Rethinking strategies for blood transfusion in hip fracture patients.

OBJECTIVES: Most patients can tolerate a hemoglobin (Hgb) > 8 g per deciliter. In some cases, however, transfusion will delay physical therapy and hospital discharge. This study aims to review Hgb and transfusion data for a large volume of recent hip fracture patients in order to identify new opportunities for decreasing the length of hospital stay. Our hypotheses are that in some cases, earlier transfusion of more blood will be associated with shorter hospital stays, and that Hgb levels consistently decrease for more than 3 days postoperatively. DESIGN: Retrospective chart review. SETTING: Two academic medical centers with Geriatric Fracture Programs. PATIENTS: Data was collected from patients 50 years and older with hip fractures April 2015 and October 2017. INTERVENTION: Operative stabilization of the hip fractures according to standard of care for the fracture type and patient characteristics. Transfusion according to established standards. MAIN OUTCOME MEASUREMENTS: Electronic records were retrospectively reviewed for demographic information, Hgb levels, and transfusion events. RESULTS: One thousand fifteen patients with femoral neck or intertrochanteric hip fractures were identified. Eight hundred sixty met the inclusion criteria. The average length of hospital stay was 6.7 days. The mean patient age was 82 years. The average American Society of Anesthesiologists score was 2.9. The average Hgb level consistently decreased for 5 days postoperatively before beginning to increase on day 6. There was poor consistency between intraoperative Hgb levels and preoperative or postoperative Hgb levels. Three hundred sixty-eight (42.8%) patients were transfused an average of 1.9 (range 1-6) units. One hundred five patients required a transfusion on postoperative day (POD) 1: 72 received only 1 unit of blood: 36 (50%) of the 72 required a second transfusion in the following days, compared to 9 of 33 (27%) who received 2 units on POD 1 (χ2 = 3.8898; P < .05). Patients who received transfusions on POD 3 or later had an average length of stay >2.5 days longer than those who received a transfusion earlier (P = 0.005). CONCLUSIONS: Our findings do not support earlier transfusion of more blood. Although in some cases, there is an association between earlier transfusion of more blood and shorter hospital stay, routine transfusion of more blood would incur higher transfusion risks in some patients who would not otherwise meet criteria for transfusion. After hip fracture surgery, the Hgb usually decreases for 5 days and does not begin to increase until POD 6. This information will provide utility in the population health management of hip fracture patients. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Effect of Trochlear Dysplasia on Outcomes After Isolated Soft Tissue Stabilization for Patellar Instability.

BACKGROUND: Trochlear dysplasia is a well-described risk factor for patellofemoral instability. Despite its clear association with the incidence of patellar instability, it is unclear whether the presence of high-grade trochlear dysplasia influences clinical outcome after patellofemoral stabilization. PURPOSE: To determine whether isolated proximal soft tissue stabilization for patellofemoral instability is as successful in patients with high-grade dysplasia compared with low-grade or no dysplasia, as measured by disease-specific quality-of-life and pain scores. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 277 patellofemoral stabilization procedures were performed during the study period. An isolated stabilization was performed in 233 patients, and 203 of these patients (87%) had adequate lateral radiographs and complete Banff Patella Instability Instrument (BPII) scores available for assessment. Of these, 152 patients underwent a medial patellofemoral ligament reconstruction (MPFL-R) and 51 patients received a medial patellofemoral ligament imbrication (MPFL-I). There were 21 patients with no trochlear dysplasia, 89 patients with low-grade dysplasia (Dejour type A), and 93 patients with high-grade dysplasia (Dejour types B-D). An independent-samples t test was used to determine the difference between the pre- and postoperative BPII scores. A Spearman rho correlation was calculated between 3 trochlear dysplasia groups and the BPII scores at a mean 24 months after patellofemoral stabilization. An independent-samples t test was used to assess the influence of trochlear bump size on outcomes by stratifying data and assessing for a relationship to BPII scores. RESULTS: The independent-samples t test demonstrated statistically significant improvements in pre- to postoperative BPII scores for both groups. The MPFL-R group improved from a mean BPII score of 24.36 to 65.16 (P < .001), and the MPFL-I group improved from a mean of 28.92 to 73.45 (P < .01). For the MPFL-R patient cohort, the Spearman rho correlation demonstrated a significant relationship between postoperative BPII scores and presence of a trochlear bump and degree of dysplasia (P ≤ .05). Overall, a trochlear bump of ≥5 mm was associated with lower postoperative BPII scores (t(193) = 2.65, η(2) = 0.04). CONCLUSION: This research has established a statistically significant correlation between trochlear dysplasia and disease-specific outcomes after MPFL-R surgery. Overall, there was evidence of significant improvement in disease-specific quality-of-life scores after patellofemoral stabilization surgery. This study is the largest cohort reported to date and therefore adds substantially to the evidence that trochlear dysplasia is a significant risk factor for and predictor of outcome among patients with patellofemoral instability.