Outcomes of surgical fixation of greater tuberosity fractures: A systematic review.

BACKGROUND: Isolated greater tuberosity fractures account for up to a fifth of all proximal humeral fractures. There have been several retrospective cohort studies and case series reporting outcomes after treatment of this pathology. This study aims to report on the clinical outcomes of surgically treated isolated greater tuberosity fractures, as well as diagnostic workup and complications associated with fracture fixation. METHODS: A systematic review was performed under PRISMA guidelines to identify studies that reported the results or clinical outcomes of isolated greater tuberosity fracture. The searches were performed using MEDLINE through PubMed, the Elsevier Embase database, and the Cochrane Database of Systematic Reviews. RESULTS: Sixteen studies met inclusion criteria comprising 345 patients and 345 shoulders. The mean age was 52.9 years and mean follow-up was 3.4 months. The mean postoperative American Shoulder and Elbow Surgeon Score, the most frequently utilized patient reported outcome measure across studies, was 90.1% of ideal maximum. All studies used standard shoulder radiographs in their initial workup and most commonly referred to a minimum of 5mm displacement as an indication for surgery. Fifty five percent of patients were treated using open fixation and 35.9 with arthroscopic fixation. Ninety three percent of patients were able to return to work. A total of fifty-two (15.1%) complications were reported in the included studies. CONCLUSIONS: The current literature describes overall satisfactory functional outcomes and minimal occupational morbidity following either open or arthroscopic fixation of isolated greater tuberosity fractures despite a notable rate of complications. LEVEL OF EVIDENCE: IV, systematic review.

Risk factors for readmission within thirty days following revision total hip arthroplasty.

BACKGROUND: The number of total hip arthroplasties (THA) being performed has been steadily increasing for decades. With increased primary THA surgical volume, revision THA numbers are also increasing at a steady pace. With the aging, increasingly comorbid patient populations and newly imposed financial penalties for hospitals with high readmission rates, refining understanding of factors influencing readmission following THA is a research priority. We hypothesize that numerous preoperative medical comorbidities and postoperative medical complications will emerge as significant positive risk factors for 30-day readmission. METHODS: ACS-NSQIP database identified patients who underwent revision THA from 2005 to 2015. The primary outcome assessed was hospital readmission within 30 days. Patient demographics, preoperative comorbidities, laboratory studies, operative characteristics, and postsurgical complications were compared between readmitted and non-readmitted patients. Logistic regression identified significant independent risk factors for 30-day readmission among these variables. RESULTS: 10,032 patients underwent revision THA in the ACS-NSQIP from 2005 to 2015; 855 (8.5%) were readmitted within 30-days. Increasing age, the presence of preoperative comorbidities, high ASA class, and increased operative time were significant positively associated independent risk factors for 30-day readmission. Several postoperative medical and surgical complications such as myocardial infarction, stroke, pneumonia, and sepsis demonstrated significant positive associations with readmission. CONCLUSION: Identifying and understanding risk factors associated with readmission allows for the implementation of evidence-based interventions aimed at minimizing risk and reducing 30-day readmission rates following revision THA.

Syndesmotic Fixation With Suture Button: Neurovascular Structures at Risk: A Cadaver Study.

OBJECTIVES: The objective of this study was to describe the anatomic variations in the saphenous nerve and risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation. METHODS: Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1, 2, and 3 cm above the tibial plafond on 10 below-knee cadaver leg specimens. The distance and position of each button from the greater saphenous vein and saphenous nerve were evaluated. RESULTS: The mean distance of the saphenous nerve to the suture buttons at 1, 2, and 3 cm were 7.1 ± 5.6, 6.5 ± 4.6, and 6.1 ± 4.2, respectively. Respective rate of nerve compression was as follows, 20% at 1 cm, 20% at 2 cm, and 10% at 3 cm. Mean distance of the greater saphenous vein from the suture buttons at 1, 2, and 3 cm was 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9 mm, respectively. Respective rate of vein compression was 20%, 10%, and 10%. A single nerve branch was identified in 7 specimens, and 2 branches were identified in 3 specimens. CONCLUSION: There was at least one case of injury to the saphenous vein and nerve at every level of button insertion at a rate of 10% to 20%. Neurovascular injury may occur despite vigilant use of fluoroscopy and adequate surgical technique. Further investigation into the use of direct medial visualization of these high-risk structures should be done to minimize the risk. Levels of Evidence: Therapeutic, Level II: Prospective, comparative study.

The utility of electrocautery for suture passage through bone: A biomechanical study.

Electrosurgical devices are routinely employed during surgery. The use of a Bovie Electrosurgical Unit (ESU) to facilitate the passage of a suture needle through bone has not been studied in the literature. This study aimed to identify force reduction with the application of Bovie ESU to the suture needle through the bone. Peak and the average axial force required for a suture needle to penetrate cadaveric proximal humeri were measured using a custom setup. Twenty-four trials were conducted without electricity, and 72 trials were conducted with a Bovie ESU applying current. Needle size and Bovie ESU power settings were varied. t Tests and analysis of variance were used with p ≤ 0.05 denoting statistical significance. The application of electricity reduced the peak and average axial force needed for a needle to pierce bone, regardless of the Bovie ESU power setting (p < 0.001). The average peak force with the Bovie ESU was 65.7 N, compared with 126.0 N without (p < 0.001), a 47.9% reduction. The average axial force with the Bovie ESU was 38.2 N compared with 81.8 N without (p < 0.001), a 53.3% reduction. There was no significant difference in peak or average axial forces between power settings. At 30 and 90 W of power, larger needle size was associated with significantly lower peak (p = 0.001 and p < 0.001, respectively) and axial (p = 0.002 and p = 0.004, respectively) force. The Bovie ESU reduces the axial force required to pass a suture needle through bone. The use of this technique may allow for the avoidance of drilling for soft tissue repair. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:954-960, 2020.

Prevalence and Safety of Left-Footed Driving Following Right Foot Surgery Patients Including a Driving Simulation.

BACKGROUND: For many patients, returning to driving after right foot and ankle surgery is a concern, and it is not uncommon for patients to ask if driving may be performed with their left foot. A paucity of literature exists to guide physician recommendations for return to driving. The purpose of this study was to describe the driving habits of patients after right-sided foot surgery and assess the safety of left-footed driving using a driving simulator. METHODS: Patients who underwent right foot or ankle operations between January 2015 and December 2015 were retrospectively identified. A survey assessing driving habits prior to surgery and during the recovery period was administered via a REDCap database through email or telephone. Additionally, simulated driving scenarios were conducted using a driving simulator in 20 volunteer subjects to compare characteristics of left- versus right-footed driving. RESULTS: Thirty-six of 96 (37%) patients who responded to the survey reported driving with the left foot postoperatively. No trends were found associating left-footed driving prevalence and socioeconomic status. In driving simulations, patients exceeded the speed limit significantly more (P < .001) and hit other vehicles more (P < .026) when driving with the right foot than the left. The time to fully brake and fully release the throttle in response to vehicular hazards was significantly prolonged in left-footed driving compared with right (P = .019 and P = .034, respectively). CONCLUSION: A significant proportion of right foot ankle surgery patients engaged in left-footed driving during postoperative recovery. Driving with both the right and left foot presents a risk of compromised safety. This study provides novel objective data regarding the potential risks of unipedal left-footed driving using a standard right-footed console, which indicates that driving with the left foot may prolong brake and throttle release times. Further studies are warranted for physicians to be able to appropriately advise patients about driving after foot and ankle surgery. LEVEL OF EVIDENCE: Level IV, case series.

Incidence of and Risk Factors for Venous Thromboembolism After Foot and Ankle Surgery.

Background: Venous thromboembolism (VTE) is a rare but potentially lethal complication after orthopaedic foot and ankle surgery. The true incidence of VTE after orthopaedic foot and ankle surgery stratified by specific procedure has yet to be examined. The purpose of this study is to report the incidence of and identify risk factors for VTE in a large sample of patients receiving orthopaedic foot and ankle surgery. Methods: In this study, we retrospectively analyzed data from the National Surgical Quality Improvement Program 2006 to 2015 data files. The incidence of VTE was calculated for 30 specific orthopaedic foot and ankle surgeries and for 4 broad types of foot and ankle surgery. Demographic, comorbidity, and complication variables were analyzed to determine associations with development of VTE. Results: The overall incidence of VTE in our sample was 0.6%. The types of procedures with the highest frequency of VTE were ankle fractures (105/15 302 cases, 0.7%), foot pathologies (28/5466, 0.6%), and arthroscopy (2/398, 0.5%). Female gender, increasing age, obesity, inpatient status, and nonelective surgery were all significantly associated with VTE. Conclusion: Although VTE after orthopaedic foot and ankle surgery is a rare occurrence, several high-risk groups and procedures may be especially indicated for chemical thromboprophylaxis. Levels of Evidence: Level III: Retrospective, comparative study.

Hemiarthroplasty Versus Total Joint Arthroplasty for Hallux Rigidus: A Systematic Review and Meta-analysis.

BACKGROUND: When surgery is indicated for hallux rigidus, toe arthroplasty is an alternative procedure to arthrodesis for patients who wish to preserve toe range of motion. Our study investigated midterm outcomes of first metatarsophalangeal joint (MTPJ) arthroplasty in an effort to discern whether or not partial or total joint replacement confers benefit in these patients. METHODS: A systematic review of MTPJ arthroplasty was performed for the years 2000 to 2017. A Forest plot was created comparing preoperative and postoperative American Orthopedic Foot and Ankle Score (AOFAS), Visual Analogue Scale (VAS), and range of motion (ROM) results for both hemitoe and total-toe arthroplasty. Statistical analysis was performed. RESULTS: Mean postoperative AOFAS scores in patients undergoing hemiarthroplasty improved by 50.7 points (95% CI = 48.5, 52.8), whereas the mean AOFAS score improvement in total joint arthroplasty patients was 40.6 points (95% CI = 38.5, 42.8). VAS outcomes were comparable. Mean postoperative MTPJ ROM improved by 43.0° (95% CI = 39.3°, 46.6°) in hemitoe patients, which exceeded the mean ROM improvement of 32.5° (95% CI = 29.9°, 35.1°) found in total joint arthroplasty cases. A meta-analysis revealed no significant difference. CONCLUSION: Hemisurface implants in MTPJ arthroplasty may improve postoperative AOFAS and ROM results to a greater extent than total-toe devices. LEVEL OF EVIDENCE: Level IV: Systematic review.

Is interposition arthroplasty a viable option for treatment of moderate to severe hallux rigidus? - A systematic review and meta-analysis.

INTRODUCTION: When conservative therapy for hallux rigidus fails, surgical options such as arthrodesis and interposition arthroplasty can be considered. Although arthrodesis of MTP joint is the gold standard treatment. However patients desiring MTP joint movement may opt for either interposition arthroplasty or implant arthroplasty to avoid the movement restrictions of arthrodesis. The purpose of this systematic review was to investigate clinical outcomes and complications following interposition arthroplasty for moderate to severe hallux rigidus, for patietns who would prefer to maintain range of motion in the MTP joint. METHODS: A systematic search on MEDLINE, EMBASE and Cochrane library database was performed during February 2018. Demographics, surgical techniques, clinical outcomes, radiological outcomes and complications were recorded from each included study. Pooled statistics performed for variables with homogenous data across the studies. A linear regression model used to compare the clinical outcomes between autogenous vs allogenous material interposition arthroplasty. RESULTS: Fifteen articles were included in the systematic review. Mean AOFAS scores improved from preoperative 41.35 to postoperative 83.17. Mean pain, function, and alignment score improved from preoperative values of 14.9, 24.9, and 10 to postoperative values of 33.3, 35.8, and 14.5. Mean dorsiflexion increased from 21.27° (5-30) to 42.03° (25-71). Mean ROM improved from 21.06° to 46.43°. Joint space increased from 0.8mm to 2.5mm. The most common postoperative complications included metatarsalgia (13.9%), loss of ground contact (9.7%), osteonecrosis (5.4%), great toe weakness (4.8%), hypoesthesia (4.2%), decreased push off power (4.2%), and callous formation (4.2%). CONCLUSION: Interposition arthroplasty is an effective treatment option with acceptable clinical outcomes in patients with moderate-severe hallux rigidus who prefer to maintain range of motion and accept the risk of future complications. LEVEL OF EVIDENCE: IV.

Inhospital Complications of Patients With Neuromuscular Disorders Undergoing Total Joint Arthroplasty.

INTRODUCTION: Orthopaedic surgeons are wary of patients with neuromuscular (NM) diseases as a result of perceived poor outcomes and lack of data regarding complication risks. We determined the prevalence of patients with NM disease undergoing total joint arthroplasty (TJA) and characterized its relationship with in-hospital complications, prolonged length of stay, and total charges. METHODS: Data from the Nationwide Inpatient Sample from 2005 to 2014 was used for this retrospective cohort study to identify 8,028,435 discharges with total joint arthroplasty. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify 91,420 patients who had discharge diagnoses for any of the NM disorders of interest: Parkinson disease, multiple sclerosis, cerebral palsy, cerebrovascular disease resulting in lower extremity paralysis, myotonic dystrophy, myasthenia gravis, myositis (dermatomyositis, polymyositis, and inclusion-body myositis), spinal muscular atrophy type III, poliomyelitis, spinal cord injury, and amyotrophic lateral sclerosis. Logistic regression was used to estimate the association between NM disease and perioperative outcomes, including inpatient adverse events, length of stay, mortality, and hospital charges adjusted for demographic, hospital, and clinical characteristics. RESULTS: NM patients undergoing TJA had increased odds of total surgical complications (odds ratio [OR] = 1.21; 95% confidence interval [CI], 1.17 to 1.25; P < 0.0001), medical complications (OR = 1.41; 95% CI, 1.36 to 1.46; P < 0.0001), and overall complications (OR = 1.32; 95% CI, 1.28 to 1.36; P < 0.0001) compared with non-NM patients. Specifically, NM patients had increased odds of prosthetic complications (OR = 1.09; 95% CI, 0.84 to 1.42; P = 0.003), wound dehiscence (OR = 5.00; 95% CI, 1.57 to 15.94; P = 0.0002), acute postoperative anemia (OR = 1.20; 95% CI, 1.16 to 1.24; P < 0.0001), altered mental status (OR = 2.59; 95% CI, 2.24 to 2.99; P < 0.0001), urinary tract infection (OR = 1.45; 95% CI, 1.34 to 1.56; P < 0.0001), and deep vein thrombosis (OR = 1.27; 95% CI, 1.02 to 1.58; P = 0.021). No difference of in-hospital mortality was observed (P = 0.155). DISCUSSION: Because more patients with NM disease become candidates of TJA, a team of neurologists, anesthesiologists, therapists, and orthopaedic surgeon is required to anticipate, prevent, and manage potential complications identified in this study. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The surgical anatomy of the dorsal scapular nerve: a triple-tendon transfer perspective.

BACKGROUND: Iatrogenic or traumatic injury to the spinal accessory nerve is a rare but debilitating injury. An effective treatment, known as the Eden-Lange modification triple-tendon transfer procedure, involves the transfer of the rhomboid major (RM), rhomboid minor (Rm), and levator scapulae (LS). Careful detachment of their insertions is necessary to avoid injury of the dorsal scapular nerve (DSN). This study evaluated the surgical anatomy and safety of the DSN relative to this procedure. METHODS: The study used 12 cadavers (22 shoulders). The RM, Rm, and LS were detached from their insertions, and the DSN was dissected. Measurements were taken to evaluate the anatomy of each relative to the triple-tendon transfer procedure. Additional measurements were taken to identify "danger zones" for DSN injury, regarding detachment of RM, Rm, and LS from their respective insertions. RESULTS: Measurements of the 22 shoulders included in the study showed wide variation in anatomy. The minimum distance between the scapula and the DSN at the vertebral scapular border was 0.7 cm, suggesting that care and precision are needed to perform this technique. The region where the DSN crosses the superior border of the Rm was shown to be the greatest "danger zone" of this technique, with a mean distance to the scapula of 1.61 ± 0.53 cm CONCLUSIONS: This study provides insight into the surgical anatomy of the DSN relative to a rare but successful procedure used to treat trapezius paralysis. The results of this study can inform the surgeon regarding potential anatomic considerations when performing the triple-tendon transfer.

RISK FACTORS FOR EARLY HOSPITAL READMISSION FOLLOWING TOTAL KNEE ARTHROPLASTY.

OBJECTIVE: To identify independent risk factors, complications and early hospital readmission following total knee arthroplasty. METHODS: Using the ACS-NSQIP database, we identified patients who underwent primary TKA from 2012-2015. The primary outcome was early hospital readmission. Patient demographics, preoperative comorbidities, laboratory data, operative characteristics, and postoperative complications were compared between readmitted and non-readmitted patients. Logistic regression identified independent risk factors for 30-day readmission. RESULTS: 137,209 patients underwent TKA; 3.4% were readmitted within 30 days. Advanced age, male sex, black ethnicity, morbid obesity, presence of preoperative comorbidities, high ASA classification, and increased operative time were independently related risk factors. Asian and no reported race were negative risk factors. Postoperative complications: acute myocardial infarction, acute renal failure, stroke, pneumonia, pulmonary embolism, and deep vein thrombosis show positive associations. CONCLUSIONS: Advanced age, male sex, black ethnicity, morbid obesity, presence of comorbidities, high ASA classification and long operative time are independent risk factors for postoperative complications and early hospital readmission following total knee arthroplasty. Level of Evidence III, Case control study.

OBJETIVO: Identificar fatores de risco independentes, complicações e reinternação precoce após artroplastia total do joelho. MÉTODOS: A partir de banco de dados ACS-NSQIP, identificamos pacientes submetidos à ATJ primária de 2012 a 2015. O desfecho primário foi a reinternação hospitalar precoce. Dados demográficos, comorbidades pré-operatórias, dados laboratoriais, características cirúrgicas e complicações pós-operatórias foram comparadas entre os pacientes reinternados e não reinternados. A regressão logística identificou fatores de risco independentes para a reinternação em 30 dias. RESULTADOS: Foram identificados 137.209 pacientes submetidos à ATJ, sendo que 3,4% foram reinternados no período de 30 dias. A idade avançada, o sexo masculino, a raça negra, a obesidade mórbida, a presença de comorbidades pré-operatórias, a alta classificação ASA e o aumento do tempo cirúrgico foram fatores de risco relacionados independentemente. A raça asiática e as não relatadas foram fatores de risco negativos. As complicações pós-operatórias infarto agudo do miocardio, insuficiência renal aguda, acidente vascular cerebral, pneumonia, embolia pulmonar e trombose venosa profunda apresentaram associações positivas. CONCLUSÕES: Idade avançada, sexo masculino, raça negra, obesidade mórbida, presença de comorbidades, classificação ASA elevada e tempo cirúrgico prolongado são fatores de risco independentes de complicações pós-operatórias e reinternação precoce após artroplastia total do joelho. Nível de evidência III, Estudo de caso de controle.

Risk factors for early hospital readmission following total knee arthroplasty / Fatores de risco de reinternação hospitalar precoce após artroplastia total do joelho

ABSTRACT Objective: To identify independent risk factors, complications and early hospital readmission following total knee arthroplasty. Methods: Using the ACS-NSQIP database, we identified patients who underwent primary TKA from 2012-2015. The primary outcome was early hospital readmission. Patient demographics, preoperative comorbidities, laboratory data, operative characteristics, and postoperative complications were compared between readmitted and non-readmitted patients. Logistic regression identified independent risk factors for 30-day readmission. Results: 137,209 patients underwent TKA; 3.4% were readmitted within 30 days. Advanced age, male sex, black ethnicity, morbid obesity, presence of preoperative comorbidities, high ASA classification, and increased operative time were independently related risk factors. Asian and no reported race were negative risk factors. Postoperative complications: acute myocardial infarction, acute renal failure, stroke, pneumonia, pulmonary embolism, and deep vein thrombosis show positive associations. Conclusions: Advanced age, male sex, black ethnicity, morbid obesity, presence of comorbidities, high ASA classification and long operative time are independent risk factors for postoperative complications and early hospital readmission following total knee arthroplasty. Level of Evidence III, Case control study.

RESUMO Objetivo: Identificar fatores de risco independentes, complicações e reinternação precoce após artroplastia total do joelho. Métodos: A partir de banco de dados ACS-NSQIP, identificamos pacientes submetidos à ATJ primária de 2012 a 2015. O desfecho primário foi a reinternação hospitalar precoce. Dados demográficos, comorbidades pré-operatórias, dados laboratoriais, características cirúrgicas e complicações pós-operatórias foram comparadas entre os pacientes reinternados e não reinternados. A regressão logística identificou fatores de risco independentes para a reinternação em 30 dias. Resultados: Foram identificados 137.209 pacientes submetidos à ATJ, sendo que 3,4% foram reinternados no período de 30 dias. A idade avançada, o sexo masculino, a raça negra, a obesidade mórbida, a presença de comorbidades pré-operatórias, a alta classificação ASA e o aumento do tempo cirúrgico foram fatores de risco relacionados independentemente. A raça asiática e as não relatadas foram fatores de risco negativos. As complicações pós-operatórias infarto agudo do miocardio, insuficiência renal aguda, acidente vascular cerebral, pneumonia, embolia pulmonar e trombose venosa profunda apresentaram associações positivas. Conclusões: Idade avançada, sexo masculino, raça negra, obesidade mórbida, presença de comorbidades, classificação ASA elevada e tempo cirúrgico prolongado são fatores de risco independentes de complicações pós-operatórias e reinternação precoce após artroplastia total do joelho. Nível de evidência III, Estudo de caso de controle.

Total hip arthroplasty for posttraumatic osteoarthritis following acetabular fracture: A systematic review of characteristics, outcomes, and complications.

PURPOSE: Posttraumatic arthritis (PTA) may develop years after acetabular fracture, hindering joint function and causing significant chronic musculoskeletal pain. Given the delayed onset of PTA, few studies have assessed outcomes of delayed total hip arthroplasty (THA) in acetabular fracture patients. This study systematically reviewed the literature for outcomes of THA in patients with PTA and prior acetabular fracture. METHODS: Pubmed, EMBASE, SCOPUS, and Cochrane library were searched for articles containing the keywords "acetabular", "fracture", "arthroplasty", and "post traumatic arthritis" published between 1995 and August 2017. Studies with less than 10 patients, less than 2 years of follow-up, conference abstracts, and non-English language articles were excluded. Data on patient demographics, surgical characteristics, and outcomes of delayed THA, including implant survival, complications, need for revision, and functional scores, was collected from eligible studies. RESULTS: With 1830 studies were screened and data from 10 studies with 448 patients were included in this review. The median patient age on date of THA was 51.5 years, ranging from 19 to 90 years. The median time from fracture to THA was 37 months, with a range of 27-74 months. Mean follow-up times ranged from 4 to 20 years. The mean Harris hip scores (HHS) improved from 41.5 pre-operatively, to 87.6 post-operatively. The most prevalent postoperative complications were heterotopic ossification (28%-63%), implant loosening (1%-24%), and infection (0%-16%). The minimum 5-year survival of implants ranged from 70% to 100%. Revision rates ranged from 2% to 32%. CONCLUSION: Despite the difficulties associated with performing THA in patients with PTA from previous acetabular fracture (including soft tissue scarring, existing hardware, and acetabular bone loss) and the relatively high complication rates, THA in patients with PTA following prior acetabular fracture leads to significant improvement in pain and function at 10-year follow-up. Further high quality randomized controlled studies are needed to confirm the outcomes after delayed THA in these patients.