Total Knee Arthroplasty With Lateral Parapatellar Approach Results in Less Early Postoperative Skin Numbness Than Medial Approach, but No Difference at Mid-Term Follow-Up: A Randomized Control Trial.

Background: Anterior skin numbness is a common complication after total knee arthroplasty (TKA) that may impact postoperative functional outcomes. This study aimed to compare skin numbness area, functional outcomes, and patient satisfaction between patients undergoing TKA with a medial parapatellar approach (medial group) and a lateral parapatellar approach (lateral group). Methods: A prospective randomized study included 68 knees undergoing TKA via the medial parapatellar approach (n = 32) and the lateral parapatellar approach (n = 32) through the midline skin incision. Anterior skin numbness was assessed as the primary outcome using Semmes-Weinstein monofilaments at 6 postoperative timepoints (2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years). Knee range of motion, Knee Injury and Osteoarthritis Outcome Score (KOOS), and patient satisfaction scores were collected. Fifty-nine patients were retrieved at the 2-year final follow-up. Statistical analysis considered repeated outcome measurements with adjusted P-values. Results: The lateral group had a significantly smaller area of anterior skin numbness at 2 weeks (11.2 vs 20.2 sq.cm.), 6 weeks (8.2 vs 17.2 sq.cm.), and 3 months (7.8 vs 14.4 sq.cm.) postoperatively compared to the medial group. No difference in the area of numbness was found at 6 months, 1 year, and 2 years. Although the lateral group showed significantly higher satisfaction scores (P = .027) and the KOOS symptoms subdomain (P = .018), there were no differences in knee range of motion and other components of KOOS in both groups. Conclusions: Compared to the medial approach, the lateral parapatellar approach in TKA demonstrates a reduced area of early postoperative skin numbness and expedited 6-month recovery, along with marginally superior patient satisfaction scores. However, both approaches yield comparable outcomes in terms of postoperative knee motion and overall functional outcomes.

Summary of the Thai Osteoporosis Foundation (TOPF) Clinical Practice Guideline on the diagnosis and management of osteoporosis 2021.

Objectives: The Thai Osteoporosis Foundation (TOPF) is an academic organization that consists of a multidisciplinary group of healthcare professionals managing osteoporosis. The first clinical practice guideline for diagnosing and managing osteoporosis in Thailand was published by the TOPF in 2010, then updated in 2016 and 2021. This paper presents important updates of the guideline for the diagnosis and management of osteoporosis in Thailand. Methods: A panel of experts in the field of osteoporosis was recruited by the TOPF to review and update the TOPF position statement from 2016. Evidence was searched using the MEDLINE database through PubMed. Primary writers submitted their first drafts, which were reviewed, discussed, and integrated into the final document. Recommendations are based on reviews of the clinical evidence and experts' opinions. The recommendations are classified using the Grading of Recommendations, Assessment, Development, and Evaluation classification system. Results: The updated guideline comprises 90 recommendations divided into 12 main topics. This paper summarizes the recommendations focused on 4 main topics: the diagnosis and evaluation of osteoporosis, fracture risk assessment and indications for bone mineral density measurement, fracture risk categorization, management according to fracture risk, and pharmacological management of osteoporosis. Conclusions: This updated clinical practice guideline is a practical tool to assist healthcare professionals in diagnosing, evaluating, and managing osteoporosis in Thailand.

The efficacy of intra-articular triamcinolone acetonide 10 mg vs. 40 mg in patients with knee osteoarthritis: a non-inferiority, randomized, controlled, double-blind, multicenter study.

BACKGROUND: Intra-articular (IA) corticosteroid injection is recommended in refractory knee osteoarthritis patients. However, 40-mg of triamcinolone IA every 3 months for 2 years reduces cartilage volume as compared to saline IA. OBJECTIVE: To determine the non-inferiority of 10-mg versus 40-mg of triamcinolone acetonide (TA) for treatment of pain in symptomatic knee osteoarthritis at week 12. METHODS: This was a double-blind, randomized, controlled trial conducted in 84 symptomatic knee osteoarthritis patients. The 10-mg or 40-mg of TA were 1:1 randomized and injected to the affected knees. The primary outcome was the 12-week difference from baseline in pain VAS, with a pre-specified lower margin for non-inferiority of 10 mm. The measuring instruments used were: Visual analog scale (VAS: 0-10), modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol Group 5 Dimensions (EQ5D), Knee Injuries and Osteoarthritis Outcome Score (KOOS) questionnaire, chair standing test and 20-m walking time at baseline, at week 4, and week 12 after randomization. Adverse events were recorded. RESULTS: Baseline characteristics were similar between two groups. The mean differences of pain VAS (95% confidence interval: CI) between the two groups at baseline and week 12 were 0.8 (-0.8, 2.4) with p of 0.002 for non-inferiority. There were no differences in pain reduction and quality of life improvement between 10-mg and 40-mg groups. The mean differences (95%CI) of WOMAC, KOOS pain, EQ5D and KOOS quality of life between baseline and week 12 were 0.4 (-1.1, 1.9). -8.7 (-21.3, 3.9), 1.3(-7.1, 9.6) and 1.8 (-11.5, 15.0), respectively. There were significant improvements in pain and quality of life between baseline and week 12 in both groups. CONCLUSION: The 10 mg of TA is non-inferior to 40 mg TA in improving pain in patients with symptomatic knee OA. Both 10 mg and 40 mg of TA significantly improved pain and quality of life in patients with symptomatic knee OA. TRIAL REGISTRATION: TCTR, I TCTR20210224002. Retrospectively registered 24 February 2021, http://www.thaiclinicaltrials.org/show/TCTR20210224002.

Comparison of Dislocation and Outcome Between Piriformis-Sparing and Conventional Posterior Approach After Bipolar Hemiarthroplasty for Femoral Neck Fracture in Patients Over 60 Years.

BACKGROUND: Hemiarthroplasty is a treatment option for femoral neck fractures in patients aged more than 60 years and postoperative dislocation after a posterior approach is not uncommon. The piriformis tendon is one of the structures providing posterior hip stability. However, evidence of piriformis-sparing approach in hemiarthroplasty is unclear regarding a reduced dislocation rate. METHODS: Between January 2017 and December 2019, 321 patients underwent a posterior approach in consecutive cohorts for a hemiarthroplasty for femoral neck fractures with the minimum 24 months follow-up time (24-60 months). There were two cohorts: (1) 129 underwent the conventional posterior (CP) approach and (2) 192 underwent the piriformis-sparing (PS) approach. The differences in dislocation rate, postoperative Harris Hip Society at 1 and 2 years and other surgical complications were compared in both groups. RESULTS: There were 6 dislocations of 129 (4.7%) underwent the CP approach and 0 dislocation from 192 underwent the PS approach that had posterior hip dislocations (P = .004). In addition, the CP group had a significantly higher mortality rate (14.7% versus 7.3%, P = .031) and lower functional outcomes as assessed by mean Harris Hip Scores at 1 year (73 versus 78, P = .005) and 2 years postoperatively (73 versus 80, P < .001) relative to the PS group. CONCLUSION: PS hemiarthroplasty was associated with a lower dislocation and mortality rate. Moreover, this approach gained a superior early to the mid-term functional outcome than the conventional posterior approach in elderly femoral neck fractures. LEVEL OF EVIDENCE: II, prospective cohort study.

An innovative scoring system for predicting an excellent Harris hip score after proximal femoral nail anti-rotation in elderly patients with intertrochanteric fracture.

Typically, intramedullary and extramedullary devices are used to treat elderly with intertrochanteric fractures. The majority of previous research has focused on the association between surgical factors and mechanical failure after internal fixation. There is, however, limited evidence to demonstrate the association between functional outcomes after proximal femoral nail anti-rotation (PFNA) fixation and the non-surgical factors such as patient's comorbidities. The aim of this study is to determine the predictive factors associated with excellent outcome, as well as to develop an integrated scoring system to predict the outcome after PFNA fixation in elderly patients with an intertrochanteric fracture. A retrospective study was conducted between January 2012 and December 2018. Elderly patients with low-energy intertrochanteric fractures who underwent PFNA fixation and at least a year of follow-up were recruited. Demographics, comorbidities, cognitive status, time to operation, and surgical parameters of the patients were all identified. Excellent and non-excellent outcomes were assessed by Harris Hip Score (HHS) after a one-year follow up. Regression analysis was used to determine the predictors for an excellent functional outcome. A new integrated scoring system (ISSI; Integrate Scoring System in elderly patients with Intertrochanteric fracture) was developed and validated. 450 elderly patients were randomly divided into two cohorts: a development (N = 225) and validation cohorts (N = 225). In this study, age < 85 years, normal weight/overweight, Charlson comorbidity index (CCI) < 6, no cognitive impairment, a modified AO/OTA 31A1.3, time to operation < 6 days, and Tip Apex Distance between 20 and 30 mm were significantly associated with an excellent outcome after PFNA fixation. The range of ISSI score was between 0 to 16 and the cut-off score of 13 was found to have the highest discriminatory power to determine the excellent functional outcome where the area of ROC was 0.85. In regards to the validation cohort, the sensitivity and specificity of ISSI score was 69% and 87%, respectively, and the AUC was 0.81. The ISSI score is effortless and practical for orthopedic surgeons for predicting an outcome after PFNA fixation in elderly patients with an intertrochanteric fracture.

The effect of CKD on intertrochanteric fracture treated with proximal femoral nail anti-rotation: A 7-year study.

Background: Intertrochanteric fracture is one of the most burdensome osteoporotic fractures in the elderly. Chronic kidney disease is associated with sarcopenia, especially in its advanced stages and, thus may impact functional status. Combining an intertrochanteric fracture with advanced CKD may diminish results after surgical fixation. This study aims to distinguish whether CKD affects the result of intertrochanteric fracture fixation in terms of mechanical and functional outcomes. Methods: A retrospective study reviews all intertrochanteric fractures treated with PFNA fixation from 2012 to 2018. 445 patients were classified into 5 stages of CKD and divided by eGFR = 90 ml/min/1.73 m2 into CKD and non-CKD group and by eGFR = 30 ml/min/1.73 m2 into advanced CKD and non-advanced CKD group. The primary outcome was one year Harris Hip Score (HHS). Secondary outcomes were medical complications, surgical complications, and a 1-year mortality rate. Results: Harris Hip Scores (HHS) were not different between non-CKD and CKD groups (eGFR <90 mL/min/1.73 m2). However, there was a difference between non-advanced CKD and advanced CKD groups (eGFR <30 mL/min/1.73 m2) (p < 0.001). Medical complications were not different, except for sepsis in CKD stage 5 compared with stage 1 (p = 0.023). Even though AO/OTA types were more severe in the advanced CKD group, surgical complications and 1-year mortality were not different. Conclusion: Advanced stage CKD treated with PFNA fixation is associated with lower functional outcomes at one year. Sepsis is more prone to occur after surgery in CKD stage 5. Level of evidence: Level III; Retrospective cohort study.

The proximal humeral locking plate positioning to the pectoralis major tendon in achieving the proper calcar screw location: a cadaveric study.

BACKGROUND: Proximal humeral fracture is the third most common of osteoporotic fracture. Most surgical cases were treated by fixation with anatomical locking plate system. The calcar screw plays a role in medial support and improving varus stability. Proximal humerus fracture in elderly patients are commonly seen with greater tuberosity (GT) fracture. The GT fragment is sometimes difficult to use as an anatomic landmark for proper plate and screw position. Therefore, the insertion of pectoralis major tendon (PMT) may be used as an alternative landmark for appropriate plate and calcar screw position. The purpose of study is going to identify the vertical distance from PMT to a definite point on the position of locking plate. METHODS: 30 cadaveric shoulders at the department of clinical anatomy were performed. Shoulders with osteoarthritic change (n = 5) were excluded. Finally, 25 soft cadaveric shoulders were recruited in this study. The PHILOS™ plate was placed 2 mm posterior to the bicipital groove. A humeral head (HH) was cut in the coronal plane at the level of the anterior border of the PHILOS plate with a saw. A calcar screw was inserted close to the inferior cortex of HH. Distance from the upper border of elongated combi-hole (UB-ECH) to the upper border of pectoralis major tendon (UB-PMT) was measured. The plate was then moved superiorly until the calcar screw was 12 mm superior to the inferior border of HH and the distance was repeatedly measured. RESULTS: The range of distance from UB-PMT to the UB-ECH was from - 4.50 ± 7.95 mm to 6.62 ± 7.53 mm, when calcar screw was close to inferior border of HH and when the calcar screw was 12 mm superior to the inferior border of HH, respectively. The highest probability of calcar screw in proper location was 72% when UB-ECH was 3 mm above UB-PMT. DISCUSSION AND CONCLUSION: The GT fragment is sometimes difficult to use as an anatomic landmark for proper plate and screw position. PMT can be used as an alternative anatomic reference. UB-PMT can serve as a guide for proper calcar screw insertion. UB-ECH should be 3 mm above UB-PMT and three-fourths of cases achieved proper calcar screw location.

Functional outcome and complication following THA through modified direct anterior approach correlated to cadaveric study: are there any differences in Asian hip?

BACKGROUND: Direct anterior approach (DAA) has several advantages including shorter length of hospital stay, faster recovery, and better functional outcome while this approach may cause damage to the lateral femoral cutaneous nerve (LFCN) as high as 81% in the works of literature. Not much data has identified the LFCN pattern in the Asian population. Therefore, the purpose of our study was to identify characteristics of the LFCN patterns representing an Asian hip, which would aid to provide the most appropriate incision of modified direct anterior approach (MDAA) for total hip arthroplasty (THA), and to identify the clinical outcome and complications following THA through MDAA correlated with cadaveric hip in the Asian population. METHODS: After IRB approval, a cadaveric study was done to identify pattern and course of the LFCN in Asian population. The MDAA defined as the incision 2 fingerbreadths posteriorly to anterior superior iliac spine to avoid injury to the LFCN. The clinical phase identified 32 patients who underwent THA because of late-stage osteoarthritis of the hip. The anterolateral skin numbness was measured along tensor fascia lata between 2 weeks until 2 years. The functional outcome assessed by Harris Hip Score (HHS) and complications were evaluated in all patients. RESULTS: The characteristics of the LFCN from cadaveric study (phase 1) was predominantly in sartorius type (60.0%) followed by posterior type (26.6%), fan type (6.7%), and variant type (6.7%). The clinical phase demonstrated that 23 patients (71.9%) had no numbness while 9 patients (28.1%) came with numbness after undergoing THA through the MDAA. Finally, a small area of skin numbness remained in only 3 patients (9.4%) at 2 years follow-up. Additionally, there was no significant difference in functional score at 2 years follow-up (89.0 vs 91.2, p = 0.422) between those with LFCN injury and those without LFCN injury. CONCLUSIONS: The LFCNs were divided into four types. Modified direct anterior approach, which is an alternative approach for THA, allowing for a lower rate of skin numbness and faster recovery without hip dislocation, abductor weakness, and serious nerve complication. Functional outcome was comparable with and without LFCN injury. LEVEL OF EVIDENCE: Level II, prospective observation study.

TKR after posttraumatic and primary knee osteoarthritis: a comparative study.

BACKGROUND: A few literatures reported that the outcomes of total knee replacement (TKR) in posttraumatic osteoarthritis (PTOA) were lower compared to TKR in primary osteoarthritis (primary OA). The study's purpose was to compare the comorbidity and outcome of TKR among fracture PTOA, ligamentous PTOA, and primary OA. The secondary aim was to identify the effect of postoperatively lower limb mechanical axis on an 8-year survivorship after TKR between PTOA and primary OA. METHODS: Seven hundred sixteen patients with primary OA, 32 patients with PTOA (knee fracture subgroup), and 104 PTOA (knee ligamentous injury subgroup) were recruited. Demography, comorbidities, Charlson Comorbidity Index (CCI), operative parameters, mechanical axis, functional outcome assessed by WOMAC, and complications were compared among the three groups. RESULTS: PTOA group was significantly younger (p<0.0001) with a higher proportion of men (p=0.001) while the primary OA group had higher comorbidities than the PTOA group, including anticoagulant usage (p=0.0002), ASA class ≥3 (p<0.0001), number of diseases ≥ 4 (p<0.0001), and CCI (p<0.0001). Both the fracture PTOA group (p<0.0001) and ligamentous PTOA group (p = 0.009) had a significantly longer operative time than the primary OA group. The fracture PTOA group had significantly lower pain components and stiffness components than the primary OA group. There was no significant difference in the rate of an aligned group, outlier group, and an 8-year survivorship in both groups. CONCLUSION: The outcome following TKR in the fracture PTOA was poorer compared to primary knee OA in the midterm follow-up. However, no difference was detected between the ligamentous PTOA and primary knee OA. The mechanical axis alignment within the neutral axis did not affect the 8-year survivorship after TKR in both groups. LEVEL OF EVIDENCE: Level III; retrospective cohort study.

Effectiveness of Periarticular Injection After Bipolar Hemiarthroplasty for Displaced Femoral Neck Fracture in Elderly Patients: A Double Blinded Randomized, Controlled Study.

BACKGROUND: Bipolar hemiarthroplasty is a standard treatment for displaced femoral neck fracture in elderly with a normal acetabulum. Several studies have shown controversial results regarding postoperative visual analogue scale, opioid consumption, and the effectiveness of periarticular injection in hip arthroplasty. The purpose of this study is going to identify the effectiveness of periarticular injection after bipolar hemiarthroplasty compared with the patients treated with conventional pain control. METHODS: A prospective, randomized, controlled study was performed for displaced femoral neck fracture in elderly who underwent bipolar hemiarthroplasty from 2017 to 2019. Patients were classified into two groups: Periarticular injection (PAI) group and nonperiarticular injection (non-PAI) group. All patients were recorded pain score (VAS) during admission. Morphine usage was collected in both groups including its side effects. RESULTS: There was no difference in demography, intraoperative parameters, ambulatory status, and length of stay in both groups. Postoperative VAS at 8,16, 24, 60 hours, and before discharge in the non-PAI group was significantly higher than the PAI group (P = .001, P = .006, P = .002, P = .003, and P = .001, respectively). Morphine consumption at 8 hours after surgery was significantly higher in the non-PAI group than the PAI group (P = .001). CONCLUSIONS: Intraoperative, periarticular injection may be used as an adjunctive pain management in bipolar hemiarthroplasty for displaced femoral neck fracture in elderly. LEVEL OF EVIDENCE: level I, Prospective Randomized Controlled Trial.

Predictors for readmission following primary total hip and total knee arthroplasty.

BACKGROUND: Readmission following total joint arthroplasty has become a closely watched metric for many hospitals in the United States due to financial penalties imposed by Centers for Medicare and Medicaid Services. The purpose of this study was to identify both preoperative and postoperative reasons for readmission within 30 days following primary total hip and total knee arthroplasty (TKA). METHODS: Retrospective data were collected for patients who underwent elective primary total hip arthroplasty (THA; CPT code 27130) and TKA (27447) from 2008 to 2013 at our institution. The sample was separated into readmitted and nonreadmitted cohorts. Demography, comorbidities, Charlson comorbidity index (CCI), operative parameters, readmission rates, and causes of readmission were compared between the groups using univariate and multivariate regression analysis. RESULTS: There were 42 (3.4%) and 28 (2.2%) readmissions within 30 days for THA and TKA, respectively. The most common cause of readmission within 30 days following total joint arthroplasty was infection. Trauma was the second most common reason for readmission of a THA while wound dehiscence was the second most common cause for readmission following TKA. With univariate regression, there were multiple associated factors for readmission among THA and TKA patients, including body mass index, metabolic equivalent (MET), and CCI. Multivariate regression revealed that hospital length of stay was significantly associated with 30-day readmission after THA and TKA. CONCLUSION: Patient comorbidities and preoperative functional capacity significantly affect 30-day readmission rate following total joint arthroplasty. Adjustments for these parameters should be considered and we recommend the use of CCI and METs in risk adjustment models that use 30-day readmission as a marker for quality of patient care. LEVEL OF EVIDENCE: Level III/Retrospective cohort study.

Increasing posterior condyle cut for high-flex knee prosthesis may injure popliteus tendon origin: A comparison between real clinical setting and cadaveric study.

BACKGROUND: High-flex total knee prosthesis designs were proposed to improve flexion in total knee replacement (TKA). One of high-flex features is increasing posterior condyle cut which put popliteal tendon in higher risk of injury and may result in gap changes. METHODS: Prevalence of popliteus footprint injuries were compared between conventional and high-flex TKA in real clinical setting. Thirty-six popliteal origin sites from eighteen fresh cadavers were measured distances between the posterior rim of popliteal tendon origin and posterior border of the lateral femoral condyle (distance A) using digital "Vernier caliper". The mean distances were compared to posterior condyle thickness of different prosthesis designs. RESULTS: The prevalence of posterior popliteus footprint injury was significantly higher in high-flex TKA compared to the conventional design TKA (17.8% vs 3.5%, p =0.005). The mean of distance A on the right knee was 9.59 mm (6.03-12.70) while the mean of distance A on the left knee was 9.13 mm (5.80-11.07). Posterior condyle thickness of the femoral prostheses varies upon their design and size from 7.4 to 10 mm for conventional model and from 8.2 to 12.5 mm for high-flex design. Possibilities of popliteal tendon injury during posterior condyle bone cut was at least 16.7% for conventional model and 27.8% for the high-flex design. CONCLUSION: High-flex TKA prosthesis with thicker posterior condyle relates to higher possibility of popliteal tendon origin injury compared to standard one.

Anterior skin numbness after total knee arthroplasty: A prospective comparison study between diabetic and non-diabetic patients.

BACKGROUND: Anterior skin numbness from injury of the infrapatellar branch of saphenous nerve (IPBSN) and/or the anterior-inferior branch of the femoral cutaneous nerve (AIBFN) has been reported after TKA. A recent study has demonstrated no difference in skin numbness between minimally invasive and standard approach TKA. The purpose of our study was to compare the area of skin numbness following TKA in the diabetic and non-diabetic patient. MATERIAL AND METHODS: 120 patients (41 type II diabetic and 74 non-diabetic) undergoing TKA were evaluated. Five diabetic patients with preoperative skin numbness were excluded. Area of anterior skin numbness was periodically evaluated with a minimum 2-year follow-up (FU). RESULTS: Clinically, there was no difference in prevalence of skin numbness (73.2% vs 68.9%, p = 0.36) and warmness (97.6% vs 97.3%, p = 1.00) between diabetics and non-diabetics. Average area of numbness was comparable. However, duration of numbness recovery was significantly longer in diabetics (8.6 vs 5.3 months, p = 0.001). Diabetics had a higher rate of global anterior numbness (48.3% vs 22.9%, p = 0.045). Prevalence of supero-lateral skin numbness (2.6%, n = 3) correlated with the skin incision extended proximally above upper pole of patella at least 4.0 cm. CONCLUSION: The duration of numbness recovery following TKA was significantly longer in diabetic patients.

Comparison of Outcomes and Complications of Isolated Acetabular Fractures and Acetabular Fractures With Associated Injuries.

OBJECTIVE: To compare patients with acetabular fractures that are isolated (acetabular fracture alone) and acetabular fracture presenting with additional nonacetabular injury using functional outcomes, complications, and readmissions. DESIGN: Retrospective review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Two hundred fifteen patients underwent open surgical treatment for acetabular fracture between 2003 and 2012 with age ≥18 years and minimum 1-year follow-up inclusive of functional scores and complications. INTERVENTION: Surgical treatment of acetabular fracture. MAIN OUTCOME MEASUREMENTS: Postoperative functional outcomes at 1 year as assessed with the Short Form 36 (SF-36) Health Survey Questionnaire and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), postoperative complications including readmissions. RESULTS: Acetabular fractures patients with associated nonacetabular injuries exhibited a longer length of hospital stay (P < 0.0001) and higher readmission rate within 90 days (P = 0.012) compared with patients in the isolated injury group. Acetabular fracture with either chest or abdominal injury had the longest average hospital stay (19.2 and 19.1 days, respectively). Functional scores between 2 groups were comparable at 1-year follow-up, except acetabular fractures with pelvic ring injury, which had a significantly lower physical component score of SF-36 (P = 0.007) compared with the isolated group. CONCLUSIONS: Acetabular fractures with associated nonacetabular injuries have longer hospital stays, higher complications, and readmissions. Specifically, patients with associated truncal injury had worse clinical outcome and longer hospital stays. These conclusions should be taken into account when counseling patients with acetabular fractures, as additional injuries will greatly affect the course of treatment and the outcomes. LEVEL OF EVIDENCE: Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

Incidence of and Preoperative Risk Factors for Surgical Delay in Primary Total Hip Arthroplasty: Analysis From the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Total joint arthroplasty is a proven treatment for osteoarthritis of the knee and hip that has failed conservative treatment. While most of total joint arthroplasty is considered elective with surgery on the day of admission, a small subset of patients may require delay in surgery past the day of admission. Recently, surgical delay for primary total knee arthroplasty has been identified. However, the incidence, outcomes, and risk factors for delay in surgery before total hip arthroplasty (THA) have not been previously defined. QUESTIONS/PURPOSE: In patients undergoing THA, we sought to define (1) the incidence of and risk factors for delay in surgery, (2) the postoperative complications between surgical delay and no surgical delay cohorts, and (3) association of the Charlson comorbidity index (CCI) in patients with delay of surgery. METHODS: We retrospectively queried the National Surgical Quality Improvement Program database using Current Procedural Terminology billing codes and identified 7890 THAs performed between 2006 and 2010. Univariate and subsequent multivariate logistic regression analysis were then used to identify risk factors for surgical delay. Correlation between CCI and surgical delay in THA was evaluated. RESULTS: One-hundred seventy-nine patients (2.31%) were identified as experiencing a surgical delay before THA. Multivariate analysis identified congestive heart failure (CHF) (P = .0038), bleeding disorder (P < .0001), sepsis (P < .0001), prior operation in past 30 days (P = .0001), dependent functional status (P < .0001), American Society of Anesthesiologists class 3 (P = .0001), American Society of Anesthesiologists class 4 (P = .0023), significant weight loss (P = .0109), and hematocrit <38% (P < .0001) as independent risk factors for delay in surgery. Compared with the nondelay cohort, those experiencing surgical delay before THA had higher rates of postoperative surgical (8.9% vs 3.1%, P < .0001) and medical complications (23.5% vs 10.1%, P < .0001). Mean CCI was higher in the THA surgical delay cohort (3.16 vs 2.24, P < .0001) compared with the nondelay group. CONCLUSION: Surgical delay in patients undergoing THA may cause undue disruption in surgeon and hospital resource utilization. In an era of quality assessment and cost consciousness, it is important to understand that the short-term outcomes of elective, same day THA differ dramatically from those hospitalized for medical necessity before surgery. Surgeons should consider thorough medical evaluation in those with CHF, bleeding disorders, sepsis, significant weight loss, and hematocrit <38% before hospital admission.

Preoperative Risk Factors for, and Incidence of Delayed Surgery in Elective Primary Total Knee Arthroplasty After Hospital Admission: The ACS-NSQIP.

BACKGROUND: Approximately 600,000 total knee arthroplasties (TKA) are performed every year in the United States and the number of procedures has increased substantially every year. These demands may further strain the government, insurers, and patients struggling with increasing healthcare spending. A delay in proceeding to surgery after hospital admission may affect the overall healthcare costs. To our knowledge, the current literature has not addressed the incidence of, and preoperative risk factors for, a surgical delay in TKA. METHODS: The ACS-NSQIP 2011 database was reviewed to identify patients undergoing elective primary total knee arthroplasty (TKA) using the Current Procedural Terminology (CPT) code 27447. 14,881 cases were no delay in proceeding to surgery after hospital admission while 139 cases were delayed for TKA. Risk factors or comorbidities contributing to surgical delay in TKA were identified. A univariate analysis of all patient parameters was conducted to measure the difference between the two cohorts. Finally, a multivariate logistic regression analysis was then conducted to identify risk factors or comorbidities for surgical delay. RESULTS: There were 139 cases of surgical delay in TKA (0.93%). Congestive heart failure (P = 0.017), bleeding disorder (P <0.0001), sepsis (P <0.0001), a prior operation in the past 30 days (P <0.0001), dependent functional status (P <0.0001), ASA class 3 (P = 0.046), and hematocrit <38% (P <0.0001) were independent risk factors for a surgical delay. Postoperative medical complication (2.2% vs 0.8%, P < 0.0001) in surgical delay was significantly higher than non-delayed cohort. CONCLUSION: The optimization of preoperative modifiable risk factors appears to be one of the best strategies to reduce delayed surgery and therefore costs in TKA.

Preinjury Aerobic Fitness Predicts Postoperative Outcome and Activity Level After Acetabular Fracture Fixation.

OBJECTIVES: To investigate whether aerobic fitness as determined by preoperative metabolic equivalents (METS) better predicts postoperative functional outcomes after open reduction and internal fixation (ORIF) of acetabular fractures than chronologic age. DESIGN: Retrospective review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: A total of 157 patients underwent open surgical treatment for acetabular fracture between January 2005 and December 2013 with age ≥18 years and minimum 1-year follow-up inclusive of imaging, functional outcome scores, and complications. INTERVENTION: ORIF of acetabular fracture. MAIN OUTCOME MEASUREMENTS: Final postoperative functional outcomes as assessed with the University of California Los Angeles activity score and the Western Ontario and McMaster Universities Osteoarthritis Index. RESULTS: Multivariate logistic regression analysis demonstrated elevated preinjury METS, female gender, and lower injury severity score (<18) to be significant independent factors predictive of improved functional outcome per the University of California Los Angeles score. Similarly, preinjury METS were identified as significant predictors for improved Western Ontario and McMaster Universities Osteoarthritis Index scores for both the stiffness and physical function components. Chronologic age was not a significant predictor for any functional outcome score. Furthermore, a Pearson correlation analysis demonstrated a weak relationship between preoperative METS and chronologic age (r = -0.346). CONCLUSIONS: Pre-operative aerobic fitness as determined by METS may prove to be a superior prognostic factor for predicting postoperative functional outcome after acetabular fracture fixation than chronologic age. Consideration of aerobic fitness, in addition to other established prognostic factors, may be useful to patients and surgeons for injury counseling purposes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Incidence, Risk Factors, and Causes for Thirty-Day Unplanned Readmissions Following Primary Lower-Extremity Amputation in Patients with Diabetes.

BACKGROUND: The Centers for Medicare & Medicaid Services targeted thirty-day readmissions as a quality-of-care measure. Hospitals can be penalized on unplanned readmissions. Given the frequency of amputation in diabetic patients and our changing health-care system, the purpose of this study was to determine the incidence, risk factors, and causes for unplanned thirty-day readmissions following primary lower-extremity amputation in diabetic patients. METHODS: Patients with a diagnosis of diabetes undergoing primary lower-extremity amputation between 2002 and 2013 were retrospectively identified in a single-center patient database. Chart review determined patient factors including comorbidities, hemoglobin A1c level, amputation level, and demographic characteristics. Patients were divided into groups with and without unplanned readmission within thirty days postoperatively. Univariate and multivariate logistic regression analyses were used to compare cohorts and to identify variables associated with readmission. RESULTS: Overall, forty-six (10.5%) of 439 diabetic patients undergoing primary lower-extremity amputation had an unplanned thirty-day readmission. The top reason for readmission was a major surgical event requiring reoperation (37.0%), followed by medical events (28.3%) and minor surgical events (28.3%). In the univariate analysis, discharge on antibiotics (p = 0.002), smoking (p = 0.003), chronic kidney disease (p = 0.002), peripheral vascular disease (p = 0.002), and higher Charlson Comorbidity Index (p = 0.001) were each associated with readmission. In the multivariate analysis, diagnosis of gangrene (odds ratio [OR], 2.95 [95% confidence interval (95% CI), 1.37 to 6.35]), discharge on antibiotics (OR, 4.48 [95% CI, 1.71 to 11.74]), smoking (OR, 3.22 [95% CI, 1.40 to 7.36]), chronic kidney disease (OR, 2.82 [95% CI, 1.30 to 6.15]), and peripheral vascular disease (OR, 2.47 [95% CI, 1.08 to 5.67]) were independently associated with readmission. CONCLUSIONS: Thirty-day readmission rates following primary lower-extremity amputation in patients with diabetes were high at >10%. Both medical and surgical complications, many of which were unavoidable, contributed to readmission. Quality-reporting metrics should include these risk factors to avoid undeservedly penalizing surgeons and hospitals caring for this patient population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Simple Neurectomy Versus Neurectomy With Intramuscular Implantation for Interdigital Neuroma: A Comparative Study.

BACKGROUND: Simple neurectomy is a standard treatment of interdigital nerve neuroma after failure of conservative treatment. Recently, neurectomy with intramuscular implantation of the proximal nerve stump has been proposed as a safe and effective alternative method providing significant pain improvement. However, there remains little evidence supporting one technique over the other. The purpose of this study was to compare functional outcomes and complications of simple neurectomy versus neurectomy with intramuscular implantation. METHODS: Retrospective chart review along with prospectively collected data of 99 consecutive patients (105 feet with 118 neuromas) who were diagnosed with interdigital neuroma of the foot and underwent simple neurectomy (66 patients / 72 feet / 78 neuromas) and neurectomy with intramuscular implantation of proximal nerve stump into intrinsic muscle of foot (33 patients / 33 feet / 40 neuromas) between 2000 and 2013. The minimum follow-up to be included in the study was 6 months for both techniques (mean = 44.6 months, range = 6 to 150 months for simple neurectomy; and mean = 19.3 months, range = 6 to 66 months for neurectomy with intramuscular implantation of proximal nerve stump into the intrinsic muscle). The primary outcomes were Foot Function Index (FFI); pain, disability, activity limitation, and total score, Short Form-36 (SF-36: physical and mental component scores); and visual analog scale (VAS). Secondary outcomes included operative time and complications. Pre- and postoperative SF-36, and FFI, and pain (VAS) scores were obtained and compared using a paired t test. An independent t test was used to assess the functional outcomes and operative time between the 2 groups, and a chi-square test was used to compare the complications between the 2 techniques. RESULTS: Both groups demonstrated significant improvement of postoperative functional outcomes (FFI, SF-36, and VAS; P < .001, all) compared to the preoperative period. Neurectomy with intramuscular implantation demonstrated significant improvement of pain compared to simple neurectomy as measured with VAS (P = .002); however, the operative time was significantly longer than the simple neurectomy technique (P = .001). The rest of the functional outcomes measured were comparable between the 2 techniques. Complications in both simple neurectomy and implantation techniques were persistent pain (11.5% vs. 2.5%, P = .07), revision rate (5.1% vs. 0.0%, P = .08), and painful scar (5.1% vs. 5.0%, P = .83), respectively, but it did not reach statistical significance (P > .05, all). CONCLUSION: Both simple neurectomy and neurectomy with intramuscular implantation demonstrated significant improvement in terms of functional outcomes as measured with the FFI, SF-36, and VAS in patients with interdigital neuroma. Although requiring a longer operative time, neurectomy with intramuscular implantation technique might offer superior pain relief with comparable complications to the simple neurectomy technique.