm; dMC, - 4.7 ± 4.1 mm; dLA, 0.9 ± 1.0 mm; and dMA, 0.1 ± 1.5 mm. The mean (± standard deviation) ratio of tibial to femoral condylar width was 0.91 ± 0.03, and the ratio of tibial to femoral articular width was 1.01 ± 0.04. CONCLUSIONS: The articular width of the tibia laterally and medially was slightly wider than the femoral articular width. These small differences and deviations indicate that the femur might be used as a reference to judge tibial plateau width reduction.

Effect of Depth of Sedation in Older Patients Undergoing Hip Fracture Repair on Postoperative Delirium: The STRIDE Randomized Clinical Trial.

Importance: Postoperative delirium is the most common complication following major surgery in older patients. Intraoperative sedation levels are a possible modifiable risk factor for postoperative delirium. Objective: To determine whether limiting sedation levels during spinal anesthesia reduces incident delirium overall. Design, Setting, and Participants: This double-blind randomized clinical trial (A Strategy to Reduce the Incidence of Postoperative Delirum in Elderly Patients [STRIDE]) was conducted from November 18, 2011, to May 19, 2016, at a single academic medical center and included a consecutive sample of older patients (≥65 years) who were undergoing nonelective hip fracture repair with spinal anesthesia and propofol sedation. Patients were excluded for preoperative delirium or severe dementia. Of 538 hip fractures screened, 225 patients (41.8%) were eligible, 10 (1.9%) declined participation, 15 (2.8%) became ineligible between the time of consent and surgery, and 200 (37.2%) were randomized. The follow-up included postoperative days 1 to 5 or until hospital discharge. Interventions: Heavier (modified observer's assessment of sedation score of 0-2) or lighter (observer's assessment of sedation score of 3-5) propofol sedation levels intraoperatively. Main Outcomes and Measures: Delirium on postoperative days 1 to 5 or until hospital discharge determined via consensus panel using Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) criteria. The incidence of delirium was compared between intervention groups with and without stratification by the Charlson comorbidity index (CCI). Results: Of 200 participants, the mean (SD) age was 82 (8) years, 146 (73%) were women, 194 (97%) were white, and the mean (SD) CCI was 1.5 (1.8). One hundred participants each were randomized to receive lighter sedation levels or heavier sedation levels. A good separation of intraoperative sedation levels was confirmed by multiple indices. The overall incident delirium risk was 36.5% (n = 73) and 39% (n = 39) vs 34% (n = 34) in heavier and lighter sedation groups, respectively (P = .46). Intention-to-treat analyses indicated no statistically significant difference between groups in the risk of incident delirium (log-rank test χ2, 0.46; P = .46). However, in a prespecified subgroup analysis, when stratified by CCI, sedation levels did effect the delirium risk (P for interaction = .04); in low comorbid states (CCI = 0), heavier vs lighter sedation levels doubled the risk of delirium (hazard ratio, 2.3; 95% CI, 1.1- 4.9). The level of sedation did not affect delirium risk with a CCI of more than 0. Conclusions and Relevance: In the primary analysis, limiting the level of sedation provided no significant benefit in reducing incident delirium. However, in a prespecified subgroup analysis, lighter sedation levels benefitted reducing postoperative delirium for persons with a CCI of 0. Trial Registration: clinicaltrials.gov Identifier: NCT00590707.