Frequency and Characteristics of Posterior Labral Injuries in Operative Acetabular Fractures Treated Through a Posterior Approach: A Prospective Observational Study.

OBJECTIVES: The association between labral injuries and acetabular fractures is unknown. This study aimed to identify the frequency and characteristics of labral injuries in operatively treated acetabular fractures that cannot be identified on preoperative imaging. METHODS: . DESIGN: Prospective observational cohort. SETTING: Level I trauma center. PATIENT SELECTION CRITERIA: Adult patients with an acetabular fracture operatively treated through a posterior approach. OUTCOME MEASURES AND COMPARISONS: The frequency and characteristics of labral injuries. RESULTS: Fifty-three of 71 acetabular fractures (75%; 95% confidence interval, 63%-83%) demonstrated a labral injury visible via the posterior approach. Posterior labral injuries occurred in 89% of operative acetabular fracture patterns involving the posterior wall and most commonly represent a detachment of the posteroinferior labrum (n = 39, 75%). Fractures with a labral injury were more likely to have gluteus minimus damage (93% vs. 61%, P = 0.02), femoral head lesions (38% vs. 17%, P = 0.03), joint capsule detachment (60% vs. 33%, P = 0.05), and fracture patterns involving the posterior wall (89% vs. 50%, P = 0.05). CONCLUSIONS: This study describes the high rate (89%) of posterior labral injuries in posterior wall fractures, the most common injury pattern being a detachment of the posteroinferior labrum. Labral injuries in acetabular fractures may have important clinical implications and this study is the first to identify the frequency and characteristics of these injuries. Further studies should assess the relationship between labral injuries, treatment strategies, and the progression to post-traumatic osteoarthritis. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Frailty on Outcomes Following Primary Total Hip Arthroplasty in Patients of Different Sex and Race: Is Frailty Equitably Detrimental?

BACKGROUND: Whether frailty impacts total hip arthroplasty (THA) patients of different races or sex equally is unknown. This study aimed to assess the influence of frailty on outcomes following primary THA in patients of differing race and sex. METHODS: This is a retrospective cohort study utilizing a national database (2015-2019) to identify frail (≥2 points on the modified frailty index-5) patients undergoing primary THA. One-to-one matching for each frail cohort of interest (race: Black, Hispanic, Asian, versus White (non-Hispanic), respectively; and sex: men versus women) was performed to diminish confounding. The 30-day complications and resource utilizations were then compared between cohorts. RESULTS: There was no difference in the occurrence of at least 1 complication (P > .05) among frail patients of differing race. However, frail Black patients had increased odds of postoperative transfusion (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 1.02-1.77), deep vein thrombosis (OR: 2.61, 95% CI: 1.08-6.27), as well as >2-day hospitalization and nonhome discharge (P < .001). Frail women had higher odds of having at least 1 complication (OR: 1.67, 95% CI: 1.47-1.89), nonhome discharge, readmission, and reoperation (P < .05). Contrarily, frail men had higher 30-day cardiac arrest (0.2% versus 0.0%, P = .020) and mortality (0.3 versus 0.1%, P = .002). CONCLUSION: Frailty appears to have an overall equitable influence on the occurrence of at least 1 complication in THA patients of different races, although different rates of some individual, specific complications were identified. For instance, frail Black patients experienced increased deep vein thrombosis and transfusion rates relative to their non-Hispanic White counterparts. Contrarily, frail women, relative to frail men, have lower 30-day mortality despite increased complication rates.

The impact of heterotopic ossification prophylaxis after surgical fixation of acetabular fractures: national treatment patterns and related outcomes.

BACKGROUND: Heterotopic ossification (HO) is a common complication after surgical fixation of acetabular fractures. Numerous strategies have been employed to prevent HO formation, but results are mixed and optimal treatment strategy remains controversial. The purpose of the study was to describe current national heterotopic ossification (HO) prophylaxis patterns among academic trauma centers, determine the association between prophylaxis type and radiographic HO, and identify if heterogeneity in treatment effects exist based on outcome risk strata. METHODS: We used data from a subset of participants enrolled in the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. We included only patients with closed AO-type 62 acetabular fractures that were surgically treated via a posterior (Kocher-Langenbeck), combined anterior and posterior, or extensile exposure. PREPARE Clinical Trial Registration Number: NCT03523962 Patient population This cohort study was nested within the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. The PREPARE trial is a multicenter cluster-randomized crossover trial evaluating the effectiveness of two alcohol-based pre-operative antiseptic skin solutions. All PREPARE trial clinical centers that enrolled at least one patient with a closed AO-type 62 acetabular fracture were invited to participate in the nested study. RESULTS: 277 patients from 20 level 1 and level 2 trauma centers in the U.S. and Canada were included in this study. 32 patients (12%) received indomethacin prophylaxis, 100 patients (36%) received XRT prophylaxis, and 145 patients (52%) received no prophylaxis. Administration of XRT was associated with a 68% reduction in the adjusted odds of overall HO (OR 0.32, 95% CI, 0.14 - 0.69, p = 0.005). The overall severe HO (Brooker classes III or IV) rate was 8% for the entire cohort; XRT reduced the rate of severe HO in high-risk patients only (p=0.03). CONCLUSION: HO prophylaxis patterns after surgical fixation of acetabular fractures have changed dramatically over the last two decades. Most centers included in this study did not administer HO prophylaxis. XRT was associated with a marked reduction in the rate of overall HO and the rate of severe HO in high-risk patients. Randomized trials are needed to fully elucidate the potential benefit of XRT. PREPARE Clinical Trial Registration Number: NCT03523962.

Is External Beam Radiation Therapy Really Associated With Low Rates of Heterotopic Ossification After Acetabular Surgery?

OBJECTIVES: Describe rate of postoperative heterotopic ossification (HO) after acetabular surgery in patients who received external beam radiation (XRT) as HO prophylaxis. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Consecutive series of patients who presented to a single, level I, academic trauma center over a 10-year period (2008-2018) for surgical fixation of an acetabular fracture. Patients eligible for inclusion were those who underwent surgical fixation of an acetabular fracture through a posterior (Kocher-Langenbeck), combined anterior and posterior, or extensile exposure. Patients were excluded if an isolated anterior approach was performed or if an acute total hip arthroplasty was performed at the time of index surgery. INTERVENTION: XRT. MAIN OUTCOME: Severe HO (Brooker class III or IV). RESULTS: The severe HO (Brooker class III or IV) rate for entire cohort was 12% (44 of 361 patients). Of these 44 patients, 30 patients were classified as Brooker III and 14 patients were classified as Brooker IV. The Brooker IV rate for the entire cohort was 4% (14 of 361 patients). Severe HO rates showed a declining trend over the period examined, with a risk reduction of -1.0% per year (95% confidence interval -2.1% to 0.2%; P = 0.10). CONCLUSION: To our knowledge, this is the largest single consecutive series on acetabular fracture patients who received XRT as HO prophylaxis. The overall severe HO rate was 12%, which is similar to other comparably large series data on patients who did not receive XRT after surgical fixation acetabular fractures. Although these data suggest that XRT may not be beneficial when used universally for all patients, comparative studies are required to rule out the benefits of XRT for preventing HO in this population. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Increased Time to Surgery in Geriatric Patients With Acetabular Fractures.

OBJECTIVES: To explore the association between time to surgery (TTS) and postoperative complications in geriatric patients with acetabular fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: 51 consecutive geriatric patients (60 years of age or older) who presented to a Level 1 trauma center for surgical fixation of an acetabular fracture between 2013 and 2020. MAIN OUTCOME MEASUREMENT: The primary and secondary outcomes were 30-day postoperative complications and length of hospital stay (LOS), respectively. TTS was determined by time between arrival to ED and time of surgery, with a threshold of 48 hours (early vs. delayed TTS group). RESULTS: Nineteen patients (37.3%) had ≥1 postoperative complications. Patients in the delayed TTS group had 5× higher odds of developing ≥1 complications (odds ratio: 4.86, confidence interval: 1.48-15.96). There were no 30-day mortalities in either group. Patients in the delayed TTS group had an average LOS of 19 days compared with early TTS patients who had an average LOS of 12 days ( P = 0.040). CONCLUSION: Geriatric patients with acetabular fractures with delayed TTS had increased postoperative complications and LOS. These data suggest that expedited care may have a similar protective effect in geriatric patients with acetabular fractures, as it does in the acute hip fracture population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Frailty Is Age Dependent in Patients Undergoing Primary Total Knee Arthroplasty: The Age-Adjusted Modified Frailty Index.

BACKGROUND: Frailty is a well-established risk factor in patients undergoing total knee arthroplasty (TKA). How age modifies the impact of frailty on outcomes in these patients, however, remains unknown. In this study, we aimed to describe and evaluate the applicability of a novel risk stratification tool-the age-adjusted modified Frailty Index (aamFI)-in patients undergoing TKA. METHODS: A national database was queried for all patients undergoing primary TKA from 2015 to 2019. There were 271,271 patients who met inclusion criteria for this study. First, outcomes were compared between chronologically young and old frail patients. In accordance with previous studies, the 75th percentile of age of all included patients (73 years) was used as a binary cutoff. Then, frailty was classified using the novel aamFI, which constitutes the 5-item mFI with the addition of 1 point for patients ≥73 years. Multivariable logistic regressions were then used to investigate the relationship between aamFI and postoperative outcomes. RESULTS: Frail patients ≥73 years had a higher incidence of complications compared to frail patients <73 years. There was a strong association between aamFI and complications. An aamFI of ≥3 (reference aamFI of 0) was associated with an increased odds of 30-day mortality (odds ratio [OR] 8.6, 95% CI 5.0-14.8), any complication (OR 3.1, 95% CI 2.9-3.3), deep vein thrombosis (OR 1.5, 95% CI 1.2-1.8), and nonhome discharge (OR 6.1, 95% CI 5.8-6.4; all P < .001). CONCLUSION: Although frailty negatively influences outcomes following TKA in patients of all ages, chronologically old, frail patients are particularly vulnerable. The aamFI accounts for this and represents a simple, but powerful tool for stratifying risk in patients undergoing primary TKA.

Opioid Prescribing Behavior in the Emergency Department During Routine Orthopedic Manipulations.

BACKGROUND: The emergency department (ED) often represents the first exposure orthopedic trauma patients have to prescription opioids and thus a critical opportunity for prevention of potential long-term opioid use. This study will analyze the impact of opioid prescribing patterns among both ED providers and orthopedic surgery residents on the utilization of opioids during routine orthopedic trauma manipulations. MATERIALS AND METHODS: This retrospective study reviewed opioid utilization among patients with an ankle or distal radius fracture at a large, urban, level 1 trauma center. Data on clinical providers, patient demographics, and injury severity score (ISS) were collected. Total opioid use was reported in oral morphine milligram equivalents (MME). Regression analyses were performed to determine how provider opioid prescribing intensity affected administered MME. RESULTS: Five-hundred and ninety-five patients were included. The mean MME administered was 40.84 (SD 30.0) and was inversely associated with ISS (R = -.05; P = .40). Patients treated by a high-intensity ED prescriber had approximately three times higher odds of receiving over 40.84 MME (OR 2.8, 95% CI 1.33-5.90 P = .07). For those with an ISS score less than 15, the presence of a low-intensity orthopedic resident decreased the odds of receiving over 40.84 MME from 2.25 to 1.78 in the presence of a high-intensity ED prescriber. CONCLUSION: For isolated orthopedic manipulations in the ED, involvement of a low-intensity prescribing orthopedic resident significantly decreased the quantity of opioids administered for those with lower ISS injuries, thus effectively mitigating the effect of high-intensity prescribing behavior prescriber.

Impact of Intraoperative Hypothermia on Transfusion Requirements in Patients With Pelvic and Acetabular Trauma.

OBJECTIVES: To explore the association between intraoperative hypothermia and perioperative blood loss and blood transfusion requirements in patients with operative pelvic and acetabular fractures. DESIGN: Retrospective review. SETTING: Single, Level 1 trauma center in Atlanta, Georgia. PATIENTS/PARTICIPANTS: Three hundred seventy-four patients who underwent surgical fixation of an acetabular fracture and/or pelvic ring injury at a single Level 1 trauma center during the years 2013-2017. MAIN OUTCOME MEASURES: Estimated blood loss during surgery (EBL, mL), drain output (mL) on postoperative day 1 (POD1), and rate of postoperative packed red blood cell (pRBC) transfusion (%). RESULTS: A significant association was found between intraoperative hypothermia and postoperative transfusion requirement (P = 0.016). The rate of postoperative blood transfusion was 42% for patients with intraoperative hypothermia compared with 28% for controls. In a subgroup analysis of patients presenting with an admission acidosis, the rate of postoperative transfusion was significantly increased to more than 4 times as likely when intraoperative hypothermia was present, even after controlling for admission hemoglobin, Injury Severity Score, and rate of preoperative transfusion (OR 4.4; P = 0.018). CONCLUSIONS: For patients with pelvic trauma who present with an admission acidosis, intraoperative hypothermia is an independent risk factor for postoperative blood transfusion. This information is clinically important given the modifiable nature of intraoperative patient temperature and the known complications and sequelae associated with increased transfusion rates. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Infection After Open Long Bone Fractures: Can We Improve on Prophylaxis?

INTRODUCTION: Current standards recommend antibiotic prophylaxis administered after open fracture injury. The purpose of this study was to assess culture results in patients with open fracture-associated infections, hypothesizing that cultures obtained do not vary by Gustilo-Anderson (GA) classification. METHODS: We examined cultured bacterial species from patients with open long bone fractures that underwent irrigation and debridement at a Level 1 trauma center (2008-2016), evaluating our current and two hypothetical antibiotic protocols to assess whether they provided appropriate coverage. The antibiotic protocols included protocols 1 (cefazolin, with gentamicin added for type III fractures), 2 (vancomycin and cefepime) and 3 (ceftriaxone). RESULTS: GA classification was not associated with bacterial gram stain (P = 0.161), nor was it predictive of mono- versus polymicrobial infection (P = 0.094). Of 42 culture-positive infections, 31 were type III and 11 were type I or II fractures. 27% of the infections for type I or II fractures were caused by organisms targeted by protocol 1 (OR 0.18, 95% CI 0.04-0.82; P = 0.027). There was no difference in coverage by fracture type among protocol 2 (P = 0.771) or protocol 3 (P = 0.891). For type III fractures, protocol 2 provided 94% appropriate coverage compared to 68% and 61% coverage by protocols 1 and 3, respectively. CONCLUSION: For open fractures complicated by infection, isolated bacterial organisms do not correlate with GA open fracture classification, suggesting that hypothetical protocol 2 should be used for all fracture types. Protocol 2's broad coverage, across all GA fracture types, may prevent infection by organisms not covered by current antibiotic prophylaxis.

Fully threaded sacroiliac lag screws have higher load to failure when compared to partially threaded screws: A biomechanical study.

The purpose of this study is to compare biomechanical properties of fully and partially threaded iliosacral screws. We hypothesise that fully threaded screws will have a higher yield force, and less deformation than partially threaded screws following axial loading. Twenty sawbone blocks were uniformly divided to simulate vertical sacral fractures. Ten blocks were affixed with fully threaded iliosacral screws in an over-drilled, lag-by-technique fashion whilst the remaining ten were fixed with partially threaded lag-by-design screws. All screws measured 7.3-mm x 145 mm, and were inserted to a 70% of calculated maximal insertional torque, ensuring uniform screw placement throughout across models. Continuous axial loads were applied to 3 constructs of each type to failure to determine baseline characteristics. Five hundred loading cycles of 500 N at 1 Hz were applied to 4 constructs of each type, and then axially loaded to failure. Force displacement curves, elastic, and plastic deformation of each construct was recorded. Fully threaded constructs had a 428% higher yield force, 61% higher stiffness, 125% higher ultimate force, and 66% lower yield deformation (p < 0.05). The average plastic deformation for partially threaded constructs was 336% higher than fully threaded constructs (p = 0.071), the final elastic deflection was 10% higher (p = 0.248), and the average total movement was 21% higher (p = 0.107). We conclude from this biomechanical study that fully threaded, lag-by-technique iliosacral screws can withstand significantly higher axial loads to failure than partially threaded screws. In addition, fully threaded screws trended towards exhibiting a significantly lower plastic deformation following cyclical loading.

Release of the Tibialis Posterior Muscle Osseofascial Sheath Improves Results of Deep Exertional Compartment Syndrome Surgery: A Comparative Analysis and Long-term Results.

BACKGROUND: Success rates for surgical management of chronic exertional compartment syndrome (CECS) are historically lower with release of the deep posterior compartment compared with isolated anterolateral releases. At our institution, when a deep posterior compartment release is performed, we routinely examine for a separate posterior tibial muscle osseofascial sheath and release it if present. PURPOSE: Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in patients who underwent 2-compartment fasciotomy versus a modified 4-compartment fasciotomy for CECS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients treated with fasciotomy for lower extremity CECS from 2007 to 2017 were retrospectively identified. In all patients in whom a 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath, which was released when present. Patients completed a series of validated patient-reported outcome (PRO) surveys, including the Marx activity score, Tegner activity score, 12-Item Short Form Health Survey, and Likert score for patient satisfaction. RESULTS: Of the 48 patients who were included in this study, 34 (71%) patients with a total of 52 operative limbs responded and completed PRO surveys. The mean follow-up for the entire cohort was 5.5 ± 2.6 years. Of the 34 patients, 23 (68%) underwent 2-compartment fasciotomy and 11 (32%) underwent 4-compartment fasciotomy. Among the patients in the 4-compartment fasciotomy group, 7 (64%) were found to have a fifth compartment. No significant difference was found in any of the validated PRO measures between patients who had a 2- versus 4-compartment fasciotomy or those who underwent 4-compartment fasciotomy with or without a present fifth compartment. At a mean 5.5-year follow-up, 74% of patients who underwent a 2-compartment release reported good or excellent outcomes compared with 82% of patients who underwent our modified 4-compartment release. CONCLUSION: The current study, which included the longest follow-up on CECS patients in the literature, demonstrated that the addition of a release of the posterior tibial muscle fascia led to no significant difference in PRO measures between patients who underwent a 2- versus 4-compartment fasciotomy, when historically the 2-compartment fasciotomy group has had higher success rates.

Fusions ending at the thoracolumbar junction in adolescent idiopathic scoliosis: comparison of lower instrumented vertebrae.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare clinical outcomes and radiographic parameters between patients treated with a posterior spinal fusion that had a lower instrumented vertebra at T11, T12, and L1. BACKGROUND: Posterior instrumented fusions are well established for treating patients with adolescent idiopathic scoliosis (AIS). Fusions limited to the thoracic spine can adequately correct a spinal deformity while preserving lumbar segmental mobility. However, fusions that end at the thoracolumbar junction have been proposed to cause adjacent segment complications. Studies comparing outcomes between patients who were treated with fusions that end at the thoracolumbar junction with varying LIVs are limited. METHODS: A multicenter database was queried for patients with AIS that had Lenke Type 1 and 2 curves treated with a fusion that had an LIV at T11, T12, or L1. Coronal curve magnitude, degree of junctional kyphosis, C7-central sacral line, thoracic apical translation, and sagittal stable vertebrae were measured. Clinical and functional outcomes were assessed using the Scoliosis Research Society-22 (SRS-22) questionnaire and lumbar flexibility testing. RESULTS: The lower instrumented level was below the sagittal stable vertebrae in 22.7%, 40%, and 66.2% of patients in the LIV-T11, T12, and L1 groups, respectively (p < 0.001). The 5-year postoperative lumbar curve magnitudes were 20.3°, 16.3°, and 14.0° for T11, T12, and L1-LIV, respectively (p < 0.001). No patients in the T11 group (0%), two patients in the T12 group (2.5%), and one patient in the L1 (0.8%) group developed distal junctional kyphosis (p = 0.5). The 5-year postoperative total SRS-22 scores were 4.21, 4.50, and 4.38 (p = 0.029). Lumbar flexion decreased by 0.78 cm in the T11-LIV group, increased by 0.01 cm in the T12-LIV group, and decreased by 0.15 cm in the L1-LIV group (p = 0.434). CONCLUSION: There was no significant difference in SRS-22 scores, development of distal junctional kyphosis or loss of lumbar mobility between patients treated with a spinal fusion that had an LIV at T11, T12, or L1. LEVEL OF EVIDENCE: Level III.

Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department.

Importance: Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed. Objective: To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures. Design, Setting, and Participants: This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019. Main Outcomes and Measures: Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care. Results: Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03). Conclusions and Relevance: The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

Impact of Prolonged Skeletal Traction in Patients With Acetabular Fractures.

OBJECTIVES: To explore the association between increased time in traction and in-hospital pulmonary complications in patients with acetabular fractures. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: One hundred ninety consecutive patients. INTERVENTION: Application of skeletal traction before fixation of acetabular fracture. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was pulmonary complication as defined by pulmonary embolism, pneumonia, and acute respiratory distress syndrome. Secondary outcome measures included length of intensive care unit stay (in days), total length of hospital stay (in days), deep hardware-associated infection, subsequent conversion to total hip arthroplasty, urinary tract infection, and lower-extremity deep venous thrombosis. RESULTS: The mean time in traction for patients who developed a pulmonary complication was 210 hours compared with 62 hours for those who did not (P < 0.001). After controlling for Injury Severity Score, chest injury, and concomitant long bone injury requiring intramedullary nailing, the odds of developing a pulmonary complication for patients who spent longer than 120 hours in traction were over 40 times higher than those treated within 5 days (P < 0.001). The mean intensive care unit stay for patients who spent at least 120 hours in traction was 17 days compared with 5 days for those treated in less than 120 hours (P < 0.001). CONCLUSION: Early definitive fixation and decreased time in skeletal traction is associated with a lower rate of complications in patients with acetabular fractures. Our results would suggest that fixation of acetabular fractures before 120 hours (5 days) confers a significant risk-reduction benefit. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of Frailty on 30-Day Morbidity and Mortality of Patients With Intertrochanteric Femur Fractures.

The aim of this study was to evaluate the association between frailty and 30-day morbidity and mortality in patients with intertrochanteric femur fractures. Furthermore, the authors sought to identify a specific frailty index score that would help identify high-risk patients. This retrospective study evaluated 229 consecutive patients 50 years or older who presented to a single level I trauma center for surgical fixation of an intertrochanteric femur fracture. Frailty was determined using a previously validated 11-point modified frailty index (mFI) scale. Primary outcome variables included 30-day morbidity and mortality. Of the 229 patients included in this study, 82 (36%) had a postoperative complication and there were 10 (4%) mortalities. The most common complications were delirium (n=40; 17%) and acute kidney injury (n=25; 11%). Mean mFI score for those who developed a postoperative complication was 0.24 compared with 0.14 for those who did not (P<.001). The mortality rate increased from 0% for mFI of 0 to 11% for mFI of 0.27 or more. Patients with an mFI of 0.27 or more were more than 9 times as likely to have a mortality compared with patients with an mFI of less than 0.27 (P=.006). This study demonstrates that the mFI is associated with 30-day morbidity and mortality in patients aged 50 years or older with intertrochanteric femur fractures. The authors identified an mFI score of 0.27 or more as the most robust predictor of increased 30-day morbidity and mortality following surgical fixation of intertrochanteric femur fractures. [Orthopedics. 2019; 42(6):344-348.].

Impact of closed suction drainage after surgical fixation of acetabular fractures.

INTRODUCTION: The purpose of the present study was to evaluate the prevalence of closed suction drainage after a Kocher-Langenbeck (K-L) approach for surgical fixation of acetabular fractures and to determine the impact of closed suction drainage on patient outcomes. METHODS: This retrospective study reports on 171 consecutive patients that presented to a single level I trauma center for surgical fixation of an acetabular fracture. Medical records were reviewed to evaluate the use of closed suction drains. The primary outcomes measures were rate of packed red blood cell (PRBC) transfusion and length of hospital stay (LOS). Secondary outcome measures were 30-day post-operative wound complication and 1-year deep infection rates. RESULTS: Of the 171 patients included in this study, 140 (82%) patients were treated with drains. There was a significant association between the use of closed suction drainage and post-operative blood transfusion rate (p = 0.002). Thirty-five patients (25%) treated with drains required a post-operative blood transfusion compared to 0% in the no drain cohort. Regarding the total number of drains used, for every additional closed suction drain that was placed beyond a single drain, the odds of receiving a blood transfusion doubled (p = 0.002). Use of closed suction drainage was associated with a significantly longer LOS (p = 0.015), and no difference in wound complication or deep infection rates. CONCLUSION: The use of closed suction drains for treatment of acetabular fractures using a K-L approach is associated with increased rates of blood transfusion and increased length of hospital stay, with no impact on surgical site infection rates. The results of this study suggest against routine drain usage in acetabular surgery.

Frailty and Malnutrition Are Associated With Inpatient Postoperative Complications and Mortality in Hip Fracture Patients.

OBJECTIVE: To examine the relationship of nutrition parameters with the modified frailty index (mFI) and postoperative complications in hip fracture patients. DESIGN: Retrospective observational cohort study. SETTING: Urban, American College of Surgeons-Verified, Level-1, Trauma Center. PATIENTS/PARTICIPANTS: Three hundred seventy-seven consecutive patients with isolated hip fractures. INTERVENTION: N/A. MAIN OUTCOME MEASURES: On admission, albumin and total lymphocyte count (TLC) levels and complication data were collected. Additionally, mFI scores were calculated. Statistical analysis was then used to analyze the association between frailty, malnutrition, and postoperative complications. RESULTS: Overall, 62.6% and 17.5% of patients were malnourished as defined by TLC of <1500 cells per cubic millimeter and albumin of <3.5 g/dL, respectively. Both TLC (P = 0.024; r = -0.12) and albumin (P < 0.001; r = -0.23) weakly correlated with frailty. Combining malnutrition and frailty revealed predictive synergy. Albumin of <3.5 g/dL and mFI of ≥0.18 in the same patient resulted in a positive predictive value of 69% and a likelihood ratio of 4 (2.15-7.43) for postoperative complications. Similarly, the combination of hypoalbuminemia and frailty resulted in a positive predictive value of 23.3% and likelihood ratio of 8.52 (P < 0.001) for mortality. CONCLUSIONS: When patients are frail and malnourished, there is a risk elevation beyond that of frailty or malnutrition in isolation. This high-risk cohort can be easily identified at admission with routine laboratory values and clinical history. There is an opportunity to improve outcomes in frail hip fracture patients because malnutrition represents a potentially modifiable risk factor. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Validated Single-View Radiographic Alternative to Computed Tomography for the Measurement of Femoral Anteversion: A Method-Comparison Study.

BACKGROUND: Although preoperative templating in total hip arthroplasty is helpful to ensure appropriate component position, there is no single-view radiographic method to determine femoral anteversion (FA) preoperatively. The aim of the present study was to validate the use of radiographic measurement of FA using a modified Budin view. METHODS: This prospective study reports on 105 limbs from 65 patients. Computed tomography (CT) scans and radiographs were obtained to measure native FA. Radiographs were obtained using the modified Budin protocol with 90° flexion at the knee and 90° flexion and 30° abduction at the hip. Pearson correlation analyses, paired-samples t-test, and Bland-Altman plots were performed to assess correlation and agreement between methods. Data were grouped into subsets based on CT-derived FA in 5° intervals. Groups included all limbs, FA < 35°, FA < 30°, and FA < 25°. RESULTS: For all limbs, Bland-Altman analysis revealed a fixed bias (mean bias, -0.8°; 95% confidence interval, -1.4° to -0.2°) and showed that radiographic methods underestimated FA. Subset analyses were performed and revealed excellent correlation between CT and radiographic measurements for all subgroups (r = 0.97, P < .001). Paired-samples t-tests revealed no significant difference between methodologies for any of the subgroups. Radiographic and CT methods showed excellent agreement, and the bias between methods was within 0.5° for all subgroups. There was no fixed bias and thus no systematic difference in methods within any of the subgroup analyses. CONCLUSION: Radiographic measurement of FA using a modified Budin view is a valid and reliable technique.

No difference in survivorship after unicompartmental knee arthroplasty with or without an intact anterior cruciate ligament.

PURPOSE: Anterior cruciate ligament deficiency (ACLD) has been considered a contraindication for Oxford unicompartmental knee arthroplasty (UKA) because of the reported higher incidence of failure when implanted in ACLD knees. However, given the potential advantages of UKA over total knee arthroplasty (TKA), we have performed UKA in a limited number of patients with ACL deficiency and end-stage medial compartment osteoarthritis (OA) over the past 11 years. The primary aim of this study was to establish the clinical outcome of this cohort; the secondary aim was to compare both clinical and radiographic data with a matched cohort of ACL-intact (ACLI) patients who have undergone UKA for anteromedial OA. METHODS: This retrospective observational study describes the clinical and radiological outcome in 46 medial Oxford UKAs implanted in 42 consecutive patients with ACL deficiency and concomitant symptomatic medial compartment OA at mean follow-up of 5 years. It also compares the outcomes with a matched cohort of UKA patients with an intact ACL (ACLI group). RESULTS: At the time of last follow-up, there was no significant difference in clinical results or survivorship between the two groups in this study. CONCLUSION: The successful short-term results of the ACLD group suggest ACL deficiency may not always be a contraindication to Oxford UKA as previously thought. Until long-term data is available, however, we maintain our recommendation that ACLD be considered a contraindication.