Integrated Dual Lag Screws Have Higher Reoperation Rates for Fixation Failure Than Single Lag Component Cephalomedullary Nails: A Retrospective Study of 2,130 Patients with Intertrochanteric Femoral Fractures.

BACKGROUND: Previous studies comparing reoperation risk between integrated dual lag screw (IDL) and single lag component (SL) cephalomedullary nails (CMNs) in the treatment of intertrochanteric femoral fractures have demonstrated mixed results. The purpose of this study was to assess the rates of reoperation for fixation failure and all-cause reoperation in a large, multi-institutional cohort of patients with an intertrochanteric fracture treated with an IDL or SL CMN. We hypothesized that there would be no difference between the groups with respect to either of the reoperation rates. METHODS: Adults (≥18 years old) who sustained an intertrochanteric fracture (AO/OTA 31A1 to 31A3) treated with an IDL or SL CMN between January 2014 and May 2021 at 1 of 13 Level-I trauma centers were included. Patients with <3 months of follow-up or pathologic fractures were excluded. Rates of reoperation were compared with use of the chi-square test and multivariable regression, controlling for age, gender, injury mechanism, fracture pattern, and postoperative neck-shaft angle. RESULTS: A total of 2,130 patients met the inclusion criteria. The median age was 78 years, and 62.5% of patients were female. The cohort consisted of 287 patients (13.5%) with an IDL CMN and 1,843 patients (86.5%) with an SL CMN. A total of 99 patients (4.6%) had a reoperation of any type, of whom 29 (1.4% of all patients) had a reoperation for fixation failure. Compared with patients with an SL CMN, those with an IDL CMN had higher rates (4.2% versus 0.9%; p < 0.001) and odds (odds ratio [OR], 4.95 [95% confidence interval (CI), 2.29 to 10.69]; p < 0.001) of reoperation for fixation failure as well as higher rates (7.3% versus 4.2%; p = 0.021) and odds (OR, 1.83 [95% CI, 1.10 to 3.06]; p = 0.021) of all-cause reoperation. CONCLUSIONS: Intertrochanteric femoral fractures treated with an IDL CMN were associated with low but significantly higher rates and significantly higher odds of reoperation for fixation failure and all-cause reoperation compared with those treated with an SL CMN. We suggest caution to surgeons in the use of IDL CMNs for high-risk patients and recommend using SL CMNs for most patients with intertrochanteric femoral fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Patients with Preoperative Thrombocytosis After Hip Fracture Surgery.

INTRODUCTION: Low platelet counts have clinically relevant effects on patient outcomes after hip fracture surgery; however, the relationship between abnormally high platelet counts and postoperative outcomes in this population is unknown. METHODS: The ACS-NSQIP database was queried for patients who underwent hip fracture surgery between 2015 and 2019. Outcomes were compared between patients with normal platelet counts (150,000 to 450,000/µL) and thrombocytosis (>450,000/µL). RESULTS: Eighty-six thousand three hundred eleven hip fracture patients were identified, of which 1067 (1.2%) had preoperative thrombocytosis. Compared with patients with normal platelet counts, patients with preoperative thrombocytosis had increased rates of 30-day mortality (6.4% vs 4.5%, P = 0.004; OR 1.15 [95% CI 0.88 to 1.50], P = 0.322) as well as increased rates and odds of readmission (11.4% vs 7.8%, P < 0.001; OR 1.35 [95% CI 1.10 to 1.65], P = 0.004) and venous thromboembolic events (3.2% vs 1.7%, P < 0.001; OR 1.88 [95% CI 1.31 to 2.71], P < 0.001). CONCLUSIONS: Hip fracture patients with preoperative thrombocytosis had increased rates of early mortality as well as increased odds of venous thromboembolic events and readmission. A patient with thrombocytosis may benefit from close postoperative surveillance and careful follow-up. Future prospective studies are needed to verify causation and investigate how to mitigate adverse outcomes in hip fracture patients with preoperative thrombocytosis.

Using machine-learning to decode postoperative hip mortality Trends: Actionable insights from an extensive clinical dataset.

BACKGROUND: Hip fractures are one of the most common injuries experienced by the general population. Despite advances in surgical techniques, postoperative mortality rates remain high. identifying relevant clinical factors associated with mortality is essential to preoperative risk stratification and tailored post-surgical interventions to improve patient outcomes. The purpose of this study aimed to identify preoperative risk factors and develop predictive models for increased hip fracture-related mortality within 30 days post-surgery, using one of the largest patient cohorts to date. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program database, comprising 107,660 hip fracture patients treated with surgical fixation was used. A penalized regression approach, least absolute shrinkage and selection operator was employed to develop two predictive models: one using preoperative factors and the second incorporating both preoperative and postoperative factors. RESULTS: The analysis identified 68 preoperative factor outcomes associated with 30-day mortality. The combined model revealed 84 relevant factors, showing strong predictive power for determining postoperative mortality, with an AUC of 0.83. CONCLUSIONS: The study's comprehensive methodology provides risk assessment tools for clinicians to identify high-risk patients and optimize patient-specific care.

Postoperative sepsis and septic shock after hip fracture surgery.

INTRODUCTION: There is a paucity of research in the rates for sepsis and septic shock in the hip fracture population specifically, despite marked clinical and prognostic differences between these conditions. The purpose of this study was to determine the incidence, risk factors, and mortality rates for sepsis and septic shock as well as evaluate potential infectious causes in the surgical hip fracture population. METHODS: The ACS-NSQIP (2015-2019) was queried for patients who underwent hip fracture surgery. A backward elimination multivariate regression model was used to identify risk factors for sepsis and septic shock. Multivariate regression that controlled for preoperative variables and comorbidities was used to calculate the odds of 30-day mortality. RESULTS: Of 86,438 patients included, 871 (1.0%) developed sepsis and 490 (0.6%) developed septic shock. Risk factors for both postoperative sepsis and septic shock were male gender, DM, COPD, dependent functional status, ASA class ≥3, anemia, and hypoalbuminemia. Unique risk factors for septic shock were CHF and ventilator dependence. The 30-day mortality rate was 4.8% in aseptic patients, 16.2% in patients with sepsis, and 40.8% in patients who developed septic shock (p < 0.001). Patients with sepsis (OR 2.87 [95% CI 2.37-3.48], p < 0.001) and septic shock (OR 11.27 [95% CI 9.26-13.72], p < 0.001) had increased odds of 30-day mortality compared to patients without postoperative septicemia. Infections that preceded a diagnosis of sepsis or septic shock included urinary tract infections (24.7%, 16.5%), pneumonia (17.6%, 30.8%), and surgical site infections (8.5%, 4.1%). CONCLUSIONS: The incidence of sepsis and septic shock after hip fracture surgery was 1.0% and 0.6%, respectively. The 30-day mortality rate was 16.2% in patients with sepsis and 40.8% in patients with septic shock. Potentially modifiable risk factors for both sepsis and septic shock were anemia and hypoalbuminemia. Urinary tract infections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock. Prevention, early identification, and successful treatment of sepsis and septic shock are paramount to lowering mortality after hip fracture surgery.

Clostridium difficile colitis portends poor outcomes in lower extremity orthopaedic trauma surgery.

INTRODUCTION: Clostridium difficile is the most common cause of healthcare-associated infectious diarrhea and colitis, and carries the potential for high morbidity, particularly in frail patient populations. The purpose of this study was to utilize a large nationally representative database in order to report 1.) the incidence of CDC in patients with operative lower extremity fractures, 2.) risk factors for the development of CDC, 3.) the association of CDC with length of stay (LOS), readmission, and 30-day mortality rates. METHODS: The ACS-NSQIP (2015-2019) was queried for patients who underwent surgical fixation of lower extremity fractures. A backward elimination multivariate regression model was used to identify risk factors for CDC. Chi squared and multivariate regression that controlled for preoperative variables and comorbidities were used to compare outcomes in patients with and without CDC. RESULTS: 95,532 patients were included, 681 (0.71%) of whom developed CDC. Risk factors for CDC were advanced age, ASA class ≥ 3, smoking, dialysis, anemia, hypoalbuminemia, preoperative SIRS, preoperative wound infections, preoperative sepsis, and the use of spinal anesthesia or MAC/IV sedation. Patients with CDC had significantly increased 30-day mortality rates (10.6% vs 4.4%; OR 1.80, 95% CI 1.41-2.31), readmission (34.2% vs 7.5%; OR 5.13, 95% CI 4.36-6.05, and length of stay (7.5 days vs 5.3 days) compared to patients without CDC. CONCLUSION: The incidence of CDC in lower extremity orthopedic trauma patients was 0.71%. An occurrence of CDC was associated with approximately a 2.5 times increase in 30-day mortality, five times the readmission rate, and a longer hospital stay compared to patients without CDC. Mitigating the spread of c. diff through improved antibiotic stewardship and prompt treatment of CDC is paramount to decreasing the burden this infection imposes on orthopedic trauma patients and the healthcare system.