Identifying Risk Factors for Osteonecrosis After Talar Fracture.

OBJECTIVE: To identify patient, injury, and treatment factors associated with the development of avascular necrosis (AVN) after talar fractures, with particular interest in modifiable factors. DESIGN: Retrospective chart review. SETTING: 21 US trauma centers and 1 UK trauma center. PATIENT SELECTION CRITERIA: Patients with talar neck and/or body fractures from 2008 through 2018 were retrospectively reviewed. Only patients who were at least 18 years of age with fractures of the talar neck or body and minimum 12 months follow-up or earlier diagnosis of AVN were included. Further exclusion criteria included non-operatively treated fractures, pathologic fractures, pantalar dislocations, and fractures treated with primary arthrodesis or primary amputation. OUTCOME MEASUREMENTS AND COMPARISONS: The primary outcome measure was development of AVN. Infection, nonunion, and arthritis were secondary outcomes. RESULTS: In total, 798 patients (409 men; 389 women; age 18-81 years, average 38.6 years) with 798 (532 right; 264 left) fractures were included and were classified as Hawkins I (51), IIA (71), IIB (113), III (158), IV (40), neck plus body (177), and body (188). In total, 336 of 798 developed AVN (42%), more commonly after any neck fracture (47.0%) versus isolated body fracture (26.1%, P < 0.001). More severe Hawkins classification, combined neck and body fractures, body mass index, tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN ( P < 0.05). After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and body mass index remained significant ( P < 0.05). Excluding late cases (>7 days), time to joint reduction for Hawkins type IIB-IV neck injuries was no different for those who developed AVN or not. AVN rates for reduction of dislocations within 6 hours of injury versus >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions. CONCLUSIONS: Forty-two percent of all talar fracture patients developed AVN, with talar neck fractures, more displaced fractures, and open injuries having higher rates. Injury-related factors are most prognostic of AVN risk. Surgical technique to emphasize anatomic reduction, without iatrogenic damage to remaining blood supply appears to be prudent. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes and complications of primary reverse shoulder arthroplasty with minimum of 2 years' follow-up: a systematic review and meta-analysis.

BACKGROUND: Primary reverse shoulder arthroplasty (rTSA) is an effective treatment option for reducing pain and improving function for patients with rotator cuff tear arthropathy, irreparable rotator cuff tears, glenoid deformity, and other challenging clinical scenarios, including fracture sequelae and revision shoulder arthroplasty. There has been a wide range of reported outcomes and postoperative complication rates reported in the literature. The purpose of this systematic review and meta-analysis is to provide an updated review of the clinical outcomes and complication rates following primary rTSA. METHODS: A systematic review and meta-analysis was performed to evaluate outcomes and complications following primary rTSA according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Demographics, range of motion, patient-reported outcome measures (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant scores), number of complications, and revisions were extracted, recorded, and analyzed from the included articles. RESULTS: Of the 1415 studies screened, 52 studies met the inclusion criteria comprising a total of 5824 shoulders. The mean age at the time of surgery was 72 years (range: 34-93), and the mean follow-up was 3.9 years (range: 2-16). Patients demonstrated a mean improvement of 56° in active flexion, 50° in active abduction, and 14° in active external rotation. Regarding functional outcome scores, rTSA patients demonstrated a mean clinically significant improvement of 37 in Constant score (minimal clinically important difference [MCID] = 5.7) and ASES score (42.0; MCID = 13.6). The overall complication rate for rTSA was 9.4% and revision rate of 2.6%. Complications were further subdivided into major medical complications (0.07%), shoulder- or surgical-related complications (5.3%), and infections (1.2%). The most frequently reported shoulder- or surgical-related complications were scapular notching (14.4%), periprosthetic fracture (0.8%), glenoid loosening (0.7%), and prosthetic dislocation (0.7%). DISCUSSION: Primary rTSA is a safe and reliable procedure with low complication, revision, infection, and scapular notching rates. Additionally, patients demonstrated clinically significant improvements in both range of motion and clinical outcome scores.

Total Joint Arthroplasty in Homeless Patients at an Urban Safety Net Hospital.

INTRODUCTION: Homelessness is a key social determinant of health, and the patient population has grown to over 580,000. Total joint arthroplasty (TJA) is an effective treatment of symptomatic end-stage osteoarthritis of the hip and knee and has been shown to improve health-related quality of life in the general population. However, the literature on the outcomes of TJA among homeless patients is limited. METHODS: We retrospectively reviewed 442 patients who underwent primary, unilateral TJA between June 1, 2016, and August 31, 2017, at an urban, tertiary, academic safety net hospital. Based on self-reported living status, we classified 28 homeless patients and 414 control nonhomeless patients. Fisher exact tests, Student t-tests, and multivariate logistic regression were used to compare the demographics, preoperative conditions, and surgical outcomes between the two groups. RESULTS: The homeless group were younger, more often male, and smokers; had alcohol use disorder; and used illicit drugs. After controlling for age, sex, and preoperative medical and social conditions, homeless patients were 15.83 times more likely to have an emergency department visit (adjusted odds ratio, 15.83; 95% confidence interval, 5.05 to 49.59; P < 0.0001) within 90 days but had similar rates of readmission (P = 0.25), revision surgery (P = 0.38), and prosthetic joint infection (P = 0.25) when compared with nonhomeless patients. DISCUSSION: Although homeless patients did not have higher rates of readmission or revision surgery, homelessness still presents unique challenges for the TJA patients and providers. With careful preoperative optimization and collaborative support, however, the benefits of TJA may outweigh the risk of poor outcomes for these patients.

Early Discharge After Total Hip Arthroplasty at an Urban Tertiary Care Safety Net Hospital: A 2-Year Retrospective Cohort Study.

INTRODUCTION: Previous studies have shown that shorter inpatient stays after total hip arthroplasty (THA) are safe and effective for select patient populations with limited medical comorbidity and perioperative risk. The purpose of our study was to compare the postoperative complications because they relate to the length of hospital stay at a safety net hospital in the urban area of the United States. METHODS: We retrospectively reviewed the medical records of 236 patients who underwent primary THA in 2017 at an urban safety net hospital. We collected data on demographics, medical comorbidities, and surgical admission information. Patients were categorized as "early discharge" if they were discharged on postoperative day 0 to 1 and "standard discharge" if they were discharged on postoperative day 2 to 5. The outcomes of interest were 90-day and 2-year postoperative complications, emergency department visit, readmissions, and revision surgeries. Data were analyzed using t-test or chi-square test for univariate analysis and linear logistic regression for controlled analysis. RESULTS: Compared with the standard discharge group, there were markedly more male patients in the early discharge group (44.5% versus 80%). Early discharge patients were markedly younger (53.3 versus 59.5 years old), more likely to be White/non-Hispanic (64.4% versus 42.4%) and less likely to have heart disease and diabetes (2.2% versus 15.2% and 2.2% versus 19.9%, respectively). With adjustment for these potential confounders, no notable difference was observed in all-type complications, emergency department visits, readmission, or revision surgery between the two groups. DISCUSSION: This study confirmed that early discharge after THA is as safe as standard discharge in a safety net hospital with appropriate preoperative risk screening. Increased perioperative counseling and optimization of social and medical risk factors mitigated possible risk factors for increased length of stay and surgical complication.

Ethnic Barriers to Utilization of Total Joint Arthroplasty Among Chinese Immigrants in the United States.

BACKGROUND: Previous studies have documented disparities in total joint arthroplasty (TJA) utilization among African American and Hispanic patients, but utilization among non-English-speaking Chinese patients in the United States has not been studied. METHODS: To quantify the utilization rate and detect ethnic factors effecting TJA utilization in non-English-speaking Chinese patients, data were gathered prospectively from the practice of a single fellowship-trained Caucasian surgeon from October 2012 to February 2013. A customized survey was drafted and validated in collaboration with a social scientist. Questions assessed demography, lifestyle factors, socioeconomic status, language skills, cultural beliefs, and prior experience with surgery. Surveys were administered in patients' native language and were collected in a blinded fashion. RESULTS: Overall, 269 patients were surveyed (157 Caucasian and 65 Chinese), 85 of which were recommended surgery (42 Caucasian and 26 Chinese). Seventy-six percent of Caucasian patients elected surgery, compared to 35% of Chinese patients. A multivariate logistic regression showed Chinese ethnicity to be a significant predictor of surgical decision after controlling for age, gender, socioeconomic status, and education. Several questions drafted to detect cultural differences in the aforementioned 6 categories were answered significantly differently (P < .05, chi-square). CONCLUSION: Language, lack of familiarity with surgery, lack of TJA knowledge, family members' role in decision making, and preference for a doctor of the same race may contribute to decreased utilization of TJA in this population. We believe a better understanding of the cultural beliefs and behaviors of Chinese patients will help physicians provide more optimal care to this patient population.