Risk factors for malalignment after intramedullary nail treatment of distal tibia fractures with associated fibula fractures.

PURPOSE: Malalignment of distal tibia fractures can lead to malunion/nonunion or alter the limb mechanical axis which may cause arthritis. Proposed methods to decrease malalignment include fibular fixation or multiplanar interlocking screws, however these remain controversial. This study aimed to identify factors associated with malalignment in distal tibial fractures with associated fibular shaft fractures. METHODS: A retrospective review was performed of distal tibia fractures with associated fibular shaft fractures treated with intramedullary nailing at two level one trauma centers between 2015 and 2019. Cases involving malalignment (> 5° of deviation from anatomic axis on either coronal/sagittal axis) on final follow-up (minimum three months postoperatively) were compared to those without malalignment with regard to demographics, fracture characteristics, intraoperative characteristics, and complications. RESULTS: The rate of malalignment was 13%. On multivariate analysis, multiplanar distal interlocking screw fixation (odds ratio [OR], 0.18; 95% confidence interval [CI] 0.03-0.92) was associated with a decreased rate of final malalignment, while nail diameter > 10 mm was associated with a higher rate (OR, 4.05; 95% CI 1.25-13.11). Fibular fixation was not associated with malalignment. CONCLUSION: Multiplanar distal interlocking screws may protect against malalignment. Fibula fixation does not appear associated with a decreased rate of malalignment in distal tibia fractures treated with intramedullary nails. LEVEL OF EVIDENCE: III.

Comparing Pain and Pain Coping Mechanisms in Patients Undergoing Total Joint Arthroplasty as Part of a Mission Trip to Those in the United States.

BACKGROUND: Access to total joint arthroplasty can be difficult in low-resource settings. Service trips are conducted to provide arthroplasty care to populations in need around the world. This study aimed to compare the pain, function, surgical expectations, and coping mechanisms of patients from one such service trip to the United States. METHODS: In 2019, the Operation Walk program conducted a service trip in Guyana during which 50 patients had hip or knee arthroplasties. Patient demographics, patient-reported outcome measures, questionnaires assessing pain attitudes and coping, and pain visual analog scales were collected preoperatively and at 3 months postoperatively. These outcomes were compared with a matched cohort of elective total joint arthroplasty at a US tertiary care medical center. There were 37 patients matched between the 2 cohorts. RESULTS: The mission cohort had significantly lower preoperative self-reported function scores than the US cohort (38.3 versus 47.5, P = .003), as well as a significantly larger improvement at 3 months (42.4 versus 26.4, P = .014). The mission cohort had significantly higher initial pain (8.0 versus 7.0, P = .015), but there were no differences with regard to pain at 3 months (P = .420) or change in pain (P = .175). The mission cohort had significantly greater preoperative scores in pain attitude and coping responses. CONCLUSION: Patients in low-resource settings were more likely to have preoperative functional limitations and pain, and they coped with pain through prayer. Understanding the key differences between these 2 types of populations and how they approach pain and functional limitations may help improve care for each group. LEVEL OF EVIDENCE: II, prospective study.

Ultracongruent Designs Compared to Posterior-Stabilized and Cruciate-Retaining Tibial Inserts - What Does the Evidence Tell Us? A Systematic Review and Meta-Analysis.

BACKGROUND: Posterior-stabilized (PS) and cruciate-retaining (CR) have been the most common tibial designs used in total knee arthroplasty. Ultra-congruent (UC) inserts are becoming popular because they preserve bone without relying on the posterior cruciate ligament balance and integrity. Despite increasing use, there is no consensus on how UC inserts perform versus PS and CR designs. METHODS: A comprehensive literature search of 5 online databases was performed for articles from January 2000 to July 2022 comparing the kinematic and clinical outcomes of PS or CR tibial inserts to UC inserts. There were nineteen studies included. There were 5 studies comparing UC to CR and 14 comparing UC to PS. Only one randomized controlled trial (RCT) was rated "good quality". RESULTS: For CR studies, pooled analyses showed no difference in knee flexion (n = 3, P = .33) or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (n = 2, P = .58). For PS studies, meta-analyses showed better anteroposterior stability (n = 4, P < .001) and more femoral rollback (n = 2, P < .001) for PS but no difference in knee flexion (n = 9, P = .55) or medio-lateral stability (n = 2, P = .50). There was no difference with WOMAC (n = 5, P = .26), Knee Society Score (n = 3, P = .58), Knee Society Knee Score (n = 4, P = .76), or Knee Society Function Score (n = 5, P = .51). CONCLUSION: Available data demonstrates there are no clinical differences between CR or PS and UC inserts in small short-term studies ending around 2 years after surgery. More importantly, high-quality research comparing all inserts is lacking, demonstrating a need for more uniform and longer-term studies beyond 5 years after surgery to justify increased UC usage.

How sandbag-able are concussion sideline assessments? A close look at eye movements to uncover strategies.

Background: Sideline diagnostic tests for concussion are vulnerable to volitional poor performance ("sandbagging") on baseline assessments, motivated by desire to subvert concussion detection and potential removal from play. We investigated eye movements during sandbagging versus best effort on the King-Devick (KD) test, a rapid automatized naming (RAN) task.Methods: Participants performed KD testing during oculography following instructions to sandbag or give best effort.Results: Twenty healthy participants without concussion history were included (mean age 27 ± 8 years). Sandbagging resulted in longer test times (89.6 ± 39.2 s vs 48.2 ± 8.5 s, p < .001), longer inter-saccadic intervals (459.5 ± 125.4 ms vs 311.2 ± 79.1 ms, p < .001) and greater numbers of saccades (171.4 ± 47 vs 138 ± 24.2, p < .001) and reverse saccades (wrong direction for reading) (21.2% vs 11.3%, p < .001). Sandbagging was detectable using a logistic model with KD times as the only predictor, though more robustly detectable using eye movement metrics.Conclusions: KD sandbagging results in eye movement differences that are detectable by eye movement recordings and suggest an invalid test score. Objective eye movement recording during the KD test shows promise for distinguishing between best effort and post-injury performance, as well as for identifying sandbagging red flags.

A Fall Within 3 Months Before Total Joint Arthroplasty is Associated With Adverse Outcomes in Elderly Patients.

BACKGROUND: Falls are associated with morbidity and death in the elderly. The consequences of falls after total joint arthroplasty (TJA) are known, but the consequences of preoperative falls are unclear. We assessed associations between preoperative fall history and hospital readmission rates and discharge disposition after primary TJA. METHODS: We queried the National Surgical Quality Improvement Program Geriatric Pilot Project for cases of primary total hip arthroplasty (THA) (n = 3671) and total knee arthroplasty (TKA) (n = 6194) performed between 2014 and 2018 for patients aged ≥65 years. Patient characteristics, comorbidities, functional status indicators, and 30-day outcomes were compared among patients with falls occurring within 3 months, from >3 to 6 months, and from >6 to 12 months before surgery, and patients with no falls in the year before surgery. The timing of falls was assessed for independent associations with hospital readmission and discharge to a skilled care facility (SCF). Alpha = 0.05. RESULTS: Patients who fell within 3 months before surgery had greater odds of SCF discharge (for THA, odds ratio [OR] 2.5, 95% confidence interval [CI] 1.8-3.4; for TKA, OR 1.8, 95% CI 1.4-2.3) and hospital readmission (for THA, OR 1.8, 95% CI 1.1-3.0; for TKA, OR 2.4, 95% CI 1.6-3.5) compared with the no-fall cohort. No such associations were observed for the other two fall cohorts. CONCLUSION: Falls within 3 months before primary TJA are associated with SCF discharge and readmission for patients aged ≥65 years. Fall history screening should be included in preoperative evaluation. LEVEL OF EVIDENCE: III.

Routine Basic Metabolic Panels Are Not Needed in All Patients After Primary Total Joint Arthroplasty: An Opportunity for Cost Reduction.

BACKGROUND: As the incidence of total joint arthroplasty (TJA) increases, identifying methods for cost reduction is essential. Basic metabolic panels (BMPs) are obtained routinely after TJA. We aimed at assessing the prevalence of intervention secondary to abnormal BMPs after primary TJA and at identifying predictors of the need for postoperative BMPs. METHODS: We reviewed 802 cases (758 patients) of primary lower-extremity TJA performed from January 1 through December 31, 2018, at our tertiary care medical center. Patient characteristics, preoperative and postoperative BMPs, comorbidities, current medications, and in-hospital interventions were recorded. Age-adjusted Charlson Comorbidity Index (AA-CCI) values were calculated. Institutional costs of 1 BMP and of all BMPs not prompting intervention were calculated. We used multiple regression to identify independent predictors of in-hospital interventions secondary to abnormal postoperative BMPs. RESULTS: Our institutional BMP cost was $36. A total of 1032 postoperative BMPs were ordered; 958 (93%) prompted no intervention. This equated to $34,488 of avoidable BMP costs. We identified 27 cases (3.4%) requiring intervention secondary to abnormal BMPs. Independent predictors of intervention were preoperative renal dysfunction (ie, abnormal creatinine or glomerular filtration rate <60 mL/min) (odds ratio [OR], 7.8; 95% confidence interval [CI], 2.8-22), number of current nephrotoxic medications (OR, 1.9; 95% CI, 1.3-2.9), and AA-CCI value (OR, 1.2; 95% CI, 1.0-1.5). CONCLUSION: Routine postoperative BMPs are unwarranted for most patients undergoing primary TJA. Testing may be reserved for those with renal dysfunction, those taking multiple nephrotoxic medications, or those with a high AA-CCI value.

Published Operative Times Do Not Reflect Surgeon Effort: A Novel Approach for Calculating Operative Times in Total Hip Arthroplasty to Better Quantify Surgeon Work.

BACKGROUND: Current estimates of operative time (OT) for total hip arthroplasty (THA) are reported as the mean OT across all procedures. This method does not reflect variability among surgeons and surgical settings and should not be used to infer individual surgeon work. We hypothesized that this method would underestimate the time it takes individual surgeons to perform THA. Therefore, we compared the mean OT for all THA cases ("overall OT") with the mean OT for individual surgeons ("individual surgeon OT") and examined which factors were associated with each. METHODS: Mean OT was calculated for 3972 primary THA cases ("overall OT") by 41 surgeons from 2015 to 2018 in a single health system. The mean OT for each surgeon was determined ("individual surgeon OT"), averaged across surgeons, and compared with overall OT. Overall OT and individual surgeon OT were assessed for associations with surgeon-related (adult reconstruction fellowship training, THA volume, years' experience), hospital-related (hospital type, trainee presence), and patient-related (age, body mass index category, American Society of Anesthesiologists physical status classification) factors (alpha = 0.05). RESULTS: Mean individual surgeon OT was significantly longer (106 ± 21 minutes) than overall OT (96 ± 28 minutes) (P = .03), with 73% of individual surgeon OTs being greater than overall OT. Although all surgeon-, hospital-, and patient-related factors were associated with significant differences in overall OT, only hospital type was associated with differences in individual surgeon OT. CONCLUSION: Individual surgeon OT was longer than overall OT for most surgeons and provides a better estimate of surgeon work.

Humanitarian Needs: The Arthroplasty Community and the COVID-19 Pandemic.

BACKGROUND: As the world struggles with the COVID-19 pandemic, health care providers are on the front lines. We highlight the value of engaging in humanitarian medical work, contributions of the hip and knee arthroplasty community to date, and future needs after the resolution of the pandemic. We sought to understand how the arthroplasty community can contribute, based on historical lessons from prior pandemics and recessions, current needs, and projections of the COVID-19 impact. METHODS: We polled members of medical mission groups led by arthroplasty surgeons to understand their current efforts in humanitarian medical work. We also polled orthopedic colleagues to understand their role and response. Google Search and PubMed were used to find articles relevant to the current environment of the COVID-19 pandemic, humanitarian needs after previous epidemics, and the economic effects of prior recessions on elective surgery. RESULTS: Hip and knee arthroplasty surgeons are not at the center of the pandemic but are providing an invaluable supportive role through continued care of musculoskeletal patients and unloading of emergency rooms. Others have taken active roles assisting outside of orthopedics. Arthroplasty humanitarian organizations have donated personal protective equipment and helped to prepare their partners in other countries. Previous pandemics and epidemics highlight the need for sustained humanitarian support, particularly in poor countries or those with ongoing conflict and humanitarian crises. CONCLUSION: There are opportunities now to make a difference in this health care crisis. In the aftermath, there will be a great need for humanitarian work both here and throughout the world.

Routine Preoperative Nutritional Screening in All Primary Total Joint Arthroplasty Patients Has Little Utility.

BACKGROUND: Nutritional optimization before total joint arthroplasty (TJA) may improve patient outcomes and decrease costs. However, the utility of serologic laboratory markers, including albumin, transferrin, and total lymphocyte count (TLC), as primary indicators of nutrition is unclear. We analyzed the prevalence of abnormal nutritional values before TJA and identified factors associated with them. METHODS: We retrospectively reviewed 819 primary cases of TJA performed at 1 institution from January to December 2018. Patient demographic characteristics were assessed for associations with abnormal preoperative nutritional values (albumin <3.5 g/dL, transferrin <200 mg/dL, and TLC <1.5 cells/µL3). Associations of comorbidities, American Society of Anesthesiologists Physical Status classification, and age-adjusted Charlson Comorbidity Index (CCI) with abnormal values were assessed with logistic regression. RESULTS: Values were abnormal for albumin in 21 cases (2.6%), transferrin in 26 cases (5.6%), and TLC in 185 cases (25%). Thirteen cases (1.7%) had abnormal values for 2 markers. Age was associated with abnormal albumin and TLC, and race with abnormal transferrin. Congestive heart failure, chronic kidney disease, pancreatic insufficiency, gastroesophageal reflux disease, osteoporosis, dementia, and CCI were associated with abnormal albumin; Parkinson disease and American Society of Anesthesiologists Physical Status with abnormal transferrin; and dementia, body mass index, cancer history, and CCI with abnormal TLC. CONCLUSION: We report low prevalence of and a low concordance rate among abnormal nutritional values before primary TJA. Our results suggest that routine testing of all healthy patients is not warranted before TJA.

Surgeon Mean Operative Times in Total Knee Arthroplasty in a Variety of Settings in a Health System.

BACKGROUND: High-quality care is essential in total joint arthroplasty. Multiple initiatives such as centers of excellence, patient optimization, and alternative payment models have demonstrated improved outcomes and decreased cost. Many studies have shown that longer operative times (OTs) are associated with increased frequency of postoperative complications. These findings often come from large data sets and may not accurately represent the average OT of individual surgeons. The purpose of this study was to determine the hospital and patient-related factors that influence OT. METHODS: This retrospective study reviewed OT of 6003 total knee arthroplasty cases performed by 41 surgeons at 4 hospitals in a single health-care system. Mean OT was calculated for each surgeon. The effect of surgeon, hospital-, and patient-related factors on OT was assessed. RESULTS: Among the 41 surgeons, the mean OT was 105 ± 25 minutes. Two community hospitals had significantly faster OT compared with the tertiary care academic hospital. Surgeons' OT for morbidly obese patients was significantly longer compared with normal, overweight, and obese patients. Surgeon volume, surgeon experience, trainee presence, and American Society of Anesthesiologists status did not significantly affect surgical time. CONCLUSIONS: Operative time was influenced by hospital-related (tertiary, community) and patient-related (morbid obesity vs lower body mass index groups) factors. However, specific surgeon factors (surgical volume, experience), surgical team factors (presence or absence of trainee), and patient factors (American Society of Anesthesiologists status) did not significantly alter the OT. Additional studies of larger health systems are needed to examine additional patient, surgeon, and hospital factors which may influence the OT.

Nail-plate Combination Treatment of Ipsilateral Humeral Shaft and Distal Humerus Fractures - A Case Report.

Introduction: Humeral shaft and distal humerus fractures have several different treatment options, including plate fixation and intramedullary nailing. Each has its own benefits, but typically, they are not used in conjunction. While nail-plate combinations (NPCs) have become more common in the lower extremity, literature on their use in upper extremity fractures remains scarce. Case Report: A 74-year-old right-hand dominant male presented after a fall with a closed left transverse midshaft humerus fracture and an associated supracondylar distal humerus fracture with intercondylar extension through a medial column. Due to the segmental nature of his injury, medial column plating was used in conjunction with a retrograde intramedullary nail to obtain anatomic reduction and fixation of the articular injury while stabilizing the midshaft humerus fracture with minimal soft tissue disruption. The patient was recommended non-weight bearing through his left arm for 6 weeks, at which point he returned to weight bearing as tolerated. He was allowed to range his left elbow after 2 weeks. His left elbow range of motion at the 4-month follow-up was 20-135 degrees, and he reported minimal pain. Conclusion: The retrograde NPC should be considered in segmental humeral fractures involving the distal articular surface and midshaft humerus fractures as it limits violation of the soft tissue while avoiding iatrogenic disruption of the articular surface at the shoulder or elbow.

Comparison of estimated glomerular filtration rate using five equations to predict acute kidney injury following hip fracture surgery.

BACKGROUND: Decreased estimated glomerular filtration rate (eGFR) is associated with acute kidney injury (AKI) following hip fracture surgery. Delaying surgery for preoperative treatment of comorbidities is controversial in this patient population. The purpose of this study was 1) to assess differences in demographics and comorbidities between AKI and non-AKI groups, 2) to analyze equations used in calculating eGFR, and 3) to identify the equation which best predicts the development of AKI following hip fracture surgery. We hypothesize that one of the equations used to calculate eGFR will be superior to the others. PATIENTS AND METHODS: 124,002 cases of hip fracture surgery were performed from 2012 to 2019, based upon a query of the National Surgical Quality Improvement Program (NSQIP). Preoperative eGFR was calculated using the following: Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Chronic Kidney Disease Epidemiology Collaboration, Mayo quadratic, and Cockcroft-Gault equations. Independent associations between preoperative eGFR and postoperative renal failure were evaluated using multivariate regression analysis. The predictive ability of each equation was determined using the Akaike information criterion (AIC). RESULTS: AKI was diagnosed in 584 (0.71%) out of the 82,326 patients following hip fracture surgery. The AKI and no AKI cohorts differed significantly by patient sex (p = <0.001), race (p = <0.001), BMI (p = < 0.001), preoperative hematocrit (p = <0.001), preoperative albumin (p = <0.001), diabetes mellitus (p = <0.001), hypertension (p = <0.001), and congestive heart failure (p = <0.001). The Mayo equation (84.0 ± 23.7) was the equation with the highest calculated mean eGFR, followed by the CKD-EPI equation (83.6 ± 20.0), MDRD II equation (83.0 ± 38.9), CG equation (74.7 ± 35.5), and finally the re-expressed MDRD II equation (68.5 ± 36.0) which had the lowest calculated mean eGFR.. All five equations detected that a decrease in preoperative eGFR was associated with an increased risk of postoperative AKI. Lower preoperative eGFR, as calculated by each of the five equations, was significantly associated with an increased risk of AKI following surgical fixation of hip fracture. The AIC was the lowest in the Mayo equation, demonstrating the best fit of the equations to predict postoperative AKI CONCLUSIONS: We propose that using the equation that best identifies those at risk of developing postoperative AKI may help with perioperative decision making and treatment to improve outcomes, which we found to be the Mayo equation. The risk of postoperative AKI was independently associated with decreased preoperative eGFR. The results of this study may warrant further investigation utilizing prospective studies. LEVEL OF EVIDENCE: III; retrospective cohort study.

Comparison of Short-Arm Immobilization and Long-Arm Immobilization in Conservatively Managed Distal Radius Fractures: A Meta-Analysis and Systematic Review.

Distal radius fractures are often treated conservatively with immobilization. Immobilizing above the elbow limits forearm rotation, though recent literature has suggested the effects on radiographic or functional outcomes may be negligible. This systematic review and meta-analysis aimed to analyze the radiographic and functional outcome scores of distal radius fractures managed with short-arm (SA) immobilization and long-arm (LA) immobilization. An electronic systematic search was performed of the PubMed and EMBASE databases from inception to October 5, 2022. All randomized controlled trials (RCTs) involving patients with acute distal radius fractures undergoing nonoperative treatment (involving application/maintenance of immobilization) comparing above-elbow versus below-elbow constructs were included. The outcomes of interest were changes in radiographic parameters (loss of volar tilt [VT], radial height [RH], and radial inclination [RI]), loss of reduction, requirement for surgery, and patient-reported functional outcomes (Disabilities of the Arm, Shoulder, or Hand [DASH] or Quick DASH survey). The Cochrane Risk of Bias Tool 2.0 was used for study quality assessment. The effect size of the interventions was assessed using random effect models to calculate mean differences (MDs) for continuous variables and odds ratios (ORs) for categorical variables. Standardized mean difference (SMD) was calculated for patient-reported functional outcome scores. Nine studies involving 983 cases were included, including 497 SA and 486 LA. No statistically significant differences were observed with regards to VT (P = 0.83), RH (P = 0.81), RI (P = 0.35), loss of reduction (P = 0.33), requirement for surgery (P = 0.33), or patient-reported functional outcomes (P = 0.10). There was no difference in radiographic outcomes, need for surgery, or functional scores among patients treated with SA and LA immobilization. Utilizing SA immobilization is a safe option for conservative management of distal radius fractures and the benefits of mitigating complications associated with LA immobilization may supersede the theoretical limited forearm rotational stability observed with SA immobilization. Further study is required to determine the optimal method of SA immobilization.

Evaluation of the Posterior Tilt Angle in Predicting Failure of Nondisplaced Femoral Neck Fractures After Internal Fixation: A Systematic Review.

OBJECTIVE: To evaluate the posterior tilt angle (PTA) in predicting treatment failure after internal fixation of nondisplaced femoral neck fractures as graded by the Garden classification, which is based solely on anterior-posterior radiographic evaluation. DATA SOURCES: A search was conducted of all published literature in the following databases from inception to December 20, 2021: PubMed, Embase, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov . STUDY SELECTION: We included English-language randomized controlled trials, prospective and retrospective cohort studies that reported malunion/nonunion, avascular necrosis, fixation failure, or reoperations in patients with nondisplaced femoral neck fractures treated with internal fixation who were evaluated for PTA using either lateral radiograph or computed tomography. DATA EXTRACTION: All abstract, screening, and quality appraisal was conducted independently by 2 authors. Data from included studies were extracted manually and summarized. The Methodological Index for Non-Randomized Studies criteria was used for quality appraisal. DATA SYNTHESIS: Odds ratios with 95% confidence intervals were calculated for treatment failure, defined as nonunion/malunion, avascular necrosis, fixation failure, or reoperation, in cases involving preoperative PTA ≥20-degrees and <20-degrees. Statistical significance was set at P < 0.05. RESULTS: Nondisplaced femoral neck fractures with PTA >20-degrees had a 24% rate of treatment failure compared with 12% for those <20-degrees [odds ratios, 3.21 (95% confidence intervals, 1.95-5.28); P < 0.001]. CONCLUSION: PTA is a predictor of treatment failure in nondisplaced femoral neck fractures treated with internal fixation. Nondisplaced femoral neck fractures with a PTA >20-degrees may warrant alternative treatment modalities. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute kidney injury in the context of staged revision arthroplasty and the use of antibiotic-laden cement spacers: a systematic review.

BACKGROUND: The most common cause of revision arthroplasty is prosthetic joint infection (PJI). Chronic PJI is commonly treated with two-stage exchange arthroplasty involving the placement of antibiotic-laden cement spacers (ACS) in the first stage, often containing nephrotoxic antibiotics. These patients often have significant comorbidity burdens and have higher rates of acute kidney injury (AKI). This systematic review aims to assess the current literature to identify (1) AKI incidence, (2) associated risk factors, and (3) antibiotic concentration thresholds in ACS that increase AKI risk following first-stage revision arthroplasty. METHODS: An electronic search was performed of the PubMed database of all studies involving patients undergoing ACS placement for chronic PJI. Studies assessing AKI rates and risk factors were screened by two authors independently. Data synthesis was performed when possible. Significant heterogeneity prevented meta-analysis. RESULTS: Eight observational studies consisting of 540 knee PJIs and 943 hip PJIs met inclusion criteria. There were 309 (21%) cases involving AKI. The most commonly reported risk factors included perfusion-related factors (lower preoperative hemoglobin, transfusion requirement, or hypovolemia), older age, increased comorbidity burden, and nonsteroidal anti-inflammatory drug consumption. Only two studies found increased risk with greater ACS antibiotic concentration (> 4 g vancomycin and > 4.8 g tobramycin per spacer in one study, > 3.6 g of vancomycin per batch or > 3.6 g of aminoglycosides per batch in the other); however, these were reported from univariate analyses not accounting for other potential risk factors. DISCUSSION: Patients undergoing ACS placement for chronic PJI are at an increased risk for AKI. Understanding the risk factors may lead to better multidisciplinary care and safer outcomes for chronic PJI patients.

Not All Patients Need Supervised Physical Therapy After Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

Although postoperative physical therapy (PT) has long been considered essential to successful total knee arthroplasty (TKA) recovery, recent literature has suggested that unsupervised home exercise regimens may offer similar benefits to formal supervised sessions. We aimed to compare objectively measured physical function and subjective patient-reported outcomes (PROs) between primary TKA patients who received formal supervised physical therapy sessions and those who received unsupervised home exercise regimens after discharge. Six electronic databases were queried to identify randomized controlled trials comparing supervised physical therapy to unsupervised home exercise regimens in primary TKA patients after discharge. Outcomes of interest included change from baseline in objective measures (knee flexion range of motion (ROM), lower extremity strength, and aerobic capacity) and PROs (physical function and quality of life scores). These outcomes were subdivided into short-term (<6 months from surgery; closest data point to three months is used if multiple measurements were made in this time period) and long-term (≥6 months from surgery; closest data point to 12 months is used if multiple measurements were made in this time period) assessments. A total of 1,884 cases performed in 11 studies were included in this review. There were no significant differences between cohorts with regard to short-term knee flexion ROM (p = 0.7), lower extremity strength (p = 0.6), or patient-reported quality of life (p = 0.5), as well as long-term knee flexion ROM (p = 0.7), patient-reported quality of life (p = 0.2), or patient-reported physical outcome scores (p = 0.3). A small difference in short-term patient-reported physical outcomes was observed in favor of the supervised cohort (standardized mean difference (SMD): 0.3 (95% confidence interval (CI): 0.01, 0.6); I2 = 82%; p = 0.04). Formal supervised physical therapy regimens do not confer clinically significant benefits over unsupervised home exercise regimens following primary TKA. The routine use of supervised physical therapy after discharge may not be warranted. Further study is needed to determine the subset of patients that may benefit from supervised care.

Predictors of Hospice Discharge After Surgical Fixation of Hip Fractures.

BACKGROUND: Each year, over 300,000 people older than 65 years are hospitalized for hip fractures. Given the notable morbidity and mortality faced by elderly patients in the postinjury period, recommendations have been put forth for integrating palliative and, when needed, hospice care to improve patients' quality of life. Our objective was to (1) understand the proportion of patients discharged to hospice after hip fracture surgery and their 30-day mortality rates and (2) identify the independent predictors of discharge to hospice. METHODS: We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program for all hip fracture surgeries between the years of 2016 and 2018. Included cases were stratified into two cohorts: cases involving a discharge to hospice and nonhospice discharge. Variables assessed included patient demographics, comorbidities, perioperative characteristics, and postoperative outcomes. Differences between hospice and nonhospice patients were compared using chi-squared analysis or the Fisher exact test for categorical variables and Student t -tests for continuous variables. A binary logistic regression model was used to assess independent predictors of hospice discharge with 30-day mortality. RESULTS: Overall, 31,531 surgically treated hip fractures were identified, of which only 281 (0.9%) involved a discharge to hospice. Patients discharged to hospice had a 67% 30-day mortality rate in comparison with 5.6% of patients not discharged to hospice ( P < 0.001). Disseminated cancer, dependent functional status, >10% weight loss over 6 months preoperatively, and preoperative cognitive deficit were the strongest predictors of hospice discharge with 30-day mortality after hip fracture surgery. CONCLUSIONS: Current hospice utilization in hip fracture patients remains low, but 30-day mortality in these patients is high. An awareness of the associations between patient characteristics and discharge to hospice with 30-day mortality is important for surgeons to consider when discussing postoperative expectations and outcomes with these patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Determining a preoperative international normalised ratio threshold safe for hip fracture surgery.

INTRODUCTION: The purpose of this study was first, to assess the relationship between preoperative INR (international normalised ratio) and postoperative complication rates in patients with a hip fracture, and second, to establish a threshold for INR below which the risk of complications is comparable to those in patients with a normal INR. METHODS: We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program and found 35,910 cases who had undergone surgery for a hip fracture between 2012 and 2018. Cases were stratified into 4 groups based on their preoperative INR levels: <1.4; ⩾1.4 and <1.6; ⩾1.6 and <1.8 and ⩾1.8. These cohorts were assessed for differences in preoperative factors, intraoperative factors, and postoperative course. Multivariate logistic regression was used to assess the risk of transfusion, 30-day mortality, cardiac complications, and wound complications adjusting for all preoperative and intraoperative factors. RESULTS: Of the 35,910 cases, 33,484 (93.2%) had a preoperative INR < 1.4; 867 (2.4%) an INR ⩾1.4 and <1.6; 865 (2.4%) an INR ⩾ 1.6 and <1.8 and 692 (1.9%) an INR ⩾ 1.8. A preoperative INR ⩾ 1.8 was independently associated with an increased risk of bleeding requiring transfusion. A preoperative INR ⩾ 1.6 was associated with an increased risk of mortality. CONCLUSIONS: We found that an INR of <1.6 is a safe value for patients who are to undergo surgery for a hip fracture. Below this value, patients avoid an increased risk of both transfusion and 30-day mortality seen with higher INR values. These findings may allow adjustment of preoperative protocols and improve the outcome of hip fracture surgery in this group of patients.