Perioperative management of acetabular and pelvic fractures: evidence-based recommendations.

PURPOSE: The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF. METHODS: A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis. RESULTS: A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic. CONCLUSION: The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Time-Driven Activity-Based Costing in Preoperative Tasks for Total Hip and Knee Arthroplasty.

BACKGROUND: Substantial work in the preoperative phase of total hip arthroplasty (THA) and total knee arthroplasty (TKA) is unaccounted for in current Relative Value Scale Update Committee methodology. A Time-Driven Activity-Based Costing (TDABC) analysis allows for an accurate assessment of the preoperative costs associated with total joint replacement surgery. METHODS: The mean time that clinical staff members spent on preoperative tasks per patient was multiplied by the hourly salary. Clinical staff members included orthopedic surgeons, nurse practitioners or physician assistants, nurses, medical assistants, and surgical coordinators. Mean time spent on preoperative tasks was obtained from the most recent literature. Salaries were obtained from the nationwide database provided by Glassdoor Inc. RESULTS: Total time spent among clinical staff involved in preoperative tasks for each arthroplasty patient was 8.45 hours (2.96-13.94). Total TDABC was calculated to be $348.17 (132.46-562.64). Accounting for preoperative tasks, the TDABC for TKA/THA increases from $13321.5 to $13669.67. Preoperative tasks are composed of 2.6% of total TKA/THA TDABC. In 2020, an estimated $544,189,710 of preoperative TKA/THA work was completed. CONCLUSION: Surgeons, providers, and ancillary staff involved in THA/TKA spend a cumulative preoperative work time of approximately 8.5 hours per patient, which equates to $348.17 that is currently unaccounted for in Relative Value Scale Update Committee methodology.

Survivorship and Outcomes of Femoral Neck Preserving Stems in Primary Total Hip Arthroplasty.

BACKGROUND: Short-stem femoral implants (SSFIs) promote the preservation of bone in the femoral neck, reduce soft tissue disruption, and facilitate minimally invasive surgical techniques. The purpose of this study was to report the revision rate, complication rate, patient satisfaction, patient-reported outcomes, and radiographic outcomes of patients who underwent total hip arthroplasty (THA) with the Alteon Neck Preserving Femoral Stem (ANPS). METHODS: A prospectively maintained database was reviewed which analyzed 92 THAs between the years 2016 and 2018. Patient-reported outcomes, patient satisfaction, complication rates, and radiographic outcomes were assessed at 2-5 years postoperatively. RESULTS: The final cohort consisted of 63 hips. Five patients (7.9%) underwent revision surgery and 2 (3.2%) had other complications not requiring revision. Survivorship when considering only the femoral component was 93.7% at an average of 41.4 months of follow-up. The average postoperative Oxford Hip Score (41.5 ± 8.3) and Harris Hip Score (77.9 ± 16.6) demonstrated significant improvement among our nonrevised patients, respectively (P < .001). Radiographs demonstrated spot welding in 56% of arthroplasties most commonly in Gruen Zones 2, 3, and 13 and that femur radiolucencies were visualized in 58% predominantly along the distal aspect of the stem. Radiographic femoral component subsidence was present in 9.7% of patients. CONCLUSION: The ANPS may be less reliable than previously reported. Our cohort's revision rate was unacceptably high with 6.3% requiring revision surgery for femoral component loosening in less than 5 years. Surgeons should consider the challenges and prohibitive failure rate associated with SSFIs before routine usage in THA.

Dynamic Locking Plate versus Multiple Cancellous Screws for the Fixation of Intracapsular Femoral Neck Fractures: Long-Term Results and Quality-Of-Life Assessment Based on Patient-Reported Outcome Measures.

The purpose of this study was to compare the long-term clinical outcomes and quality-of-life measures for two fixation methods in the setting of displaced femoral neck fractures. The two groups included fixation with multiple cancellous screws (group 1) and telescopic femoral neck screws and a small locking plate device (Targon FN) (group 2). Patients underwent reduction and internal fixation with either multiple cancellous screws or the Targon FN device from March 2000 to January 2012. Failure endpoints included nonunion, osteonecrosis of the femoral head, and revision surgery. Patient-reported outcome measures included chronic pain, ability to ambulate, and the use of ambulation assistive devices. Statistical analysis demonstrated a statistically significant lower rate of non-union and overall complication in the Targon FN group (p value < 0.001 and p value = 0.005, respectively). Logistic regression analysis showed that operative fixation with the Targon FN device decreased the odds ratio for overall complication by a factor of 0.34 (p = 0.02). There were no statistically significant differences between groups 1 and 2 in patient-reported outcomes (chronic pain (p = 0.21), ability to ambulate (p = 0.07), and the use of an ambulation assistive device (p = 0.07)). When compared to traditional cancellous screw fixation of femoral neck fractures, the Targon FN device has significantly lower complication rates and equivalent patient-reported outcomes.

CT and MRI as Diagnostic and Management Decision Tools for First Time Lateral Patellar Dislocations: A Cross-Sectional, Retrospective Study.

Background: Following first-time lateral patellar dislocation (FTLPD), most patients are treated conservatively, although 50% of patients will have recurrent dislocations. Typically, radiographs followed by CT and/or MRI are used to assist the clinician in determining treatment strategy and, combined with clinical findings, intraarticular free bodies (CT/MRI), significant medial patellofemoral ligament (MPFL) tear (MRI) and lateral displacement of the patella (CT) form relative indications for surgery. Methods: Radiographs, MRI and CT knee studies of 34 patients after lateral patellar dislocation (26 FTLPD) were evaluated for intraarticular free bodies, patellar/trochlear fracture, lateral femoral condyle compression, MPFL tear, tibial tuberosity-trochlear groove (TT-TG) distance, and surgery indications. Free bodies and fractures were also evaluated on knee radiographs. FTLPD was analyzed as a subgroup. Surgical indications were compared between imaging modalities. Results: Among FTLPD (26 patients); free bodies were identified in 13 and 19 patients using MRI and CT respectively, compared with 5 patients on radiographs; this was statistically significant. In 8 cases surgery was indicated based on MPFL tear (MRI) combined with lateral patellar displacement (CT). When MRI and CT results were combined, 21 of 26 patients had imaging indications for surgery compared to 13 and 19 patients based on the MRI or CT alone, respectively.CT was statistically better than MRI alone or MRI with radiographs in identifying patients requiring surgery. Conclusion: An MRI or CT study is warranted to determine the need for surgery. A second imaging study (different from the first) should be considered, if surgical indication was not established from the initial study or clinical presentation.

Effects of Venous Insufficiency in Patients Undergoing Primary Total Knee Arthroplasty: An Analysis of 1.2 Million Patients.

Chronic venous insufficiency (CVI) is extraordinarily prevalent in our aging population with over 30 million people in the United States suffering from the disease. There is a paucity of data analyzing the effects of CVI on outcomes following total knee arthroplasty (TKA). The purpose of this study was to utilize a nationwide administrative claims database to determine whether patients with CVI undergoing TKA have higher rates of: (1) in-hospital lengths of stay (LOS); (2) readmission rates; (3) medical complications; (4) implant-related complications; and (5) costs of care compared to controls. Using a nationwide database, we matched patients with CVI undergoing TKA to controls without CVI undergoing TKA in a 1:5 ratio by age, sex, and medical comorbidities associated with CVI. Primary outcomes analyzed within the study included LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, in addition to 90-day total global episode of care costs. The query yielded 1,265,534 patients with (n = 210,926) and without (n = 1,054,608) CVI undergoing primary TKA. Patients with CVI had significantly longer LOS (4 vs. 3 days, p < 0.0001), higher 90-day readmission rates (20.96 vs. 15.34%; odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.44-1.48, p < 0.0001), and higher odds of medical complications (2.27 vs. 1.30%; OR: 1.76, 95% CI: 1.70-1.83, p < 0.0001) compared to matched controls. Patients with CVI also had higher odds of periprosthetic joint infections (2.23 vs. 1.03%; OR: 2.18, p < 0.0001) and implant-related complications in general (4.27 vs. 2.17%; OR: 2.01, 95% CI: 1.96-2.06, p < 0.0001). Additionally, patients with CVI had higher total global 90-day episode of care costs ($15,583.07 vs. $14,286.95, p < 0.0001). Patients with CVI undergoing TKA have increased LOS, higher odds of medical and implant complications, and increased costs of care compared to those without CVI. The study can be utilized by orthopaedic surgeons to counsel patients on the potential complications following this procedure. This is a level III, retrospective cohort study.

Corrigendum to "Relative frequency of avascular necrosis of the hip as indication for primary Total Hip Arthroplasty in the USA vs. India" [J. Orthop. 36C (2023) 1-6].

[This corrects the article DOI: 10.1016/j.jor.2022.12.002.].

Relative frequency of avascular necrosis of the hip as indication for primary Total Hip Arthroplasty in the USA vs. India.

Introduction: Background: Primary total hip arthroplasty (THA) is performed for a variety of pathologies. Osteoarthritis (OA) is the most common indication for THA in the United States of America (USA). The study aims to establish the incidence of indications for THA in the USA as compared to India and to assess whether Avascular Necrosis (AVN) of the Hip is a more frequent indication for THA in India than in the USA. Methods: The National Inpatient Sample database (USA) and two Indian databases (one national and one regional) were analyzed to identify all patients who underwent primary THA within the databases. The relative frequencies of each indication for THA were determined. The patients' demographics and risk factors for AVN of the hip were recorded and assessed. The data were then compared across the patients in the USA and the patients in India. Results: 225,061 primary THA patients were identified in the USA database and 20,288 in the Indian database. The proportion of primary THA performed for AVN in the American database (5.97%) was significantly lower than the proportion of THA performed for AVN in the Indian database (51.8%). Conclusion: The relative frequency of AVN as an indication for THA is significantly higher in India than in the USA. It is important to recognize the differences in relative indications for THA between world populations, as outcomes after THA among Eastern populations of the world may not be equivalent to ones seen in their Western counterparts.

A Tale of Two Suprascapular Neuropathy Presentations: A Case ReportLearning Point of the Article.

Introduction: Supra-scapular nerve (SSN) neuropathy is a rare condition that can cause shoulder dysfunction. Prior literature has identified mass effect, space occupying lesions, trauma, and repetitive overhead activities as possible etiologies. Cases Presentations: We report two cases of SSN neuropathy; a 21-year-old competitive female volleyball player with traction associated neuropathy and a 45-year-old male with a large paralabral ganglion cyst causing compressive neuropathy. Conclusion: The following report highlights two different etiologies of SSN neuropathy and reviews the treatment of these conditions. Clinicians should consider SSN neuropathy in patients with unexplained shoulder pain and dysfunction.

Relative frequency of primary total hip arthroplasty for avascular necrosis in the United States as compared to a regional center: A data review.

Background: The relative frequencies of indications for primary total hip arthroplasty (THA) are not well-established. This study aims to establish the incidence of THA performed for Avascular Necrosis of the hip (AVN), as well as the other most common indications for THA in the United States, as compared to the incidences at a high-volume tertiary referral center in Miami, Florida. We hypothesize that the relative incidence of AVN and each other indication for THA will vary significantly between the United States as a whole and the tertiary referral center. Methods: A query of the 2016-2017 National Inpatient Sample (NIS) and a tertiary referral center adult reconstruction registry was completed. The relative frequencies of each indication for THA, demographics, and behavioral risk factors were analyzed. Results: 225,061 primary THA patients in the National Inpatient Sample database and 447 in the Miami tertiary referral center database were included in the final analysis. The proportion of primary THA for AVN in the NIS database (5.97%) was significantly lower than the same proportion in the tertiary referral center database (22.2%), p < .001. There was no significant difference in the incidence of primary THA for osteoarthritis, inflammatory arthritis, or hip dysplasia between the two populations. Conclusion: The incidence of THA for AVN is significantly different between a tertiary referral center and the greater United States. Patient demographics, race, and behavioral risk factors are associated with the disparity. Orthopaedic surgeons should recognize the differences in THA indication between populations when counseling patients on treatments, outcomes, and the most current literature.

Septic Arthritis of the Shoulder After SARS-CoV-2 Pfizer Vaccination: A Case Report.

CASE: We report a case of a 68-year-old woman who developed left shoulder glenohumeral joint septic arthritis within 1 week of receiving the COVID-19 Pfizer-BioNTech vaccine. CONCLUSION: Common vaccine complications include injection site pain, fever, chills, arthralgia, and hypersensitivity reactions. A less common and more serious complication of septic arthritis has been reported and requires invasive treatment of surgical irrigation and debridement, and culture-specific parenteral antibiotic therapy. The current report highlights the clinical presentation and significant potential for serious complication with the improper technique. We urge vaccine administrators to practice caution and aseptic technique when vaccinating patients to reduce the risk of complication and morbidity.

Nationwide analysis on the impact of peripheral vascular disease following primary total knee arthroplasty: A matched-control analysis.

BACKGROUND: As the prevalence of peripheral vascular disease (PVD) continues to increase nationwide, studies demonstrating its effects following primary total knee arthroplasty (TKA) are limited. Therefore, the purpose of this study was to evaluate whether patients with PVD have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) medical complications; 4) implant-related complications; and 5) costs of care. METHODS: Using a nationwide database, patients with PVD undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 1,547,092 between the cohorts. Outcomes analyzed included: in-hospital LOS, readmission rates, complications, and costs of care. A p-value less than 0.004 was considered statistically significant. RESULTS: PVD patients had significantly longer in-hospital LOS (4-days vs. 3-days, p < 0.0001). Additionally, the study cohort had a higher incidence and odds (OR) of readmissions (20.5 vs. 15.2%; OR: 1.43, 95% CI: 1.42-1.45, p < 0.0001), medical complications (2.46 vs. 1.32%; OR: 1.88, CI: 1.83-1.94, p < 0.0001), and implant-related complications (3.82 vs. 2.18%; OR: 1.78, CI: 1.26-1.58, p < 0.0001). Additionally, the study found patients with PVD had higher day of surgery (p < 0.0001) and 90-day costs of care (p < 0.0001). CONCLUSIONS: After adjusting for confounding variables the results of the study show patients with PVD undergoing primary TKA have longer in-hospital LOS; in addition to higher rates of complications, readmissions, and costs of care. The study can be utilized by orthopaedists to adequately counsel patients of the potential complications following their procedure.

Surgeon Level of Expertise in Adult Reconstruction: A Brief Communication Regarding the Need for Reporting the Level of Expertise.

The purpose of the current brief communication is to establish a discussion regarding level of expertise (LOE) documentation in future arthroplasty clinical studies and to document the trend in adoption of LOE among arthroplasty publications to date. A review of Arthroplasty Today, Journal of Arthroplasty (JOA), Journal of Bone and Joint Surgery (JBJS), and International Orthopedics (IO) databases for original studies published between April 2016 and July 2020 was performed. A total of 105 articles were identified and evaluated in Arthroplasty Today, 1011 in JOA, 127 in JBJS, and 383 in IO. Of 1011 articles identified in JOA, only one manuscript (1/1011; 0.1%), by Uluyardimci et.al, included the LOE of the surgeon(s) involved in the study. No articles in Arthroplasty Today (0/125; 0%), JBJS (0/127; 0%), or IO (0/383; 0%) reported the LOE according to Tang's recommendations during the same period. Documenting LOE may provide readers with additional information for incorporation of novel techniques into their practices as well as identify procedures that require a baseline LOE for effective performance. Further evaluation of LOE criteria may improve the reliability of the numeric scale, while widespread adoption of this scale will allow future outcome analysis by LOE.