Hip hemiarthroplasty for the treatment of femoral neck fractures in dialysis patients.

OBJECTIVES: This study sought to delineate the postoperative outcomes in dialysis patients undergoing hip hemiarthroplasty (HHA) for the treatment of femoral neck fractures (FNF) in order to better optimise pre- and postoperative management and minimise short-term morbidity and mortality rates. METHODS: 16,955 patients who had undergone HHA for femoral neck fractures from 2005 to 2018 were isolated from a multi-institutional surgical registry, of which 343 (2.0%) were on dialysis and 16,612 (98.0%) were not. The cohorts were identified/analysed for differences in their comorbidities, demographic factors, and 30-day postoperative complications using Fischer's exact tests and Mann-Whitney U-tests. Coarsened exact matching (CEM) was implemented in order to control for baseline difference in demographics and comorbidities. Multivariate logistic regression analyses were used to assess the impact of dialysis as an independent risk factor for various complications, including reoperations, readmissions, and mortality. RESULTS: Upon CEM-matching (L1-statistic <0.001), weighted multivariate logistic regression analyses demonstrated dialysis to be an independent risk factor for minor complications (OR 3.051, p < 0.001), pneumonia (OR 3.943, p < 0.001), urinary tract infections (UTIs) (OR 2.684, p < 0.001), major complications (OR 1.892, p < 0.001), unplanned intubation (OR 2.555, p = 0.047), cardiac arrest (OR 11.897, p < 0.001), deep vein thrombosis (DVT), (OR 2.610, p = 0.049), and mortality (OR 2.960, p < 0.001). CONCLUSIONS: Dialysis independently increased the risk for unplanned intubation, cardiac arrest, blood transfusions, pneumonia, DVT, and mortality. In communicating postoperative expectations, surgeons should aim to clarify the patients' preferences and potential resuscitation designations prior to surgical intervention due to the increased risk of serious complications. A lower threshold of suspicion for DVT in this population is reasonable. Identifying high-risk patient populations that may experience increased rates of complications, with the ensuing financial expenditures, due to medical complexity rather than subpar management may help providers avoid penalties in caring for these patients.

Risk Factors for Blood Transfusions in Primary Anatomic and Reverse Total Shoulder Arthroplasty for Osteoarthritis.

Background: The purpose of this study was to determine risk factors for blood transfusion in primary anatomic and reverse total shoulder arthroplasty (TSA) performed for osteoarthritis. Methods: Patients who underwent anatomic or reverse TSA for a diagnosis of primary osteoarthritis were identified in a national surgical database from 2005 to 2018 by utilizing both CPT and ICD-9/ICD-10 codes. Univariate analysis was performed on the two transfused versus non-transfused cohorts to compare for differences in comorbidities and demographics. Independent risk factors for perioperative blood transfusions were identified via multivariate regression models. Results: 305 transfused and 18,124 nontransfused patients were identified. Female sex (p<0.001), age >85 years (p=0.001), insulin-dependent diabetes mellitus (p=0.001), dialysis dependence (p=0.001), acute renal failure (p=0.012), hematologic disorders (p=0.010), disseminated cancer (p<0.001), ASA ≥ 3 (p<0.001), and functional dependence (p=0.001) were shown to be independent risk factors for blood transfusions on multivariate logistic regression analysis. Conclusion: Several independent risk factors for blood transfusion following anatomic/reverse TSA for osteoarthritis were identified. Awareness of these risk factors can help surgeons and perioperative care teams to both identify and optimize high-risk patients to decrease both transfusion requirements and its associated complications in this patient population. Level of Evidence: III.

Complications following regional anesthesia versus general anesthesia for the treatment of distal radius fractures.

PURPOSE: Open reduction and internal fixation (ORIF) are commonly utilized for the repair of distal radius fractures (DRF). While general anesthesia (GA) is typically administered for ORIF, recent studies have also demonstrated promising results with the usage of regional anesthesia (RA) in the surgical treatment of distal radius fractures. This study will compare complication rates between the use of RA versus GA for ORIF of DRFs. METHODS: A multi-institutional surgical registry was utilized to identify patients who had undergone ORIF for DRFs from 2005 to 2018-these patients were stratified into GA and RA cohorts. Patients were matched utilizing coarsened-exact-matching (CEM) to compare postoperative outcomes and rates of 30-day complications were compared between the two cohorts. RESULTS: Upon CEM-matching, 1191 patients receiving RA were matched to 9250 patients who had received GA, with a multivariate imbalance measure (L1) statistic of < 0.001. In the matched-cohort analysis, no significant differences were observed in rates of any complication (all p ≥ 0.083). On multivariate regression analyses, RA was not associated with increased risk for any complication (p = 0.445), minor complications (p = 0.093), major complications (p = 0.758), unplanned reoperations (p = 0.355), unplanned readmissions (p = 0.799), or mortality (p = 0.579). CONCLUSION: With similar safety profiles, RA is a safe and reasonable alternative to GA when managing DRFs surgically. RA may be the preferred anesthetic technique for ORIF of DRFs in patients at high risk with GA, such as those with reactions to GA in the past or with significant cardiopulmonary risk factors.

Absence of a "July Effect" on Hospital Length of Stay After Primary Total Hip or Knee Arthroplasty.

There is a commonly held belief in a "July effect" resulting in suboptimal outcomes as residents begin or advance in their training each summer. Previous studies have shown an absence of a July effect on clinical outcomes after total hip arthroplasty (THA) or total knee arthroplasty (TKA). However, it remains unknown whether there is a July effect on hospital length of stay (LOS) after primary THA/TKA. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2006 to 2012 for cases of primary THA/TKA, excluding emergency cases or cases where the ATTEND variable indicating resident participation was coded as missing or unknown. The primary outcome was prolonged LOS, defined as greater than 4 days postoperative. Secondary outcomes, including mortality, unplanned return to the operating room, and adverse clinical events, were also recorded. Univariate and multivariate analyses, including correction for comorbidities, evaluated associations between resident involvement in a case and any outcomes, and whether this association was different in quarter 3 (July through September) vs the remainder of the year. A total of 34,818 cases were included. Residents were involved in 9669 (28%). Length of stay greater than 4 days occurred in 12% of resident cases overall vs 11% of non-resident cases. Quarter 3 also had significantly more cases with prolonged LOS (12%) vs quarters 1 and 2 and quarter 4 (all 11%). On multivariate analysis, the resident effect on LOS greater than 4 days remained significant during the entire year; however, resident involvement in quarter 3 was not associated with prolonged LOS. These results do not support the presence of a July effect on LOS after primary THA/TKA. [Orthopedics. 2021;44(4):e503-e508.].

Hemiarthroplasty versus total hip arthroplasty for femoral neck fractures in patients with chronic obstructive pulmonary disease.

PURPOSE: This study sought to delineate whether total hip arthroplasty (THA) or hip hemiarthroplasty (HHA) had more complication rates following the treatment of femoral neck fractures (FNF) in chronic obstructive pulmonary disease (COPD) patients. MATERIALS AND METHODS: The ACS-NSQIP database was queried for all patients with a history of COPD who had undergone THA and HHA with FNFs, isolated by CPT codes and ICD-9/ICD-10 codes. Propensity score matching without replacement in a 1:1 manner was done to control for patient demographics/preoperative comorbidities. Multivariate logistic regression models were utilized to assess the independent effect of HHA in comparison to THA. RESULTS: The propensity-matched (PM) HHA cohort was significantly older (76.14 years vs. 73.33 years, p = 0.001) and had significantly higher rates of pneumonia (p = 0.017), extended length of stay (LOS) (p = 0.017), and mortality (p = 0.002), but lower rates of blood transfusions (p = 0.016) and reoperation (p = 0.020). HHA was independently associated with an increased risk of pneumonia (p = 0.043), extended LOS (p = 0.050), and death (p = 0.044) but a decreased risk for blood transfusions (p = 0.008) and reoperation (p = 0.028) when compared to THA. DISCUSSION: Patients with more comorbidities are more likely to receive HHA than THA, which may explain some of the increased complications and mortality associated with HHA for FNFs compared to THA. Patients undergoing THA were at increased risk for blood transfusion and reoperation. THA does not appear to result in increased morbidity in this population compared to HHA. While THA should be considered in these patients given improved functional outcomes, further prospective studies are needed to establish superiority. LEVEL OF EVIDENCE: III.

No change in performance metrics in major league baseball players sustaining wrist fractures after being struck by an errant pitch.

OBJECTIVE: This study aimed to determine the effect of wrist fractures on performance metrics in Major League Baseball Players after they were hit by an errant pitch. METHODS: Players who sustained wrist fractures after being struck by a pitch were identified and changes in performance metrics were calculated. RESULTS: In both the short- and medium-term analysis, there were no significant differences in all pre- and post-injury offensive statistics following return to play. CONCLUSION: Wrist fractures sustained after being struck by an errant pitch do not significantly impact professional baseball player performance if the player is able to return to sport.

Impact of diabetes mellitus on surgical complications in patients undergoing revision total knee arthroplasty: Insulin dependence makes a difference.

OBJECTIVES: Assessing the effects of diabetes mellitus (DM), non-insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) on revision TKA (rTKA) has become increasingly imperative due to the increased rates of revisions associated with DM. This study sought to identify complications in rTKA that were independently associated with NIDDM/IDDM compared to non-diabetic (Non-DM) patients and whether IDDM was associated with specific postoperative complications compared to NIDDM. METHODS AND MATERIALS: 16,428 rTKA patients were identified from the ACS-NSQIP database from 2005 to 2016 and stratified into three separate cohorts. 12,922 (78.66%) were Non-DM, 2335 (14.21%) had NIDDM, and 1171 (7.13%) had IDDM. Univariate analyses were utilized to assess for differences in demographics, preoperative comorbidities, and postoperative complication rates. Multivariate logistic regression analyses were then employed to control for significant differences in patients characteristics to assess NIDDM and IDDM as independent risk factors for complications in comparison to Non-DM. IDDM was further analyzed as a risk factor in comparison to NIDDM for the purpose of elucidating the impact of insulin dependence on risk for postoperative complications. RESULTS: NIDDM was an independent risk factor for deep incisional surgical site infections (Odds Ratio (OR): 2.477) and urinary tract infections (UTI) (OR 1.862) (p < 0.05). Compared to NIDDM, IDDM was independently associated with greater risk for pneumonia (OR 2.603), septic shock (OR 6.597), blood transfusions (OR 1.326), and an extended length of stay (OR: 1.331) (p < 0.05). IDDM additionally increased the risk for acute renal failure (OR 3.269) and cardiac arrest (OR 3.268) (p < 0.05) when compared to Non-DM. DM patients overall had increased rates of worse outcomes and infectious complications. CONCLUSION: Although differences between diabetes and non-diabetes rTKA patients were seen, differences in complication rates between diabetes patients further divided based on insulin dependence status were also noted. Future work examining whether targeting perioperative glucose levels <200 mg/dL in DM rTKA patients decreases infectious complications is warranted. Future work analyzing the role of tranexamic acid administration and 24-h postoperative antibiotics in rTKA IDDM patients may be warranted given the elevated risk of pneumonia, septic shock, and blood transfusions.

The impact of chronic kidney disease on postoperative complications in patients undergoing revision total knee arthroplasty: A propensity matched analysis.

OBJECTIVES: Though the role of chronic kidney disease (CKD) has been studied previously in primary arthroplasty procedures of the hips and knees, there is a paucity of literature analyzing CKD's impact on surgical outcomes in revision total knee arthroplasty (rTKA) patients. As the number of patients with CKD requiring revision surgery increases, more vigilant pre-operative and post-operative measures can be taken to ensure successful outcomes. This retrospective study sought to 1) determine differences in demographics and preoperative comorbidities of patients with normal or mild CKD and those with moderate/severe CKD and 2) establish moderate/severe CKD as an independent risk factor for complications in the 30-day postoperative period in patients undergoing rTKA. METHODS: The ACS-NSQIP database was queried for patients who had undergone rTKA from 2005 to 2016. Patient were assigned to one of five CKD severity classes after eGFR calculation and were further stratified into two cohorts: stages 1/2 vs. stages 3/4/5. After propensity matching to generate a matched normal/mild CKD cohort of rTKA patients, univariate and multivariate analyses were used to assess differences and the impact of severe CKD on the risk for complications. RESULTS: There were significant differences in several demographic features, comorbidities, and complications between the two cohorts upon univariate analyses. Upon multivariate analyses, CKD of moderate/severe/failure status was found to be a significant independent risk factor for acute renal failure (OR 18.097, 95% CI 4.970-65.902, p < 0.001), blood transfusions (OR 1.697, 95% CI 1.500-1.919, p < 0.001), return to the operating room (OR 1.257, 95% CI 1.009-1.566, p = 0.041), extended length of stay (OR 1.707, 95% CI 1.292-2.255, p < 0.001), and mortality (OR 2.165, 95% CI 1.116-4.200, p = 0.022) in the 30-day postoperative period. CONCLUSION: This current study found moderate/severe CKD to be an independent risk factor for several complications and should guide healthcare professionals for better patient-optimization. Orthopaedic surgeons should factor in CKD severity in the management of patients undergoing rTKA to effectively mitigate the effects of adverse events.

Repeat irrigation & debridement for patients with acute septic knee arthritis: Incidence and risk factors.

BACKGROUND: Septic knee arthritis is considered an orthopedic emergency due to its significant morbidity and potential to be life-threatening. One important outcome in treatment of septic knee arthritis is whether return to the operating room for repeat irrigation and debridement is required. This complication presents extra burden to the patient, as well as to the health care system. This study aims to first isolate the incidence of repeat irrigation and debridement at the authors' home institution and then define risk factors for repeat washout for septic arthritis of the knee. METHODS: Records from all patients at a single academic institution with acute septic knee arthritis who had arthroscopic or open I&D of the knee joint from January 2005-December 2015 were collected retrospectively. Patients were initially identified on the basis of diagnosis coding in the institution's medical information system. Following collection/screening based on strict inclusion/exclusion criteria, a cohort of 63 patients was ultimately included. 18 patients were assigned to a "repeat washout" (RW) cohort and 45 patients were assigned to a "no repeat washout" (NRW) cohort. Univariate analyses and multivariable regression models were performed between the two washout cohorts to identify variables associated with repeat washout. RESULTS: Patients requiring a repeat washout (RW) had a statistically significant association with African American/Hispanic race, higher BUN levels, higher serum white blood cell (WBC) count on admission, concurrent infection, and isolated bacteremia when compared to those patients who did not require a repeat washout (NRW) (all respective P < 0.05). Multivariable regression analysis demonstrated concurrent infection and higher synovium WBC count to increase the risk for another repeat washout. Patients who had a concurrent infection were shown to have nearly 12-fold higher odds of needing a repeat washout than those without a concurrent infection (95% CI:2.40-56.88; P = 0.0023). For every 1000 unit increase in synovium WBC count, the odds of needing a repeat washout increased by 1% in patients with concurrent infection (95% CI:1-2%; P = 0.0168). CONCLUSION: This study retrospectively isolated risk factors associated with repeat surgical lavage. In the multivariable regression analysis, both concurrent infection and increased synovial WBC count were significantly associated with the need for repeat knee I&D. This finding is significant, as it may signify a potential for increased infectious resilience for acute septic arthritis of the knee secondary to seeding from systemic infection, thus requiring multiple I&Ds to meet resolution. This finding may carry clinical significance in the early stages of patient counseling regarding hospital course and prognosis. LEVEL OF EVIDENCE: IV.

Impact of smoking on outcomes following knee and shoulder arthroscopy.

OBJECTIVE: The purpose of this study is to evaluate any association between preoperative smoking and perioperative and early postoperative complications in patients following shoulder and knee arthroscopic surgery. METHODS: This is a retrospective study using the prospectively collected National Surgery Quality Improvement Program database. All patients who underwent eight specific shoulder and knee arthroscopy procedures, identified by current procedural terminology codes, were included in this study and analyzed using univariate and multivariate analyses to determine the impact of preoperative smoking status on postoperative complications. These procedures were knee arthroscopy with meniscectomy (medial or lateral), knee arthroscopy with meniscectomy (medial and lateral), knee arthroscopy with chondroplasty, knee arthroscopy with anterior cruciate ligament reconstruction, shoulder arthroscopy with subacromial decompression, shoulder arthroscopy with debridement, subacromial arthroscopy with rotator cuff repair, and shoulder arthroscopy with distal clavicle excision. Thirty-day complications including cardiac, renal, wound, pulmonary, clotting, and mortality were assessed following knee and shoulder arthroscopy. RESULTS: A total of 134,822 cases were included in the study. Multivariate analysis found that smoking was an independent risk factor for complications in shoulder arthroscopy with subacromial decompression (odd's ratio [OR] = 1.46; 95% confidence interval [CI] 1.030-2.075), shoulder arthroscopy with debridement (OR = 1.933; 95% CI 1.211-3.084), and knee arthroscopy with medial and lateral meniscectomy (OR = 1.97; 95% CI 1.407-2.757). Smoking was not an independent risk factor for complications in the other five procedures studied. CONCLUSIONS: Preoperative smoking was found to be an independent risk factor for complications for several arthroscopic procedures, though with variability between specific procedures.

Impact of Clavicle Fractures on Return to Play and Performance Ratings in NFL Athletes.

OBJECTIVE: Clavicle fractures in the National Football League (NFL) have gained significant attention because of their impact on high profile athletes; however, little has been published on the overall impact of these injuries. This study sought to determine the time to return to play and quantitative impact on athletic performance after clavicle fractures in NFL athletes. DESIGN: Retrospective Cohort Study; Level of evidence, 3. SETTING: Retrospective cohort study of NFL athletes based on published injury reports and player statistics. PARTICIPANTS: This study consisted of 17 NFL athletes who sustained a clavicle fracture from 1998 to 2015 and returned to the field after the injury during the study period. Three athletes were excluded from performance analysis because of not playing for the entire season after injury. Control groups consisted of position-matched NFL athletes who competed in the 2013 NFL season without an identified clavicle injury. MAIN OUTCOME MEASURES: Median time to return to play after a clavicle fracture and the impact on player performance rating. RESULTS: Athletes returned to the competition after a median of 3.47 months after injury and missed a median of 8 games. There was no statistically significant impact on athletic performance after returning to play. CONCLUSION: Although clavicle fractures did have a significant impact on athletes because of lost playing time, there was no statistically significant difference in player performance after the injury when compared with a control group.

Surgical complications associated with congestive heart failure in elderly patients following primary hip hemiarthroplasty for femoral neck fractures.

INTRODUCTION: Although there are reports of the impact of congestive heart failure (CHF) on total knee arthroplasty and total hip arthroplasty, there is a lack of literature analyzing CHF in hip hemiarthroplasty (HHA) procedures. The main objective of this study was to evaluate the effect of CHF on risks for complications following HHA for the treatment of FNF. METHODS: The ACS-NSQIP database was queried for all patients who had undergone HHA from 2005 to 2016. Patients were propensity-matched without replacement in a 1:1 manner based on age and gender. Pearson's Chi squared tests and Fischer's exact tests were utilized to compare differences in demographics, comorbidities, and complication rates. Multivariate logistic regression analyses were used to assess the impact of CHF as an independent risk factor for postoperative complications. RESULTS: A propensity-matched cohort of 537 (4.24%) non-CHF patients was generated in order to analyze differences between the two cohorts. CHF was found to be a significant independent risk factor for pneumonia (p = 0.003), progressive renal insufficiency (p = 0.040), myocardial infarctions (p = 0.050), extended length of stay (≥ 5 days) (p < 0.001), and mortality (p < 0.001). CONCLUSION: This study has established CHF as an independent risk factor for various postoperative complications following HHA for the treatment of FNF. Although orthopedic surgeons may decline to perform elective procedures on CHF patients, FNFs require urgent surgical intervention. Therefore, it is important to be aware of various increased risks of certain complications in this subset patient population.

Patients With Chronic Obstructive Pulmonary Disease Are at Higher Risk for Pneumonia, Septic Shock, and Blood Transfusions After Total Shoulder Arthroplasty.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has been associated with several complications after surgery, including pneumonia, myocardial infarction, septic shock, and mortality. To the authors' knowledge, there has been no work analyzing the impact of COPD on complications after total shoulder arthroplasty (TSA). Although previous work has elucidated the complications COPD has on TKA and THA, extrapolating the results of lower extremity arthroplasty to TSA may prove to be inaccurate. Compared with lower extremity arthroplasty, TSA is a relatively new procedure that has only recently gained popularity. Therefore, this study seeks to elucidate COPD's effects on complications in TSA specifically so that postoperative care can be tailored for these patient populations. Assessing these patients may enable surgeons to implement preoperative precautionary measures to prevent serious adverse events in these patients. QUESTIONS/PURPOSES: What serious postoperative complications are patients with COPD at risk for within the 30-day postoperative period after TSA? METHODS: The American College of Surgeons National Surgical Quality Improvement Program® (ACS-NSQIP) database was queried to identify 14,494 patients who had undergone TSA between 2005 and 2016, excluding patients who had undergone hemiarthroplasties of the shoulder and revision shoulder arthroplasties. The ACS-NSQIP database was utilized in this study for the comprehensive preoperative and postoperative medical histories it provides for each patient for 274 characteristics. Among the 14,494 patients undergoing TSA, 931 (6%) patients who had a history of COPD were identified, and the two cohorts-COPD and non-COPD-were analyzed for differences in their demographic factors, comorbidities, and acute complications occurring within 30 days of their procedure. Univariate analyses were utilized to assess differences in the prevalence of demographic features, comorbidities, and perioperative/postoperative outcomes after surgery. Multivariate regression analyses were used to assess COPD as an independent risk factor associated with complications. RESULTS: COPD is an independent risk factor for three complications after TSA: pneumonia (odds ratio [OR], 2.793; 95% confidence interval [CI], 1.426-5.471; p = 0.003), bleeding resulting in transfusion (OR, 1.577; 95% CI, 1.155-2.154; p = 0.004), and septic shock (OR, 9.259; 95% CI, 2.140-40.057; p = 0.003). CONCLUSIONS: In light of the increased risk of these serious complications, surgeons should have a lower threshold of suspicion for infection in patients with COPD after TSA so that adequate measures can be taken before developing severe infectious complications including pneumonia and septic shock. Surgeons may also consider administering tranexamic acid in patients with COPD undergoing TSA to reduce the amount of blood transfusions necessary. Future work through randomized control trials analyzing (1) the effectiveness of more aggressive infection prophylaxis in decreasing the risk of pneumonia/septic shock; and (2) the use of tranexamic acid in decreasing blood transfusion requirements in patients with COPD undergoing TSA is warranted. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Effect of Turf Toe Injuries on Player Performance in the National Football League.

Background: "Turf toe" results from hyperdorsiflexion of the first metatarsophalangeal joint, injuring the plantar capsuloligamentous complex. We hypothesized that National Football League (NFL) player performance following turf toe injury would decrease in comparison to controls at the same position. Methods: Demographics, return to play, and season performance data on players sustaining turf toe injuries in the NFL from 2010-2015 were collected. An Offensive Power Rating (OPR=[total yards/10]+[total touchdowns x6]) or Defensive Power Rating (DPR=total tackles+[total sacks x2]+[total interceptions x2]) was calculated for each player. Control data were collected for NFL players in 2013 with no history of turf toe injury. Statistical analysis was performed using Wilcoxon Rank Sum tests. Results: Twenty-four injured players and 436 controls were included. Nineteen players returned to play within the regular season of injury (mean 36.7 ± 28.9 days). Seventeen players were removed from team injury reports for turf toe within the regular season (mean 42.6 ± 26.2 days). Three players required season-ending surgery. Comparison of 1-year post- versus pre-injury revealed an insignificant median OPR difference (-18.9 IQR -43.4 to 10.3 vs. control -12.2 IQR -46.2 to 47.7, p = 0.328) and median DPR difference (-1.0 IQR -26.0 to 17.0 vs. control 2.0 IQR -15.0 to 18.0, p = NA). Comparison of 2-year data revealed no significant median OPR difference (-32.6 IQR -122.2 to 1.0 vs. control -20.7 IQR -72.6 to 44.7, p = 0.327) and median DPR difference (-5.0 IQR -19.0 to 6.0 vs. control -4.5 IQR -22.0 to 12.5, p= NA). Conclusions: Turf toe results in significant loss of playing time. Despite the long recovery period, NFL players have similar performance following injury compared to controls. The effect of turf toe injuries on performance is variable.Level of evidence: IV.

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.

Identifiable risk factors for thirty-day complications following arthroscopic rotator cuff repair.

OBJECTIVES: Shoulder arthroscopy has increased in frequency over the past decade, with rotator cuff repair comprising the majority of cases performed. Prior studies have detailed risk factors for 30-day complications and readmission rates after arthroscopic shoulder surgery using the National Surgical Quality Improvement Program (NSQIP) database, but no study has specifically looked at arthroscopic rotator cuff repair. The purpose of the study is to evaluate the risk factors for 30-day complications following arthroscopic rotator cuff repair using the NSQIP database. METHODS: The NSQIP database was queried for all patients undergoing arthroscopic rotator cuff repair from 2006-2015. Demographics and thirty-day outcomes for these patients were analyzed using univariate analyses and multivariate regression analysis to determine the risk factors for complications. RESULTS: 21,143 patients underwent arthroscopic rotator cuff repair, with 147 patients (0.70%) having a complication within 30-days. Univariate analysis found age >65 (p = 0.0028), male gender (p = 0.0053), elevated BMI (p = 0.0054), ASA class >2 (p < 0.0001), history of chronic obstructive pulmonary disease (p < 0.0001), hypertension (p < 0.0002), dyspnea (p < 0.0001), steroid use (p = 0.0350), and operative time >90 min (p = 0.0316) to be associated with increased risk of complications. Multivariate analysis found female sex to be protective or complication (OR 0.56, p = 0.0017), while American Society of Anesthesiology (ASA) class >2 (OR 1.51, p = 0.0335) and history of COPD (OR 2.41, p = 0.0030) and dyspnea (OR 1.89, p = 0.0359) to be risk factors for complication. The most common complication is venothromboembolic events, accounting for 36.7% of all complications. CONCLUSION: Male sex, ASA class > 2, and history of COPD and dyspnea were independent risk factors for thirty-day complications following arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: IV.

Comparing hospital outcomes between open and closed tibia fractures treated with intramedullary fixation.

INTRODUCTION: Tibial shaft fractures comprise a large portion of operatively treated long bone fractures, and present with the highest rate of open injuries. Intramedullary fixation has become the standard of care for both open and closed injuries. The rates of short term complications and hospital length of stay for open and closed fractures treated with intramedullary fixation is not fully known. Previous series on tibia fractures were performed at high volume centers, and data were not generalizable, further they did not report on length of stay and the impact of preoperative variables on infections, complications and reoperation. We used a large surgical database to compare these outcomes while adjusting for preoperative risk factors. METHODS: Data were extracted from the ACS-NSQIP database from 2005 to 2014. Cases were identified based on CPT codes for intramedullary fixation and categorized as closed vs open based on ICD9 code. In addition to demographic and case data, primary analysis examined correlation between open and closed fracture status with infection, complications, reoperation and hospital length of stay. Secondary analysis examined preoperative variables including gender, race, age, BMI, and diabetes effect on outcomes. RESULTS: There were 272 cases identified. There were no significant demographic differences between open and closed tibia fracture cases. Open fracture status did not increase the rate of infection, 30day complications, reoperation, or length of stay. The only preoperative factor that correlated with length of stay was age. There was no correlation between BMI, presence of insulin dependent and nondependent diabetes, and any outcome measure. DISCUSSION: When considering the complication rates for open and closed tibial shaft fractures treated with intramedullary fixation, there is no difference between 30-day complication rate, length of stay, or return to the operating room. Our reported postoperative infection rates were comparable to previous series, adding validity to our results. The heterogeneity of the hospitals included in ACS-NSQIP database allow our data to be generalizable. These methods may underrepresent the true occurrence of infection as operatively treated tibia infections may present late, requiring late revision. Despite limitations, the data reflect on the current burden of managing these once devastating injuries.

Results of ACL reconstruction with tibial Retroscrew fixation: Comparison of clinical outcomes and tibial tunnel widening.

UNLABELLED: ACL reconstruction with the RetroScrew™ shows superior clinical outcomes compared to historical Achilles allograft studies with antegrade screws. Addition of antegrade screw augmentation to retrograde fixation causes an increase in tibial tunnel widening. INTRODUCTION: In traditional antegrade screw fixation of Anterior cruciate ligament (ACL) soft tissue allografts, the screw is secured in the opposite direction of graft tension, potentially altering the appropriate tension on the graft. The RetroScrew (Arthrex) is a bioabsorbable screw placed in a retrograde fashion, potentially improving the tension of the graft by placing the screw in a proximal-to-distal direction. In addition, the RetroScrew theoretically decreases tibial tunnel widening by closing the aperture of the tibial tunnel, which prevents ingress of synovial fluid. Early tunnel expansion has been implicated due to excessive transverse and longitudinal graft motion. The clinical effects of tunnel expansion have yet to be fully understood. The purpose of this study is to assess the clinical results and tunnel width after ACL soft tissue fixation in the tibia with the RetroScrew. METHODS: Fifty-nine patients who underwent ACL reconstruction performed by two surgeons using the RetroScrew device returned for postoperative evaluation at an average of 25 months following surgery with a minimum follow-up of 12 months. Clinical evaluation, SF-36, IKDC and KT-1000 scores were recorded, and knee radiographs were used to measure tibial tunnel widening. Thirty-five patients had backup antegrade screw fixation in conjunction with the RetroScrew, and 24 patients had RetroScrew fixation alone. The results were compared to two previously reported studies on ACL reconstruction with Achilles tendon allograft that used antegrade screws. RESULTS: The average IKDC score was 87 (range: 44-100), with mean KT-1000 side-to-side difference of 1.2 mm (range: 0-5 mm). Tibial tunnel widening was 4.93 mm (SD 3.32) on AP radiographs and 4.40 mm (SD 2.72) on lateral radiographs greater than the native tunnel drilling. Patients with additional backup fixation had significantly more tunnel widening than patients without backup fixation (P < 0.05). There was one failure based on KT-1000 measurements. When compared to previous studies using ACL allografts, RetroScrew patients had statistically superior Lachman exams, KT-1000 side-to-side differences and decreased tibial tunnel widening (P < 0.05) when antegrade fixation was excluded. CONCLUSION: Patients who underwent Achilles allograft ACL reconstruction with the RetroScrew had improved clinical results compared to historical controls using antegrade fixation. Tibial tunnel widening was increased when using additional antegrade screw fixation, suggesting that the amount of bioabsorbable material within the tibial tunnel was related to the degree of tunnel widening.

Clinical measurement of patellar tendon: accuracy and relationship to surgical tendon dimensions.

Patellar tendon width and length are commonly used for preoperative planning for anterior cruciate ligament reconstruction (ACLR). In the study reported here, we assessed the accuracy of preoperative measurements made by palpation through the skin, and correlated these measurements with the actual dimensions of the tendons at surgery. Before making incisions in 53 patients undergoing ACLR with patellar tendon autograft, we measured patellar tendon length with the knee in full extension and in 90° of flexion, and tendon width with the knee in 90° of flexion. The tendon was then exposed, and its width was measured with the knee in 90° of flexion. The length of the central third of the tendon was measured after the graft was prepared. Mean patellar tendon length and width with the knee in 90° of flexion were 39 mm and 32 mm, respectively. No clinical difference was found between the estimated pre-incision and surgical widths. However, the estimated pre-incision length with the knee in full extension and in 90° of flexion was significantly shorter than the surgical length. Skin measurements can be used to accurately determine patellar tendon width before surgery, but measurements of length are not as reliable.

Inter- and intra-observer reliability of the Baumann angle of the humerus in children with supracondylar humeral fractures.

The Baumann angle of the humerus has been commonly used as an outcome measure for supracondylar fractures in children. However, there is limited or no information about the reliability of this measurement. The purpose of this study was to determine the inter-observer reliability (IEOR) and intra-observer reliability (IAOR) of the Baumann angle of the humerus. The Baumann angle of the humerus was measured by five observers on the anteroposterior radiographs of 35 children's elbows, all of which had sustained a nondisplaced supracondylar humeral fracture. The values of IEOR and IAOR were calculated using a Pearson coefficient of correlation. Ranges of differences in the measurement of the Baumann angle of the humerus were established, and the percentage of agreement between observers was then calculated using those ranges. The Baumann angle of the humerus is a simple, repeatable and reliable measurement that can be used for the determination of the outcome of supracondylar humeral fractures in the paediatric population. An excellent IEOR was found for the measurement of the Baumann angle (r = 0.78, p = 0.0001). When the difference between observers in the reported measurement of the Baumann's angle was calculated to be within seven degrees of each other, at least four of the five observers agreed 100% of the time. Similarly, excellent values of IAOR were found for the measurement of the Baumann's angle (r = 0.80, p = 0.0001). Level of evidence for this study was III.