No Differences in Major In-Hospital Outcome Metrics When Comparing the Direct Lateral Approach to the Posterior Approach for Hemiarthroplasties After Traumatic Displaced Femoral Neck Fractures.

Introduction: The surgical approach of hemiarthroplasty for displaced femoral neck fractures remains debated. The study objective was to compare in-hospital outcomes for geriatric displaced femoral neck fractures treated with hemiarthroplasty based on surgical approach (direct lateral vs. posterior approach). Materials and Methods: This retrospective cohort study included geriatric patients (≥60 y/o) admitted 7/1/2016-3/31/2020 treated with hemiarthroplasty. Outcomes included: operative time (incision to closure), length of stay (HLOS), and blood loss volume (mL). The Harding direct lateral approach was compared to the posterior approach; P < .05. Results: There were 164 patients (59% direct lateral, 41% posterior). Patients treated with the direct lateral approach had an advanced directive (P = .03), dementia, (P = .03), or were functionally dependent (P = .03) more often than patients treated with the posterior approach. Time to surgery was comparable between groups (P = .52). The direct lateral approach was associated with a shorter operative time (2.3 vs. 2.8 h, P = .03), a longer HLOS (5.0 vs. 4.0 days, P < .01), and a lower median volume of blood loss (50 vs. 100 mL, P = .01), than the posterior approach, respectively. In a stratified analysis, for those who were not functionally dependent, did not have dementia or an advanced directive, the direct lateral approach led to a longer HLOS (P = .03) and shorter operative time (P = .04) than the posterior approach. Whereas among those who were functionally dependent, had dementia or had an advanced directive, the direct lateral approach led to less blood loss (P = .02) than the posterior approach. Discussion: While those treated with the direct lateral approach lost significantly less blood, they had a significantly longer HLOS than those treated with the posterior approach. Comorbidities significantly modified outcomes, which may suggest their presence could assist with treatment decisions. Conclusions: This study found neither approach, the direct lateral nor posterior, to be superior. Surgical approach could remain physician preference.

Displaced Geriatric Femoral Neck Fractures: A Retrospective Comparison of Total Hip Arthroplasties Versus Hemiarthroplasty.

Introduction: Controversary exists around the best surgical management for traumatic geriatric displaced femoral neck fractures. The study objective was to compare outcomes among those managed with a total hip arthroplasty (THA) to those managed with a hemiarthroplasty (HA). Methods: This retrospective matched cohort study included geriatric hip fractures (≥65 y/o) admitted 7/1/16-3/31/20. Patients were matched on having an advanced directive, pre-existing dementia, and age. Outcomes included: time to surgery, length of stay (LOS), blood loss volume, and discharge destination. THAs were compared to HAs; an alpha of <.05 indicated statistical significance. Results: There were 191 patients: 86% were treated with HA and 14% with THA. Most (40%) were 80-89 years old, 66% were female, and 92% were white. After matching, the groups were well balanced on demographics and baseline characteristics with 27 patients/arm. The median time to surgery was 23 hours for both arms, P = .38. The LOS was significantly longer for those managed with a HA when compared to those managed with a THA, 5.6 vs 4.0 days, P = .001. The median blood loss volume was significantly lower for HAs than for THAs, but the difference was small, 100 vs 120 mL, P = .02. Patients managed with a HA were less likely to be discharged home than those managed with a THA, 22% vs 70%, P = .005. Conclusions: While patients managed with a THA had significantly more blood loss than those managed with a HA, the difference in blood loss was small and not clinically relevant. Those managed with a THA experienced a significantly shorter LOS and were more likely to be discharged home than patients managed with a HA. Among a healthier, younger geriatric population, THA may lead to shortened LOS and improved discharge destinations when compared to HA for treatment of femoral neck fractures.

Unipolar Osteochondral Allograft Transplantation of the Ankle for Posttraumatic Tibial Necrosis: A Case Report.

We present the case of a 31-year-old male with debilitating post-traumatic arthritis of the ankle secondary to osteonecrosis of the tibial plafond. He was treated with a custom-cut tibial osteochondral allograft transplantation. At 1-year follow-up, radiographs confirmed incorporation of the graft. He had demonstrated significant improvement in terms of both subjective pain and functionality of the ankle and was ready to return to work. Our observation in this case suggests that osteochondral allograft implantation may be a viable alternative treatment in cases of ankle arthritis in the younger patient.

Early steroid withdrawal therapy in renal transplant recipients: a steroid-free sirolimus and CellCept-based calcineurin inhibitor-minimization protocol.

BACKGROUND: Maintenance steroid therapy is associated with significant morbidity and mortality in renal transplant recipients. Elimination of the many long-term side effects of corticosteroids, including those that impinge on cardiovascular risk, remains a laudable goal in designing immunosuppressive protocols. However, concern persists that prednisone-free maintenance immunotherapy in kidney transplant recipients will result in an increase incidence of acute rejections, renal dysfunction and ultimate graft loss. METHODS: From 24 March 2003 to 1 December 2004, 84 kidney transplant recipients (61 deceased donor, 23 living donors) discontinued prednisone on post-operative day 6. Immunotherapy consisted of polyclonal antibody induction (thymoglobulin) for five d and prednisone intraoperatively with a rapid taper over the next six d. Maintenance therapy consisted of a sirolimus and CellCept-based calcineurin inhibitor-minimization protocol. Tacrolimus and mycophenolate mofetil (CellCept) were initiated on day 0. Sirolimus immunotherpay was started on post-operative day 6 concomitant with the cessation of steroids. We compared outcomes with that of our historical controls, treated with sirolimus and tacrolimus, who did not discontinue steroids. In addition, we analyzed outcomes independently for recipients of living and deceased donors in the steroid-free protocol. RESULTS: The recipients on prednisone-free maintenance immunosuppression had excellent 2.5-yr actuarial patient survival (97%), graft survival (93%), and acceptable acute rejection-free graft survival (89%). The mean serum creatinine level (+/-SD) at one yr was 1.5 +/- 0.6 mg/dL and at two yr was 1.5 +/- 0.6 mg/dL. We noted that 5% of recipients developed cytomegalovirus (CMV) syndrome; 1%, polyoma nephropathy; 1%, post-transplant lymphoproliferative disorder (PTLD), and 5% developed post-transplant diabetes mellitus (PTDM). In all, 91% of kidney recipients with functioning grafts remain steroid-free as of 31 December 2005. When compared with historical controls, the recipients on the early steroid-withdrawal (ESW) protocol had comparable graft survival, acute rejection-free survival, graft function, but significantly better patient actuarial survival (p = 0.048). In addition, recipients on the steroid-free protocol had decreased prevalence of four risk factors for cardiovascular disease when compared with historical controls: hypertension (p = 0.008), hyperlipidemia (p = 0.003), weight gain (p = 0.024), and incidence of PTDM (p = 0.015). CONCLUSION: Early steroid-withdrawal in renal transplant recipients with a sirolimus and CellCept-based calcineurin inhibitor-minimimization protocol can effectively reduce many of the steroid-related side effects, decrease risk factors for cardiovascular disease, and is associated with improved recipient survival without compromising graft function.