Comparing five equations to calculate estimated glomerular filtration rate to predict acute kidney injury following total joint arthroplasty.

BACKGROUND: Acute kidney injury (AKI) following total joint arthroplasty (TJA) is associated with increased morbidity and mortality. Estimated glomerular filtration rate (eGFR) is used as an indicator of renal function. The purpose of this study was (1) to assess each of the five equations that are used in calculating eGFR, and (2) to evaluate which equation may best predict AKI in patients following TJA. METHODS: The National Surgical Quality Improvement Program (NSQIP) was queried for all 497,261 cases of TJA performed from 2012 to 2019 with complete data. The Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Cockcroft-Gault, Mayo quadratic, and Chronic Kidney Disease Epidemiology Collaboration equations were used to calculate preoperative eGFR. Two cohorts were created based on the development of postoperative AKI and were compared based on demographic and preoperative factors. Multivariate regression analysis was used to assess for independent associations between preoperative eGFR and postoperative renal failure for each equation. The Akaike information criterion (AIC) was used to evaluate predictive ability of the five equations. RESULTS: Seven hundred seventy-seven (0.16%) patients experienced AKI after TJA. The Cockcroft-Gault equation yielded the highest mean eGFR (98.6 ± 32.7), while the Re-expressed MDRD II equation yielded the lowest mean eGFR (75.1 ± 28.8). Multivariate regression analysis demonstrated that a decrease in preoperative eGFR was independently associated with an increased risk of developing postoperative AKI in all five equations. The AIC was the lowest in the Mayo equation. CONCLUSIONS: Preoperative decrease in eGFR was independently associated with increased risk of postoperative AKI in all five equations. The Mayo equation was most predictive of the development of postoperative AKI following TJA. The mayo equation best identified patients with the highest risk of postoperative AKI, which may help providers make decisions on perioperative management in these patients.

Predictors of Hospice Discharge After Surgical Fixation of Hip Fractures.

BACKGROUND: Each year, over 300,000 people older than 65 years are hospitalized for hip fractures. Given the notable morbidity and mortality faced by elderly patients in the postinjury period, recommendations have been put forth for integrating palliative and, when needed, hospice care to improve patients' quality of life. Our objective was to (1) understand the proportion of patients discharged to hospice after hip fracture surgery and their 30-day mortality rates and (2) identify the independent predictors of discharge to hospice. METHODS: We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program for all hip fracture surgeries between the years of 2016 and 2018. Included cases were stratified into two cohorts: cases involving a discharge to hospice and nonhospice discharge. Variables assessed included patient demographics, comorbidities, perioperative characteristics, and postoperative outcomes. Differences between hospice and nonhospice patients were compared using chi-squared analysis or the Fisher exact test for categorical variables and Student t -tests for continuous variables. A binary logistic regression model was used to assess independent predictors of hospice discharge with 30-day mortality. RESULTS: Overall, 31,531 surgically treated hip fractures were identified, of which only 281 (0.9%) involved a discharge to hospice. Patients discharged to hospice had a 67% 30-day mortality rate in comparison with 5.6% of patients not discharged to hospice ( P < 0.001). Disseminated cancer, dependent functional status, >10% weight loss over 6 months preoperatively, and preoperative cognitive deficit were the strongest predictors of hospice discharge with 30-day mortality after hip fracture surgery. CONCLUSIONS: Current hospice utilization in hip fracture patients remains low, but 30-day mortality in these patients is high. An awareness of the associations between patient characteristics and discharge to hospice with 30-day mortality is important for surgeons to consider when discussing postoperative expectations and outcomes with these patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Preoperative Hypoalbuminemia Is Associated With Early Morbidity and Mortality After Revision Total Hip Arthroplasty.

Hypoalbuminemia is associated with early morbidity and mortality in revision total knee arthroplasty. We evaluated the effect of preoperative hypoalbuminemia on 30-day morbidity and mortality in revision total hip arthroplasty (THA). The National Surgical Quality Improvement Program (NSQIP) database was queried from 2015 to 2018 to identify patients who underwent revision THA. Patients were stratified based on the presence or absence of preoperative hypoalbuminemia and their odds of a major complication or death within 30 days of revision THA with multivariate logistic regression. After Bonferroni correction for these 2 primary outcomes, statistical significance was defined as P<.025. A total of 2492 revision THAs with complete data were identified, of which 486 (20%) had preoperative hypoalbuminemia. Preoperative hypoalbuminemia increased the absolute risk of a major complication by 15.3% compared with patients with revision THA without hypoalbuminemia (30% vs 14.7%, P<.001). Patients with preoperative hypoalbuminemia also had nearly a 7-fold higher incidence of death (3.3%) compared with those with revision THA without preoperative hypoalbuminemia (0.5%, P<.001). After logistic regression, the odds of having a major complication after revision THA with preoperative hypoalbuminemia within 30 days were increased by 80% (odds ratio, 1.8; 95% CI, 1.4-2.3; P<.001), and the odds of death within 30 days were increased by 210% (odds ratio, 3.1; 95% CI, 1.2-7.8; P=.020). Hypoalbuminemia is associated with early morbidity and mortality after revision THA. [Orthopedics. 2022;45(5):281-286.].

Total Knee Arthroplasty after Anterior Cruciate Ligament Reconstruction.

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing in the United States, particularly in the older athlete. Patients who undergo ACL reconstruction are at higher risk for undergoing total knee arthroplasty (TKA) later in life. TKA in patients with prior ACL reconstruction has been associated with longer operative time due in-part to difficulty with exposure and retained hardware. Outcomes after TKA in patients with prior ACL reconstruction are not well defined, with some reports showing increased rate of complications and higher risk of reoperation compared with routine primary TKA, but these results are based on small and nonrandomized cohorts. Future research is needed to determine whether graft choice or fixation technique for ACL reconstruction influences outcomes after subsequent TKA. Furthermore, whether outcomes are affected by choice of TKA implant design for patients with prior ACL reconstruction warrants further study. This review analyzes the epidemiology, operative considerations, and outcomes of TKA following ACL reconstruction.

Incidence and risk factors for perioperative death after revision total hip arthroplasty: a 20-year analysis.

INTRODUCTION: The number of revision total hip arthroplasty (THA) procedures is increasing in the US. Revision THA is associated with higher complication rates compared with primary THA. We describe patterns in incidence and risk factors for perioperative death after revision THA. METHODS: Using the National Hospital Discharge Survey, we identified nearly 700,000 cases of revision THA from 1990 through 2010. Procedure incidence, perioperative mortality rates, comorbidities, discharge disposition, and duration of hospital stay were analysed. Multivariable logistic regression was used to identify independent risk factors for perioperative death. Alpha = 0.01. RESULTS: Population-adjusted incidence of revision THA per 100,000 people increased from 9.2 cases in 1990 to 15 cases in 2010 (p < 0.001). The rate of perioperative death was 0.9% during the study period and decreased from 1.5% during the "first" period (1990-1999) to 0.5% during the "second" period (2000-2010) (p < 0.001), despite an increase in comorbidity burden over time. Factors associated with the greatest odds of perioperative death were acute myocardial infarction (odds ratio [OR], 37; 95% confidence interval [CI], 33-40; p < 0.001), pneumonia (OR, 16; 95% CI, 15-18; p < 0.001), and pulmonary embolism (OR, 13; 95% CI, 11-15; p < 0.001). CONCLUSIONS: The rate of perioperative death in patients undergoing revision THA in the US decreased from 1990 to 2010 despite an increase in comorbidities. Acute myocardial infarction, pneumonia, and pulmonary embolism were associated with the highest odds of perioperative death after revision THA.

Extremity fasciotomy for patients on extracorporeal membrane oxygenation is independently associated with inpatient mortality.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) maintains end-organ perfusion in critically ill patients with cardiac or respiratory failure; however, ECMO cannulation in the extremities has been associated with significant limb ischemia and risk of compartment syndrome. Current literature on ECMO and fasciotomies is limited to small single-center retrospective studies. This study aimed to (1) compare the incidence of postoperative outcomes and mortality in patients undergoing fasciotomy while on ECMO to those of non-fasciotomy ECMO patients, and (2) assess the difference in adjusted mortality risk between the two groups. HYPOTHESIS: We hypothesized that patients undergoing fasciotomy while on ECMO would have significantly higher odds of in-hospital mortality than non-fasciotomy ECMO patients after adjustment for perioperative variables. METHODS: We conducted a retrospective review of NIS from January 1st, 2012-September 30, 2015 for all hospitalizations involving ECMO and stratified them into two cohorts based on whether they underwent fasciotomy after ECMO. Patient baseline characteristics, in-hospital procedures, and postoperative outcomes were compared between the two cohorts. Logistic regression was used to assess in-hospital mortality risk between the two cohorts adjusting for age, sex, Elixhauser score, and perioperative procedures and non-fasciotomy perioperative morbidity. RESULTS: There were 7,085 estimated eligible discharges between 2012 and 2015 identified, 149 (2.1%) of which underwent fasciotomy following ECMO. One hundred and thirteen of the 149 hospitalizations (77%) in the fasciotomy cohort resulted in in-hospital mortality, compared to 3,805 of the 6,936 (55%) in the non-fasciotomy cohort. There were no differences in rates of transfusion (p=0.290), length of stay (p=0.282), or discharge disposition (p=0.126) between the two cohorts. In the logistic regression model, the fasciotomy cohort had a higher odds of in-hospital mortality than non-fasciotomy cohort (OR, 2.5; 95% CI, 1.1-5.6). DISCUSSION: Operative treatment of acute compartment syndrome for patients on ECMO therapy is associated with significantly increased mortality and morbidity. Whether fasciotomy is a marker of sickness or represents a cause-and-effect relationship is unknown and future should investigate the role of non-operative treatment of compartment syndrome on mortality in this population. LEVEL OF EVIDENCE: III; Prognostic.

Perceptions of Financial Conflict of Interest and Knowledge of the Sunshine Act Among Orthopedic Surgery Patients.

The orthopedic surgical specialty is strongly tied to partnerships with industry that have fostered innovation and greatly enhanced patient care. A substantial number of orthopedic surgeons currently receive some form of industry support. These relationships are highly scrutinized because they present the possibility of both personal and financial conflicts of interest (COI). The authors examined orthopedic patients' awareness of existing regulation and perceptions of financial COI by performing a prospective survey-based study of patients seen in an academic orthopedic department. Data were collected during 1 year, in a cross-section of hospital-based and community clinical settings. The authors collected 513 surveys during a 1-year period between 4 clinical locations. Of all respondents, 55% were unconcerned regarding gifts or direct compensation their physicians received from industry, and only 16% were very or extremely concerned regarding these benefits. Patients' opinions regarding possible influence of benefits were similarly ambivalent, with 54% of patients minimally or not at all concerned regarding the potential influence of industry gifts or compensation. Seventy-six percent of patients had never heard of the Sunshine Act, and only 3% indicated that they were aware of the legislation and its intention. The income of the respondents and their level of education were positively correlated with increased concern about handling of COI, as well as knowledge regarding the Sunshine Act. These data suggest that orthopedic surgery patients are widely unconcerned regarding physician COI, but specific subsets of patients may be more likely to have concerns regarding these relationships. [Orthopedics. 2021;44(5):e682-e686.].

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration.

BACKGROUND: Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery. AIM: To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients. METHODS: In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05. RESULTS: Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort. CONCLUSION: The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

A guide to resecting tumors of the sciatic notch.

Sciatic notch tumors are rare and have numerous etiologies. Tumor presentation varies widely and no uniform recommendations exist for approaching resection. Most studies on the topic have been small case series, with the approach dictated by surgeon experience and comfort. We provide an overview of surgical approaches for resecting sciatic notch tumors reported in the literature, as well as a conceptual framework for application of these approaches based on standard oncologic principles. The advantages and disadvantages of each approach are described on the basis of anatomic location of the tumor. For tumors that span the notch with intra- and extra-pelvic extension, notchplasty is a novel technique that provides superior visualization and access for en-bloc excision.

Factors Associated With Perioperative Transfusion in Lower Extremity Revision Arthroplasty Under a Restrictive Blood Management Protocol.

INTRODUCTION: Approximately 37% of patients undergoing lower extremity revision total joint arthroplasty (TJA) receive allogeneic blood transfusions (ABTs), which are associated with increased risk of morbidity and death. It is important to identify patient factors associated with needing ABT because the health of higher-risk patients can be optimized preoperatively and their need for ABT can be minimized. Our goal was to identify the patient and surgical factors independently associated with perioperative ABT in revision TJA. METHODS: We included all 251 lower extremity revision TJA cases performed at our academic tertiary care center from January 1, 2016, to December 31, 2018. We assessed the following factors for associations with perioperative ABT: patient age, sex, race, body mass index, preoperative hemoglobin level, and infection status (ie, infection as indication for revision TJA); use of vasopressors, tranexamic acid (TXA), surgical drains, tourniquets, and intraoperative cell salvage; and procedure type (hip versus knee), procedure complexity (according to the number of components revised), and surgical time. Multivariable regression was used to identify factors independently associated with perioperative ABT. RESULTS: The following characteristics were independently associated with greater odds of perioperative ABT: preoperative hemoglobin level (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5 to 2.2), infectious indication for revision (OR, 3.6; 95% CI, 1.3 to 9.7), and procedure complexity. TXA use was a negative predictor of ABT (OR, 0.47; 95% CI, 0.23 to 0.98). Compared with polyethylene liner exchanges, single-component revisions (OR, 14; 95% CI, 3.6 to 56) and dual-component revisions (OR, 7.8; 95% CI, 2.3 to 26) were associated with greater odds of ABT. DISCUSSION: Patients with preoperative anemia, those undergoing revision TJA because of infection, those who did not receive TXA, and those undergoing more complex TJA procedures may have greater odds of requiring ABT. We recommend preoperative optimization of the health of these patients to reduce the need for ABT. LEVEL OF EVIDENCE: Level III, prognostic study.

Complications and 30-Day Mortality Rate After Hip Fracture Surgery in Superobese Patients.

OBJECTIVE: Paradoxically, overweight and obesity are associated with lower odds of complications and death after hip fracture surgery. Our objective was to determine whether this "obesity paradox" extends to patients with "superobesity." In this study, we compared rates of complications and death among superobese patients with those of patients in other body mass index (BMI) categories. METHODS: Using the National Surgical Quality Improvement Program database, we identified >100,000 hip fracture surgeries performed from 2012 to 2018. Patients were categorized as underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obese (BMI 30-39.9), morbidly obese (BMI 40-49.9), or superobese (BMI ≥50). We analyzed patient characteristics, surgical characteristics, and 30-day outcomes. Using multivariate regression with normal-weight patients as the referent, we determined odds of major complications, minor complications, and death within 30 days by BMI category. RESULTS: Of 440 superobese patients, 20% had major complications, 33% had minor complications, and 5.2% died within 30 days after surgery. When comparing patients in other BMI categories with normal-weight patients, superobese patients had the highest odds of major complications [odds ratio (OR): 1.6, 95% confidence interval (CI), 1.2-2.0] but did not have significantly different odds of death (OR: 0.91, 95% CI, 0.59-1.4) or minor complications (OR: 1.2, 95% CI, 0.94-1.4). CONCLUSION: Superobese patients had significantly higher odds of major complications within 30 days after hip fracture surgery compared with all other patients. This "obesity paradox" did not apply to superobese patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a Complete Description of Levels of Evidence.

Compensated Cirrhosis Is Associated With Increased Risk of Complications Following Total Hip Arthroplasty in a Large Medicare Database.

BACKGROUND: The aim of this study is to evaluate medical and surgical complications of liver cirrhosis patients following total hip arthroplasty (THA), with attention to different etiologies of cirrhosis and their financial burden following THA. METHODS: In total, 18,321 cirrhotics and 722,757 non-cirrhotics who underwent primary elective THA between 2006 and 2013 were identified from a retrospective database review. This cohort was further subdivided into 2 major etiologies of cirrhosis (viral and alcoholic cirrhosis) and other cirrhotic etiology. Cirrhotics were compared to non-cirrhotics for hospital length of stay, 90-day mean total charges and reimbursement, hospital readmission, and major medical and arthroplasty-specific complications. RESULTS: Cirrhosis was associated with increased rates of major medical complications (4.3% vs 2.4%; odds ratio [OR] 1.20, P < .001), minor medical complications, transfusion (3.4% vs 2.1%; OR 1.16, P = .001), encephalopathy, disseminated intravascular coagulation, and readmission (13.5% vs 8.6%; OR 1.18, P < .001) within 90 days. Cirrhosis was associated with increased rates of revision, periprosthetic joint infection, hardware failure, and dislocation within 1 year postoperatively (3.1% vs 1.6%; OR 1.37, P < .001). Cirrhosis independently increased hospital length of stay by 0.14 days (P < .001), and it independently increased 90-day charges and reimbursements by $13,791 (P < .001) and $1707 (P < .001), respectively. Viral and alcoholic cirrhotics had higher rates of 90-day and 1-year complications compared to controls-other causes only had higher rates of 90-day medical complications, encephalopathy, readmission, and 1-year revision, hardware failure, and dislocation compared to controls. CONCLUSION: Cirrhosis, especially viral and alcoholic etiologies, is associated with higher risk of early postoperative complications and healthcare utilization following elective THA.

Distance Between Reproductive Structures and the Insertion Point of the Retrograde Pubic Ramus Screw.

OBJECTIVE: To identify the distance between the guidewire for a retrograde pubic ramus screw and critical reproductive structures in men and women. METHODS: Twenty hemipelves from 10 fresh-frozen cadavers (pelvis to distal femur) were studied. The mean (±SD) age was 77 ± 6 years for the 5 male cadavers and 71 ± 9 years for the 5 female cadavers. A 2.8-mm guidewire for a cannulated screw was inserted from the parasymphyseal bone using fluoroscopic guidance. The soft tissue was dissected and measurements performed by the first author. In men, we measured the closest distances from the guidewire entry point to the contralateral spermatic cord and corpus cavernosum. In women, we measured the closest distances from the guidewire entry point to the base of the clitoral body and clitoral glans. RESULTS: In male cadavers, mean distances were 8.8 ± 4.2 mm to the spermatic cord and 13 ± 6.7 mm to the corpus cavernosum. The guidewire did not penetrate these structures in any specimen. In female cadavers, mean distances were 12 ± 5.7 mm to the base of the clitoral body and 40 ± 8.2 mm to the clitoral glans. The guidewire also did not penetrate these structures. CONCLUSIONS: The contralateral spermatic cord and corpus cavernosum in men and the base of the clitoral body in women are close to the pathway of the retrograde ramus screw guidewire. Careful identification of the entry point and avoidance of multiple attempts of guidewire insertion may reduce the risk of injury to these structures.

Opioid Prescribing Trends and Geographic Variation After Anterior Cruciate Ligament Reconstruction.

INTRODUCTION: Opioid prescribing patterns play an important role in the opioid epidemic in the United States. The purpose of this study is to examine the trends and geographic variation in opioid prescribing patterns after anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS: Regional differences in opioid prescribing patterns after ACL reconstruction are present. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: The Truven Health MarketScan Commercial Claims database was used to analyze all patients with perioperative private insurance coverage who underwent ACL reconstruction from January 1, 2010, to November 31, 2017. Total number and morphine milligram equivalents per day (MMED) of opioid prescriptions were examined, and regional and statewide variation was assessed. RESULTS: A total of 90,068 ACL reconstruction patients who underwent surgery between 2010 and 2017 were included in the study. Overall, 67% received an opioid prescription within 30 days of surgery and 17% received an opioid prescription ≥90 MMED. The West (20%) had the highest proportion of patients with an opioid prescription ≥90 MMED and the Northeast had the lowest (12%), P < 0.001. The number of opioid prescriptions as well as proportion of opioid prescriptions ≥90 MMED varied significantly by state, P < 0.001. There was a significant increase in number of opioid prescriptions from 2010 to 2017 (62% in 2010 and 83% in 2017; P < 0.001). A significant change in the proportion of patients being prescribed ≥90 MMED was also present (P = 0.04; 15% in 2010, 17% in 2011, 17% 2012, 17% in 2013, 15% in 2014, 20% in 2015, 18% in 2016, and 15% in 2017). CONCLUSION: This study shows a trend of increasing opioid prescriptions and geographic variations in the amount and MMED of opioid prescriptions for patients undergoing ACL reconstruction. These data highlight several areas of improvement that state officials and national entities can use to help curb the opioid epidemic and underscore the importance of national guidelines for opioid prescribing. CLINICAL RELEVANCE: Knowledge of prescribing patterns after specific procedures may help provide more direct insight and guidance to surgeons and patients regarding postoperative pain management.

Establishing Telemedicine in an Academic Total Joint Arthroplasty Practice: Needs and Opportunities Highlighted by the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has prompted rapid restructuring of the health-care system in an effort to stop the spread of the virus and to treat patients who are acutely ill with COVID-19, while continuing to provide outpatient care for the remainder of patients. To help control spread of this pandemic, many centers, including total joint arthroplasty clinics, have boosted telemedicine capability to care for patients who would typically be seen in person in outpatient settings. We review key components relevant to the establishment and effective use of telemedicine, focused on patient education, practice logistics, technological considerations, and sensitive patient health information-associated compliance factors, which are necessary to provide care remotely for total joint arthroplasty patients.

Kneeling after Total Knee Arthroplasty.

The ability to kneel is one of the many patient goals after total knee arthroplasty (TKA). Few studies have addressed patients' ability to kneel after TKA as a primary outcome. Given the altered biomechanics of the knee after TKA, the various implant designs, and multiple surgical approaches, there is a need to further understand the patient's kneeling ability after TKA. We evaluated the available literature on this topic to help to guide postoperative care recommendations. Biomechanical data show that the load borne by the patellofemoral joint is elevated significantly at all flexion angles, whereas tibiofemoral articulation pressures are elevated only at 90 to 120 degrees of flexion. However, these increased pressures are rarely borne by prosthetic knees because patients often avoid kneeling after TKA. In patients who do kneel after surgery, data show that increased range of motion promotes improved kneeling performance. Targeted interventions to encourage kneeling after TKA, including preoperative education, have not shown an ability to increase the frequency with which patients kneel after TKA. Reasons for patient avoidance of kneeling are multifaceted and complex. There is no biomechanical or clinical evidence contraindicating kneeling after TKA. There are insufficient data to recommend particular prosthetic designs or surgical approaches to maximize kneeling ability after surgery. Musculoskeletal health care providers should continue to promote kneeling to allow patients to achieve maximum clinical benefit after TKA.

The impact of patient blood management on blood utilization and clinical outcomes in complex spine surgery.

BACKGROUND: Patient blood management (PBM) is especially applicable in major spine surgery, during which bleeding and transfusion are common. What remains unclear in this setting is the overall impact of bundled PBM measures on transfusion requirements and clinical outcomes. We compared these outcomes before and after implementing a PBM program. STUDY DESIGN AND METHODS: We conducted a retrospective review of 928 adult complex spine surgery patients performed by a single surgeon between January 2009 and June 2016. Although PBM measures were phased in over time, tranexamic acid (TXA) administration became standard protocol in July 2013, which defined our pre- and post-PBM periods. Transfusion rates for all blood components before and after PBM implementation were compared, as were morbid event rates and mortality. RESULTS: Baseline characteristics were similar before and after PBM. Before PBM, the mean number of units/patient decreased for red blood cells (RBCs; by 19.5%; p = 0.0057) and plasma (by 33%; p = 0.0008), but not for platelets (p = 0.15). After risk adjustment by multivariable analyses, the composite outcome of morbidity or mortality showed a nonsignificant trend toward improvement after PBM (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.39-1.01; p = 0.055), and the risk of thrombotic events was unchanged (OR, 1.12; 95% CI, 0.42-2.58; p = 0.80). CONCLUSION: In complex spine surgery, a multifaceted PBM program that includes TXA can be advantageous by reducing transfusion requirements without changing clinical outcomes.

Opioid-related compartment syndrome and associated morbidity.

INTRODUCTION: Opioid-related compartment syndrome (ORCS) is an understudied complication related to opioid overdose. We hypothesized that ORCS would be associated with worse clinical outcomes, including higher amputation rates, need for multiple surgical procedures, and rhabdomyolysis on admission, compared with nonopioid-related compartment syndrome (NORCS). METHODS: We used Current Procedural Terminology codes for fasciotomy as a proxy marker for cases of compartment syndrome treated at 1 health system from January 1, 2016, to December 21, 2018. We excluded patients younger than 18 years, those treated for exertional compartment syndrome, and those who underwent elective fasciotomies. Seventy-four patients met our inclusion criteria. Data reviewed included patient characteristics, cause of compartment syndrome, time until evaluation for compartment syndrome, peak creatinine kinase levels, number of surgical procedures required, duration of hospital stay, and postoperative inpatient morbidity and death. Patients were categorized as having ORCS (n = 8) or NORCS (n = 66). Alpha = .05. RESULTS: All cases of ORCS occurred in men. Opioid use was the third most common cause of compartment syndrome. Two patients underwent amputation, both in the ORCS group (p <  0.01). The median number of debridements was significantly higher for the ORCS group (median, 4; interquartile range [IQR]: 3-6) than for the NORCS group (median, 3; IQR 2-4) (p =  0.03). Duration of hospital stay was longer for the ORCS group (median, 27 days; IQR 16-38) compared with the NORCS group (median, 9 days; IQR: 5-13) (p <  0.001). Mean (± standard deviation) peak creatinine kinase level was significantly higher in the ORCS group (224,000 ± 225,052 U/L) compared with the NORCS group (7550 ± 32,500) (p <  0.001). The proportion of patients who underwent hemodialysis was higher in the ORCS group (88%) than in the NORCS group (35%) (p <  0.001). All ORCS patients presented >8 h after immobilization in a dependent position. CONCLUSION: Patients in the ORCS group had delayed presentations and significantly more morbidity compared with patients in the NORCS group.

Reducing routine laboratory tests in patients with isolated extremity fractures: a prospective safety and feasibility study in 246 patients.

BACKGROUND: Daily routine laboratory testing is unnecessary in most admitted patients. The opportunity to reduce daily laboratory testing in orthopaedic trauma patients has not been previously investigated. METHODS: A prospective observational study was performed based on a new laboratory testing reduction protocol for 12 months at two tertiary care trauma centers. Admitted patients with surgically treated isolated upper or lower extremity fractures were included (n = 246). The testing protocol consisted of a complete blood count (CBC) and basic metabolic panel (BMP) on postoperative day 2. Thereafter, tests were obtained at individual providers' discretion. Patients were followed for 30 days postoperatively. The primary outcome was number of laboratory tests reduced. Secondary outcomes included provider protocol compliance, and adverse patient outcomes. Chi-squared tests were used to compare differences in categorical variables among the cohorts. Analysis of variance tests were used for continuous variables. The relative reductions in testing utilization were calculated using our division's standard-of-care before program implementation (1 CBC and 1 BMP per patient per inpatient day). Significance was defined as P < 0.05. RESULTS: Of the 246 patients, there were 45 protocol fall outs due to provider deviation (n = 24) or medically justified necessity for additional testing (n = 21). Across all groups, a total of 778 CBC or BMP tests were avoided, amounting to a 69% reduction in testing compared to the pre-implementation baseline. Ninety-five percent of protocol group patients were safely discharged either without laboratory testing or with one set of tests obtained on postoperative day 2. There were no 30-day readmissions or reported complications associated with the new laboratory testing protocol. CONCLUSIONS: In patients with surgically treated fractures about the elbow and knee, obtaining a single set of laboratory tests on postoperative day 2 is safe and efficacious in terms of reducing inappropriate resource utilization. TRIAL REGISTRATION: retrospectively registered.

A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures.

INTRODUCTION: In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population. METHODS: In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation. RESULTS: After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival. DISCUSSION: A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL. LEVEL OF EVIDENCE: Level III, retrospective cohort study.