Chronic Oral Corticosteroid Use and 10-Year Incidence of Major Complications Following Total Knee Arthroplasty.

BACKGROUND: Oral corticosteroids are the primary treatment for several autoimmune conditions. The risk of long-term implant, bone health, and infectious-related complications in patients taking chronic oral corticosteroids before total knee arthroplasty (TKA) is unknown. We compared the 10-year cumulative incidence of revision, periprosthetic joint infection (PJI), fragility fracture (FF), and periprosthetic fracture following TKA in patients who had and did not have preoperative chronic oral corticosteroid use. METHODS: A retrospective cohort analysis was conducted using a national database. Primary TKA patients who had chronic preoperative oral corticosteroid use were identified using Current Procedural Terminology and International Classification of Disease 9 and 10 codes. Exclusion criteria included malignancy, osteoporosis treatment, trauma, and < 2-year follow-up. Primary outcomes were 10-year cumulative incidence and hazard ratios (HRs) of all-cause revision (ACR), aseptic revision, PJI, FF, and periprosthetic fracture. A Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized. Overall, 611,596 patients were identified, and 5,217 (0.85%) were prescribed chronic corticosteroids. There were 10,000 control patients randomly sampled for analysis. RESULTS: Corticosteroid patients had significantly higher 10-year HR of FF (HR; 95% confidence interval); P value (1.47; 1.34 to 1.62; P < .001)], ACR (1.21; 1.05 to 1.40; P = .009), and PJI (1.30; 1.01 to 1.69; P = .045) when compared to the control. CONCLUSIONS: Patients prescribed preoperative chronic oral corticosteroids had higher risks of ACR, PJI, and FF within 10 years following TKA compared to patients not taking corticosteroids. This information can be used by surgeons during preoperative counseling to educate this high-risk patient population about their increased risk of postoperative complications.

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty.

The study found that patients undergoing total knee arthroplasty with prior fragility fracture had increased risk of subsequent fragility fracture and periprosthetic fracture within 8 years postoperatively when compared to those without a prior history. However, these patients were not at increased risk for all-cause revision within this period. PURPOSE: The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA. METHODS: Patients at least 50 years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3 years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8 years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk. RESULTS: In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF. CONCLUSIONS: Recent FF before TKA is associated with increased risk for additional FF and PPF within 8 years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

Mortality and morbidity following operative management of tibial shaft fractures in octogenarians.

PURPOSE: As the geriatric population continues to grow, the incidence of tibial shaft fractures in octogenarians is projected to increase. There is significant variation in the functional and physiologic status within the geriatric population. The purpose of this study is to compare the complications following operative treatment of tibial shaft fractures for patients who are 65- to79-year-old compared to patients who are 80- to 89-year-old. METHODS: Data were collected through the National Surgical Quality Improvement Program database for the years 2007-2018. All isolated tibial shaft fractures that were treated with open reduction internal fixation (ORIF) or intramedullary nail (IMN) were identified. Patients were divided into a 65- to 79-year-old group and an 80-to 89-year-old group. Primary and secondary outcomes were studied and included 30-day mortality. Univariate and multivariate analyses were performed with a significance set at p < 0.05. RESULTS: In total, 434 patients with tibial shaft fractures were included in the study. Of these, 333 were 65- to 79-year-old and 101 were 80- to 89-year-old (Table 1). On multivariate analysis, there was no significant difference in complication rates between the two cohorts. CONCLUSION: After controlling for demographics and comorbidities, age was not independently associated with 30-day mortality or any other peri-operative complications between patients aged 80 to 89 and patients aged 65 to 79 following operative management of tibial shaft fractures. In appropriately selected octogenarian patients, operative management of tibial shaft fractures represents a relatively safe treatment modality that may promote early rehabilitation.

Does Prior Lumbar Fusion Influence Dislocation Risk in Hip Arthroplasty Performed for Femoral Neck Fracture?

BACKGROUND: Immobility of the lumbar spine predicts instability following elective total hip arthroplasty (THA). The purpose of this study is to determine how prior lumbar fusion (LF) influenced dislocation rates and revision rates for patients undergoing THA or hemiarthroplasty (HA) for femoral neck fracture (FNF). METHODS: A retrospective cohort analysis was conducted utilizing the PearlDiver database from 2010 to 2018. Patients who underwent arthroplasty for FNF were identified based on history of LF and whether they underwent THA or HA. Univariate and multivariate analyses were performed. RESULTS: A total of 328 patients with prior LF and FNF who underwent THA were at increased risk for 1-year dislocation (odds ratio [OR] 2.19, P < .001) and 2-year revision (OR 2.22, P < .001) compared to 14,217 patients without LF. The 461 patients with prior LF and FNF who underwent HA were at increased risk for dislocation (OR 2.22, P < .001) compared to 42,327 patients without LF. Patients with prior LF and FNF who underwent THA had higher rates of revision than patients with prior LF who underwent HA for FNF (OR 2.11, P < .001). In patients with prior LF and FNF, THA was associated with significantly increased risk for dislocation (OR 3.07, P < .001) and revision (OR 2.53, P < .001) compared to THA performed for osteoarthritis. CONCLUSION: Patients with prior LF who sustained an FNF and underwent THA or HA were at increased risk for early dislocation and revision compared to those without prior LF. This risk of dislocation and revision is even greater than that observed in patients with prior LF who underwent THA for osteoarthritis. LEVEL OF EVIDENCE: Level III.

Morbidity and Mortality After Surgical Management of Tibial Plateau Fractures in Octogenarians.

BACKGROUND: Because the geriatric population continues to increase in number, the incidence of geriatric tibial plateau fractures in octogenarians is projected to increase. The functional and physiological status varies within this population. The purpose of this study was to compare the complications after surgical management of tibial plateau fractures in patients aged 65 to 79 years with those in patients aged 80 to 89 years. METHODS: In this retrospective cohort study, data were collected from the National Surgical Quality Improvement Program database for the years 2006 to 2018. The Current Procedural Terminology codes and International Classification of Diseases codes were used to identify all tibial plateau fractures that were treated with open reduction and internal fixation. Patients were divided into two groups: 65- to 79-year-old group and 80- to 89-year-old group. Primary and secondary outcomes were studied and included the 30-day mortality. Univariate and multivariate analyses were done with a statistical significance set at P < 0.05. RESULTS: In total, 718 patients with tibial plateau fractures who underwent open reduction and internal fixation were included in this study. Of these, 612 were aged 65 to 79 years, and 106 were aged 80 to 89 years. On multivariate analysis, patients aged 80 to 89 years were at increased risk of postoperative anemia requiring transfusion (odds ratio 2.83; 95% confidence interval 1.37 to 5.84; P = 0.005) and extended length of hospital stay (odds ratio 2.72; 95% confidence interval 1.64 to 4.51; P < 0.001) in comparison with patients aged 65 to 79 years. CONCLUSION: In appropriately selected octogenarian patients, surgical management of tibial plateau fractures was associated with greater risks of transfusion and longer hospital stay. However, comparisons of the rates of late complications and reoperations remain unknown.

Comparison of Short-term Complication Rates Between Cephalomedullary Hip Screw Devices and Sliding Hip Screws: An Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: The literature pertaining to the management of intertrochanteric hip fractures using cephalomedullary hip screws (CMHSs) and sliding hip screws (SHSs) has shown varying results. CMHS use has increased over time without validation of its superiority in the literature. METHODS: We conducted a retrospective cohort study using the American College of Surgeons National Quality Improvement Program database. Patients who had sustained a peritrochanteric hip fracture were identified. Short-term (<30 day) complications were identified with adjustments made for preoperative comorbidities. We also examined the relative percentages of CMHS and SHS surgeries over time. RESULTS: A total of 14,415 subjects met the inclusion criteria. Patients undergoing SHS surgery were generally healthier, having a lower American College of Surgeon class, preoperative bleeding, hypertension, pulmonary risk factors, congestive heart failure, and higher preoperative hematocrit. After adjusting for demographics and comorbidities, we noted a higher rate of 30-day mortality (odds ratio [OR] = 1.19; P = 0.024), bleeding (OR = 1.10; P = 0.007), pulmonary complications (OR = 1.19; P = 0.049), and clotting events (OR = 1.35; P = 0.035) in the CMHS group. We observed a higher rate of urinary tract infection (OR = 0.81; P = 0.023) and length of stay (1.0 days; P < 0.0001) in the SHS group. The overall percentage of SHS cases was 33% and trended lower over time. CONCLUSIONS: Although differences in complication subtypes and the overall complication rate were found, further multicenter, randomized controlled trials would be helpful in elucidating differences between the treatment groups. The popularity of the CMHS continues to increase over time.

Current Publication Rates of Abstracts Presented at the Orthopaedic Trauma Association Annual Meetings: 2005-2010.

OBJECTIVES: To evaluate the publication rate of abstracts presented at the 2005-2010 Orthopaedic Trauma Association (OTA) Annual Meetings. METHODS: All abstracts from the 2005 to 2010 OTA meetings were identified through the OTA's official website. Each abstract was searched across PubMed and Google to determine its publication status. The overall publication rate of abstracts was determined, along with the first authors' sex, number of authors, time and journal of publication, and analyzed with statistical testing. RESULTS: Of the 392 abstracts presented at the 2005-2010 OTA meetings, the overall publication rate was 66.3%, with an overall mean time to publication of 28.3 months. The Journal of Orthopaedic Trauma published 38.5% of published OTA abstracts, the most of any journal. The proportions of published OTA abstracts with female first authors exhibit increasing trends within the time period. CONCLUSION: The quality of research presented at OTA meetings is relatively high compared with other orthopaedic meetings, with 66.3% of OTA abstracts progressing to peer-reviewed publication. The publication rate of 2005-2010 OTA abstracts was greater than that of the 1990-1995 abstracts. The Journal of Orthopaedic Trauma remains the most frequent publisher of manuscripts presented as abstracts at OTA meetings. Although most abstracts are eventually published, the information presented at these meetings, like all scholarly work, should be critically evaluated as they have undergone a less robust peer-review process and may be modified in the future in preparation for publication.

The impact of trauma centre accreditation on patient outcome.

Trauma centre accreditation originated as a North American initiative in the 1970's with the aim of standardising and improving care for injured patients. This system of grading a hospital's ability to receive serious trauma has subsequently spread, most notably to Australasia. Many studies have focussed on determing whether this accreditation results in improved patient outcomes. We review the evidence to date, which suggests significant mortality reductions albeit from mainly Class III studies and reflect on the future sustainability of this initiative given mounting financial pressures.