Dual-Mobility Articulations for Patients at High Risk for Dislocation.

BACKGROUND: The purpose of this study was to evaluate the performance of dual-mobility articulations in patients at high risk for dislocation after revision total hip arthroplasty. METHODS: We reviewed the results of 36 consecutive revision total hip arthroplasties performed on patients considered high risk for instability. Indications for inclusion included abductor insufficiency, recurrent instability, failure of constrained liner, or inadequate intraoperative stability when trialing. RESULTS: At a minimum of 2 years, there were 4 (11.1%) repeat revisions including both dual-mobility liners that were cemented into an acetabular shell and 2 for deep infection treated with a 2-stage exchange. There was one dislocation that was successfully closed reduced but no revisions for recurrent instability. The mean Harris hip score improved from 45 to 90 points (P < .001). CONCLUSION: Dual-mobility articulations are associated with a low rate of failure with no revisions for instability in this challenging group of patients.

Pilot study for an orthopedic surgical training laboratory for basic motor skills.

The most effective way to teach and assess a resident's knowledge of musculoskeletal medicine, including orthopedic-specific surgical skills, remains unclear. We designed a surgical skills training session to educate junior-level orthopedic residents in 4 core areas: comfort with basic power equipment, casting/splinting, suturing, and surgical instrument identification. As part of the study reported here, 11 orthopedic residents (postgraduate year 1-3) completed a skills session and were evaluated with written examinations and an ankle fracture model before and after the session. Four other junior residents were unable to attend the session because of clinical responsibilities. For the group of 11 residents who completed the written examination, mean (SD) presession percentile was 87.3 (10.4), mean (SD) postsession percentile was 92 (8.4), median was 96, and mode was 96. There was a significant pre-post difference among all test takers, regardless of training level (P < .05). In the ankle fracture model, for the entire group, mean (SD) overall presession percentile was 68.6 (13.9), and mean (SD) overall postsession percentile was 95.2 (5.2). There was a significant pre-post difference among all test takers, regardless of training level (P = .03). An intensive laboratory has the potential to improve junior-level residents' basic surgical skills and knowledge.

Treatment of avascular necrosis of the femoral head utilising free vascularised fibular graft: a systematic review.

We conducted a systematic review to determine whether the literature supports the use of free vascularised fibular graft (FVFG) over other salvage procedures for the treatment of avascular necrosis (AVN) of the femoral head, and if there are patient-specific and defect-specific factors that may predict better outcomes after FVFG. Fifteen total studies were identified for inclusion. Three comparative studies showed an overall statistically significant superiority of FVFG over NVFG; two comparative studies demonstrated FVFG better than core decompression. One study show a better but not statistically significant superiority of FVFG comparing with vascularised iliac pedicle bone graft procedures, likely due to small sample size. This review suggests that vascularised fibular grafting is a better treatment option than core decompression and nonvascularised fibular grafting.

Comorbidity-polypharmacy scoring facilitates outcome prediction in older trauma patients.

OBJECTIVES: To determine the association between comorbidity-polypharmacy score (CPS) and clinical outcomes in a large sample of older trauma patients, focusing on outcome prognostication. DESIGN: The CPS combines number of preinjury medications and comorbidities to more objectively quantify the severity of comorbid conditions. SETTING: An urban tertiary care level 1 trauma center in the Midwest. PARTICIPANTS: Trauma patients aged 45 and older. METHODS: Participants were stratified into four groups according to CPS ranges. Survival analyses were performed using Kaplan-Meier/Mantel-Cox testing. Factors influencing mortality, complications, and survivor discharge destination were evaluated using analysis of covariance and multivariate logistic regression. RESULTS: Records for 469 individuals (mean age 62.1, mean injury severity score 9.3) were reviewed. Higher CPS is associated with greater mortality, complications, longer hospital and intensive care unit stay, and need for discharge to a facility. Higher CPS is associated with lower 90-day survival (Mantel-Cox, P < .001). Mortality was independently associated with older age (odds ratio (OR) = 1.06 per year), higher injury severity score (OR = 1.19 per point), and higher CPS (OR = 1.11 per point) in multivariate analysis (all P < .01). Complications and need for discharge to a facility were independently associated with older age and higher injury severity score and CPS. CONCLUSION: CPS can be readily determined in the era of medication reconciliation. Trauma patients with CPS of 15 or greater are at greater risk of poor clinical outcomes. CPS constitutes a useful adjunct to currently available injury severity scoring tools as a predictor of morbidity, mortality, hospital resource utilization, and postdischarge disposition in older trauma patients.

A retrospective statistical analysis of high-grade soft tissue sarcomas.

Soft-tissue sarcomas have a mortality rate ranging from 40-60% for high-grade lesions. Prior identified risk factors for post-surgical mortality include tumor size, lesion histology, and margin status at resection. A better understanding of prognostic factors is needed to guide patient counseling and treatment. Data were collected from 129 patients surgically treated for high-grade extremity soft tissue sarcomas during 2002-2010. The primary endpoint was death related to high-grade soft tissue sarcoma. Thirteen variables were investigated: age, gender, race, tumor size, margin status, location, estimated blood loss, operative blood transfusions, pre-operative metastatic disease, pre-operative radiation, post-operative radiation, pre-operative chemotherapy, and post-operative chemotherapy. A Cox Survival Analysis model was created to determine the best predictors of survival time. Tumor size and the presence of pre-surgical metastasis were statistically significant predictors of overall survival. Patients with a tumor greater than 8 cm in any cross section had a 3.15 times greater chance of death. Presence of pre-surgical metastasis carried a 3.47 greater chance of death. The remaining variables did not predict patient outcomes in a statistically significant manner. The hazard ratios calculated add new data and can be used to more effectively guide patients in prognosis and treatment regimens.

The impact of antiplatelet therapy on pelvic fracture outcomes.

INTRODUCTION: Despite increasing use of antiplatelet agents (APA), little is known regarding the effect of these agents on the orthopedic trauma patient. This study reviews clinical outcomes of patients with pelvic fractures (Pfx) who were using pre-injury APA. Specifically, we focused on the influence of APA on postinjury bleeding, transfusions, and outcomes after Pfx. METHODS: Patients with Pfx admitted during a 37-month period beginning January 2006 were divided into APA and non-APA groups. Pelvic injuries were graded using pelvic fracture severity score (PFSS)-a combination of Young-Burgess (pelvic ring), Letournel-Judet (acetabular), and Denis (sacral fracture) classifications. Other clinical data included demographics, co-morbid conditions, medications, injury severity score (ISS), associated injuries, morbidity/mortality, hemoglobin trends, blood product use, imaging studies, procedures, and resource utilization. Multivariate analyses for predictors of early/late transfusions, pelvic surgery, and mortality were performed. RESULTS: A total of 109 patients >45 years with Pfx were identified, with 37 using preinjury APA (29 on aspirin [ASA], 8 on clopidogrel, 5 on high-dose/scheduled non-steroidal anti-inflammatory agents [NSAID], and 8 using >1 APAs). Patients in the APA groups were older than patients in the non-APA group (70 vs. 63 years, P < 0.01). The two groups were similar in gender distribution, PFSS and ISS. Patients in the APA group had more comorbidities, lower hemoglobin levels at 24 h, and received more packed red blood cell (PRBC) transfusions during the first 24 h of hospitalization (all, P < 0.05). There were no differences in platelet or late (>24 h) PRBC transfusions, blood loss/transfusions during pelvic surgery, lengths of stay, post-ED/discharge disposition, or mortality. In multivariate analysis, predictors of early PRBC transfusion included higher ISS/PFSS, pre-injury ASA use, and lower admission hemoglobin (all, P < 0.03). Predictors of late PRBC transfusion included the number of complications, gender, PFSS, and any APA use (all, P < 0.05). Mortality was associated with pelvic hematoma/contrast extravasation on imaging, number of complications, and higher PFSS/ISS (all, P < 0.04). CONCLUSIONS: Results of this study support the contention that preinjury use of APA does not independently affect morbidity or mortality in trauma patients with Pfx. Despite no clinically significant difference in early postinjury blood loss, pre-injury use of APA was associated with increased likelihood of receiving PRBC transfusion within 24 h of admission. Furthermore, multivariate analyses demonstrated that among different APA, only preinjury ASA (vs. clopidogrel or NSAID) was associated with early PRBC transfusions. Late transfusion was associated with the use of any APA, complications, higher PFSS, and need for pelvic surgery.

Pre-injury polypharmacy as a predictor of outcomes in trauma patients.

BACKGROUND: One of the hallmarks of modern medicine is the improving management of chronic health conditions. Long-term control of chronic disease entails increasing utilization of multiple medications and resultant polypharmacy. The goal of this study is to improve our understanding of the impact of polypharmacy on outcomes in trauma patients 45 years and older. MATERIALS AND METHODS: Patients of age ≥45 years were identified from a Level I trauma center institutional registry. Detailed review of patient records included the following variables: Home medications, comorbid conditions, injury severity score (ISS), Glasgow coma scale (GCS), morbidity, mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, functional outcome measures (FOM), and discharge destination. Polypharmacy was defined by the number of medications: 0-4 (minor), 5-9 (major), or ≥10 (severe). Age- and ISS-adjusted analysis of variance and multivariate analyses were performed for these groups. Comorbidity-polypharmacy score (CPS) was defined as the number of pre-admission medications plus comorbidities. Statistical significance was set at alpha = 0.05. RESULTS: A total of 323 patients were examined (mean age 62.3 years, 56.1% males, median ISS 9). Study patients were using an average of 4.74 pre-injury medications, with the number of medications per patient increasing from 3.39 for the 45-54 years age group to 5.68 for the 75+ year age group. Age- and ISS-adjusted mortality was similar in the three polypharmacy groups. In multivariate analysis only age and ISS were independently predictive of mortality. Increasing polypharmacy was associated with more comorbidities, lower arrival GCS, more complications, and lower FOM scores for self-feeding and expression-communication. In addition, hospital and ICU LOS were longer for patients with severe polypharmacy. Multivariate analysis shows age, female gender, total number of injuries, number of complications, and CPS are independently associated with discharge to a facility (all, P < 0.02). CONCLUSION: Over 40% of trauma patients 45 years and older were receiving 5 or more medications at the time of their injury. Although these patients do not appear to have higher mortality, they are at increased risk for complications, lower functional outcomes, and longer hospital and intensive care stays. CPS may be useful when quantifying the severity of associated comorbid conditions in the context of traumatic injury and warrants further investigation.