Clinical Outcomes Following Distal Femur Replacement for Periprosthetic Distal Femur Fractures: A Systematic Review and Meta-Analysis.

BACKGROUND: Management of periprosthetic distal femur fractures (PDFFs) is often complicated by poor bone quality and limited bone stock making fixation attempts challenging and prone to failure. Distal femoral replacement (DFR) is being used to treat such injuries although outcome data are mostly from small case series. We sought to systematically review the literature on DFR for PDFF to summarize their outcomes. METHODS: PubMed, MEDLINE (EBSCO), and Cochrane Central Database were searched to identify reports of PDFFs treated with DFR. Articles reporting on 5 or more knees were systematically reviewed for clinical function, complications, and mortality. Random effects meta-analysis was used to create summary estimates and publication bias also assessed. RESULTS: Of 287 identified and screened articles, 15 were included, 14 retrospective, reporting on 352 knees. Following DFR, 87% (95% confidence interval [CI] 71-95) of patients were able to ambulate. The mean postoperative Knee Society Score was 80 (95% CI 77-84). The risk of periprosthetic joint infection was 4.3% (95% CI 2.2-8.2). One-year postoperative mortality rate was 10% (95% CI 6-18). There was some evidence of publication bias with a trend toward smaller studies reporting lower infection risk and mortality. CONCLUSION: DFR for PDFFs is associated with high functional outcomes and a relatively modest risk of infection. The periprosthetic joint infection and 1-year mortality rates reported here should be considered lower bounds estimates due to publication bias and loss to follow-up. Further investigation of long-term outcomes following DFR for PDFFs is warranted though short-term functional outcomes are promising.

Radiation Exposure Among Orthopaedic Trauma Surgeons: Deconstructing Commonly Held Myths and Misperceptions.

OBJECTIVES: To review and evaluate the validity of common perceptions and practices regarding radiation safety in orthopaedic trauma. DESIGN: Retrospective study. SETTING: Level 1 trauma center. SUBJECTS: N/A. INTERVENTION: The intervention involved personal protective equipment. MAIN OUTCOME MEASUREMENTS: The main outcome measurements included radiation dose estimates. RESULTS: Surgeon radiation exposure estimates performed at the level of the thyroid, chest, and pelvis demonstrate an estimated total annual exposure of 1521 mR, 2452 mR, and 1129 mR, respectively. In all cases, wearing lead provides a significant reduction (90% or better) in the amount of radiation exposure (in both radiation risk and levels of radiation reaching the body) received by the surgeon. Surgeons are inadequately protected from radiation exposure with noncircumferential lead. The commonly accepted notion that there is negligible exposure when standing greater than 6 feet from the radiation source is misleading, particularly when cumulative exposure is considered. Finally, we demonstrated that trauma surgeons specializing in pelvis and acetabular fracture care are at an increased risk of exposure to potentially dangerous levels of radiation, given the amount of radiation required for their caseload. CONCLUSION: Common myths and misperceptions regarding radiation in orthopaedic trauma are unfounded. Proper use of circumferential personal protective equipment is critical in preventing excess radiation exposure.

Comparison of 3 C-Arm Draping Techniques to Prevent Far Side Contamination.

OBJECTIVE: To assess the effectiveness of reducing contamination using 2 methods of C-Arm draping compared with traditional methods. MATERIALS AND METHODS: The authors simulated an operating room using an extremity drape, commercially available C-Arm drapes, and C-Arm. A black light was placed above the field. A fluorescent powder was placed on the nonsterile portions of the field. Baseline light intensity was recorded by photo. The C-Arm was brought into the surgical field for orthogonal imaging for 15 cycles. A repeat photograph was taken to measure the increase in intensity of the fluorescent powder to assess degree of contamination. This was repeated 5 times for each configuration: standard C-Arm drape, a proprietary close-fitting drape, and a split drape secured to the far side with the split wrapped around the C-Arm receiver. Light intensity difference was measured and average change in intensity was compared. RESULTS: Compared with standard draping, the proprietary close-fitting drape resulted in a 71.3% decrease in contamination (4.84% vs. 16.90%, P = 0.101) that trended toward significance and the split drape resulted in a 99.5% decrease (0.09% vs. 16.90%, P = 0.017) that was statistically significant. CONCLUSION: Far side contamination can be reduced by using a split drape connecting the operative table to the C-Arm receiver, effectively "sealing off" contaminants. The proprietary close-fitting drape may also decrease contamination, but this was not statistically significant in this study. Use of the split drape technique will help prevent contamination and may ultimately lead to decreased infection risk.

The Effect of Rotation on Intraoperative Fluoroscopic Evaluation of Hindfoot Alignment and How to Help Prevent Error.

OBJECTIVE: Restoration of hindfoot alignment correlates with improved clinical and biomechanical outcomes after fracture care and reconstruction. Intraoperative assessment of alignment with fluoroscopy is challenging. This study was designed to determine the effect of rotation on the measurement of hindfoot alignment and to determine if any radiographic landmarks can be utilized to help surgeons identify appropriate rotation during intraoperative imaging. METHODS: Ten unmatched cadaveric limbs that had been disarticulated at mid-tibia were used and placed supine in a radiolucent jig. Fluoroscopic images were obtained with the C-arm positioned at 45°. Images were obtained in sequential rotational adjustments from 12° of internal rotation to 12° of external rotation. The location of the fibula relative to the base of the fifth metatarsal was measured on images and recorded as an interval percentage overlap (0% to 50%, 50% to 100%, and greater than 100%). Hindfoot alignment was recorded by measuring the angle between the tibial and calcaneal axis. RESULTS: Varus and valgus hindfoot alignment demon-strated a linear relationship to leg rotation (r2 = 0.998, p < 0.001). In these uninjured cadaveric specimens, 8° to 15° of internal rotation relative to the medial border of the foot produced a normal valgus angle (0° to 5°). Using 50% to 100% overlap of the fibula over the fifth metatarsal base as a radiographic test was a reliable indicator of predicted measurement, with 89% sensitivity and 99% specificity. CONCLUSIONS: The measurement of hindfoot alignment changes with foot rotation. Use of the fibula overlap of the fifth metatarsal base may be a helpful tool to judge appro-priate rotation intraoperatively.

The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population.

OBJECTIVE: The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications. DESIGN: Retrospective case control study. SETTING: Academic level-1 trauma center. PATIENTS/PARTICIPANTS: Patients with long bone, lower extremity fractures requiring operative fixation. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Postoperative hospital admissions, emergency room (ER) visits, and reoperations. RESULTS: 399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003). CONCLUSIONS: Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.

The Learning Curve of Suprapatellar Nailing: Adoption Over Time Can Decrease Operative Time and Radiation Exposure.

OBJECTIVE: To determine whether suprapatellar nailing (SPN) over time can decrease operative time and radiation exposure when compared with infrapatellar nailing (IPN) of tibial shaft fractures. DESIGN: Retrospective. SETTING: Single, Level 1 trauma center. PATIENTS: Extra-articular adult tibial shaft fractures treated with intramedullary nailing alone within a 7-year period. INTERVENTION: Patients were treated with SPN or IPN techniques based on the discretion of the operating surgeon. MAIN OUTCOME MEASUREMENTS: Operative time and radiation exposure. RESULTS: Three hundred forty-one fractures (SPN: 177, IPN: 164) were included in the analysis. No differences in patient body mass index, sex, or open fracture incidence existed between the 2 groups. A significant difference in average operative time (IPN 130 minutes vs. SPN 110 minutes, P < 0.01), fluoroscopy time (IPN 159 minutes vs. SPN 143 minutes, P = 0.02), and radiation dose (IPN 8.6 mGy vs. SPN 6.5 mGy, P < 0.01) existed between IPN and SPN. Early tibias treated with SPN had similar operative times (P = 0.11), fluoroscopy time (P = 0.94), and radiation dose (P = 0.34) compared with IPN. Later SPN patients had significantly lower operative time (P = 0.03), fluoroscopy time (P < 0.01), and radiation dose (P < 0.013) compared with earlier SPN. Regression analysis revealed with the increased use of SPN, operative time, fluoroscopy time, and radiation dose significantly decreased (P = 0.018, 0.046, 0.011). CONCLUSIONS: Tibia fractures treated with SPN have significantly decreased operative times and radiation exposure compared with those treated with IPN, after allowing time for the surgeon to gain sufficient experience with the technique. The surgeon should consider this when deciding to adopt this technique. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Spine patients demystified: what are the predictive factors of poor surgical outcome in patients after elective cervical and lumbar spine surgery?

BACKGROUND CONTEXT: Pre-existing comorbid psychiatric mood disorders are a known risk factor for impaired health-related quality of life and poor long-term outcomes after spine surgery. PURPOSE: The purpose of this study was to investigate the effect of preexisting mood disorders on (1) pre- and postoperative patient-reported outcomes, (2) complications, and (3) pre- and postoperative opioid consumption in patients undergoing elective cervical or lumbar spine surgery. STUDY DESIGN/SETTING: Retrospective review at a single academic institution from 2014 to 2017. PATIENT SAMPLE: Consecutive adult patients who underwent cervical or lumbar surgery. OUTCOME MEASURES: Quantitative measurements of pain (visual analog scale [VAS]) and spinal region-specific disability scores (Neck Disability Index [NDI] and Oswestry Disability Index [ODI]). METHODS: This is a retrospective review of 435 consecutive patients (179 cervical, 256 lumbar) who underwent elective spine surgery at a single academic institution from 2014 to 2017. Patient preoperative diagnosis of psychiatric mood disorder (eg, depression, anxiety, schizophrenia, bipolar, or dementia), baseline characteristics, medical (nonpsychiatric) comorbidities, operative variables, and surgical complications (eg, superficial and deep infection, wound complication, emergency department [ED] visits, readmissions, and repeat operations) were recorded. Additionally, preoperative ED visits, pre- and postoperative opioid requirements, total opioid prescription quantities and most recent dateof opioid prescription were collected. VAS, NDI, and ODI scores were recorded preoperatively and at 2, 6, and 12 weeks after surgery. Continuous variables were compared between those with and without diagnosed psychiatric comorbidity using two-tailed independent t test, and categorical variables were compared using chi-square or Fisher's exact tests. Analyses of variance and analysis of covariance were used to compare patient-reported outcomes between groups. A multivariate approach was taken to account for contribution of potential covariates in significant findings. Multiple linear regressions were used to determine variables associated with the number of postoperative opioid prescriptions. RESULTS: Of the cervical and lumbar cohorts, 78 (43.6%) and 113 (44.1%), respectively, had a preoperative diagnosis of comorbid psychiatric mood disorder. Cervical patients with mood disorders received a significantly higher total number of opioid prescriptions post-operatively (4.6±5.2 vs. 2.8±3.9; p=.002). Patients with mood disorders had worse NDI scores at all time points (p=.04), however there were no differences in VAS pain scores (p=.5). There were no statistical differences between patients with and without mood disorders regarding baseline characteristics, medical (nonpsychiatric) comorbidities, operative variables, surgical complications, preoperative ED visits or prior opioid use (p>.05). For lumbar patients, patients with mood disorders were more commonly females (p=.04), tobacco users (p=.003), alcohol dependent (p=.01) and illicit-drug abusers (p=.03). There were no differences regarding surgical complications or opioid consumption. Tobacco use (p<.001) was the sole contributor to postoperative VAS pain scores. Patients with mood disorders had significantly higher VAS values both before and 3 months following surgery (p=.01), but there was no difference in ODI scores. CONCLUSIONS: Patients with preoperative psychiatric mood disorders undergoing elective cervical surgery had worse NDI scores and received more opioid prescriptions, despite similar VAS scores as those without mood disorders. Lumbar surgery patients with mood disorders were demographically different than those without mood disorders and had worse pain before and after surgery, though ODI scores were not different. Tobacco use was the sole contributor to postoperative VAS pain scores. This information can be useful in counseling patients with mood disorders before elective spinal surgery.