Periprosthetic fracture following arthroplasty for femoral neck fracture: is a cemented stem protective?

BACKGROUND: Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS: Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS: There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS: In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

Diagnostic Accuracy of a Trauma Risk Assessment Tool Among Geriatric Patients With Crash Injuries.

ABSTRACT: The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a risk stratification tool. We evaluated the STTGMA's accuracy in predicting 30-day mortality and the odds of unfavorable clinical trajectories among crash-related trauma patients. This retrospective cohort study (n = 912) pooled adults aged 55 years and older from a single institutional trauma database. The data were split into training and test data sets (70:30 ratio) for the receiver operating curve analysis and internal validation, respectively. The outcome variables were 30-day mortality and measures of clinical trajectory. The predictor variable was the high-energy STTGMA score (STTGMAHE). We adjusted for the American Society of Anesthesiologists Physical Status. Using the training and test data sets, STTGMAHE exhibited 82% (95% CI: 65.5-98.3) and 96% (90.7-100.0) accuracies in predicting 30-day mortality, respectively. The STTGMA risk categories significantly stratified the proportions of orthopedic trauma patients who required intensive care unit (ICU) admissions, major and minor complications, and the length of stay (LOS). The odds of ICU admissions, major and minor complications, and the median difference in the LOS increased across the risk categories in a dose-response pattern. STTGMAHE exhibited an excellent level of accuracy in identifying middle-aged and geriatric trauma patients at risk of 30-day mortality and unfavorable clinical trajectories.

Hip Fracture Care during COVID-19: Evolution through the Pandemic.

INTRODUCTION: The purpose of this epidemiologic study was to analyze the care provided by our institution to middle-aged and geriatric hip fracture patients throughout the pandemic to examine for any differences compared to pre-pandemic care and across the pandemic stages. METHODS: Consecutive patients >55 years old treated for hip fractures at our institution between October 2014 and January 2022 were analyzed for demographics, coronavirus disease 2019 (COVID-19) and vaccination status at admission, injury characteristics, hospital quality measures, and outcomes. Patients were divided into three separate cohorts: Pre-COVID-19 (PRECOV), COVID-19 Pre-Vaccine (PREVAX), and COVID-19 Post-Vaccine (POSTVAX). A sub-analysis removed COVID-19-positive patients across the study period. Comparative analyses were conducted. RESULTS: A total of 2,633 hip fracture patients were included. For the overall cohort, there was no difference in the rate of inpatient deaths between the PRECOV, PREVAX, and POSTVAX cohorts (p=0.278). PRECOV had a significantly lower 30-day mortality rate compared to PREVAX or POSTVAX (p=0.012). Differences in complication rates for surgical site infection, urinary tract infection, and anemia (p<0.01 for all) were seen between cohorts. PRECOV had the longest length of hospital stay (p<0.01). PREVAX patients required more ICU level of care (p<0.01). When removing COVID-19-positive patients, all three cohorts had similar inpatient (p=0.872) and 30-day mortality rates (p=0.130). CONCLUSION: The care of patients treated for hip fractures did not change throughout the pandemic at our institution. The elevated mortality rate due to the effects of COVID-19 seen in the pre-vaccine cohort decreased over time as the understanding of COVID-19 improved and the vaccine was introduced. We recommend continuation of the same hip fracture care protocols as used pre-pandemic.

The Cost We Bear: Financial Implications for Hip Fracture Care Amidst the COVID-19 Pandemic.

INTRODUCTION: The purpose of this study was to assess the impact of COVID-19 on the cost of hip fracture care in the geriatric/middle-aged cohort, hypothesizing the cost of care increased during the pandemic, especially in COVID+ patients. METHODS: Between October 2014 and January 2022, 2,526 hip fracture patients older than 55 years were analyzed for demographics, injury details, COVID status on admission, hospital quality measures, and inpatient healthcare costs from the inpatient admission. Comparative analyses were conducted between: (1) All comers and high-risk patients in the prepandemic (October 2014 to January 2020) and pandemic (February 2020 to January 2022) cohorts and (2) COVID+ and COVID- patients during the pandemic. Subanalysis assessed the difference in cost breakdown for patients in the overall cohorts, the high-risk quartiles, and between the prevaccine and postvaccine pandemic cohorts. RESULTS: Although the total costs of admission for all patients, and specifically high-risk patients, were not notably higher during the pandemic, further breakdown showed higher costs for the emergency department, laboratory/pathology, radiology, and allied health services during the pandemic, which was offset by lower procedural costs. High-risk COVID+ patients had higher total costs than high-risk COVID- patients ( P < 0.001), most notably in room-and-board ( P = 0.032) and allied health ( P = 0.023) costs. Once the pandemic started, subgroup analysis demonstrated no change in the total cost in the prevaccine and postvaccine cohort. CONCLUSION: The overall inpatient cost of hip fracture care did not increase during the pandemic. Although individual subdivisions of cost signified increased resource utilization during the pandemic, this was offset by lower procedural costs. COVID+ patients, however, had notably higher total costs compared with COVID- patients driven primarily by increased room-and-board costs. The overall cost of care for high-risk patients did not decrease after the widespread administration of the COVID-19 vaccine. LEVEL OF EVIDENCE: III.

Does a hip fracture mean we should we operate on a concomitant proximal humerus fracture?

BACKGROUND: Concomitant upper extremity and hip fractures present a challenge in postoperative mobilization in the geriatric population. Operative fixation of proximal humerus fractures allows for upper extremity weight bearing. This retrospective study compared outcomes between operative and non-operative proximal humerus fracture patients with concomitant hip fractures. METHODS: A trauma database of 13,396 patients age > 55 years old was queried for concomitant hip and proximal humerus fracture patients between 2014-2021. Medical records were reviewed for demographics, hospital quality measures, Neer classification, morphine milligram equivalents (MME), and outcomes. All hip fractures were treated operatively. Patients were grouped based on operative vs. non-operative treatment of their proximal humerus fracture. Primary outcomes included comparing postoperative ambulatory status, pain, length of stay (LOS), intensive care unit (ICU) need, discharge disposition, and readmission rates. RESULTS: Forty-eight patients (0.4%) met inclusion criteria. Twelve patients (25%) underwent operative treatment for their proximal humerus fracture and 36 (75%) received non-operative treatment. Patients with operative fixations were younger (p < 0.01), had more complex Neer classifications (p = 0.031), more likely to be community ambulators (p < 0.01), and required more inpatient MMEs (p < 0.01). There were no differences in LOS (p = 0.415), need for ICU (p = 0.718), discharge location (p = 0.497), 30-day readmission (p = 0.228), or 90-day readmission (p = 0.135) between cohorts. At 6 months postoperatively, among community or household ambulators, a higher percentage of operative patients returned to their baseline ambulatory functional status, however, this was not significant (70% vs. 52%, p = 0.342). There were three deaths in the non-operative cohort and no deaths in the operative cohort. CONCLUSION: Patients with hip fractures and concomitant proximal humerus fractures treated operatively required more inpatient MMEs and trended toward maintaining baseline ambulatory function. There were no differences in inpatient LOS, ICU need, discharge location, or readmissions. Future larger, multicenter studies are needed to further delineate if operative repair of concomitant proximal humerus fractures provides a benefit in the geriatric population.

Implications of COVID-19 on hip fracture care discharge locations during the early stages of the pandemic.

Objectives: To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort. Design: Retrospective cohort study. Setting: Academic medical center. Patients/Participants: Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020). Intervention: Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility]. Main Outcome Measurements: Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L). Results: In COVID+ patients, 93% (13/14) were discharged to a facility, 62% (8/13) of whom passed away within 1 year of discharge. Of COVID+ patients discharged to an SNF, 80% (8/10) died within 1 year. Patients discharged to an SNF in 2020 were 1.8x more likely to die within 1 year compared with 2019 (P = 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes. Conclusions: All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic. Level of Evidence: III.

Defining Characteristics of Middle-Aged and Geriatric Orthopedic Trauma in New York City over a 7-Year Period.

OBJECTIVES: Examine the patterns and defining characteristics of middle-aged and geriatric patients who sustain orthopedic trauma in New York City. STUDY DESIGN: Retrospective cohort study. METHODS: 11,677 patients >55 years old treated for traumatic orthopedic injuries were grouped into cohorts based on their age group (cohorts of 55-64, 65-74, 75-84, 85-94, ≥95 years) and year of presentation (2014-2021). Each patient was reviewed for demographics/comorbidities, injury mechanism/type, mortality data. Comparative analyses were conducted. RESULTS: The average age of our cohort was 74 years old. The majority of patients were female (69%) and sustained their injuries via a ground level fall. The most common injuries sustained by patients occurred at the upper extremity (40%), hip (26%), and lower extremity (25%) with 820 (7%) patients sustaining polytrauma. The incidence of hip fractures and pelvic injuries increased with older age. Older patients had a higher rate of mortality through 1-year in addition to a longer length of stay. In contrast, the incidence of injury to the upper and lower extremity decreased with older age. CONCLUSIONS: The rate of mortality out through 1-year following orthopedic trauma increased as patients got older. Significantly more women experienced a traumatic injury during 2014-2021. As age increased, ground level falls were the most common mechanism of injury with injuries more likely to occur in the axial skeleton, notably the hip and pelvis. Younger patients experienced higher rates of upper and lower extremity trauma. Providers should keep these patterns in mind to optimize care for middle-aged and geriatric trauma patients.

One year later: How outcomes of hip fractures treated during the "first wave" of the COVID-19 pandemic were affected.

The purpose of this study was to assess the impact of COVID-19 on long-term outcomes in the geriatric hip fracture population. We hypothesize that COVID + geriatric hip fracture patients had worse outcomes at 1-year follow-up. Between February and June 2020, 224 patients > 55 years old treated for a hip fracture were analyzed for demographics, COVID status on admission, hospital quality measures, 30- and 90-day readmission rates, 1-year functional outcomes (as measured by the EuroQol- 5 Dimension [EQ5D-3L] questionnaire), and inpatient, 30-day, and 1-year mortality rates with time to death. Comparative analyses were conducted between COVID + and COVID- patients. Twenty-four patients (11%) were COVID + on admission. No demographic differences were seen between cohorts. COVID + patients experienced a longer length of stay (8.58 ± 6.51 vs. 5.33 ± 3.09, p < 0.01) and higher rates of inpatient (20.83% vs. 1.00%, p < 0.01), 30-day (25.00% vs. 5.00%, p < 0.01), and 1-year mortality (58.33% vs. 18.50%, p < 0.01). There were no differences seen in 30- or 90-day readmission rates, or 1-year functional outcomes. While not significant, COVID + patients had a shorter average time to death post-hospital discharge (56.14 ± 54.31 vs 100.68 ± 62.12, p = 0.171). Pre-vaccine, COVID + geriatric hip fracture patients experienced significantly higher rates of mortality within 1 year post-hospital discharge. However, COVID + patients who did not die experienced a similar return of function by 1-year as the COVID- cohort.

COVID-19 vaccination improved outcomes in the treatment of geriatric hip fractures between December 2020 and January 2022.

INTRODUCTION: Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture. METHODS: Between December 2020 and January 2022, 506 patients treated for hip fracture were analysed for demographics, hospital quality measures, and outcomes. Patients were grouped according to vaccine series administration status. During the study period, there were 329 (65%) unvaccinated patients (NV), 14 (3%) partially vaccinated (PV) patients, 138 (27%) fully vaccinated (FV) patients, and 25 (5%) patients received a booster shot (BV). Variables were compared using chi square, independent sample t-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination. RESULTS: The rate of minor complications decreased if any vaccination status was achieved (NV: 37.99%, PV: 21.34%, FV: 28.26%, BV: 20.00%; p = 0.054). Vaccinated patients had a decreased need for Intensive Care Unit (ICU) level care (NV: 14.89%, PV: 7.14%, FV: 5.80%, BV: 8.00%; p = 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications. DISCUSSION: In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.

Adaptive Risk Modeling: Improving Risk Assessment of Geriatric Hip Fracture Patients Throughout their Hospitalization.

INTRODUCTION: The purpose of this study was twofold: 1. To assess how adaptive modeling, accounting for development of inpatient complications, affects the predictive capacity of the risk tool to predict inpatient mortality for a cohort of geriatric hip fracture patients. 2. To compare how risk triaging of secondary outcomes is affected by adaptive modeling. We hypothesize that adaptive modeling will improve the predictive capacity of the model and improve the ability to risk triage secondary outcomes. METHODS: Between October 2014-August 2021, 2421 patients >55 years old treated for hip fracture obtained through low-energy mechanisms were analyzed for demographics, injury details and hospital quality measures. The baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for hip fractures (STTGMAHIP) was calculated in the emergency department setting. A new mortality risk score (STTGMAHIP_ADPTV) was created including inpatient complications. Each models' predictive ability was compared using DeLong's test. Patients were grouped into quartiles based on their respective STTGMAHIP_ADPTV and comparative analyses were conducted. RESULTS: AUROC comparison demonstrated STTGMAHIP_ADPTV significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP (p < 0.01). STTGMAHIP_ADPTV correctly triaged 80% and 64% of high-risk patients with inpatient and 30-day mortality compared to 64% and 57% for STTGMAHIP. STTGMAHIP_ADPTV quartile stratification demonstrated that the highest risk cohort had the worst mortality outcomes and hospital quality measures. Patients whose risk classification changed from minimal risk using STTGMAHIP to high risk using STTGMAHIP_ADPTV experienced the highest rate of mortality, readmission, ICU admission, with longer lengths of stay and higher hospital costs. DISCUSSION: Adaptive modeling accounting for inpatient complications improves the predictive capacity and risk triaging of the STTGMAHIP tool. Real-time modulation of a patient's mortality risk profile can inform their requisite level of medical management to improve the quality and value of care as patients progress through their index hospitalization. STTGMAHIP_ADPTV can better identify patients at risk for developing complications whose mortality and readmission risk profile increase significantly, allowing their new risk classification to inform higher levels of care. While this may increase length of stay and total costs, it may improve outcomes in both the short and long-term. LEVEL OF EVIDENCE: III.

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care "Value".

BACKGROUND: Value is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF). METHODS: Between October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01). RESULTS: There were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001). CONCLUSION: Among Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.

The Role of Smoking and Body Mass Index in Mortality Risk Assessment for Geriatric Hip Fracture Patients.

Background Smoking, obesity, and being below a healthy body weight are known to increase all-cause mortality rates and are considered modifiable risk factors. The purpose of this study is to assess whether adding these risk factors to a validated geriatric inpatient mortality risk tool will improve the predictive capacity for hip fracture patients. We hypothesize that the predictive capacity of the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool will improve. Methodology Between October 2014 and August 2021, 2,421 patients >55-years-old treated for hip fractures caused by low-energy mechanisms were analyzed for demographics, injury details, hospital quality measures, and mortality. Smoking status was recorded as a current every-day smoker, former smoker, or never smoker. Smokers (current and former) were compared to non-smokers (never smokers). Body mass index (BMI) was defined as underweight (<18.5 kg/m2), healthy weight (18.5-24.9 kg/m2), overweight (25.0-24.9 kg/m2), or obese (>30 kg/m2). The baseline STTGMA tool for hip fractures (STTGMAHIP_FX_SCORE) was modified to include patients' BMI and smoking status (STTGMA_MODIFIABLE), and new mortality risk scores were calculated. Each model's predictive ability was compared using DeLong's test by analyzing the area under the receiver operating curves (AUROCs). Comparative analyses were conducted on each risk quartile. Results A comparison of smokers versus non-smokers demonstrated that smokers experienced higher rates of inpatient (p = 0.025) and 30-day (p = 0.048) mortality, myocardial infarction (p < 0.01), acute respiratory failure (p < 0.01), and a longer length of stay (p = 0.014). Comparison among BMI cohorts demonstrated that underweight patients experienced higher rates of pneumonia (p = 0.033), decubitus ulcers (p = 0.046), and the need for an intensive care unit (ICU) (p < 0.01). AUROC comparison demonstrated that STTGMA_MODIFIABLE significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.792 vs. 0.672, p = 0.0445). Quartile stratification demonstrated the highest risk cohort had a longer length of stay (p < 0.01), higher rates of inpatient (p < 0.01) and 30-day mortality (p < 0.01), and need for an ICU (p < 0.01) compared to the minimal risk cohort. Patients in the lowest risk quartile were most likely to be discharged home (p < 0.01). Conclusions Smoking, obesity, and being below a healthy body weight increase the risk of perioperative complications and poor outcomes. Including smoking and BMI improves the STTGMAHIP_FX_SCORE tool to predict mortality and risk stratify patient outcomes. Because smoking, obesity, and being below a healthy body weight are modifiable patient factors, providers can counsel patients and implement lifestyle changes to potentially decrease their risk of longer-term poor outcomes, especially in the setting of another fracture. For patients who are former smokers, providers can use this information to encourage continued restraint and healthy choices.

Seasonality Affects Elderly Hip Fracture Mortality Risk During the COVID-19 Pandemic.

Background The incidence of geriatric hip fractures, respiratory infections (e.g., coronavirus disease 2019 (COVID-19), influenza), and mortality is higher during the fall and winter. The purpose of this study is to assess whether the addition of seasonality to a validated geriatric inpatient mortality risk tool will improve the predictive capacity and risk stratification for geriatric hip fracture patients. We hypothesize that seasonality will improve the predictive capacity. Methodology Between October 2014 and August 2021, 2,421 patients >55-year-old treated for hip fracture were analyzed for demographics, date of presentation, COVID-19 status (for patients after February 2020), and mortality. Patients were grouped by season based on their admission dates into the following four cohorts: fall (September-November), winter (December-February), spring (March-May), and summer (June-August). Patients presenting during the fall/winter and spring/summer were compared. The baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for hip fractures (STTGMAHIP_FX_SCORE) and the seasonality iteration (STTGMA_SEASON) were also compared. Sub-analysis was conducted on 687 patients between February 2020 and August 2021 amid the COVID-19 pandemic. The baseline score (STTGMAHIP_FX_SCORE) and the COVID-19 iteration (STTGMACOVID_ORIGINAL_2020) were modified to include seasonality (STTGMA_COVID/SEASON). Patients were stratified by risk score and compared. The predictive ability of the models was compared using DeLong's test. Results For the overall cohort, patients who presented during the fall/winter had a higher rate of inpatient mortality (2.87% vs. 1.25%, p < 0.01). STTGMA_SEASON improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE but not significantly (0.773 vs. 0.672, p = 0.105) On sub-analysis, regression weighting showed a coefficient of 0.643, with fall and winter having a greater absolute effect size (fall = 2.572, winter = 1.929, spring = 1.286, summer = 0.643). STTGMA_COVID/SEASON improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.882 vs. 0.581, p < 0.01) and STTGMACOVID_ORIGINAL_2020 (0.882 vs. 0.805, p = 0.04). The highest risk quartile contained 89.5% of patients who expired during their index inpatient hospitalization (p < 0.01) and 68.2% of patients who died within 30 days of discharge (p < 0.01). Conclusions Seasonality may play a role in both the incidence and impact of COVID-19 and additional respiratory infections. Including seasonality improves the predictive capacity and risk stratification of the STTGMA tool during the COVID-19 pandemic. This allows for effective triage and closer surveillance of high-risk geriatric hip fracture patients by better accounting for the increased respiratory infection incidence and the associated mortality risk seen during fall and winter.

Does nutrition consultation in the year leading up to neuromuscular scoliosis surgery result in significant weight gain, or just a larger magnitude curve?

PURPOSE: Patients with neuromuscular scoliosis undergoing posterior instrumented spinal fusion can be underweight, malnourished, and have higher complication rates. A nutrition consult is common in this population and it is unclear if weight gain occurs from the consult or surgery. The purpose of the study was to determine if nutrition consultation in the year prior to spinal fusion resulted in significant differences in weight gain or percentile on the CP growth chart. The secondary aim was to determine if there would be deformity progression during that time. METHODS: Retrospective chart and radiograph review was performed for all patients with neuromuscular spinal deformity treated with posterior instrumented spinal fusion at one institution between January 1, 2009 and August 1, 2015. Inclusion criteria included < 20 years old, diagnosis of neuromuscular scoliosis, and 1-year pre-operative percentile on the CP growth chart < 50. Patient demographics, GMFCS level, weight, percentile on appropriate CP growth chart, major curve and pelvic obliquity at 1 year pre-operatively and at surgery were recorded. RESULTS: Sixty-eight patients met inclusion criteria. Thirty-seven patients had a nutrition appointment within 1 year pre-operatively, 31 patients did not. There were no significant differences between the groups when comparing increase in weight (p = 0.9), percentile on CP growth charts (p = 0.3), major deformity (p = 0.1), and pelvic obliquity (p = 0.2). Overall, there was a mean 3.2 kg weight gain, 5.2% increase on CP growth charts, 40° increase in major curve, and 5° worsening of pelvic obliquity in the year before surgery. There was an average overall increase in the pre-operative albumin value, but this was not different between groups (p = 0.6). Children who were tube fed gained on average 10.8 percentiles on the CP growth chart, whereas children without gained only 0.5 percentiles (p = 0.002). CONCLUSIONS: Nutrition consultations in the year preceding posterior instrumented spinal fusion do not lead to weight optimization prior to surgery in comparison to patients without nutrition consults. Gastrostomy tubes were found to be helpful for weight optimization and should be considered as an alternative nutrition option in pre-operative planning in underweight patients. LEVEL OF EVIDENCE: III-therapeutic study: retrospective comparative study.

Resolution of Psoriatic Plaques of the Leg After Nailing of an Ipsilateral Tibial Shaft Fracture: A Case Report.

CASE: This case describes a 45-year-old man with documented history of untreated bilateral lower extremity psoriasis of equal severity who sustained a closed left tibial-fibular shaft fracture. After operative fixation with an intramedullary nail under a regional nerve block, the left lower extremity circumferential psoriatic plaque resolved throughout 1 year of follow-up with persistence of the contralateral limb disease. CONCLUSION: This case describes a rare outcome for a patient with bilateral leg psoriasis who experienced resolution of psoriatic plaques on the operated leg only after surgery. It is unknown which process: injury, anesthetic, surgery, or fracture healing mediated this unique finding.

Increasing Reoperations and Failures With Increasing BMI in Patients Undergoing 2-Stage Exchange for Infected Total Hip Arthroplasty.

BACKGROUND: While morbid obesity is associated with increased infection after total hip arthroplasty, little is known on the outcomes after 2-stage reimplantation for prosthetic joint infection (PJI) in this population. The purpose of this study is to evaluate the impact of morbid obesity (body mass index>40 kg/m2) on reinfection, postoperative complications, readmissions, and reoperations. METHODS: We conducted a retrospective review of 107 patients undergoing first time 2-stage reimplantation for PJI from 2013 to 2019. 18 patients (50% women) with body mass index>40 kg/m2 were identified. To minimize confounders, three propensity score matched cohorts were created, yielding 16 nonobese (<30 kg/m2), 16 obese (30-39.9 kg/m2), and 18 morbidly obese (>40 kg/m2) patients. Outcomes were compared using chi-square or Fisher's exact tests. All patients had minimum 12-month follow-up, with mean follow-up of 36.3, 30.1, and 40.0 months in the nonobese, obese, and morbidly obese cohorts, respectively. RESULTS: Compared with nonobese patients, morbidly obese patients had a higher rate of reinfection (0% vs 33%, P = .020 and higher likelihood of length of stay>4 days (19% vs 61%, P = .012). In addition, compared with nonobese and obese patients, morbidly obese patients had higher rate of return to the operating room for any reason (13% vs 19% vs 50%, respectively, P = .020). No differences between cohorts were found regarding complications, death, or revision surgery. CONCLUSION: Morbidly obese patients have significantly increased risk of reinfection and reoperation after 2-stage reimplantation for PJI when compared with obese and nonobese patients. These data can be used to counsel morbidly obese patients contemplating total hip arthroplasty and supports the notion of deferring arthroplasty in this population pending optimization.