Does a 2-Stage Debridement Result in Higher Rates of Implant Retention Compared With Single Debridement Alone?

BACKGROUND/METHODS: We retrospectively reviewed 89 patients with acute prosthetic joint infection treated with debridement, antibiotics, and implant retention (DAIR) or 2-DAIR. Patients had <3 weeks of symptoms and met Musculoskeletal Infection Society criteria for infection. Sixty-three patients were treated with DAIR, whereas 26 patients were managed using a 2-DAIR protocol where patients underwent initial debridement, antibiotic bead placement, and subsequent return to the operating room at an average of 16.3 days for repeat debridement and modular component exchange. Patients received a 6-week course of intravenous antibiotics and 3 months of oral antibiotics for suppression. Demographics, comorbidities, implant retention rates, and complications were compared between the groups. The McPherson host type and infection type classification system were used to categorize patients in both the DAIR and 2-DAIR groups. Regression analysis was performed to control postoperative vs acute hematogenous infection, procedure, and comorbidities. The McPherson host types and infection types were not different between DAIR and 2-DAIR patients, P = .728 and P = .061, respectively. RESULTS: There was no difference in the overall implant retention rate between DAIR and 2-DAIR (63.49% vs 69.23%, P = .605). The average days to reinfection was significantly longer for the 2-DAIR cohort compared with DAIR (271.3 vs 165.3, P = .024) in patients who failed treatment. However, when controlling for infection, microorganism, index procedure, and comorbidities, there was no difference in days to reinfection (P = .679). There were no differences in complications, 90-day readmission, or revision rates between the groups. CONCLUSIONS: A staged debridement for acute prosthetic joint infection did not improve the rates of infection control. Randomized trials are needed to define indications and potential benefits of 2-DAIR.

Voluntary acromioclavicular joint dislocation: a case report and literature review.

Voluntary glenohumeral dislocations have been reported in academic literature; however, voluntary dislocations of the acromioclavicular joint are rare, with four cases previously reported in published literature. We present a case of an adolescent female with bilateral, atraumatic acromioclavicular joint dislocation who ultimately was treated with arthroscopic reconstruction of the coracoclavicular ligament. The case is discussed in addition to a review of previously reported cases of voluntary acromioclavicular joint dislocations. Treatment methods in each of the four previously reported cases are discussed with recommendation for surgeons that may encounter this rare shoulder problem in future patients.

The hip fracture assessment tool: A scoring system to assess high risk geriatric hip fracture patients for post-operative critical care monitoring.

INTRODUCTION: Intensive care unit risk stratification models have been utilized in elective joint arthroplasty; however, hip fracture patients are fundamentally different in their clinical course. Having a critical care risk calculator utilizing pre-operative risk factors can improve resourcing for hip fracture patients in the peri­operative period. METHODS: A cohort of geriatric hip fracture patients at a single institution were reviewed over a three-year period. Non-operative patients, peri­implant fractures, additional procedures performed under the same anesthesia period, and patients admitted to the intensive care unit (ICU) prior to surgery were excluded. Pre-operative laboratory values, Revised Cardiac Risk Index (RCRI), and American Society of Anesthesiologists (ASA) scores were calculated. Pre-operative ambulatory status was determined. The primary outcome measure was ICU admission in the post-operative period. Outcomes were assessed with Fisher's exact test, Kruskal-Wallis test, logistic regression, and ROC curve. RESULTS: 315 patient charts were analyzed with 262 patients meeting inclusion criteria. Age ≥ 80 years, ASA ≥ 4, pre-operative hemoglobin < 10 g/dL, and a history of CVA/TIA were found to be significant factors and utilized within a "training" data set to create a 4-point scoring system after reverse stepwise elimination. The 4-point scoring system was then assessed within a separate "validation" data set to yield an ROC area under the curve (AUC) of 0.747. Score ≥ 3 was associated with 96.8 % specificity and 14.2 % sensitivity for predicting post-op ICU admission. Score ≥ 3 was associated with a 50 % positive predictive value and 83 % negative predictive value. CONCLUSION: A hip fracture risk stratification scoring system utilizing pre-operative patient specific values to stratify geriatric hip patients to the ICU post-operatively can improve the pre-operative decision-making of surgical and critical care teams. This has important implications for triaging vital hospital resources. LEVEL OF EVIDENCE: III (retrospective study).

Should patients with lumbar stenosis and grade I spondylolisthesis be treated differently based on spinopelvic alignment? A retrospective, two-year, propensity matched, comparison of patient-reported outcome measures and clinical outcomes from multiple sites within a single health system.

BACKGROUND: Degenerative lumbar spondylolisthesis is one of the most common pathologies addressed by surgeons. Recently, data demonstrated improved outcomes with fusion in conjunction with laminectomy compared to laminectomy alone. However, given not all degenerative spondylolistheses are clinically comparable, the best treatment option may depend on multiple parameters. Specifically, the impact of spinopelvic alignment on patient reported and clinical outcomes following fusion versus decompression for grade I spondylolisthesis has yet to be explored. PURPOSE: This study assessed two-year clinical outcomes and one-year patient reported outcomes following laminectomy with concomitant fusion versus laminectomy alone for management of grade I degenerative spondylolisthesis and stenosis. The present study is the first to examine the effect of spinopelvic alignment on patient-reported and clinical outcomes following decompression alone versus decompression with fusion. STUDY DESIGN/SETTING: Retrospective sub-group analysis of observational, prospectively collected cohort study. PATIENT SAMPLE: 679 patients treated with laminectomy with fusion or laminectomy alone for grade I degenerative spondylolisthesis and comorbid spinal stenosis performed by orthopaedic and neurosurgeons at three medical centers affiliated with a single, tertiary care center. OUTCOME MEASURES: The primary outcome was the change in Patient-Reported Outcome Measurement Information System (PROMIS), Global Physical Health (GPH), and Global Mental Health (GMH) scores at baseline and post-operatively at 4-6 and 10-12 months postoperatively. Secondary outcomes included operative parameters (estimated blood loss and operative time), and two-year clinical outcomes including reoperations, duration of postoperative physical therapy, and discharge disposition. METHODS: Radiographs/MRIs assessed stenosis, spondylolisthesis, pelvic incidence, lumbar lordosis, sacral slope, and pelvic tilt; from this data, two cohorts were created based on pelvic incidence minus lumbar lordosis (PILL), denoted as "high" and "low" mismatch. Patients underwent either decompression or decompression with fusion; propensity score matching (PSM) and coarsened exact matching (CEM) were used to create matched cohorts of "cases" (fusion) and "controls" (decompression). Binary comparisons used McNemar test; continuous outcomes used Wilcoxon rank-sum test. Between-group comparisons of changes in PROMIS GPH and GMH scores were analyzed using mixed-effects models; analyses were conducted separately for patients with high and low pelvic incidence-lumbar lordosis (PILL) mismatch. RESULTS: 49.9% of patients (339) underwent lumbar decompression with fusion, while 50.1% (340) received decompression. In the high PLL mismatch cohort at 10-12 months postoperatively, fusion-treated patients reported improved PROs, including GMH (26.61 vs. 20.75, p<0.0001) and GPH (23.61 vs. 18.13, p<0.0001). They also required fewer months of outpatient physical therapy (1.61 vs. 3.65, p<0.0001) and had lower 2-year reoperation rates (12.63% vs. 17.89%, p=0.0442) compared to decompression-only patients. In contrast, in the low PLL mismatch cohort, fusion-treated patients demonstrated worse endpoint PROs (GMH: 18.67 vs. 21.52, p<0.0001; GPH: 16.08 vs. 20.74, p<0.0001). They were also more likely to require skilled nursing/rehabilitation centers (6.86% vs. 0.98%, p=0.0412) and extended outpatient physical therapy (2.47 vs. 1.34 months, p<0.0001) and had higher 2-year reoperation rates (25.49% vs. 14.71%,p=0.0152). CONCLUSIONS: Lumbar laminectomy with fusion was superior to laminectomy in health-related quality of life and reoperation rate at two years postoperatively only for patients with sagittal malalignment, represented by high PILL mismatch. In contrast, the addition of fusion for patients with low-grade spondylolisthesis, spinal stenosis, and spinopelvic harmony (low PILL mismatch) resulted in worse quality of life outcomes and reoperation rates.

No Difference in Perioperative Complications for Bilateral Total Knee Arthroplasty Staged at 1 Week Compared With Delayed Staging.

INTRODUCTION: Controversy exists regarding the safety of simultaneous bilateral total knee arthroplasty (TKA) versus two TKA procedures staged months apart in patients with bilateral knee arthritis. Here, we investigated a third option: bilateral TKA staged 1 week apart. In this study, we examined the rate of complications in patients undergoing bilateral TKA staged at 1 week compared with longer time intervals. METHODS: A retrospective review of 351 consecutive patients undergoing bilateral TKA at our institution was conducted. Patients underwent a 1-week staged bilateral procedure with planned interim transfer to a subacute rehabilitation facility (short-staged) or two separate unilateral TKA procedures within 1 year (long-staged). Binary logistic regression was used to compare outcomes while controlling for year of surgery, patient age, body mass index, and Charlson Comorbidity Index. RESULTS: Two hundred four short-staged and 147 long-staged bilateral TKA patients were included. The average interval between procedures in long-staged patients was 200.9 ± 95.9 days. Patients undergoing short-staged TKA had a higher Charlson Comorbidity Index (3.0 ± 1.5 versus 2.6 ± 1.5, P = 0.017) with no difference in preoperative hemoglobin ( P = 0.285) or body mass index ( P = 0.486). Regression analysis demonstrated that short-staged patients had a higher likelihood of requiring a blood transfusion (odds ratio 4.015, P = 0.005) but were less likely to return to the emergency department within 90 days (odds ratio 0.247, P = 0.001). No difference was observed in short-term complications ( P = 0.100), 90-day readmissions ( P = 0.250), or 1-year complications ( P = 0.418) between the groups. CONCLUSION: Bilateral TKA staged at a 1-week interval is safe with a comparable complication rate with delayed staged TKA, but allows for a faster total recovery time. LEVEL OF EVIDENCE: Level III.

Preoperative risk stratification minimizes 90-day complications in morbidly obese patients undergoing primary total knee arthroplasty.

AIMS: It has been shown that the preoperative modification of risk factors associated with obesity may reduce complications after total knee arthroplasty (TKA). However, the optimal method of doing so remains unclear. The aim of this study was to investigate whether a preoperative Risk Stratification Tool (RST) devised in our institution could reduce unexpected intensive care unit (ICU) transfers and 90-day emergency department (ED) visits, readmissions, and reoperations after TKA in obese patients. METHODS: We retrospectively reviewed 1,614 consecutive patients undergoing primary unilateral TKA. Their mean age was 65.1 years (17.9 to 87.7) and the mean BMI was 34.2 kg/m2 (SD 7.7). All patients underwent perioperative optimization and monitoring using the RST, which is a validated calculation tool that provides a recommendation for postoperative ICU care or increased nursing support. Patients were divided into three groups: non-obese (BMI < 30 kg/m2, n = 512); obese (BMI 30 kg/m2 to 39.9 kg/m2, n = 748); and morbidly obese (BMI > 40 kg/m2, n = 354). Logistic regression analysis was used to evaluate the outcomes among the groups adjusted for age, sex, smoking, and diabetes. RESULTS: Obese patients had a significantly increased rate of discharge to a rehabilitation facility compared with non-obese patients (38.7% (426/1,102) vs 26.0% (133/512), respectively; p < 0.001). When stratified by BMI, discharge to a rehabilitation facility remained significantly higher compared with non-obese (26.0% (133)) in both obese (34.2% (256), odds ratio (OR) 1.6) and morbidly obese (48.0% (170), OR 3.1) patients (p < 0.001). However, there was no significant difference in unexpected ICU transfer (0.4% (two) non-obese vs 0.9% (seven) obese (OR 2.5) vs 1.7% (six) morbidly obese (OR 5.4); p = 0.054), visits to the ED (8.6% (44) vs 10.3% (77) (OR 1.3) vs 10.5% (37) (OR 1.2); p = 0.379), readmissions (4.5% (23) vs 4.0% (30) (OR 1.0) vs 5.1% (18) (OR 1.4); p = 0.322), or reoperations (2.5% (13) vs 3.3% (25) (OR 1.2) vs 3.1% (11) (OR 0.9); p = 0.939). CONCLUSION: With the use of a preoperative RST, morbidly obese patients had similar rates of short-term postoperative adverse outcomes after primary TKA as non-obese patients. This supports the assertion that morbidly obese patients can safely undergo TKA with appropriate perioperative optimization and monitoring. Cite this article: Bone Joint J 2021;103-B(6 Supple A):45-50.

Determination of the Optimal Location for Bone Graft Harvest in the Distal Radius.

Background: The distal radius is commonly used as a bone graft donor site for surgery in the hand and wrist. The aim of this study was to evaluate the volume and relative density of cancellous bone in the distal radius. Methods: Thirty-four consecutive computed tomographic scans of the wrist in 33 patients without distal radius pathology were included. For each subject, 6 spherical regions of interest (ROIs) were identified within the distal radius. In each ROI, volumetric measurements and mean Hounsfield unit (HFU) values were recorded by 2 observers using a 3-dimensional imaging reconstruction software. Results: Compared with proximal bone, distal bone had larger volume (0.82 vs 0.27 cm3) and greater relative density (178 vs 152 HFU) on average. Among the 6 ROIs, the distal-central region had the largest average volume (1.20 cm3) and the distal-ulnar ROI had the greatest average relative density (193 HFU). Conclusion: Based on these results, we recommend performing cancellous autograft harvest relatively distal and ulnar within the distal radius.

Comparison of Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Fixation for Medial Malleolus Fractures.

INTRODUCTION: Surgical treatment of medial malleolus (MM) fractures can be performed through open or percutaneous approaches, although comparisons between these two approaches have not been undertaken. In this study, we compared patients with MM fractures treated with closed reduction and percutaneous fixation (CRPF) with patients treated with traditional open reduction and internal fixation (ORIF). METHODS: A group of 165 consecutive patients underwent surgical fixation of a closed MM fracture from 2011 to 2015 at a single institution. Thirty-one underwent CRPF and 134 underwent ORIF. Patient demographics, injury characteristics, treatment methods, and outcome variables were recorded through review of patient charts, radiographs, and surgical reports. RESULTS: The rate of MM fracture comminution was higher in the ORIF group compared with the CRPF group (9.7% vs 27.6%; P = 0.04). All other patient and injury variables were similar between the two groups. There was no statistically significant difference observed between the CRPF and ORIF groups regarding outcomes, including nonunion, malunion, time to union, rate of hardware removal, and wound complications. DISCUSSION: Both CRPF and ORIF resulted in acceptable radiographic outcomes and low complication rates for the treatment of MM fractures.