Is preoperative radiation therapy as effective as postoperative radiation therapy for heterotopic ossification prevention in acetabular fractures?

BACKGROUND: Prophylactic approaches to prevent heterotopic ossification after acetabular fracture surgery have included indomethacin and/or single-dose external beam radiation therapy administered after surgery. Although preoperative radiation has been used for heterotopic ossification prophylaxis in the THA population, to our knowledge, no studies have compared preoperative and postoperative radiation therapy in the acetabular fracture population. QUESTIONS/PURPOSES: We determined whether heterotopic ossification frequency and severity were different between patients with acetabular fracture treated with prophylactic radiation therapy preoperatively and postoperatively. METHODS: Between January 2002 and December 2009, we treated 320 patients with a Kocher-Langenbeck approach for acetabular fractures, of whom 50 (34%) were treated with radiation therapy preoperatively and 96 (66%) postoperatively. Thirty-four (68%) and 71 (74%), respectively, had 6-month radiographs available for review and were included. For hospital logistical reasons, patients who underwent operative treatment on a Friday or Saturday received radiation therapy preoperatively, and all others received it postoperatively. The treatment groups were comparable in terms of most demographic parameters, injury severity, and fracture patterns. Six-month postoperative radiographs were reviewed and graded according to Brooker. Followup ranged from 6 to 93 months and 6 to 97 months for the preoperative and postoperative groups, respectively. Post hoc power analysis showed our study was powered to detect a difference of 22% or more between patients with severe heterotopic ossification. Sample size calculations showed 915 subjects would be needed to detect a 5% relative difference in severe heterotopic ossification status between groups. RESULTS: We detected no difference in heterotopic ossification frequency between the preoperative (eight of 36, 22%) and postoperative (19 of 71, 27%) groups (p=0.609). There was also no difference in heterotopic ossification severity between groups (p=0.666). Two of 36 (6%) in the preoperative group and three of 71 (4%) in the postoperative group developed clinically significant Grade III heterotopic ossification. No patients developed Grade IV heterotopic ossification. CONCLUSIONS: We found no difference in heterotopic ossification frequency or severity when comparing preoperative and postoperative radiation therapy. However, given the relatively low frequency of heterotopic ossification in this population, in particular the frequency of severe or symptomatic heterotopic ossification, the possibility of a Type II error must be considered. Larger, prospective studies are required to confirm our no-difference finding, but insofar as the result in this fracture population mirrors that of the THA population, unless our finding is disproven, we believe radiation therapy can be given either before or after surgery, as dictated by the clinical scenario. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Enhanced Recovery After Surgery on Persistent Opioid Use Following Pulmonary Resection.

BACKGROUND: Enhanced recovery after surgery (ERAS) has been associated with improved perioperative outcomes after thoracic surgery; however, the impact on long-term opioid use remains unknown. The aim of our study was to evaluate the effects of ERAS on long-term opioid use. METHODS: Patients who underwent pulmonary resection were identified from a prospectively maintained database and linked to the regional prescription drug monitoring program. Outcomes were compared between pre-ERAS (February 2016 to November 2018) and ERAS (December 2018 to June 2020) cohorts. Our ERAS protocol included regional anesthetic, multimodal pain control, and protocolized rehabilitation. RESULTS: We analyzed 240 pulmonary resections, 64.6% (n = 155) in the pre-ERAS era and 35.4% (n = 85) in the ERAS era. Baseline characteristics were similar; however, more patients in the ERAS cohort underwent minimally invasive surgery (67.7% vs 87.9%; P = .002). Median length of stay was reduced (5 days vs 4 days; P = .03) upon implementation of ERAS, with no change in perioperative complications or readmission rate. On multivariate analysis, ERAS was associated with decreased total inpatient morphine milligram equivalent and discharge morphine milligram equivalent. However, both long-term opioid use up to 1 year postoperatively and new persistent opioid use remained similar despite implementation of ERAS. On multivariate analysis, implementation of ERAS was not associated with a reduction in opioid use 14 to 90 days postoperatively or persistent opioid use 90 to 180 days postoperatively. CONCLUSIONS: Despite short-term opioid reduction, long-term opioid use persisted after implementation of ERAS. Additional strategies to monitor for and avoid opioid dependence are urgently needed to prevent chronic opioid use after pulmonary resection.

Characterization of the influence of spinopelvic parameters on thoracolumbar trauma.

OBJECTIVE: The current Roussouly classification identifies four groups of "normal" sagittal spine morphology, which has greatly expanded the understanding of normal heterogeneity of the spine. While there has been extensive characterization of the influence of spinopelvic parameters on outcomes after degenerative spine surgery, the influence of spinopelvic parameters on thoracolumbar trauma has yet to be described. The goal of this study was to determine if spinopelvic parameters and global spine morphology influence fracture location, fracture morphology, and rate of neurological deficit in the setting of thoracolumbar trauma. METHODS: Of 2896 patients reviewed in the authors' institutional spine database between January 2014 and April 2020 with an ICD-9/10 diagnosis of thoracolumbar trauma, 514 met the inclusion criteria of acute thoracolumbar fracture on CT and visible femoral heads on sagittal CT. Pelvic incidence (PI) was calculated on sagittal CT. Demographic and clinical data including age, sex, BMI, smoking status, concomitant cervical fracture, mechanism of injury, major fracture location, neurological deficit, AO Spine thoracolumbar injury classification, and management type (operative vs nonoperative) were collected. Patients were stratified into high-PI (≥ 50°) and low-PI (< 50°) groups. RESULTS: Patients with high PI had a lower incidence of fractures in the lower lumbar spine (below L2) compared with patients with low PI (16% vs 8%, p < 0.01). The last lordotic vertebrae were observed between T10 and L4, and of fractures that occurred at these levels, 75% were at the last lordotic vertebrae. Fall from height was the most common cause of neurological deficit, accounting for 47%. Of the patients presenting with a fall from height, AO Spine type B distraction injuries were more common in the high-PI group (41% vs 18%, p = 0.01). Similarly, within the same subgroup, AO Spine type A compression injuries were more common in the low-PI group (73% vs 53%, p = 0.01). CONCLUSIONS: Spinopelvic parameters and sagittal balance influence the location and morphology of thoracolumbar fractures. Fractures of the thoracolumbar junction are strongly associated with the inflection point, which is defined by sagittal alignment. While the importance of considering sagittal balance is known for decision-making in degenerative spinal pathology, further studies are required to determine if spinopelvic parameters and sagittal balance should play a role in the decision-making for management of thoracolumbar fractures.

Evaluation of a Novel Multidisciplinary Preoperative Workup Strategy for Geriatric Hip Fractures.

OBJECTIVE: To determine the financial and clinical impact of a standardized, multidisciplinary team for surgical clearance and optimization in geriatric hip fracture patients. DESIGN: Retrospective case series. SETTING: Level-1 trauma center. PATIENTS: One hundred twenty-four geriatric patients (age >65 years old) in the preprotocol group (cohort 1; January 2017-December 2018) and 98 geriatric patients in the postprotocol group (cohort 2; October 2019-January 2021) with operative hip fractures. INTERVENTION: Implementation of a multidisciplinary team protocol consisting of Anesthesiology, Internal Medicine and Orthopedic Surgery departments for the assessment of medical readiness and optimization for surgical intervention in geriatric hip fractures. MAIN OUTCOME MEASURES: Rate of cardiology consultation, need for cardiac workup (echocardiography stress testing, heath catheterization), time to medical readiness (TTMR), time to surgery, case-cancellation rate, length of stay (LOS), and total hospitalization charges. RESULTS: Following implementation of the new protocol, there were significant ( P < 0.001) decreases in TTMR (19 vs. 11 hours), LOS (149 vs. 120 hours), case cancellation rate, and total hospital charges ($84,000 vs. $62,000). There were no significant differences with respect to in-hospital complications or readmission rates/mortality rates at 1 year. CONCLUSIONS: Following implementation of a protocolized, multidisciplinary approach to optimizing geriatric fracture patients, we were able to demonstrate a reduction in unnecessary preoperative testing, TTMR for surgery, case cancellation rate, LOS, and total hospitalization charge-without a concomitant increase in complications or mortality. This study highlights that standardization of the perioperative care for geriatric hip fracture patients can provide effective patient care while also lowering financial and logistical burden in care for these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

C1-C2 Wiring With Timed Self-Obsolescence for Complex C2 Body Fracture.

BACKGROUND AND IMPORTANCE: Fractures of C2 are typically managed nonoperatively with good rates of healing. Management decisions are complicated, however, when there are additional fractures in the axis possibly leading to increased instability. Additionally, the techniques used for treating these unstable axis fractures can have either significant complications or permanent loss of range of motion. Here, we present a novel technique for the reduction and stabilization of complex C2 body fracture. CLINICAL PRESENTATION: A 34-yr-old woman with a complex C2 body fracture, which included a right pars and left lateral mass fracture, presented after a water slide accident. It was felt that this fracture was both unstable and would not heal in an anatomically acceptable way so an open surgical reduction was needed. After consideration of more traditional fusion and osteosynthesis techniques, we chose to perform a C1-C2 internal stabilization with C1 sublaminar and C2 spinous process wiring. The patient was then instructed to wear a Miami J collar for 3 mo. CONCLUSION: The outcome was favorable with good approximation and healing with preserved range of motion.

Treatment of protrusio fractures of the acetabulum in patients 70 years and older.

OBJECTIVE: To present clinical, radiographic, and functional outcomes in patients 70 years and older with a protrusio-type acetabulum fracture. DESIGN: Retrospective case series. SETTING: Two level 1 trauma centers. PATIENTS: Between November 2000 and December 2009, 39 consecutive patients older than 70 years with protrusio acetabulum fractures were enrolled. INTERVENTION: Open reduction internal fixation using a combination of pelvic brim and infrapectineal plates. MAIN OUTCOME MEASUREMENTS: Clinical, radiographic, and functional outcomes as assessed with the modified Merle d'Aubigné score. RESULTS: Twelve patients were lost to follow-up (<12 months), and one patient was excluded from analysis because he was treated with a percutaneous technique. The remaining 26 (67%) had a mean follow-up of 34 months (12-127 months). At the final follow-up, radiographic grades were excellent in 15, good in 3, poor in 3, and 5 patients had a total hip arthroplasty (19%) at an average of 18 months after the index procedure .The average modified Merle d'Aubigné score was 16 (9-18); categorized as excellent in 10, very good in 4, good in 7, fair in 2, and poor in 3. CONCLUSION: In the senior patient with a protrusio acetabulum fracture, a treatment strategy that optimizes preoperative conditions, minimizes operative time and blood loss, achieves a stable concentric hip joint, and encourages immediate postoperative ambulation can result in reasonable clinical, radiographic, and functional outcomes with acceptable morbidity. This appears to remain true even in the face of a less than anatomic reduction. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.