Relationship Between Preoperative Nutritional Status and Predicting Short-Term Complications Following Revision Total Hip Arthroplasty.

BACKGROUND: The association between malnutrition and complications following primary total joint arthroplasty is well-delineated; however, nutritional status has yet to be explored specifically in revision total hip arthroplasty (THA). Therefore, our objective was to examine if a patient's nutritional status based on body mass index, diabetic status, and serum albumin predicted complications following a revision THA. METHODS: A retrospective national database review identified 12,249 patients who underwent revision THA from 2006 to 2019. Patients were stratified based on body mass index (<18.5 = underweight, 18.5-29.9 = healthy/overweight, ≥30 = obese), diagnosis of diabetes (no diabetes, insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus), and preoperative serum albumin (<3.5 = malnourished, ≥3.5 = non-malnourished). Multivariate analyses were performed using chi-square tests and multiple logistic regressions. RESULTS: In all groups including underweight (1.8%), healthy/overweight (53.7%), and obese (44.5%), those without diabetes were less likely to be malnourished (P < .001), while those with IDDM had a higher rate of malnutrition (P < .001). Underweight patients were significantly more malnourished compared to healthy/overweight or obese patients (P < .05). Malnourished patients had an increased risk of wound dehiscence/surgical site infections (P < .001), urinary tract infection (P < .001), requiring a blood transfusion (P < .001), sepsis (P < .001), and septic shock (P < .001). Malnourished patients also have worse postoperative pulmonary and renal function. CONCLUSION: Patients who are underweight or have IDDM are more likely to be malnourished. The risk of complications within 30 days of surgery following revision THA significantly increases with malnutrition. This study shows the utility of screening underweight and IDDM patients for malnutrition prior to revision THA to minimize complications.

Hip-preserving surgery for nonunion about the hip.

INTRODUCTION: Nonunions about the hip occur as a result of femoral neck, intertrochanteric, and certain subtrochanteric fractures. Treatment of a hip fracture nonunion allows for the choice between hip preservation or arthroplasty. The goal of this study was to examine outcomes of hip-preservation nonunion surgery METHODS: Patients who underwent hip preservation for a fracture nonunion of the femoral neck, intertrochanteric and subtrochanteric region to 1 cm below the lesser trochanter over a 10-year period were identified in our nonunion registry. Patients were followed for a minimum of 1 year. Functional outcomes were recorded at follow-up visits. For comparison regarding surgical and hospital outcomes, a group of 23 patients who underwent conversion total hip arthroplasties (cTHA) at the same academic medical center was reviewed. Quality measures such as length of stay, reoperation, and complications were collected. All statistics analysis utilized IBM SPSS 25 (Armonk, NY) RESULTS: Thirty patients who underwent 30 hip-preserving nonunion surgeries were analyzed and compared with 23 cTHA patients. Twenty-nine nonunions went on to heal (average time to union 6.3 months). There was improvement in functional outcome scores for the hip preservation group between baseline and latest follow-up (p < 0.001). Reoperation was required in five patients (17%), including four failed to heal and required a second repair to gain union and one failure that was converted to THA rather than attempt a second nonunion repair. Hip preservation failures were older than those that healed with the index treatment (p = 0.11). There was no significant difference in hospital length of stay, complication rate, or need for reoperation when compared to cTHA group. CONCLUSION: Hip-preserving surgery is an option that should be considered for patients with nonunion of fractures about the hip. The rates of complications (20.3 vs 17.3%) and reoperation (16.7 vs 17.3%) were equivalent to conversion THA. Excellent outcomes can be achieved in terms of radiographic union and function with hip preservation.

The impact of confirmed coronavirus disease 2019 (COVID-19) infection on ambulatory procedures and associated delays in care for asymptomatic patients.

BACKGROUND: Since the reopening of ambulatory centers, minimal data has been reported regarding positive tests among patients undergoing ambulatory procedures, associated delays in care, and outcomes of patients previously positive for coronavirus disease 2019. METHODS: A retrospective observational case series of ambulatory procedures was performed. Records since the reopening of ambulatory centers in New York were searched for patients with positive coronavirus disease 2019 nasal swab results who underwent ambulatory procedures. Chart reviews were conducted to determine coronavirus disease history and hospitalizations, demographic information, procedure details, and 30-day admissions. RESULTS: A total of 3,762 patients underwent ambulatory procedures. Of those, 53 were previously diagnosed with coronavirus disease 2019 but recovered and tested negative at preprocedural testing. Of the 3,709 asymptomatic patients, 37 (1.00%) tested positive during preprocedural testing; 21 patients had their procedures delayed on average 28.6 days until testing negative, while 16 had their procedures performed before testing negative owing to the time sensitivity of the procedure. There were no major complications or 30-day admissions in any of these asymptomatic patients. Three patients tested positive for coronavirus disease after having an ambulatory procedure. CONCLUSION: Positive tests in asymptomatic patients led to procedure delays of 28.6 days. No patients who underwent ambulatory procedures after a positive coronavirus disease 2019 test had any coronavirus disease-related complications, regardless of whether or not the procedure was delayed until testing negative. Three patients tested positive for coronavirus disease 2019 after having an ambulatory procedure; however, at an average of 19.7 days after, these cases were likely community acquired making the rate of nosocomial infection negligible.

Outcomes of Patients With Nonunion After Open Tibial Shaft Fractures With or Without Soft Tissue Coverage Procedures.

OBJECTIVES: To evaluate the outcomes of patients who underwent soft tissue flap coverage during treatment of a tibia fracture nonunion. DESIGN: Retrospective analysis on prospectively collected data. SETTING: Academic medical center. PATIENTS/PARTICIPANTS: One hundred fifty-seven patients were treated for a fracture nonunion after a tibia fracture over a 15-year period. Sixty-six patients had sustained an open tibial fracture initially and 25 of these patients underwent soft tissue flaps for their open tibia fracture nonunion. INTERVENTION: Manipulation of soft tissue flaps, either placement or elevation for graft placement in ununited previously open tibial fractures. MAIN OUTCOME MEASUREMENTS: Bony healing, time to union, ultimate soft tissue status, postoperative complications, and functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA). This group was compared with a group of open tibial fracture nonunions that did not undergo soft tissue transfer. RESULTS: Bony healing was achieved in 24 of 25 patients (96.0%) who received flaps at a mean time to union of 8.7 ± 3.3 months compared with 39 of 41 patients (95.1%) at a mean 7.5 ± 3.2 months (P > 0.05) in the noncoverage group. Healing rate and time to union did not differ between groups. At latest follow-up, the flap coverage group reported a mean SMFA index of 17.1 compared with an SMFA index of 27.7 for the noncoverage group (P = 0.037). CONCLUSIONS: Utilization of soft tissue flaps in the setting of open tibia shaft nonunion repair surgery are associated with a high union rate (>90%). Coverage with or manipulation of soft tissue flaps did not result in improved bony healing rate or time to union compared with those who did not require flaps. However, soft tissue flap coverage was associated with higher functional scores at long-term follow-up. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Delayed Radial Nerve Palsy After Nonoperative Treatment of Humeral Shaft Fractures: A Report of 2 Cases.

CASE: Two patients who developed radial nerve palsy at least 6 weeks after injury during nonoperative treatment of humeral shaft fractures. This complication was associated with external bracing, progressive varus angulation during treatment, and excess callus formation. CONCLUSION: Delayed radial nerve palsy may develop during nonoperative treatment of humeral shaft fractures when functional bracing fails to maintain alignment and stability at the fracture site.

Softer Tissue Issues in Orthopaedic Trauma.

There are number of significant issues outside of the bone and/or fracture that are important to consider in the treatment of orthopaedic trauma. Joint contractures, heterotopic bone formation, managing a traumatized soft-tissue envelope or substantial soft-tissue defects represent a few of these important issues. This article reviews these issues, including the best available evidence on how to manage them.