Chronic Oral Corticosteroid Use and 10-Year Incidence of Major Complications Following Total Knee Arthroplasty.

BACKGROUND: Oral corticosteroids are the primary treatment for several autoimmune conditions. The risk of long-term implant, bone health, and infectious-related complications in patients taking chronic oral corticosteroids before total knee arthroplasty (TKA) is unknown. We compared the 10-year cumulative incidence of revision, periprosthetic joint infection (PJI), fragility fracture (FF), and periprosthetic fracture following TKA in patients who had and did not have preoperative chronic oral corticosteroid use. METHODS: A retrospective cohort analysis was conducted using a national database. Primary TKA patients who had chronic preoperative oral corticosteroid use were identified using Current Procedural Terminology and International Classification of Disease 9 and 10 codes. Exclusion criteria included malignancy, osteoporosis treatment, trauma, and < 2-year follow-up. Primary outcomes were 10-year cumulative incidence and hazard ratios (HRs) of all-cause revision (ACR), aseptic revision, PJI, FF, and periprosthetic fracture. A Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized. Overall, 611,596 patients were identified, and 5,217 (0.85%) were prescribed chronic corticosteroids. There were 10,000 control patients randomly sampled for analysis. RESULTS: Corticosteroid patients had significantly higher 10-year HR of FF (HR; 95% confidence interval); P value (1.47; 1.34 to 1.62; P < .001)], ACR (1.21; 1.05 to 1.40; P = .009), and PJI (1.30; 1.01 to 1.69; P = .045) when compared to the control. CONCLUSIONS: Patients prescribed preoperative chronic oral corticosteroids had higher risks of ACR, PJI, and FF within 10 years following TKA compared to patients not taking corticosteroids. This information can be used by surgeons during preoperative counseling to educate this high-risk patient population about their increased risk of postoperative complications.

10-Year Cumulative Incidence and Indications for Revision Total Knee Arthroplasty Among Patients Who Have Sickle Cell Disease.

BACKGROUND: Literature regarding total knee arthroplasty (TKA) outcomes in sickle cell disease (SCD) is limited. Moreover, 10-year survivorship of SCD implants is unknown. This study aimed to observe 10-year cumulative incidence and indications for revision TKA in patients who did and did not have SCD. METHODS: Patients who underwent primary TKA were identified using a large national database. The SCD patients were matched by age, sex, and a comorbidity index to a control cohort in a 1:4 ratio. The 10-year cumulative incidence rates were determined using Kaplan-Meier survival analyses. Multivariable analyses were conducted using Cox proportional hazard modeling. Chi-squared analyses were conducted to compare indications for revision between cohorts. In total, 1,010 SCD patients were identified, 100,000 patients included in the unmatched control, and 4,020 patients included in the matched control. RESULTS: Compared to the unmatched control cohort, SCD patients exhibited higher 10-year all-cause revision (HR: 1.86; P < .001) with higher proportions of revisions for periprosthetic joint infection (PJI) (P < .001), aseptic loosening (P < .001), and hematoma (P < .001). Compared to the matched control, SCD patients had higher 10-year all-cause revision (Hazard Ratio (HR): 1.39; P = .034) with a higher proportion of revisions for PJI (P = .044), aseptic loosening (P = .003), and hematoma (P = .019). CONCLUSION: Independent of other comorbidities, SCD patients are more likely to undergo revisions for PJI, aseptic loosening, and hematoma compared to patients who do not have SCD. Due to the high-risk of these complications, perioperative and postoperative surgical optimization should be enforced in SCD patients.

Nonunion of conservatively treated humeral shaft fractures is not associated with anatomic location and fracture pattern.

INTRODUCTION: Humeral shaft fractures make up 1-3% of all fractures and are most often treated nonoperatively; rates of union have been suggested to be greater than 85%. It has been postulated that proximal third fractures are more susceptible to nonunion development; however, current evidence is conflicting and presented in small cohorts. It is our hypothesis that anatomic site of fracture and fracture pattern are not associated with development of nonunion. MATERIALS AND METHODS: In a retrospective cohort study, 147 consecutive patients treated nonoperatively for a humeral shaft fracture were assessed for development of nonunion during their treatment course. Their charts were reviewed for demographic and radiographic parameters such as age, sex, current tobacco use, diabetic comorbidity, fracture location, fracture pattern, AO/OTA classification, and need for intervention for nonunion. RESULTS: One hundred and forty-seven patients with 147 nonoperatively treated humeral shaft fractures were eligible for this study and included: 39 distal, 65 middle, and 43 proximal third fractures. One hundred and twenty-six patients healed their fractures by a mean 16 ± 6.4 weeks. Of the 21 patients who developed a nonunion, two were of the distal third, 10 of the middle third, and nine were of the proximal third. In a binomial logistic regression analysis, there were no differences in age, sex, tobacco use, diabetic comorbidity, fracture pattern, anatomic location, and OTA fracture classification between patients in the union and nonunion cohorts. CONCLUSIONS: Fracture pattern and anatomic location of nonoperatively treated humeral shaft fractures were not related to development of fracture nonunion.

Sickle Cell Disease Has No Impact on 10-Year Cumulative Incidence and Indications for Revision Lumbar Fusion.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Patients with sickle cell disease (SCD) experience distinct physiological challenges that may alter surgical outcomes. There has been no research establishing 10-year lumbar fusion (LF) implant survivorship rates among individuals with SCD. This study aims to determine the 10-year cumulative incidence and indications for revision LF between patients with and without SCD. METHODS: A national database was queried to identify patients with and without SCD who underwent primary LF. SCD patients undergoing LF were propensity-score matched in a 1:4 ratio by age, gender, and Charlson Comorbidity Index (CCI) to a matched LF control. In total, 246 SCD patients were included along with 981 and 100,000 individuals in the matched and unmatched control cohorts, respectively. Kaplan-Meier survival analysis was utilized to determine the 10-year cumulative incidence rates of revision LF. Furthermore, multivariable analysis using Cox proportional hazard modeling was performed to compare indications for revisions and surgical complications between cohorts including hardware removal, drainage and evacuation, pseudoarthrosis, and mechanical failure. RESULTS: No significant differences were found in the cumulative incidence of 10-year all-cause revision LF between patients in the SCD cohort and either of the control cohorts (P > .05 for each). Additionally, there were no significant differences between the SCD cohort and either of the control cohorts in regards to the indications for revision or surgical complications in LF (P > .05 for each). CONCLUSIONS: This study indicates that SCD patients do not have increased risk for revision LF, nor any of its indications.

Multifocal Disruption of the Extensor Mechanism of the Knee: A Case Report.

CASE: A 41-year-old man presented with a transverse patella fracture and proximal patellar tendon avulsion after a fall from standing. Disruption of the extensor mechanism of the knee at multiple points is rare. He was treated operatively for his patella fracture and patellar tendon avulsion but experienced early failure of the patellar tendon fixation requiring reoperation. Both components of injury ultimately healed, and he returned to function. CONCLUSION: This case describes a rare presentation of an uncommon injury pattern affecting the extensor mechanism. This is the first report to describe multifocal failure of the extensor chain from a low-energy mechanism.

Loss of Ambulatory Level and Activities of Daily Living at 1 Year Following Hip Fracture: Can We Identify Patients at Risk?

INTRODUCTION: Operative hip fractures are known to cause a loss in functional status in the elderly. While several studies exist demonstrating the association between age, pre-injury functioning, and comorbidities related to this loss of function, no studies have predicted this using a validated risk stratification tool. We attempt to use the Score for Trauma Triage for Geriatric and Middle-Aged (STTGMA) tool to predict loss of ambulatory function and need for assistive device use. MATERIALS AND METHODS: Five hundred and fifty-six patients ≥55 years of age who underwent operative hip fracture fixation were enrolled in a trauma registry. Demographics, functional status, injury severity, and hospital course were used to determine a STTGMA score and patients were stratified into risk quartiles. At least 1 year after hospitalization, patients completed the EQ-5D questionnaire for functional outcomes. RESULTS: Two hundred and sixty-eight (48.2%) patients or their family members responded to the questionnaire. Of the 184 patients alive, 65 (35.3%) reported a return to baseline function. Eighty-nine (48.4%) patients reported a loss in ambulatory status. Patients with higher STTGMA scores were older, had more comorbidities, reported greater need for help with daily activities, increased difficulty with self-care, and a reduction in return to activities of daily living (all p ≤ 0.001). Patients with lower STTGMA scores were more likely to never require an assistive device while those with higher scores were more likely to continue needing one (p = 0.004 and p < 0.001). Patients in the highest STTGMA risk groups were 1.5x more likely to have an impairment in ambulatory status (need for ambulatory assistive device or decreased ambulatory capacity) (p = 0.004). DISCUSSION: Patients in higher STTGMA risk quartiles were more likely to experience impairment after hip fracture surgery. The STTGMA tool can predict loss of ambulatory independence following hip fracture. At-risk populations can be targeted for enhanced physiotherapy and rehabilitation services for optimal return to prior functioning.

Monitored Anesthesia Care and Soft-Tissue Infiltration With Local Anesthesia: An Anesthetic Option for High-Risk Patients With Hip Fractures.

OBJECTIVES: To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails. DESIGN: Retrospective cohort study. SETTING: The study setting involved an urban, academic Level 1 trauma center, a tertiary care academic medical center, and an orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: Twenty recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients were included in the study. INTERVENTION: All patients with an OTA/AO 31.A1-3 intertrochanteric hip fracture presenting from October 1, 2019 to March 31, 2020 treated with a short cephalomedullary nail underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA). MAIN OUTCOME MEASUREMENTS: Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost. RESULTS: A total of 60 patients (20 each: MAC, general, and spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 beats per minute). For the first 3 hours postoperatively, MAC-STILA patients reported consistently lower pain scores (visual analog scale <1) than spinal or general patients (visual analog scale > 1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately 5 times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or postoperative ambulatory distance. There was no difference in inpatient cost among cohorts. CONCLUSIONS: This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA/AO 13.A1-3 intertrochanteric fractures with a short cephalomedullary nail and may be the preferred method for patients with severe medical comorbidities or relative contraindications to general and/or spinal anesthesia. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Is There Value in Early Postoperative Visits Following Hip Fracture Surgery?

INTRODUCTION: Despite the recommendation for postoperative orthopedic follow-up after a hip fracture in elderly patients, many patients do not return for these visits. In this study, we attempt to determine if early follow-up (<4 weeks post-discharge) changes orthopedic post-operative management. MATERIALS AND METHODS: 1232 patients aged > 55 years old who underwent operative fixation for hip fractures were enrolled into an orthopedic trauma registry and followed from hospitalization through one year. Demographics, comorbidities, injury severity, and hospital course data were collected. Need for readmission and orthopedic follow-up were ascertained through chart review. RESULTS: 417 patients (33.8%) patients did not return for any follow-up and 30 (2.4%) patients died <30 days from discharge. 370 (45.5%) patients had early orthopedic follow-up ≤28 days after discharge. 317 (38.9%) patients were seen ≥29 days after discharge (late follow-up). 127 (15.6%) patients returned for isolated non-orthopedic care. There were 23 (6.2%) readmissions in the early group, 17 (5.4%) in the late group, and 24 (18.9%) in the no follow-up group (p < 0.001). Patients discharged home were more likely to present for early follow-up compared to those with late and non-orthopedic follow-up (p = 0.002), however there was no difference in readmission rates between those discharged home vs. SNFs/SARs. DISCUSSION: Patients who received isolated non-orthopedic follow-up within 4 weeks of surgery experienced more hospital readmissions than those with follow-up in that time period; however, these readmissions were primarily due to medical issues. There was no difference in orthopedic-related readmissions and changes in orthopedic management between groups. Patients discharged to SNFs/SARs did not present for early orthopedic as often as those discharged home. CONCLUSION: Early orthopedic follow up after hip fracture care does not change post-operative management in these patients and has implications for value-based care. LEVEL OF EVIDENCE: Prognostic Level III.

Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World.

OBJECTIVES: (1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING: One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION: The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS: Inpatient and 30-day mortality, major, and minor complications. RESULTS: Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION: The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective.

OBJECTIVES: To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN: Prospective cohort study. SETTING: Seven musculoskeletal care centers within New York City and Long Island. PATIENTS/PARTICIPANTS: One hundred thirty-eight recent and 115 historical hip fracture patients. INTERVENTION: Patients with hip fractures occurring between February 1, 2020, and April 15, 2020, or between February 1, 2019, and April 15, 2019, were prospectively enrolled in an orthopaedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs), or COVID negative (C-). MAIN OUTCOME MEASUREMENTS: Hospital quality measures, inpatient complications, and mortality rates. RESULTS: Seventeen (12.2%) patients were confirmed C+ by testing, and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared with Cs and C- cohorts, had an increased mortality rate (35.3% vs. 7.1% vs. 0.9%), increased length of hospital stay, a greater major complication rate, and a greater incidence of ventilator need postoperatively. CONCLUSIONS: COVID-19 had a devastating effect on the care of patients with hip fracture during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in patients with hip fracture complicated by COVID-19. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.