Transfusion timing relative to surgery does not impact outcomes in hip fracture patients.

PURPOSE: The purpose of this study is to determine the effects of blood transfusion timing in hip fracture patients. METHODS: A consecutive series of hip fracture patients 55 years and older who required a blood transfusion during hospitalization were reviewed for demographic, injury, clinical outcome, and cost information. A validated risk predictive score (STTGMA) was calculated for each patient. Patients were stratified to preoperative, intraoperative, or postoperative first transfusion cohorts. The intraoperative and postoperative cohorts were matched by STTGMA, sex, and procedure to the preoperative cohort. Baseline patient characteristics and outcomes were compared before and after matching. RESULTS: Prior to matching, the preoperative cohort was more often male (p < 0.001) with increased Charlson comorbidity index (p = 0.012), ASA class (p < 0.002), STTGMA (p < 0.001), total transfused volume (p = 0.002), incidence of inpatient mortality (p = 0.045), myocardial infarction (p = 0.005) and cardiac arrest (p = 0.014). After matching, the preoperative cohort had increased total transfused volume (p = 0.015) and decreased pneumonia incidence (p = 0.040). CONCLUSION: Matching STTGMA score, sex, and procedure results in non-inferior outcomes among hip fracture patients receiving preoperative first blood transfusions compared to intraoperative and postoperative transfusions.

Peri-implant fractures of the upper and lower extremities: a case series of 61 fractures.

PURPOSE: To assess outcomes for patients who sustained peri-implant fractures (PIFs). METHODS: Medical records of patients who sustained a PIF were reviewed for demographic, injury, outcome, and radiographic data. PIFs were classified using a reproducible system and stratified into cohorts based on fracture location. Clinical outcomes were evaluated for each cohort. RESULTS: Fifty-six patients with 61 PIFs with at least 6 months of follow-up were included. The mean age of the cohort was 60.4 ± 19.5 years. Twenty-two (36.1%) PIFs occurred in males, while 39 (63.9%) occurred in females. Fifty-two (85.2%) PIFs were sustained from a low-energy injury mechanism. PIFs were most often treated with plate/screw constructs (50.8%). Complications included: 6 (9.8%) nonunions, 5 of which were successfully treated to healing, 5 (8.2%) fracture related infections (FRI), and 1 (1.6%) hardware failure. Sixty (98.4%) PIFs ultimately demonstrated radiographic healing. CONCLUSION: PIFs are usually treated surgically and have a relatively high incidence of complications, with nonunion in femoral PIFs being the greatest. Despite this, the rate of ultimate healing is quite high.

Transfusion Thresholds Can Be Safely Lowered in the Hip Fracture Patient: A Consecutive Series of 1,496 Patients.

INTRODUCTION: The purpose of this study is to identify optimal threshold hemoglobin (Hgb) and hematocrit (Hct) laboratory values to transfuse hip fracture patients. METHODS: A consecutive series of hip fracture patients were reviewed for demographic, clinical, and cost data. Patients receiving an allogeneic transfusion of packed red blood cells (pRBCs) were grouped based on last Hct or Hgb (H&H) value before first transfusion. Multivariate logistic regressions of H&H quantile were performed to predict "good outcomes," a composite binary variable defined as admissions satisfying (1) no major complications, (2) length of stay below top tertile, (3) cost below median, (4) no mortality within 30 days, and (5) no readmission within 30 days. Odds ratios (OR) for "good outcomes" were calculated for each H&H quantile. RESULTS: One thousand four hundred ninety-six hip fracture patients were identified, of which 598 (40.0%) were transfused with pRBCs. Patients first transfused at Hgb values from 7.55 to 7.85 g/dL ( P = 0.043, OR = 2.70) or Hct values from 22.7 to 23.8% ( P = 0.048, OR = 2.63) were most likely to achieve "good outcomes." DISCUSSION: The decision to transfuse patients should be motivated by Hgb and Hct laboratory test results, given that transfusion timing relative to surgery has been shown to not affect outcomes among patients matched by trauma risk score. Surgeons should aim to transfuse hip fracture patients at Hgb levels between 7.55 g/dL and 7.85 g/dL or Hct levels between 22.7% and 23.8%. These transfusion thresholds have the potential to lower healthcare costs without compromising quality, ultimately resulting in less costly, efficacious care for the patient. LEVEL OF EVIDENCE: Level III.

Radiographic Evidence of Early Posttraumatic Osteoarthritis following Tibial Plateau Fracture Is Associated with Poorer Function.

To determine if radiographic evidence of posttraumatic osteoarthritis (PTOA) following tibial plateau fracture correlates with poorer clinical and functional outcomes, patients with tibial plateau fractures were followed at 3, 6, and 12 months. All patients had baseline radiographs and computed tomography scan. Radiographs obtained at each follow-up were reviewed for healing, articular incongruence, hardware positional changes, and the development of postinjury arthritic change. Cohorts were determined based on the presence (PTOA) or absence (NPTOA) of radiographic evidence of PTOA. Demographics, fracture classification, complications, additional procedures, and functional status were compared between cohorts. Sixty patients had radiographic evidence of PTOA on follow-up radiographs at a mean final follow-up of 24.2 months. The NPTOA cohort was composed of 210 patients who were matched to the PTOA cohort based on age and Charlson comorbidity index. Mean time to fracture union for the overall cohort was 4.86 months. Cohorts did not differ in Schatzker classification, time to healing, injury mechanism, or baseline Short Musculoskeletal Function Assessment (SMFA). Patients with PTOA had a greater degree of initial depression and postoperative step-off, higher incidence of initial external fixator usage, higher rates of reoperation for any reason, and higher rates of wound complications. Associated soft tissue injury and meniscal repair did not coincide with the development of PTOA. Range of motion and SMFA scores were significantly worse at all time points in patients with PTOA. Although fracture patterns are similar, patients who required an initial external fixator, had a greater degree of initial depression or residual articular incongruity, underwent more procedures, and developed an infection were found to have increased incidence of PTOA. Radiographic evidence of osteoarthritis correlated with worse functional status in patients. The goal of surgery should be restoration of articular congruity and stability to mitigate the risk of PTOA, although this alone may not prevent degenerative changes. Patients with early loss of range of motion should be aggressively treated as this may precede the development of PTOA.

Fractures of the Proximal Ulna: A Spectrum of Injuries and Outcomes.

Introduction: The purpose of this study is to assess the effect of radial head/ neck injury in association with proximal ulna fractures. Methods: Between 2006 and 2020, 107 patients presented to our academic medical center for treatment of a proximal ulna fracture and were enrolled into an IRB-approved database. Radiographs, injury details, and surgical interventions were retrospectively reviewed. Patients were classified as having an isolated proximal ulna fracture (PU), a PU fracture with an associated radial head dislocation (M-D), or a Monteggia fracture with an associated radial head fracture (M-V). Clinical and functional outcomes were assessed at follow-up to determine what differences exist between fracture patterns. Statistics were generated using Chi-squared tests for categorical variables and one-way ANOVA tests for numerical variables. Results: While all patients ultimately healed, time to radiographic healing in the PU cohort was shorter at 3.57 ± 1.7 months when compared to the M-V cohort (5.67 ± 3.8 months) (p < 0.05). At follow-up, patients in the M-V cohort had poorer elbow pronation and supination when compared to the PU and M-D cohorts (p < 0.05). Patients within the PU cohort had fewer complications than those in the M-D and M-V cohorts (p < 0.05). No differences were found between the three cohorts in regard to rates of reoperation, non-union, wound infection, and nerve compression (p > 0.05). Conclusion: The Monteggia fracture with a concomitant radial head/neck fracture is a more disabling injury pattern when compared to an isolated proximal ulna fracture and Monteggia fracture without an associated radial head/neck fracture.

Major depressive disorder, when under treatment, may not affect functional outcomes in patients with tibial plateau fractures.

BACKGROUND: The purpose of this study is to determine if treated psychological depression is associated with poorer functional outcomes in patients who sustain tibial plateau fractures. METHODS: Patients with a tibia plateau fracture were prospectively followed. Functional status was assessed using the Short Musculoskeletal Function Assessment (SMFA) at baseline (pre-injury), 3 months, 6 months, and 1 year post injury. Clinical outcomes were recorded at each follow up visit and radiographic outcomes were obtained from follow up radiographs. Records were reviewed to identify patients who were being treated for major depressive disorder (MDD). SMFA scores and clinical outcomes were compared between the depression and no depression cohorts. RESULTS: 420 patients were treated for a tibial plateau fracture and the mean age was 50.83 ± 15.60 years. Forty-two (10%) patients with 42 fractures were being treated for MDD at the time of their fracture. Patients with MDD were older (p = 0.05) and were more likely female (p < 0.01). At baseline, the clinical depression cohort had worse Total SMFA scores compared to the non-depressed cohort (5.90 ± 14.41 vs. 2.69 ± 8.35, p < 0.01). There were no differences in total SMFA score or any SMFA subscores at 3, 6, and 12 months. The incidence of wound complications, reoperations, and radiographic outcomes also did not differ between the cohorts. CONCLUSION: Despite patients with MDD reporting higher SMFA (poorer) scores at baseline, MDD was not associated with worse injuries, diminished clinical or poorer functional outcomes following tibial plateau fractures.

Conversion of Neer Type II Closed Distal Clavicle Fracture to an Open Fracture Following Surgery Delay: A Case Report.

Introduction: Type II distal clavicle fractures are associated with significant displacement and high rates of nonunion. Due to the risk of nonunion, these fractures are most often managed operatively soon after the injury. Case Report: We present an 84-year-old male who sustained a Type II closed distal clavicle fracture that converted to an open fracture 1 month following initial injury. The patient underwent surgical repair with open reduction internal fixation and coracoclavicular ligament reconstruction. Following surgery, the patient experienced hardware failure with nonunion. He did not have any residual soft-tissue problems. Conclusion: Delaying surgical treatment of significantly displaced Type II distal clavicle fractures may pose a risk of conversion to open fracture. Surgeons should counsel their patients on this potential complication when discussing the risks and benefits of operative versus nonoperative treatment.

Refractory Tibial Insufficiency Fracture Nonunion Healed with Parathyroid Hormone Level Correction: A Case Report.

INTRODUCTION: Insufficiency fractures are uncommon injuries, but may occur in the lower extremity due to repetitive stress on abnormal bone tissue. Management of these injuries may include weight bearing restrictions, bracing, or even surgical intervention. In addition, a proper metabolic healing environment is required to encourage healthy bone growth following an injury. CASE PRESENTATION: This case report discusses a patient who underwent surgical repair of a closed nondisplaced proximal tibia insufficiency fracture. Several reoperations were required due to hardware failure and bone resorption following operative nonunion repair. It was determined that her elevated PTH due to end-stage renal disease (ESRD) likely inhibited bone regeneration during the course of her treatment. A successful kidney transplant rapidly normalized the patient's PTH levels and permitted bony healing of her tibial stress fracture. CONCLUSION: Several studies have demonstrated a relationship between metabolic abnormalities and fracture healing. We are the first to present a case where bony union in an ESRD patient with secondary hyperparathyroidism was only achieved following a kidney transplant. Surgeons should be cognizant of the effect that metabolic abnormalities may have in the development of insufficiency fractures and subsequently achieving bony union following such fractures.

Risk factors and associated outcomes of acute kidney injury in hip fracture patients.

PURPOSE: To assess risk factors and associated outcomes of acute kidney injury (AKI) in hip fracture patients. METHODS: Risk factors for AKI were identified by multivariate logistic regression. AKI patients were matched to patients who did not experience AKI using a validated trauma triage score. Comparative analyses between matched groups were performed. RESULTS: Risk factors of AKI included increasing Charlson Comorbidity Index and use of anticoagulation medications. AKI was associated with increased likelihood of medical complications and longer, more costly hospital stays. DISCUSSION: Patients with identified risk factors for AKI may benefit from consultation with nephrology and closer lab monitoring.

Established Trauma Triage Score Predicts Risk of Falling After Femoral Neck Fracture Arthroplasty Surgery.

INTRODUCTION: The purpose of this study is to determine whether the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) patients is able to predict fall, fracture, periprosthetic fracture, or dislocation risk after femoral neck fracture arthroplasty surgery. METHODS: Four hundred one patients who underwent hip arthroplasty surgery after a femoral neck fracture at one urban academic medical center were stratified into groups based on their risk scores assigned at femoral neck fracture presentation. The cohort was reviewed for the occurrence of postdischarge falls, secondary fractures, and prosthetic dislocations that resulted in a presentation to the emergency department (ED) after discharge from their hip fracture surgery. The incidence and timing of these complications after discharge were compared between the low-risk and high-risk groups. RESULTS: The low-risk group included 201 patients, and the high-risk group included 200 patients. The high-risk group had significantly more postdischarge falls resulting in ED presentation (49 vs. 32, p = .035) that occurred significantly sooner (12.6 vs. 18.3 months, p = .034) after discharge. CONCLUSIONS: The STTGMA model was able to successfully stratify patients who are at a higher risk of sustaining a fall after an arthroplasty procedure for a femoral neck fracture.

The Efficacy and Safety of Tranexamic Acid Treatment in Orthopaedic Trauma Surgery.

¼: Tranexamic acid (TXA) is a drug used to control hemorrhage by preventing the breakdown of fibrin. ¼: TXA is a cost-effective treatment for trauma patients across a variety of economic settings. ¼: Concerns of TXA causing thromboembolic events (TEEs) in orthopaedic trauma patients are not supported by evidence. ¼: TXA has been shown to reduce blood loss in hip fracture surgery.

Clinical outcomes of a combined osteoligamentous reconstruction technique of Neer Type IIB distal clavicle fractures.

PURPOSE: To evaluate outcomes for a combined osteoligamentous reconstruction technique for Neer Type IIB clavicle fractures. METHODS: Patients with Neer Type IIB clavicle fractures treated with combined clavicular locking plate and coracoclavicular ligament suture reconstruction were identified. Demographics, clinical outcomes, and radiographic outcomes were collected. RESULTS: Twenty-four patients with mean 13 months of follow-up were included. Bony union and normal radiographic coracoclavicular relationship were achieved in 23 (96%) patients. The mean UCLA Shoulder score was 33.3. Three (13%) complications occurred. DISCUSSION: The combined osteoligamentous reconstruction approach as described is a successful option for treating Neer Type IIB clavicle fractures.

Trauma Risk Score Also Predicts Blood Transfusion Requirements in Hip Fracture Patients.

INTRODUCTION: The purpose of this study is to determine if the risk of receiving a blood transfusion during hip fracture hospitalization can be predicted by a validated risk profiling score (Score for Trauma Triage in Geriatric and Middle Aged (STTGMA)). MATERIALS AND METHODS: A consecutive series of 1449 patients 55 years and older admitted for a hip fracture at one academic medical center were identified from a trauma database. The STTGMA risk score was calculated for each patient. Patients were stratified into risk groups based on their STTGMA score quantile: minimal risk (0-50%), low risk (50-80%), moderate risk (80-95%), and high risk (95-100%). Incidence and volume of blood transfusions were compared between risk groups. RESULTS: There were 562 (38.8%) patients who received a transfusion during their admission. 58.3% of patients in the high risk group received a transfusion during admission compared to 31.2% of minimal risk group patients, 42.6% of low risk group patients, and 50.0% of moderate risk group patients (p < 0.001). STTGMA was predictive of first transfusion incidence in both the preoperative and postoperative periods. There was no difference in mean total transfusion volume between the four risk groups. CONCLUSION: The STTGMA model is capable of risk stratifying hip fracture patients more likely to receive blood transfusions during hospitalization. Surgeons can use this tool to anticipate transfusion requirements.