Percutaneous removal of hardware after orthopedic surgery: Is it safe? and What are patients saying?

OBJECTIVES: To analyze our patient's complication profile and rate after removal of hardware (ROH) surgery, and survey our patients to ask their overall status and improvement in symptomatology post-operatively. DESIGN: Retrospective chart review and survey. SETTING: Academic, tertiary referral center. PATIENTS/PARTICIPANTS: 173 patients with 314 pieces of hardware. Seventy-six patients (43.9%) responded to our survey. INTERVENTION: ROH surgery. MAIN OUTCOME MEASUREMENTS: Patient demographics and complications were recorded. All patients were sent a brief 3-question survey which asked: (1) Why did you get your hardware removed? (2) How did your overall status change after ROH? (3) How did the ROH affect your stiffness, pain, swelling, and mobility? RESULTS: There were 10 complications (5.5%): 5 infections, 2 with unresolved pain, 1 hematoma, 1 chronic regional pain syndrome exacerbation, and 1 recurrent deformity. All infections were treated with oral antibiotics and improved. All other complications resolved with treatment except for the patient who developed recurrent deformity. Patients underwent ROH surgery because their doctor suggested it (76.3%) and to improve mobility (39.5%). 86.9% reported their overall status improved after ROH. They improved regarding stiffness (73.7%), pain (73.6%), swelling (61.8%), and mobility (76.3%). Similar results were seen among different implants removed. CONCLUSIONS: The majority of patients who underwent percutaneous ROH were satisfied. They reported improvement in stiffness, pain, swelling and mobility (greatest improvement). The complication rate was low (5.5%). ROH can be a meaningful operation to patients allowing them to improve their quality of life with a low complication rate. LEVEL OF EVIDENCE: Level IV.

Extra-articular Osteotomy for the Management of Intra-articular Tibial Plateau Valgus Malunion.

OBJECTIVES: To report a case series of extra-articular osteotomies for the management of intra-articular tibial plateau malunions and to assess the ability to correct deformity and improve knee range of motion (ROM). METHODS: . DESIGN: Retrospective case series. SETTING: Academic, tertiary, referral center. PATIENT SELECTION CRITERIA: Adult patients with tibial plateau fracture malunion treated with extra-articular osteotomy of the femur and/or tibia between 2014 and 2023. OUTCOME MEASURES AND COMPARISON: Mechanical axis deviation (MAD), medial proximal tibia angle (MPTA), lateral distal femoral angle (LDFA), and posterior proximal tibia angle (PPTA) correction; knee ROM; and time to weight bearing. RESULTS: There were 7 patients included, 6 (85.7%) were female and 1 (14.3%) were male. The median age was 43.5 years (IQR 38.5-51, range 32-62). Four (57.1%) patients were treated with a high tibial osteotomy (HTO), and 3 (42.9%) patients were treated with an HTO and distal femoral osteotomy. One patient had concomitant supramalleolar osteotomy with HTO to address distal tibia procurvatum and valgus. Four were treated with hexapod frames, and 3 were treated with plates and screws. Median follow-up was 22.5 months (IQR 10.5-107 months, range 7-148 months). Surgical intervention corrected median radiographic measures of valgus malalignment preoperatively relative to postoperative values. This included MAD (42.5 mm-0 mm), valgus angle (12.5 degrees-1.5 degrees), MPTA (95 degrees-88.0°), and LDFA (86.0°-87.3 degrees). Surgical intervention increased maximal knee range of motion preoperatively to postoperatively. Median time to full weight bearing was 81.5 days (IQR 46-57 days, range 41-184 days). Two patients were converted to total knee arthroplasty after 5 and 10 years following HTO with hexapod frame. CONCLUSIONS: Extra-articular osteotomy is an effective treatment for addressing intra-articular malunion after tibia plateau fractures. It is effective in correcting the MAD, valgus deformity, MPTA, LDFA, PPTA, and improving knee ROM (measured through knee extension and flexion). LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Association of Brain Natriuretic Peptide Levels at Time of Injury with Morbidity and Mortality in Patients with Surgically Treated Hip Fractures.

An elevated brain natriuretic peptide (BNP) level has been shown to be associated with mortality and cardiac events in cardiac surgery, but its utility in the prediction of morbidity and mortality in hip fracture surgery is unknown. The primary aim of this study was to determine if there is a difference in BNP level at the time of injury between patients who do and do not develop complications after hip fracture surgery. The secondary aim was to determine if there is a predictive relationship between complications associated with the initial BNP level and mortality. Methods: A retrospective chart review of 455 hip fractures in patients ≥60 years old that were operatively treated between February 2014 and July 2018 was performed. Patients were included if they had a BNP level within 48 hours after injury (BNPi). Specific perioperative (≤7 days), 30-day, 1-year, and 2-year postoperative complications were recorded. Wilcoxon rank-sum tests were used to determine if higher BNPi values were associated with greater morbidity. The complications associated with higher BNPi values were further analyzed to assess if they were predictive of mortality, using univariate and multivariable analyses. Results: Higher BNPi was significantly associated with greater morbidity at all postoperative time points and with higher mortality at 1 and 2 years postoperatively. Furthermore, several complications including cardiac failure or exacerbation and altered mental status were associated with mortality at all time points in univariate analysis and at many time points in multivariable analysis. Conclusions: Patients with higher BNPi levels were more likely to develop complications up to 1 year postoperatively, and several of these complications were associated with increased mortality. Future studies to determine if delaying surgery until BNP levels are normalized or lowered may help guide management, and may be useful in determining the need for further medical optimization. Future studies aimed at defining a threshold BNP value at the time of injury may also help in better managing patients preoperatively. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Approach and Dislocation Risk After Hemiarthroplasty in Geriatric Patients With Femoral Neck Fracture With and Without Cognitive Impairments-Does Cognitive Impairment Influence Dislocation Risk?

OBJECTIVES: To determine whether there is an association between surgical approach and dislocation risk in patients with cognitive impairment compared with those without cognitive impairment treated with hemiarthroplasty for femoral neck fracture. DESIGN: Retrospective study. SETTING: Large, multicenter health system. PATIENTS/PARTICIPANTS: One thousand four hundred eighty-one patients who underwent hemiarthroplasty for femoral neck fractures. 828 hips met inclusion criteria, 290 (35.0%) were cognitively impaired, and 538 (65.0%) were cognitively intact. INTERVENTION: Hemiarthroplasty. MAIN OUTCOME MEASURE: Prosthetic hip dislocation. RESULTS: The overall dislocation rate was 2.1% (17 of 828), 3.4% (10 of 290) in the cognitively impaired group, and 1.3% (7 of 538) in the cognitively intact group with a median time to dislocation of 20.5 days (range 2-326 days), 24.5 days (range 3-326 days), and 19.0 days (range 2-36 days), respectively. In the entire cohort, there were no dislocations (0 of 58) with the direct anterior approach (DA); 1.1% (6 of 553) and 5.1% (11 of 217) dislocated with the modified Hardinge (MH) and posterior approaches (PA), respectively. In the cognitively impaired group, there were no dislocations with the DA (0 of 19); 1.5% (3 of 202) and 10.1% (7 of 69) dislocated with the MH and PA, respectively. In the cognitively intact group, there were no dislocations (0 of 39) with the DA; 0.85% (3 of 351) and 2.7% (4 of 148) dislocated with the MH and PA, respectively. There were statistically significant associations between surgical approach and dislocation in the entire cohort and the cognitively impaired group when comparing the MH and PA groups. This was not observed in the cognitively intact group. Patients who dislocated had 3.2 times (95% CI 1.2, 8.7) ( P = 0.0226) the hazard of death compared with patients who did not dislocate. Dislocation effectively increased the risk of death by 221% (HR 3.2 95% CI 1.2, 8.7) ( P = 0.0226). CONCLUSIONS: In this patient population, the PA has a higher dislocation rate than other approaches and has an especially high rate of dislocation when the patients were cognitively impaired. The authors of this study suggest careful consideration of surgical approach when treating these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total Elbow Arthroplasty for Distal Humerus Fractures.

Distal humerus fractures in elderly patients are challenging due to poor bone quality and may threaten the independence of elderly patients due to loss of functional range of motion. Total elbow arthroplasty has gained popularity in the treatment of these injuries. This video demonstrates total elbow arthroplasty in an elderly patient with a comminuted distal humerus fracture.