The risk of venous thromboembolism in surgically treated hip fracture: A retrospective cohort study of 5184 patients.

INTRODUCTION: Elderly patients undergoing surgery for a hip fracture are at risk of venous thromboembolism (VTE). The known risk of VTE is low due to thromboprophylaxis (1.8-2.5% at three months). Most previous studies have ignored the high mortality in that population when calculating the risk of VTE. Hip fracture treatment has also evolved over the last decade. The real risk of VTE today is unknown. We asked what was the risk of symptomatic VTE following surgery for a hip fracture in an elderly population. We also asked what kind of bleeding events were associated with thromboprophylaxis. HYPOTHESIS: The risk of VTE will be lower than previously described due to modern postoperative care. PATIENTS AND METHODS: Retrospective cohort study of all patients≥65-years-old undergoing surgery for a hip fracture in two Canadian academic centers, between January 1, 2008, and January 1, 2019. Symptomatic VTE (pulmonary embolism or deep venous thrombosis) confirmed by imagery were assessed. The follow-up was fixed at 3 months. The cumulated risks of VTE and bleeding events were calculated using the Kaplan-Meier estimator and a logistic regression model was used to determine risk factors. RESULTS: The cohort included 5184 patients. The mean age was 83±8 years old and 76% of patients were female. In total, 98.8% of this cohort received postoperative thromboprophylaxis. Low-molecular-weight heparin was given for 35 days in 87% of this cohort. The risk of venous thromboembolism was 4.7±0.5% at 3 months (n=144). Chronic obstructive pulmonary disease (odds ratio 1.6 [1.0-2.4]) and the use of warfarin as extended thromboprophylaxis (odds ratio 2.1 [1.3-3.6]) were associated with venous thromboembolism. The risk of bleeding was 5.9% (n=179) at 3 months. In total, 78% (n=141) of bleeding events were hematomas, of which only 12% (n=16) needed reoperation. The use of direct oral anticoagulant was associated with an increased risk of bleeding events (odds ratio, 2.8 [1.5-5.0]). Mortality at 3 months was 8.4%. DISCUSSION: The risk of venous thromboembolism is higher than expected in a population treated for this condition (4.7% vs. 1.8-2.5% at 3 months as previously described). Bleeding events were mostly hematomas and few needed reoperations for wound complication. Future research should focus on the management of thromboprophylaxis in that population. LEVEL OF EVIDENCE: III; retrospective cohort study.

Should We Use Bipolar Hemiarthroplasty in Patients ≥70 Years Old With a Femoral Neck Fracture? A Review of Literature and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Bipolar (BHA) and unipolar hemiarthroplasties (UHA) are interchangeably used in elderly patients with a displaced femoral neck fracture. We ask if there is a difference between BHA and UHA with regards to hip function, in elderly patients. METHODS: Systematic review and meta-analysis was conducted of randomized controlled trials comparing BHA to UHA. The primary outcome was postoperative hip function scores. Secondary outcomes were overall health-related quality of life patient-reported outcomes, acetabular erosion, and postoperative complications. Data sources, last searched on June 1, 2020, were MEDLINE, EMBASE, Cochrane Library, and Web of Science. RESULTS: Fourteen randomized controlled trials were eligible for meta-analysis. There was no difference in hip function scores between BHA and UHA (standardized mean difference 0.32, 95% confidence interval [CI] -0.06 to 0.71, n = 1084, I2 = 87%). Patients with BHA with more than 2-year follow-up had better hip function scores (standardized mean difference 0.68, 95% CI 0.18-1.18, n = 700, I2 = 87%). There was no difference in European Quality of life- five dimensions scores with BHA (mean difference 0.08, 95% CI -0.01 to 0.17, n = 967, I2 = 82%). The use of BHA decreased the risk of acetabular erosion (relative risk 0.38, 95% CI 0.17-0.83, n = 1239, I2 = 0%). There was no difference for revision, mortality, infection, and dislocation (I2 = 0%). CONCLUSION: There seems to be no difference between BHA and UHA with regards to hip function at 2 years. BHA might decrease the risk of acetabular erosion. There is a need for a large randomized controlled trial with a follow-up >2 years and better measurement tools to assess clinical benefits. LEVEL OF EVIDENCE: II.

The impact of frailty on patient-reported outcomes after elective thoracolumbar degenerative spine surgery.

OBJECTIVE: Frailty has been shown to be a risk factor of perioperative adverse events (AEs) in patients undergoing various types of spine surgery. However, the relationship between frailty and patient-reported outcomes (PROs) remains unclear. The primary objective of this study was to determine the impact of frailty on PROs of patients who underwent surgery for thoracolumbar degenerative conditions. The secondary objective was to determine the associations among frailty, baseline PROs, and perioperative AEs. METHODS: This was a retrospective study of a prospective cohort of patients older than 55 years who underwent surgery between 2012 and 2018. Data and PROs (collected with EQ-5D, Physical Component Summary [PCS] and Mental Component Summary [MCS] of SF-12, Oswestry Disability Index [ODI], and numeric rating scales [NRS] for back pain and leg pain) of patients treated at a single academic center were extracted from the Canadian Spine Outcomes and Research Network registry. Frailty was calculated using the modified frailty index (mFI), and patients were classified as frail, prefrail, and nonfrail. A generalized estimating equation (GEE) regression model was used to assess the association between baseline frailty status and PRO measures at 3 and 12 months. RESULTS: In total, 293 patients with a mean ± SD age of 67 ± 7 years were included. Of these, 22% (n = 65) were frail, 59% (n = 172) were prefrail, and 19% (n = 56) were nonfrail. At baseline, the three frailty groups had similar PROs, except PCS (p = 0.003) and ODI (p = 0.02) were worse in the frail group. A greater proportion of frail patients experienced major AEs than nonfrail patients (p < 0.0001). However, despite the increased incidence of AEs, there was no association between frailty and postoperative PROs (scores on EQ-5D, PCS and MCS, ODI, and back-pain and leg-pain NRS) at 3 and 12 months (p ≥ 0.05). In general, PROs improved at 3 and 12 months (with most patients reaching the minimum clinically important difference for all PROs). CONCLUSIONS: Although frailty predicted postoperative AEs, mFI did not predict PROs of patients older than 55 years with degenerative thoracolumbar spine after spine surgery.

The long-term postoperative trajectory of geriatric patients admitted for a hip fracture: A prospective observational cohort study.

BACKGROUND: Worldwide, 1.3 million patients sustain a hip fracture every year. In Canada, 23 621 patients over 60 have been admitted with a hip fracture in 2003. Few authors have yet investigated the full postoperative trajectory of patients admitted for a hip fracture, in terms of orientation. HYPOTHESIS: Most geriatric patients undergoing surgery for a hip fracture will not be able to return to their original residence at one-year of follow-up. OBJECTIVE: To characterize the full one-year postoperative trajectory of patients admitted for a hip fracture, in terms of orientation. PATIENTS AND METHODS: This is a prospective observational cohort study of geriatric patients undergoing surgery for a hip fracture from 2011 to 2017 in an academic center. A total of 254 patients were enrolled in this cohort. Demographic data and scores were collected throughout the hospitalisation. Patients' residences were assessed pre-fracture and at 1, 3, 6 and 12-month post-hospitalisation. RESULTS: Most patients evolved in one of the following trajectories at one-year; (1) 30% (n=63) went back at home, (2) 11% (n=22) went back to a senior residence, (3) 16% (n=36) needed rehabillitation, (4) 13% (n=28) were discharged to a different location than prior to admission and (5) 18% (n=37) were deceased. Patients evolving in trajectory 1 were younger (mean, 80.8±11.1, p<0.0001). Patients evolving in trajectory 5 had lower MNA1 scores (mean, 19.9±5.2, p.<0.0001) and lower MMSE2 scores (mean, 16.0±10.9, p<0.0001). The delay between discharge from the attending staff and real departure from the hospital was correlated to low MNA scores (-0.35627, p<0.0001), low MMSE scores (-0.35910, p=0.0004) and associated with the need for a rehabilitation center (trajectory 3) (mean, 2.67±4.36 days, p=0.0002). DISCUSSION: The postoperative evolution of geriatric patients with a hip fracture will continue to worsen due to the aging of the population. However, this study highlights important issues such as nutritional assessment, cognitive disorders and access to rehabilitation centers. LEVEL OF EVIDENCE: II, prospective cohort study.

Eight-Year Follow-Up Using a Fresh Osteochondral Allograft for a Femoral Head Chondroblastoma in a 17-Year-Old Patient.

Chondroblastoma is a rare benign tumor that affects the epiphysis of long bones in adolescents. Chondroblastoma located in the femoral head is associated with a higher recurrence rate and carries the additional risks of head collapse and degenerative hip disease. Aggressive curettage followed by bone grafting is the current mainstay of treatment. To our knowledge, the long-term postoperative outcome of this technique remains unknown due to the short follow-up of previous case reports. We present the case of a 17-year-old male who underwent fresh osteochondral allograft following curettage of a femoral head chondroblastoma, using a Ganz surgical hip dislocation. He made an uneventful recovery without tumor recurrence. The patient was followed up to 8 years postoperatively. However, there were clinical and radiographic degenerative changes at 6 years of follow-up.

Complex Case of Open Fracture-Dislocation of the Elbow.

Complex elbow instability is difficult to surgically address. Careful consideration of the fractures and soft tissue injuries is required. We present the case of a patient who sustained an open fracture-dislocation of the elbow with significant loss of the external humeral condyle and partial loss of the olecranon. He was surgically treated with an iliac crest tricortical autograft fixed with a buttress plate and a lag screw. His lateral ulnar collateral ligament was reconstructed with tendinous autograft collected from his third and fourth extensor digitorum longus tendons. While the procedure complicated with a Nocardia infection and wound breakdown, the patient almost had full range of motion without instability at 11 months of follow-up.

Negative Influence of femoral nerve block on quadriceps strength recovery following total knee replacement: A prospective randomized trial.

BACKGROUND: Postoperative pain is a major concern after total knee replacement (TKR) and can be relieved using different methods, including femoral nerve block (FNB). Quadriceps strength recovery (QSR) is the most sensitive objective indicator of functional recovery after TKR. The goal of this study was to compare the QSR following TKR between three approaches to analgesia. HYPOTHESIS: FNB delays QSR at short- and mid-term follow-up. METHODS: In this prospective randomized trial, with single-blind assessment involving 135 patients admitted for TKR in an academic center, the three following groups included were: (A) Continuous FNB 48h+PCA, (B) Single-shot FNB+PCA and (C) PCA alone. No intra-articular local anesthesia was carried out for all patients. Groups were comparable for demographic and surgical data. FNB was carried out and controlled (electric stimulation) by an expert anesthesiologist prior to the surgery. Follow-up was standardized in all groups using blinded assessors. Quadriceps strength was measured using a certified dynamometer at 6 weeks, 6 months and 12 months. Multivariate analysis (Kruskal-Wallis, Mann-Whitney) was used for the main outcome. RESULTS: A total of 135 patients were included. Two patients in group B were excluded due to a direct fall in the first postoperative week with extensor mechanism rupture and peri-prosthetic femoral fracture. QSR was significantly decreased in patients with FNB at all times (mean±SD): 6 weeks (A: 51.3±23.3%; B: 62.2±21.9%;C: 77.4±19.5%; p<0.01), 6 months (A: 65.4±22.9%; B: 82.1±24.2%;C: 95.7±20.7%; p<0.01) and 12 months (A: 87.8±17.6%; B: 97.8±26.9%;C: 104.8±25.2%; p=0.02). No significant difference between continuous or single-shot FNB was observed. CONCLUSION: FNB has a negative influence on QSR at short- and mid-term follow-up. FNB should not yet be recommended for analgesia after TKR. LEVEL EVIDENCE: I High-quality randomized controlled trial with statistically significant difference.

Osteochondroma of the Scapula with Accessory Nerve (XI) Compression.

Osteochondroma is the most common benign bone tumor and is characterized as a cartilage-capped bony stalk. This lesion usually develops from the growth plate of long bones. Most osteochondromas are asymptomatic. Neurovascular compressions or cosmetic issues can occur in specific locations. Malignant transformation is extremely rare, and MRI can help evaluate these lesions. Symptomatic mass and malignancy features are the main surgical indications. Uncommonly, an osteochondroma can develop from flat bones. We present the case of a 25-year-old patient with a right scapula osteochondroma causing an accessory nerve compression. The mass was surgically removed, and the diagnosis was confirmed. The patient fully recovered at the latest 3-year follow-up visit.

Risk Factors for Removal of Calcaneus Screws: A Retrospective Study.

Although techniques using calcaneus screws have shown high union rates, posterior heel pain due to prominent hardware at the posterior and plantar aspect of the calcaneal tuberosity seems to be a significant complaint that often leads to hardware removal. The purpose of the present study was to identify the clinical and radiologic risk factors associated with calcaneus screw removal. A retrospective study of adult patients who required calcaneus screw fixation from January 2008 to December 2016 was conducted. We reviewed the medical records and radiographs to evaluate the risk factors for screw removal. Of the 123 patients included in the present study, 63 were male and 60 were female. The mean age was 55.0 ± 6.0 years, and the mean body mass index was 31.0 ± 6.0 kg/m2. The removal rate was 8.8% (10 of 114 evaluated) at the 1-year follow-up point and 13.6% (12 of 88 evaluated) at the 2-year follow-up point. The mean interval to removal was 1.23 ± 1.22 years. A total of 16 screws (72.7%) were removed for heel pain. At the 1-year follow-up examination, the removal rate due to inflammatory arthritis was 25.0% (p = .07). Moreover, the proportion of screw removal was greater at 2 years in illicit drug users (p = .008). Screw sizes ≤6.5 mm showed a tendency (p = .12) toward a lower rate of removal at the 2-year follow-up point. Calcaneus screws should be used with caution in specific patient populations such as illicit drug users and those with inflammatory arthritis. The use of smaller diameter calcaneus screws might be an option to lower the rate of screw removal due to heel pain.