Risks and Complications After Arthroplasty for Pathological or Impending Pathological Fracture of the Hip.

BACKGROUND: Treatment options for metastatic osseous lesions of the proximal femur include hemiarthroplasty (HA) or total hip arthroplasty (THA) depending on lesion characteristics and patient demographics. Studies assessing short-term outcomes after HA/THA in this patient population are limited. Therefore, the purpose of this present study was to identify short-term rates of morbidity and mortality after HA/THA for pathological proximal femur fractures, as well as readmission and reoperation rates and reasons. METHODS: This study utilized a large, prospectively collected registry to identify patients who underwent HA/THA between 2011 and 2018. Patients were stratified by indication for surgery, including pathological fracture, nonpathological fracture, and osteoarthritis. Baseline patient characteristics and postoperative complications were compared using bivariate and/or multivariate analysis. RESULTS: In total, 883 patients undergoing HA/THA for a pathological fracture were identified. Relative to an osteoarthritis cohort, these patients tended to be older, had a lower body mass index, and had significantly more preoperative comorbidities. These patients had high rates of total complications (13.93%), including thirty-day mortality (3.29%), unplanned return to the operating room (4.98%), and pulmonary complications (3.85%). Patients with pathological fracture had a longer operative duration relative to osteoarthritis and nonpathological cohorts (+27 and +25 minutes, respectively), despite having high rates of HAs performed. CONCLUSION: Patients undergoing hip arthroplasty for pathologic proximal femur fracture have increased morbidity and mortality relative to an osteoarthritis cohort. However, patients with a pathological fracture have similar rates of morbidity and mortality when compared with a nonpathological fracture cohort, but did experience higher rates of perioperative blood transfusion and unplanned readmissions. LEVEL OF EVIDENCE: III.

Quantifying the Surgeon's Increased Burden of Postoperative Work for Modern Arthroplasty Surgery.

BACKGROUND: Arthroplasty payment traditionally includes 118 minutes for postoperative rounds and 69 minutes for postoperative office visits, amounting to 187 minutes and 7 work relative value units. Rapid recovery, ambulatory procedures, and bundled payments have altered the burden of care, with multiple studies showing an increase in physician work. Policy changes during the COVID-19 pandemic allow for precise documentation of patient touchpoints. We analyzed the duration of video, telephone, and text messaging to quantify modern arthroplasty work. METHODS: Consecutive primary hip, knee, and partial knee arthroplasties, performed 30 days before March 15, 2020 (date of practice closure), were included from a single institution, yielding 47 cases. We retrospectively quantified the duration of video telehealth documentation, telephone logs, and text messages over 90 days to calculate the postoperative work required in modern arthroplasty using descriptive statistics. RESULTS: An average of 9.4 touchpoints (2-14) by the surgeons occurred during the global period for this cohort, totaling 219 minutes (51-247 minutes). This included an average of 21 minutes of day-0 calls to family, 117 minutes for video visits, 52 minutes for phone calls, and 29 minutes for text messaging and wound photos. CONCLUSION: We found an undervaluation of 32 minutes of work. AAHKS leadership advocates for the fair payment of modern arthroplasty work. Cell phones have opened channels of contact that did not exist before, including phone accessibility, text messaging, and video calls. These data help defend against current payer efforts to cut work relative value units for arthroplasty. LEVEL OF EVIDENCE: II.

Isolated fibular stress fractures: Radiographic parameters.

BACKGROUND: Fibular stress fractures are uncommon injuries with an incompletely understood pathogenesis and predisposing characteristics. This study investigated the demographic and radiographic risk factors for fibular stress fractures. METHODS: A retrospective chart review from 2010 to 2018 revealed thirteen patients with isolated fibular stress fractures. Demographics, history of fracture, fracture location, bone quality, and heel alignment were collected. RESULTS: The cohort consisted of six men and seven women with a mean age of 41.8 years. The average BMI was 28.5kg/m2. Three patients used tobacco. 69.2% of fractures were in the distal third, 23.1% proximal third, and 7.7% middle third. No patients had evidence of osteopenia. Distal fibula stress fractures were more common in women (66.7%) and associated with hindfoot valgus. CONCLUSION: Distal third fibula stress fractures were most common and associated with hindfoot valgus. This could be due to a greater amount of axial force through fibula in this alignment. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series.

Midterm results for revision total knee arthroplasty for component malrotation.

INTRODUCTION: Accurate positioning of components in total knee arthroplasty (TKA) is essential to a satisfactory outcome. Significant malrotation may lead to chronic pain, stiffness, and dysfunction. This study aims to quantify improvements in functional outcomes following revision surgery for malrotation of either one or both components in TKA versus revision for aseptic loosening. METHODS: This was a retrospective review of TKAs that matched and compared the two-year functional outcomes of the malrotation group to a functionally similar aseptic loosening group. Functional outcomes were compared between groups using Short Form (SF-12), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and Knee Society Functional Score (KSFS). Student t-tests and chi-squared or Fisher's tests were used for statistical analysis. RESULTS: Of the patients revised, 24 had malrotation and 57 had aseptic loosening. A total of 16 femoral and 17 tibial components were revised for malrotation. All 16 femoral components were internally malrotated (mean -4.8 ± 4.1 degrees; range, -0.5 to -16.6). Of the tibial components, 15 were internally malrotated, (mean -9.5 ± 6.6 degrees; range, -2.2 to -23.5) and 2 were externally malrotated (mean 4.6 ± 2.1 degrees; range, 3.1 to 6.0). All functional outcome measures significantly improved comparably within both groups preoperatively to 24 months postoperatively. At 24 months, functional outcome measures were comparable between the groups and WOMAC function scores were significantly higher in the malrotation group. CONCLUSION: Revision TKA for malrotation can yield clinically and statistically significant functional improvements, similar in magnitude to those seen following revision TKA for aseptic loosening. LEVEL OF EVIDENCE: Level III.

Anterior-Based Muscle-Sparing (ABMS) Approach for Total Hip Arthroplasty.

The anterior-based muscle-sparing (ABMS) technique for total hip arthroplasty (THA) has gained popularity in recent years because of its proposed advantages in terms of postoperative pain and periprosthetic dislocation risk. Description: The procedure is performed with the patient in the supine position. A minimally invasive Watson-Jones approach is utilized to access the hip. Fluoroscopy can be utilized intraoperatively to assess acetabular cup position, version, and inclination. Femoral canal fill and leg lengths can also be assessed with use of fluoroscopy. Alternatives: Nonoperative alternatives for the treatment of hip osteoarthritis include nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections into the hip joint. Surgical alternatives to this procedure include the posterior approach (Moore or Southern), the direct lateral approach (Hardinge), and the direct anterior approach (Smith-Petersen). The Watson-Jones approach can also be performed with the patient in the lateral decubitus position (unlike in our technique where the patient is supine). Rationale: The anterolateral (Watson-Jones) approach to the hip has been shown to be superior to the historically more common posterior approach with regard to length of hospital stay and dislocation risk1,2. Supine positioning for this approach offers multiple advantages compared with lateral decubitus positioning. Leg lengths can be assessed intraoperatively both fluoroscopically and with manual palpation of the medial malleoli. Cup position can be assessed radiographically as well3. Supine positioning also allows for easily reproducible patient positioning. Expected Outcomes: Compared with the historically common posterior approach to the hip for THA, the anterolateral approach to the hip leads to, on average, a lower risk of hip dislocation1,2. In a 2002 study by Masonis and Bourne, the dislocation rate for the posterior approach was 3.23% (193 of 5,981), whereas the dislocation rate was 2.18% (18 of 826) for patients who underwent THA via the anterolateral approach1. In a study by Ritter et al. in 2001, which followed patients for 1 year postoperatively, no patients in the anterolateral approach group experienced a dislocation compared with 4.21% of patients in the posterior approach group2. With use of the present technique, patients will benefit from the advantages of the anterolateral approach to the hip; however, they will also benefit from easy intraoperative leg length assessment and from radiographic assistance with regard to determining the appropriate position of the femoral and acetabular components3. In a study of 199 patients (including 98 patients who had intraoperative fluoroscopy and 101 who did not), 80% of implants in the fluoroscopy group were within the combined safe zone compared with 63% in the non-fluoroscopy group. However, this approach is not without its limitations. As mentioned in the above studies, dislocation remains a possible complication of the procedure, and a minimally invasive anterior-based approach can lead to intraoperative femoral fractures when exposure and releases are inadequate4. Femoral nerve palsies are also possible with excessive medial retraction during acetabular exposure. Additionally, the benefit of a reduction in the incidence of hip dislocation compared with a posterior approach might be overstated given improvement in posterior-approach dislocation rates if posterior soft-tissue repair is used5. Both direct anterior and anterolateral approaches have the same risks of fracture with poor exposure and of neurapraxia with excessive retraction, and there does not appear to be any difference in dislocation risk between these 2 approaches6. Important Tips: Although a pannus is more detrimental to a direct anterior approach, it could overlie the desired incision in the ABMS approach as well. The pannus could be held out of the field by taping it to the contralateral shoulder before preparing and draping.The preparative process is more time-consuming because both legs must be sterile for this procedure.Acetabular exposure often requires an assistant standing on the contralateral side of the table.Although not often needed, the obturator internus and gemelli might need to be released in order to ensure adequate exposure of the femur.If femoral canal exposure is still insufficient, a femoral suspension hook system might be needed. Acronyms & Abbreviations: ASIS = anterior superior iliac spineTFL = tensor fasciae lataeITB = iliotibial bandPOD = postoperative dayIV = intravenousBID = twice daily.

Aspirin Is an Effective Prophylaxis for Venous Thromboembolism in Ambulatory Patients with Femoral Neck Fracture Undergoing Hip Arthroplasty.

BACKGROUND: Although aspirin has been adopted as an effective and safe prophylaxis against venous thromboembolism (VTE) by the arthroplasty community, the role of aspirin in the prevention of VTE in the setting of arthroplasty for trauma remains insufficiently known. Therefore, the present multicenter study investigated the efficacy of aspirin as VTE prophylaxis for patients with femoral neck fracture undergoing total hip arthroplasty or hemiarthroplasty. METHODS: We reviewed the medical records of 1,141 patients with femoral neck fracture who underwent total hip arthroplasty or hemiarthroplasty from 2008 to 2018 at 3 different institutions. Data on patient demographic characteristics, body mass index, history of VTE, and comorbidities were obtained from an electronic chart query and were confirmed by reviewing the medical records manually. Patients were allocated to cohorts based on the type of prophylaxis administered: aspirin (n = 454) and other anticoagulants (n = 687). Patients were then propensity score-matched on the basis of the risk score calculated using a previously validated tool and the remaining confounding variables. The primary outcome was the development of symptomatic VTE, namely deep vein thrombosis (DVT) or pulmonary embolism (PE) confirmed by appropriate imaging, within 90 days after the surgical procedure. A bivariable analysis was performed. RESULTS: The overall VTE rate was 1.98% for patients who received aspirin compared with 6.7% for patients who received other anticoagulants (p < 0.001). After propensity score matching and regression modeling, aspirin was found to be noninferior to more potent anticoagulation in preventing VTE after both total hip arthroplasty and hemiarthroplasty. CONCLUSIONS: Aspirin is an effective option for VTE prophylaxis in patients with femoral neck fracture who undergo hip arthroplasty. Based on the patient management benefits of aspirin for elective arthroplasty and the present study, we suggest its use in standard-risk ambulatory patients. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Anterior Tibial Tendon Pathology.

BACKGROUND: Though the tibialis anterior (TA) serves a vital role in ankle dorsiflexion, there is little information regarding risk factors and demographic information that might predispose one to tendinopathy or rupture. This study investigates the features of patients in a single institution who presented with either TA tendinopathy or rupture. The circumstances surrounding rupture were also noted. METHODS: ICD-9/10 codes were used to find patients who presented with TA pathology to 2 foot and ankle surgeons at 1 academic medical center from 2011 to 2018. Patient characteristics were noted, including age, sex, body mass index, and the presence of a gastrocnemius equinus contracture. Characteristics of patients with traumatic and atraumatic ruptures were compared. RESULTS: Ninety-four patients presented between 2011 and 2018 (79 cases of tendinopathy and 15 ruptures). The average patient age was 56 years, and the ratio of women to men was 74:20 (3.7:1). With regard to those who experienced rupture, there were 2 ruptures directly related to athletic activity (traumatic), whereas 13 ruptures were found on examination with no overt history of injury (atraumatic). The average age for patients with traumatic ruptures was 39 years compared with 73 years for those with atraumatic rupture (P < .05). CONCLUSION: This study investigates the features of patients in a single institution who presented with TA pathology. With regard to tendon ruptures, traumatic ruptures tend to occur in younger patients, whereas older patients are more likely to suffer atraumatic ruptures. Nonoperative treatment often appears to be effective for TA pathology. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Neck and Back Sprain and Hand Flexor Tendon Repair Are More Common in Victims of Domestic Violence Compared With Patients Who Were Not Victims of Domestic Violence: A Comparative Study of 1,204,596 Patients Using the National Trauma Data Bank.

INTRODUCTION: The purpose of this study was to determine the most common orthopedic diagnoses and procedures among patients who experience domestic violence (DV) and to determine whether these were more common in patients who experienced DV compared with those who did not. METHODS: We performed a retrospective cohort study of all patients identified in the National Trauma Data Bank. Patients were divided into two cohorts for comparison: victims of DV and all other patients. The main outcome measurements were a diagnosis of an orthopedic injury and/or a procedure performed for an orthopedic diagnosis. RESULTS: In total, 1,204,596 patients were included in the analysis, of whom 3191 (0.26%) were victims of DV. Adult trauma patients with DV were more likely to have a diagnosis of neck and back sprain (odds ratio 1.98, 95% confidence interval 1.60 to 2.44, P < 0.0001) and more likely to undergo surgical repair of the flexor tendon of the hand (odds ratio 2.76, 95% confidence interval 1.75 to 4.35, P < 0.0001) than patients without a diagnosis of DV. DISCUSSION: Patients who experience DV were more likely to have back and neck sprain and more likely to undergo repair of flexor tendon of the hand than those who do not experience DV.

Lower Dosing of Bupivacaine Spinal Anesthesia Is Not Associated With Improved Perioperative Outcomes After Total Joint Arthroplasty.

BACKGROUND: The choice of anesthesia plays a significant role in the success of total joint arthroplasty (TJA). Isobaric bupivacaine spinal anesthesia is often used. However, dosing of bupivacaine has not been extensively studied and is usually at the discretion of the treating anesthesiologist and surgeon. The goal of this study was to determine what, if any, effect the dose of bupivacaine spinal anesthesia had on perioperative outcomes in TJA. METHODS: A total of 761 TJAs performed with bupivacaine spinal anesthesia by arthroplasty surgeons were retrospectively reviewed. Perioperative outcomes evaluated were operation duration, estimated blood loss, length of stay (LOS) in the postanesthesia care unit, hospital LOS, discharge disposition, episodes of intraoperative hypotension, postoperative nausea and vomiting, and missed physical therapy sessions because of postoperative symptoms of hypotension. A Student's t-test was used for continuous variables, and a chi-squared test was used for categorical variables. RESULTS: Of the 761 patients, 499 (65.6%) received 15 mg isobaric bupivacaine while 262 (34.4%) received <15 mg (range = 7.5-14.5 mg, median = 12.5 mg). With the numbers available in this cohort, lower doses of bupivacaine were not associated with any significant differences between groups for any of the studied perioperative outcomes, including proportion of patients discharged home or LOS. CONCLUSION: Dosage of bupivacaine spinal anesthetic did not affect perioperative outcomes. Bupivacaine may not have a dose-related response curve in this regard, and if seeking to perform same-day or outpatient TJA, other agents may need to be considered, rather than smaller doses of bupivacaine.

Fragility Index as a Measure of Randomized Clinical Trial Quality in Adult Reconstruction: A Systematic Review.

BACKGROUND: The Fragility Index (FI) and Reverse Fragility Index are powerful tools to supplement the P value in evaluation of randomized clinical trial (RCT) outcomes. These metrics are defined as the number of patients needed to change the significance level of an outcome. The purpose of this study was to calculate these metrics for published RCTs in total joint arthroplasty (TJA). METHODS: We performed a systematic review of RCTs in TJA over the last decade. For each study, we calculated the FI (for statistically significant outcomes) or Reverse Fragility Index (for nonstatistically significant outcomes) for all dichotomous, categorical outcomes. We also used the Pearson correlation coefficient to evaluate publication-level variables. RESULTS: We included 104 studies with 473 outcomes; 92 were significant, and 381 were nonstatistically significant. The median FI was 6 overall and 4 and 7 for significant and nonsignificant outcomes, respectively. There was a positive correlation between FI and sample size (R = 0.14, P = .002) and between FI and P values (R = 0.197, P = .000012). CONCLUSIONS: This study is the largest evaluation of FI in orthopedics literature to date. We found a median FI that was comparable to or higher than FIs calculated in other orthopedic subspecialties. Although the mean and median FIs were greater than the 2 recommended by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines to demonstrate strong evidence, a large percentage of studies have an FI < 2. This suggests that the TJA literature is on par or slightly better than other subspecialties, but improvements must be made. LEVEL OF EVIDENCE: Level I; Systematic Review.

Operative Treatment of Fifth Metatarsal Jones Fractures (Zones II and III) in the NBA.

BACKGROUND: Proximal fractures of the fifth metatarsal (zone II and III) are common in the elite athlete and can be difficult to treat because of a tendency toward delayed union, nonunion, or refracture. The purpose of this case series was to report our experience in treating 10 NBA players, determine the healing rate, return to play, refracture rate, and role of foot type in these athletes. METHODS: The records of 10 professional basketball players were retrospectively reviewed. Seven athletes underwent standard percutaneous internal fixation with bone marrow aspirate concentrate (BMAC) whereas the other 3 had open bone grafting primarily in addition to fixation and BMAC. Radiographic features evaluated included fourth-fifth intermetatarsal, fifth metatarsal lateral deviation, calcaneal pitch, and metatarsus adductus angles. RESULTS: Radiographic healing was observed at an overall average of 7.5 weeks and return to play was 9.8 weeks. Three athletes experienced refractures. There were no significant differences in clinical features or radiographic measurements except that the refracture group had the highest metatatarsus adductus angles. Most athletes were pes planus and 9 of 10 had a bony prominence under the fifth metatarsal styloid. CONCLUSION: This is the largest published series of operatively treated professional basketball players who exemplify a specific patient population at high risk for fifth metatarsal fracture. These players were large and possessed a unique foot type that seemed to be associated with increased risk of fifth metatarsal fracture and refracture. This foot type had forefoot metatarsus adductus and a fifth metatarsal that was curved with a prominent base. We continue to use standard internal fixation with bone marrow aspirate but advocate additional prophylactic open bone grafting in patients with high fourth-to-fifth intermetatarsal, fifth metatarsal lateral deviation, and metatarsus adductus angles as well as prominent fifth metatarsal styloids in order to improve fracture healing and potentially decrease the risk of refracture. LEVEL OF EVIDENCE: Level IV, case series.

Multiplanar CT Analysis of Fifth Metatarsal Morphology: Implications for Operative Management of Zone II Fractures.

BACKGROUND: Percutaneous internal fixation is currently the method of choice treating proximal zone II fifth metatarsal fractures. Complications have been reported due to poor screw placement and inadequate screw sizing. The purpose of this study was to define the morphology of the fifth metatarsal to help guide surgeons in selecting the appropriate screw size preoperatively. METHODS: Multiplanar analysis of fifth metatarsal morphology was completed using computed tomographic (CT) scans from 241 patients. Specific parameters were analyzed and defined in anteroposterior (AP), lateral, and oblique views including metatarsal length, distance from the base to apex of curvature, apex medullary canal width, apex height, and fifth metatarsal angle. RESULTS: The average metatarsal length in the AP view was 71.4 ± 6.1 mm and in the lateral view 70.4 ± 6.0 mm, with 95% of patients having lengths between 59.3 and 83.5 mm and 58.4 and 82.4 mm, respectively. The average canal width at the apex of curvature was 4.1 ± 0.9 mm in the AP view and 5.3 ± 1.1 mm in the lateral view, with 95% of patients having widths between 2.2 and 5.9 mm and 3.2 and 7.5 mm, respectively. Average distance from apex to base was 42.6 ± 5.8 mm in the AP and 40.4 ± 6.4 mm in the lateral views. Every measurement taken in all 3 views had a significant correlation with height. CONCLUSIONS: When determining screw length, we believe lateral radiographs should be used since the distance from the base of the metatarsal to the apex was smaller in the lateral view. On average, the screw should be 40 mm or less to reduce risk of distraction. For screw diameter, the AP view should be used because canal shape is elliptical, and width was found to be significantly smaller in the AP view. Most canals can accommodate a 4.0- or 4.5-mm-diameter screw, and one should use the largest diameter screw possible. Larger individuals were likely to have more bowing in their metatarsal shaft, which may lead to a higher tendency to distract. LEVEL OF EVIDENCE: Level III, comparative series.

Rate of Union After Segmental Midshaft Shortening Osteotomy of the Lesser Metatarsals.

BACKGROUND: Current literature reports excellent rates of union following various lesser metatarsal osteotomy techniques. However, it is our experience that segmental midshaft shortening osteotomies heal very slowly and have a greater potential for nonunion than has previously been reported. The purpose of this study was to assess union rates and report the time required for segmental midshaft shortening osteotomies to achieve radiographic union. METHODS: We reviewed the charts and postoperative radiographs of 58 patients (representing 91 osteotomies) who underwent segmental midshaft shortening osteotomies with internal fixation between January 2009 and December 2013. Radiographs were reviewed to determine when union was achieved. Union was defined as the bridging of 2 or more cortices in the anteroposterior, lateral, and oblique radiographic views. Osteotomies were classified as delayed union if they were not healed at 3 months postoperatively and nonunions if they were not healed at 6 months postoperatively. RESULTS: Overall, 27 of 91 osteotomies met our radiographic classification of union and were healed by 3 months (29.7%). Sixty-nine of the 91 osteotomies healed by 6 months (75.8%) and were considered delayed unions. Twenty-two osteotomies were not healed yet and therefore were considered nonunions (24.2%). Of the 22 nonunions, 7 healed in an additional 2 months (8 months) for an overall healing percentage of 83.5%, (76 of 91). By 10 months, 6 more nonunions were healed (overall healing percentage of 90.1%, 82 of 91). Three additional nonunions went on to heal by 12.9 months, yielding a final union rate of 93.4% (85 of 91), while 6 were still considered nonunions (6.6%). CONCLUSION: We report that a significant percentage of segmental midshaft metatarsal shortening osteotomies experienced delayed unions and nonunions. These findings contrast those previously reported in the literature that metatarsal osteotomies have very low nonunion rates. These results support our hypothesis that these osteotomies require a prolonged amount of time to achieve bony healing and that they have a higher tendency to develop delayed and nonunions than previously reported. LEVEL OF EVIDENCE: Level IV, retrospective case series.