Medium-term patient-reported outcomes after total hip replacement for displaced hip fractures.

INTRODUCTION: The aim of the present study was to define the medium-term outcomes following total hip replacement (THR) for hip fracture. METHODS: We prospectively followed up 92 patients who underwent THR for a displaced hip fracture over a 3-year period between 2007 and 2010. These patients were followed up at 5 years using the Oxford Hip Score, Short-Form 12 (SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously reported at 2 years to determine any significant differences. RESULTS: Mean follow-up was at 5.4 years with a mean age at follow-up of 76.5 years. Seventy-four patients (80%) responded. Patients reported excellent functional outcomes and satisfaction (mean Oxford Hip Score 40.3; SF-12 Physical Health Composite Score 44.0; SF-12 Mental Health Composite Score 46.2; mean satisfaction 90%). The rates of dislocation (2%), deep infection (2%) and revision (3%) were comparable to those quoted for elective THR. When compared with 2-year follow-up, there were no statistically significant adverse changes in outcome parameters. CONCLUSIONS: Medium-term outcomes for THR after hip fracture in fit older patients are excellent, and these results demonstrate that the early proven benefits of this surgery are sustained into the midterm.

Autologous osteochondral mosaicplasty or TruFit plugs for cartilage repair.

PURPOSE: Autologous osteochondral mosaicplasty and TruFit Bone graft substitute plugs are methods used to repair symptomatic articular cartilage defects in the adult knee. There have been no comparative studies of the two techniques. METHODS: This retrospective study assessed functional outcome of patients using the EQ-5D, Knee Injury and Osteoarthritis Outcome Score (KOOS) and Modified Cincinnati scores at follow-up of 1-5 years. RESULTS: There were 66 patients in the study (35 TruFit and 31 Mosaicplasty): 44 males and 22 females with a mean age of 37.3 years (SD 12.6). The mean BMI was 26.8. Thirty-six articular cartilage lesions were due to trauma, twenty-six due to osteochondritis dissecans and three due to non-specific degenerative change or unknown. There was no difference between the two groups age (n.s.), sex (n.s.), BMI (n.s.), defect location (n.s.) or aetiology (n.s.). The median follow-up was 22 months for the TruFit cohort and 30 months for the mosaicplasty group. There was no significant difference in the requirement for re-operation (n.s). Patients undergoing autologous mosaicplasty had a higher rate of returning to sport (p = 0.006), lower EQ-5D pain scores (p = 0.048) and higher KOOS activities of daily living (p = 0.029) scores. Sub-group analysis showed no difference related to the number of cases the surgeon performed. Patients requiring re-operation had lower outcome scores regardless of their initial procedure. CONCLUSION: This study demonstrated significantly better outcomes using two validated outcome scores (KOOS, EQ-5D), and an ability to return to sport in those undergoing autologous mosaicplasty compared to those receiving TruFit plugs. LEVEL OF EVIDENCE: IV.

Outcome Following Intramedullary Nailing of Tibial Diaphyseal Fractures: Suprapatellar Nail Insertion Results in Superior Radiographic Parameters But No Difference in Mid-Term Function.

BACKGROUND: The primary aim of this study was to compare the radiographic parameters (nail insertion-point accuracy [NIPA] and fracture malalignment) of patients who had undergone tibial intramedullary nailing via the suprapatellar (SP) and infrapatellar (IP) approaches. The secondary aims were to compare clinical outcomes and patient-reported outcomes (PROs) between these approaches. METHODS: All adult patients with an acute tibial diaphyseal fracture who underwent intramedullary nailing at a single level-I trauma center over a 4-year period (2017 to 2020) were retrospectively identified. The nailing approach (SP or IP) was at the treating surgeon's discretion. Intraoperative and immediate postoperative radiographs were reviewed to assess NIPA (mean distance from the optimal insertion point) and malalignment (≥5°). Medical records and radiographs were reviewed to evaluate the rates of malunion, nonunion, and other postoperative complications. The Oxford and Lysholm Knee Scores (OKS and LKS) and patient satisfaction (0 = completely dissatisfied, 100 = completely satisfied) were obtained via a postal survey at a minimum of 1 year postoperatively. RESULTS: The cohort consisted of 219 consecutive patients (mean age, 48 years [range, 16 to 90 years], 51% [112] male). There were 61 patients (27.9%) in the SP group and 158 (72.1%) in the IP group. The groups did not differ in baseline demographic or injury-related variables. SP nailing was associated with superior coronal NIPA (p < 0.001; 95% confidence interval [CI] for IP versus SP, 1.17 to 3.60 mm) and sagittal NIPA (p < 0.001; 95% CI, 0.23 to 0.97 mm) and with a reduced rate of malalignment (3% [2 of 61] versus 11% [18 of 158] for IP; p = 0.030). PROs were available for 118 of 211 patients (56%; 32 of 58 in the SP group and 86 of 153 in the IP group) at a mean of 3 years (range, 1.2 to 6.5 years). There was no difference between the SP and IP groups in mean OKS (36.5 versus 39.6; p = 0.246), LKS (71.2 versus 73.5; p = 0.696), or satisfaction scores (81.4 versus 79.9; p = 0.725). CONCLUSIONS: Compared with IP nailing, SP nailing of tibial shaft fractures was associated with superior NIPA and a reduced rate of intraoperative malalignment but not of malunion at healing. However, the superior NIPA may not be clinically important. Furthermore, there were no differences in PROs at mid-term follow-up. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Pre-existing knee osteoarthritis and severe joint depression are associated with the need for total knee arthroplasty after tibial plateau fracture in patients aged over 60 years.

Aims: This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults. Methods: This is a retrospective cohort study of 182 displaced TPFs in 180 patients aged ≥ 60 years, over a 12-year period with a minimum follow-up of one year. The mean age was 70.7 years (SD 7.7; 60 to 89), and 139/180 patients (77.2%) were female. Radiological assessment consisted of fracture classification; pre-existing knee osteoarthritis (OA); reduction quality; loss of reduction; and post-traumatic OA. Fracture depression was measured on CT, and the volume of defect estimated as half an oblate spheroid. Operative management, complications, reoperations, and mortality were recorded. Results: Nearly half of the fractures were Schatzker II AO B3.1 fractures (n = 85; 47%). Radiological knee OA was present at fracture in 59/182 TPFs (32.6%). Primary management was fixation in 174 (95.6%) and acute TKA in eight (4.4%). A total of 13 patients underwent late TKA (7.5%), most often within two years. By five years, 21/182 12% (95% confidence interval (CI) 6.0 to 16.7) had required TKA. Larger volume defects of greater depth on CT (median 15.9 mm vs 9.4 mm; p < 0.001) were significantly associated with TKA requirement. CT-measured joint depression of > 12.8 mm was associated with TKA requirement (area under the curve (AUC) 0.766; p = 0.001). Severe joint depression of > 15.5 mm (hazard ratio (HR) 6.15 (95% CI 2.60 to 14.55); p < 0.001) and pre-existing knee OA (HR 2.70 (95% CI 1.14 to 6.37); p = 0.024) were independently associated with TKA requirement. Where patients with severe joint depression of > 15.5 mm were managed with fixation, 11/25 ultimately required TKA. Conclusion: Overall, 12% of patients aged ≥ 60 years underwent TKA within five years of TPF. Severe joint depression and pre-existing knee arthritis were independent risk factors for both post-traumatic OA and TKA. These features should be investigated as potential indications for acute TKA in older adults with TPFs.

Common peroneal nerve injury after tibial plateau fractures: A case series.

Introduction: Common peroneal nerve (CPN) injury is a rare but significant complication of knee trauma. Given its low incidence, there is limited published evidence, but reports have shown dislocations and fractures associated with varus deformity are more likely to injure the nerve, causing foot drop. This study aims to document the incidence and outcome of CPN palsy in tibial plateau fractures (TPF). Methods: We reviewed 746 cases of tibial plateau fractures treated between 2011 and 2020. We analysed patients' demographics, injury mechanisms, clinical course, and complications, and identified those with CPN palsies. Fractures were classified using the Schatzker, Luo and AO/OTA systems. The details of the CPN injury, including nerve conduction studies, duration of symptoms and outcome were recorded. Results: We identified 11 patients who had concurrent TPFs and CPN palsies, an overall incidence of 1.47 %. Most fractures involved the medial column (n = 9), with the C3 fragmentary TPF pattern being the most common (n = 4). The incidence of CPN injury was higher in medial fractures (5 %) and bicondylar fractures (3 %). We also found that most patients (n = 9) recovered full neurological function within 2 years. Discussion: This is the first study looking at a patient cohort sustaining concurrent TPFs and CPN injuries. It is a rare complication but should be looked for in high-risk medial and bicondylar fractures. We found that prognosis is better in TPF-associated CPN palsy than in other knee trauma, and that the majority of patients can expect a full recovery of nerve function.

Tibial plateau fractures in older adults are associated with a clinically significant deterioration in health-related quality of life.

To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients. We undertook a retrospective, case-control study of 67 patients at mean 3.5 years (SD 1.3; 1.3 to 6.1) after TPF (47 patients underwent fixation, and 20 nonoperative management). Patients completed EuroQol five-dimension three-level (EQ-5D-3L) questionnaire, Lower Limb Function Scale (LEFS), and Oxford Knee Scores (OKS) for current and recalled prefracture status. Propensity score matching for age, sex, and deprivation in a 1:5 ratio was performed using patient level data from the Health Survey for England to obtain a control group for HRQoL comparison. The primary outcome was the difference in actual (TPF cohort) and expected (matched control) EQ-5D-3L score after TPF. TPF patients had a significantly worse EQ-5D-3L utility (mean difference (MD) 0.09, 95% confidence interval (CI) 0.00 to 0.16; p < 0.001) following their injury compared to matched controls, and had a significant deterioration (MD 0.140, 95% CI 0 to 0.309; p < 0.001) relative to their preoperative status. TPF patients had significantly greater pre-fracture EQ-5D-3L scores compared to controls (p = 0.003), specifically in mobility and pain/discomfort domains. A decline in EQ-5D-3L greater than the minimal important change of 0.105 was present in 36/67 TPF patients (53.7%). Following TPF, OKS (MD -7; interquartile range (IQR) -1 to -15) and LEFS (MD -10; IQR -2 to -26) declined significantly (p < 0.001) from pre-fracture levels. Of the 12 elements of fracture care assessed, the most important to patients were getting back to their own home, having a stable knee, and returning to normal function. TPFs in older adults were associated with a clinically significant deterioration in HRQoL compared to preinjury level and age, sex, and deprivation matched controls for both undisplaced fractures managed nonoperatively and displaced or unstable fractures managed with internal fixation.

Open Reduction and Internal Fixation for Humeral Shaft Nonunion: Bone Grafting Is Not Routinely Required and Avoids Donor Site Morbidity.

OBJECTIVES: To document union rate, complications and patient-reported outcomes after open reduction and internal fixation (ORIF), with and without bone grafting (BG), for humeral diaphyseal nonunion after failed nonoperative management. DESIGN: Retrospective. SETTING: University teaching hospital. PATIENTS AND INTERVENTION: From 2008 to 2017, 86 consecutive patients [mean age 59 years (range 17-86), 71% (n = 61/86) women] underwent nonunion ORIF (plate and screws) at a mean of 7 months postinjury (range 3-21.5). Eleven (13%) underwent supplementary BG. MAIN OUTCOME MEASUREMENTS: Union rate and complications for 83 patients (97%) at a mean of 10 months (3-61). Patient-reported outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12, satisfaction) for 53 living, cognitively-intact patients (78%) at a mean of 4.9 years (0.3-9.2). RESULTS: Ninety-three percent (n = 77/83) achieved union after nonunion ORIF. Complications included recalcitrant nonunion (7%, n = 6/83), iatrogenic radial nerve palsy (6%, n = 5/83), infection (superficial 7%, n = 6/83; deep 2%, n = 2/83), and iliac crest donor site morbidity (38%, n = 3/8). The union rate with BG was 78% (n = 7/9) and without was 95% (n = 70/74; P = 0.125), and was not associated with the nonunion type (atrophic 91%, n = 53/58; hypertrophic 96%, n = 24/25; P = 0.663). Median QuickDASH was 22.7 (0-95), EQ-5D 0.710 (-0.181-1), EQ-visual analog scale 80 (10-100), SF-12 physical component summary 41.9 (16-60.5), and mental component summary 52.6 (18.7-67.7). Nineteen percent (n = 10/53) were dissatisfied with their outcome. CONCLUSIONS: ORIF for humeral diaphyseal nonunion was associated with a high rate of union. Routine BG was not required and avoided the risk of donor site morbidity. One in 5 patients were dissatisfied despite the majority achieving union. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors associated with delayed and aseptic nonunion following tibial diaphyseal fractures managed with intramedullary nailing.

AIMS: The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion. METHODS: A consecutive series of 647 patients who underwent intramedullary nailing for tibial diaphyseal fractures were identified from a trauma database. Demographic data, comorbidities, smoking status, alcohol consumption, use of non-steroidal anti-inflammatory drugs (NSAIDs), and steroid use were documented. Details regarding mechanism of injury, fracture classification, complications, and further surgery were recorded. Nonunion was defined as the requirement for revision surgery to achieve union. Delayed union was defined as a RUST score < 10 at six months postoperatively. RESULTS: There were 41 nonunions (6.3%), of which 13 were infected (31.7%), and 77 delayed unions (11.9%). There were 127 open fractures (19.6%). Adjusting for confounding variables, NSAID use (odds ratio (OR) 3.50; p = 0.042), superficial infection (OR 3.00; p = 0.026), open fractures (OR 5.44; p < 0.001), and high-energy mechanism (OR 2.51; p = 0.040) were independently associated with nonunion. Smoking (OR 1.76; p = 0.034), open fracture (OR 2.82; p = 0.001), and high-energy mechanism (OR 1.81; p = 0.030) were independent predictors associated with delayed union. The RUST score at six-week follow-up was highly predictive of nonunion (sensitivity and specificity of 75%). CONCLUSION: NSAID use, high-energy mechanisms, open fractures, and superficial infection were independently associated with nonunion in patients with tibial diaphyseal fractures treated with intramedullary nailing. The six-week RUST score may be useful in identifying patients at risk of nonunion. Cite this article: Bone Jt Open 2021;2(4):227-235.

Correlations between radiological classification systems and confirmed cartilage loss in severe knee osteoarthritis.

AIMS: Although knee osteoarthritis (OA) is diagnosed and monitored radiologically, actual full-thickness cartilage loss (FTCL) has rarely been correlated with radiological classification. This study aims to analyze which classification system correlates best with FTCL and to assess their reliability. METHODS: A prospective study of 300 consecutive patients undergoing unilateral total knee arthroplasty (TKA) for OA (mean age 69 years (44 to 91; standard deviation (SD) 9.5), 178 (59%) female). Two blinded examiners independently graded preoperative radiographs using five common systems: Kellgren-Lawrence (KL); International Knee Documentation Committee (IKDC); Fairbank; Brandt; and Ahlbäck. Interobserver agreement was assessed using the intraclass correlation coefficient (ICC). Intraoperatively, anterior cruciate ligament (ACL) status and the presence of FTCL in 16 regions of interest were recorded. Radiological classification and FTCL were correlated using the Spearman correlation coefficient. RESULTS: Knees had a mean of 6.8 regions of FTCL (SD 3.1), most common medially. The commonest patterns of FTCL were medial ± patellofemoral (143/300, 48%) and tricompartmental (89/300, 30%). ACL status was associated with pattern of FTCL (p = 0.023). All radiological classification systems demonstrated moderate ICC, but this was highest for the IKDC: whole knee 0.68 (95% confidence interval (CI) 0.60 to 0.74); medial compartment 0.84 (95% CI 0.80 to 0.87); and lateral compartment 0.79 (95% CI 0.73 to 0.83). Correlation with actual FTCL was strongest for Ahlbäck (Spearman rho 0.27 to 0.39) and KL (0.30 to 0.33) systems, although all systems demonstrated medium correlation. The Ahlbäck score was the most discriminating in severe knee OA. Osteophyte presence in the medial compartment had high positive predictive value (PPV) for FTCL, but not in the lateral compartment. CONCLUSION: The Ahlbäck and KL systems had the highest correlation with confirmed cartilage loss at TKA. However, the IKDC system displayed the best interobserver reliability, with favourable correlation with FTCL in medial and lateral compartments, although it was less discriminating in more severe disease. Cite this article: Bone Joint J 2020;102-B(3):301-309.

Operative repair of acute Achilles tendon rupture does not give superior patient-reported outcomes to nonoperative management.

AIMS: The aim was to compare long-term patient-reported outcome measures (PROMs) after operative and nonoperative treatment of acute Achilles tendon rupture in the context of a randomized controlled trial. METHODS: PROMs including the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS), EuroQol five-dimension (EQ-5D), satisfaction, net promoter score and data regarding re-rupture, and venous thromboembolic rates were collected for patients randomized to receive either operative or nonoperative treatment for acute Achilles tendon rupture in a previous study. Of the 80 patients originally randomized, 64 (33 treated surgically, 31 nonoperatively) patients were followed up at a mean of 15.7 years (13.4 to 17.7). RESULTS: There was no statistically significant difference between operatively and nonoperatively treated patients, in SMFA Dysfunction Index (median 1.56 (interquartile range (IQR) 0 to 5.51) vs 1.47 (IQR 0 to 5.15); p = 0.289), SMFA Bother Index (2.08 (IQR 0 to 12.50) vs 0.00 (IQR 0 to 6.25); p = 0.074), ATRS (94 (IQR 86 to 100) vs 95 (IQR 81 to 100); p = 0.313), EQ-5D-5L (1 (IQR 0.75 to 1) vs 1 (IQR 0.84 to 1); p = 0.137) or EQ-5D health today visual analogue score (85 (IQR 72.5 to 95) vs 85 (IQR 8 to 95); p = 0.367). There was no statistically significant difference between operative and nonoperative groups in terms of satisfaction (84% vs 100%; p = 0.119) or willingness to recommend treatment to friends or family (79% vs 87%; p = 0.255). Four nonoperative patients and two in the operative group sustained a re-rupture (p = 0.306). CONCLUSION: Both patient groups reported good results at long-term follow-up. The findings give no evidence of superior long-term patient reported outcomes (as measured by the SMFA) for surgical treatment over nonoperative treatment. There was no demonstrable difference in other patient reported outcome measures, satisfaction, or re-rupture rates at long-term follow-up. Cite this article: Bone Joint J 2020;102-B(7):933-940.

Patterns of cartilage loss and anterior cruciate ligament status in end-stage osteoarthritis of the knee.

AIMS: This study aims to determine the proportion of patients with end-stage knee osteoarthritis (OA) possibly suitable for partial (PKA) or combined partial knee arthroplasty (CPKA) according to patterns of full-thickness cartilage loss and anterior cruciate ligament (ACL) status. METHODS: A cross-sectional analysis of 300 consecutive patients (mean age 69 years (SD 9.5, 44 to 91), mean body mass index (BMI) 30.6 (SD 5.5, 20 to 53), 178 female (59.3%)) undergoing total knee arthroplasty (TKA) for Kellgren-Lawrence grade ≥ 3 knee OA was conducted. The point of maximal tibial bone loss on preoperative lateral radiographs was determined as a percentage of the tibial diameter. At surgery, Lachman's test and ACL status were recorded. The presence of full-thickness cartilage loss within 16 articular surface regions (two patella, eight femoral, six tibial) was recorded. RESULTS: According to articular cartilage loss and ACL status, 195/293 (67%) were suitable for PKA or CPKA: medial unicompartmental knee arthroplasty (UKA) 97/293 (33%); lateral UKA 25 (9%); medial bicompartmental arthroplasty 31 (11%); lateral bicompartmental arthroplasty 12 (4%); bicondylar-UKA 23 (8%); and patellofemoral arthroplasty (PFA) seven (2%). The ACL was intact in 166 (55%), frayed in 82 (27%), disrupted in 12 (4%), and absent in 33 (11%). Lachman testing was specific (97%) but poorly sensitive (38%) for disrupted/absent ACLs. The point of maximal tibial bone loss showed good interclass correlation (ICC 0.797, 0.73 to 0.85 95% confidence interval (CI); p < 0.001) and was more posterior when the ACL was absent. Maximum tibial bone loss occurring at > 55% of the anterior to posterior distance predicted ACL absence with 93% sensitivity and 91% specificity (area under the curve 0.97 (0.94 to 0.99 95% CI; p < 0.001). CONCLUSION: ACL status can be reliably determined from a lateral radiograph using the location of maximal tibial bone loss. According to regions of cartilage loss and ACL status, two-thirds of patients with end-stage knee OA could potentially be treated with PKA or CPKA. Cite this article: Bone Joint J 2020;102-B(6):716-726.

Thromboprophylaxis an update of current practice: Can we reach a consensus?

Diagnosis, prophylaxis, and management of venous thromboembolism (VTE) in patients with fractures remain a highly controversial topic with little consensus in clinical practice or the literature. The following manuscript represents a summary of evidence presented at the 2017 OTA Annual Meeting Symposium; "Thromboprophylaxis an Update of Current Practice: Can We Reach A Consensus?" The need for prophylaxis in pelvic and acetabular fracture patients; the existing body of evidence related to VTE, pulmonary embolism (PE), and prophylaxis for patients with fractures about the knee; current evidence in Edinburgh Scotland, regarding VTE prophylaxis in patients with isolated ankle fractures and the risk of VTE in patients with a hip fracture are topics that are addressed. The reader will benefit from the wisdom of this compilation of global contributions on thromboprophylaxis.

Total hip replacement in patients with hip fracture: a matched cohort study.

BACKGROUND: There is increasing interest in the use of total hip replacement (THR) for reconstruction in patients who have displaced intracapsular hip fractures. Patient selection is important for good outcomes, but criteria have only recently been clearly defined in the form of national guidelines. This study aimed to investigate patient reported outcomes and satisfaction after THR undertaken for displaced hip fractures and to compare these with a matched cohort of patients undergoing contemporaneous THR for osteoarthritis to assess the safety and effectiveness of national clinical guidelines. METHODS: One hundred patients were selected for treatment of displaced hip fractures using THR between January 1, 2007, and December 31, 2009. These patients were selected using national guidelines and were matched for age and sex with 300 patients who underwent contemporaneous THR as an elective procedure for osteoarthritis. RESULTS: Patients undergoing THR for both fracture and as an elective procedure reported excellent outcomes and satisfaction. Patients with hip fracture had better postoperative Oxford hip scores (p < 0.001) and SF-12 physical component scores (p < 0.001). Mental component scores were poorer for patients with hip fracture (p < 0.001). In this series, the rates of major complications for patients with hip fracture were higher than for elective patients. For patients with hip fracture, the rate of dislocation was 2%, the rate of deep infection was 3%, and early revision operation was required for 2% of patients. The 30-day mortality for patients with hip fracture was zero. Nevertheless, these complication rates are similar to those widely reported in the literature and considered within acceptable limits after elective operation. CONCLUSION: For selected patients, THR undertaken for displaced fractures of the hip produces outcomes that are at least equivalent to those achieved after elective operation. Selection is critical to this success, and the extended use of current guidelines is appropriate and safe. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Acute renal dysfunction following hip fracture.

We investigated the incidence, risk factors and outcome of acute renal dysfunction (ARD) in patients with a fractured neck of femur. 170 consecutive patients were prospectively included in the Scottish Hip Fracture Audit database and retrospectively analysed. Historically, lack of consensus definition has hindered accurate reporting of ARD. ARD was defined using the 'RIFLE' criteria. 27 patients (16%) developed ARD. Risk factors were male sex, vascular disease, hypertension, diabetes, chronic kidney disease and pre-morbid use of nephrotoxic medications (p<0.01). Inpatient, 30- and 120-day mortality was higher in the ARD group 19%, 22% and 41% respectively, versus 0%, 4% and 13% in the non-ARD group (p<0.01). Length of hospital stay was significantly longer in the ARD group. Pre- and post-operative complications were 12 and 5 times more frequent respectively in the ARD group (p<0.01). Awareness of risk factors and serial measurements of renal function allow early identification and focused monitoring of these patients.