Trapeziectomy, Partial Trapezoidectomy, and Abductor Pollicis Longus Dual Loop Ligament Reconstruction for Advanced Basal Joint Arthritis: Long-Term Outcome of 150 Cases.

BACKGROUND: Although hand surgeons usually concur that arthroplasty is indicated for disabling basal joint arthritis, controversy persists regarding the preferred surgical methods. This article describes a novel technique of trapezial excisional arthroplasty with partial trapezoidectomy and abductor pollicis longus (APL) dual ligament reconstruction, and reports the long-term results of 150 cases. Based on this experience, we hypothesize that this technique is a reliably effective and durable surgical option for basal joint arthritis. METHODS: This study evaluated consecutive patients with Eaton and Littler advanced stage III/IV basal joint arthritis, treated by this procedure, and followed for a minimum of 10 years. Outcome assessment included grip and pinch strength, thumb mobility, radiographic parameters, pain relief, and patient-reported outcomes as measured with the Disabilities of the Arm, Shoulder, and Hand (DASH) scoring system. RESULTS: A total of 150 thumbs in 124 patients with an average follow-up of 13.5 years (range, 10-22 years) were studied. Alleviation of pain and patient satisfaction were constant outcomes, and the mean DASH score was a normative 8.7. Grip and pinch strength were significantly improved (P < .001), carpometacarpal joint malalignment and adduction deformities were consistently corrected, complications were few, and revision surgery was unnecessary. CONCLUSIONS: These results support the premise that trapeziectomy and partial trapezoidectomy with APL dual ligament stabilization is a reliable and durable arthroplasty for basal joint arthritis with distinct advantages and equally favorable outcomes when compared with other frequently employed methods.

En Masse Excision and Curettage for Periarticular Gouty Tophi of the Hands.

Background: Despite increasing disease prevalence, there remains a paucity of data examining surgical treatments for gouty tophi. This article assesses en masse excision and curettage of articular tophi involving the hands and shows that carefully planned and precisely executed surgery can consistently alleviate pain, preserve function, and enhance the aesthetics of afflicted hands. Methods: A retrospective review was conducted of all consecutive patients who underwent surgical excision of tophaceous deposits from the upper extremity. All patients had an established diagnosis of gout and had been treated with urate-lowering medication. All tophi were substantive in size and were causing significant digital joint dysfunction and disfigurement with variable skin ulcerations. Results: The study group included 12 patients with 24 tophaceous deposits excised from the metacarpal and interphalangeal joints; 2 deposits were also concomitantly excised from the wrist and 2 from the elbow. The study group included 8 men and 4 women, with an average age of 67 years. Follow-up evaluation ranged from 2 to 15 years. All patients underwent successful tophus excision with restoration of tendon excursion and joint mobility without wound complications. All regained high levels of function, and all reported satisfaction with their outcome. On follow-up for as long as 15 years, recurrence has not been observed and secondary surgery has not proved necessary. Conclusions: This study indicates that surgical excision of articular tophi of the hands can provide long-term improvement in function and aesthetics with minimal risk of wound complications or recurrence.

Medial femoral trochlea flap reconstruction: Clinical outcomes and perspectives.

INTRODUCTION: We report our experience with use of the medial femoral trochlea (MFT) osteochondral flap for carpal applications. METHODS: Outcomes of all patients treated with MFT flaps were reviewed. Healing, range of motion, grip strength, carpal alignment, pain, and complication data were collected. RESULTS: MFT flaps were performed on seven patients with a mean age of 26.1 (range, 17-42) years. Indications included scaphoid proximal pole nonunion (n = 3), Kienböck's disease (n = 3), and Preiser's disease (n = 1). The mean follow-up was 32.3 (range, 5-70) months. Union was achieved in five patients at a mean of 12 (range 6-22) weeks. All five patients had increased grip strength and absence of pain at follow-up. There were two failures due to graft resorption. CONCLUSIONS: The MFT osteochondral flap is a technically challenging yet powerful tool to replace the loss of both carpal articular cartilage and adjacent bone.

Betadine-Soaked Alcohol Pad and Rigid Immobilization: An Inexpensive and Effective Method to Diminish Infections With Exposed Kirschner Wires in Hand Fractures.

This study describes a novel method of pin care with a Betadine-soaked alcohol pad in conjunction with immobilization to reduce pin site complications in hand fractures treated with exposed Kirschner wires (K-wires). We conducted a retrospective review of all phalangeal and metacarpal fractures from 2010 to 2016 treated with K-wire fixation, a Betadine-soaked alcohol pad, and immobilization in a well-moulded plaster cast. A total of 155 patients with metacarpal or phalangeal fractures were identified, of which 149 were included with 164 fractures treated with 217 exposed K-wires. Overall complication rate was 6.1% (10/164), of which 3 fractures (1.8%) developed infections. Two infections occurred in patients with a history of organ transplantation. The most common complication was stiffness requiring closed manipulation under anesthesia (2.4%, 4/164), resulting in full range of motion in 3 of 4 patients. Exposed K-wires remain an effective method of hand fracture fixation associated with a low complication rate.

La présente étude décrit une nouvelle méthode de soins des broches avec un tampon d'alcool imprégné de bétadine conjointement avec l'immobilisation pour réduire les complications au foyer des broches en cas de fractures de la main traitées par des broches K exposées. Les chercheurs ont effectué une analyse rétrospective de toutes les fractures phalangiennes et métacarpiennes traitées par des broches K entre 2010 et 2016, un tampon d'alcool imprégné de bétadine et une immobilisation dans un plâtre bien moulé. Ils ont repéré 155 patients victimes de fractures métacarpiennes ou phalangiennes et en ont inclus 149 qui ont été traités par 217 broches K exposées. Le taux de complication globale s'élevait à 6,1 % (dix sur 164) et trois fractures (1,8 %) se sont infectées. Deux infections se sont produites chez des patients ayant subi une transplantation d'organe. La complication la plus courante était une rigidité exigeant une manipulation fermée sous anesthésie (2,4 %, quatre sur 164), qui a favorisé une pleine amplitude de mouvement chez trois des quatre patients. Les broches K exposées demeurent une méthode efficace de fixation des fractures de la main, associées à un faible taux de complication.

Characterization of the Dorsal Ulnar Corner in Distal Radius Fractures in Postmenopausal Females: Implications for Surgical Decision Making.

PURPOSE: To characterize the dorsal ulnar corner fragment with regard to size and morphology using 3-dimensional software and computed tomography (CT) scans, as it presents in low-energy intra-articular distal radius fractures occurring in the female postmenopausal population. METHODS: A multicenter retrospective review was conducted to identify postmenopausal females with low-energy distal radius fractures treated surgically at level-1 trauma centers. Patients with low-energy injuries with preoperative CT scans were included. The Digital Imaging and Communications in Medicine (DICOM) data from CT scans were used to reconstruct intra-articular fracture patterns. The dorsal ulnar fragment was isolated in each CT scan and measured, then normalized based on lunate depth. RESULTS: Eighty patients met the inclusion criteria. The mean dimension measurements of the dorsal ulnar corner were dorsal surface height, 9.82 ± 5.02 mm (95% confidence interval [95% CI], 8.72-10.92); dorsal surface width, 9.06 ± 3.72 mm (95% CI, 8.25-9.88); articular surface width, 7.44 ± 3.92 mm (95% CI, 6.58-8.30); articular surface depth, 4.14 ± 2.39 mm (95% CI, 3.62-4.67). The mean lunate depth measurement (17.52 ± 1.48 mm) was used to normalize articular surface depth demonstrating that, on average, the dorsal ulnar corner comprises 23.6% of the articular surface ± 13.6% (95% CI, 20.7-26.6). CONCLUSIONS: The mean articular surface depth of the dorsal ulnar corner fragment in this study was less than 5 mm, accounting for approximately 24% of the volar-dorsal width of the distal radius at the lunate facet. CLINICAL RELEVANCE: These data expand current understanding of the morphology and size of the dorsal ulnar corner fracture fragment. If fixation of this fragment is a goal, surgeons may need to use longer screws that penetrate closer to the dorsal cortex than those required for extra-articular fractures or to consider alternative methods of fragment-specific fixation for adequate capture of this fragment.

Distal Nerve Transfers to the Triceps Brachii Muscle: Surgical Technique and Clinical Outcomes.

PURPOSE: To report the clinical outcomes and describe the surgical technique of triceps muscle reinnervation using 2 different distal nerve transfers: the flexor carpi ulnaris (FCU) fascicle of the ulnar nerve and the posterior branch of the axillary nerve (PBAN) to the triceps nerve branch. METHODS: A retrospective review of patients undergoing FCU fascicle of ulnar nerve or PBAN to triceps nerve branch transfer was performed. Outcome measures included preoperative and postoperative modified British Medical Research Council (MRC) score, EMG results, and complications. RESULTS: Between September 2003 and April 2017, 6 patients were identified. Four patients with a traumatic upper trunk and posterior cord palsy underwent ulnar nerve fascicle to triceps nerve transfer. Two patients with a recovering upper trunk following a pan-brachial plexus palsy underwent PBAN to triceps nerve branch transfer. The median age was 30.0 years (range, 18-68 years). Surgery was performed at a median of 6.9 months (range, 5.0-8.9 months) postinjury, with a median follow-up of 18.4 months (range, 7.6-176.3) months. Before surgery, 4 patients exhibited grade M0 and 2 patients exhibited grade M1 triceps strength. Four patients had M5 donor muscle strength and 2 had grade M4. Postoperatively, 4 patients regained MRC grade M4 triceps muscle strength, 1 regained M3, and 1 regained M2. There was no noticeable donor muscle weakness. CONCLUSIONS: Nerve fascicles to the FCU and PBAN are viable options for obtaining meaningful triceps muscle recovery in a select group of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Risk factors for and timing of adverse events after revision total shoulder arthroplasty.

BACKGROUND: Despite increasing rates of revision total shoulder arthroplasty (RTSA), there is a paucity of literature on optimizing perioperative outcomes. The purposes of this study were to identify risk factors for unplanned readmission and perioperative complications following RTSA, risk-stratify patients based on these risk factors, and assess timing of complications. METHODS: Bivariate and multivariate analyses of risk factors were assessed on RTSA patients from the ACS-NSQIP database from 2011 to 2015. Patients were risk-stratified and timing of severe adverse events and cause of readmission were evaluated. RESULTS: Of 809 RTSA patients, 61 suffered a perioperative complication or readmission within 30 days of discharge. Multivariate analysis identified operative time, BMI > 40, infection etiology, high white blood cell count, and low hematocrit as significant independent risk factors for 30-day complications or readmission after RTSA (p ≤ 0.05). Having at least one significant risk factor was associated with 2.71 times risk of complication or readmission within 15 days compared to having no risk factors (p < 0.001). The majority of unplanned readmission, return to the operating room, open/deep wound infection, and sepsis/septic shock occurred within two weeks of RTSA. DISCUSSION: Patients at high risk of complications and readmission after RTSA should be identified and optimized preoperatively to improve outcomes and lower costs.

Factors associated with failed ulnar nerve fascicle to biceps motor branch transfer: a case control study.

We sought to identify predictors of failed ulnar nerve fascicle (to flexor carpi ulnaris) to biceps motor branch transfer. A retrospective review of adult brachial plexus patients treated with flexor carpi ulnaris to biceps transfer with a minimum 1-year follow-up was performed. Failure, defined as modified British Medical Research Council grade <3 elbow flexion was compared with randomly selected controls (M ≥ 4-). Ninety-one patients, of which 80% regained >M3 flexion met criteria. Eighteen failures and 18 controls, with similar follow-up (20 vs 23 months) were evaluated. Preoperative flexor carpi ulnaris weakness (M < 5) was significantly more common in failures (78% vs 33%). The rate of flexor carpi ulnaris recovery after operation was significantly higher in controls (86% vs 7%). Increased failure risk can be expected with impaired preoperative flexor carpi ulnaris function. The challenge is how to identify which patients will regain near normal flexor carpi ulnaris strength as excellent outcomes can be obtained. Level of evidence: III.

Predictive Factors and Rates of Fusion in Minimally Invasive Transforaminal Lumbar Interbody Fusion Utilizing rhBMP-2 or Mesenchymal Stem Cells.

BACKGROUND: Several fusion adjuncts exist to enhance fusion rates during minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). The objective of this study was to compare fusion rates in patients undergoing MI-TLIF with either rhBMP-2 or cellularized bone matrix (CBM). METHODS: We conducted a single surgeon retrospective cohort study of patients who underwent MI-TLIF with either rhBMP-2 or CBM placed in an interbody cage. Single and multilevel procedures were included. Fusion was assessed on computed tomography scans at 12-month follow-up by an independent, blinded, board-certified neuroradiologist. Fusion rates and rate of revision surgery were compared with a Fisher exact test between the 2 groups. A multivariate regression analysis was performed to identify patient factors that were predictive of radiographic nonunion after MI-TLIF. RESULTS: A total of 93 fusion levels in 78 patients were reviewed. Thirty-nine patients received CBM, and 39 patients received rhBMP-2. The patients receiving rhBMP-2 were older on average (61.4 vs 55.6, P = .03). The overall fusion rate was 68% in the CBM group (32/47 levels) and 78% in the rhBMP-2 group (36/46) (P = .35). Only preoperative hypertension was predictive of radiographic nonunion (odds ratio = 3.5, P = .05). There were 3 smokers in the CBM group and 4 smokers in the BMP group, and 1 in each group experienced radiographic pseudarthrosis. A total of 4 patients, 3 in the CBM group and 1 in the BMP group (P = .61), required revision for symptomatic pseudarthrosis. All of these patients had a single-level index procedure. CONCLUSIONS: There were no differences in radiographic fusion and rate of revision surgery in patients who underwent MI-TLIF with either rhBMP-2 or CBM as fusion adjuncts. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Both rhBMP-2 and CBMs can be used as effective fusion adjuncts without any clear advantage of one over the other.

Arthroscopic versus open excision of dorsal ganglion cysts: a systematic review.

We conducted a systematic review comparing recurrence and complication rate following open versus arthroscopic excision of ganglion cysts. Sixteen full-text articles were included. The pooled recurrence rate of open excision was 20% (range: 5.6-40.7%) with Q value of 27 and I2 of 82%. The pooled recurrence rate of arthroscopic excision was 9% (range: 0-17%) with Q value of 10 and I2 of 2%. Eleven of 16 studies were low quality or had a high risk of bias; however, excluding low quality studies or those with high risk of bias produced similar recurrence rates in arthroscopic and open excision (7.9% versus 9.8%). For the subset of studies with complete reporting of complications, rates were similar in open and arthroscopic excision (6% versus 4%). Our review suggests that arthroscopic and open approaches have comparable outcome profiles. Nevertheless, standardized study methods with adequate powering are required to collect high quality data, allowing for greater confidence in conclusions regarding these two approaches for existing ganglion cysts. LEVEL OF EVIDENCE: II.

Outcomes of displaced olecranon fractures treated with the Olecranon Sled.

BACKGROUND: Tension-band wiring is largely considered the gold standard for fixation of displaced olecranon fractures despite high rates of hardware complications. The purpose of this study was to report the outcomes of displaced olecranon fractures treated with the Olecranon Sled. METHODS: We retrospectively reviewed all displaced olecranon fractures from 2011-2015 treated with the Olecranon Sled. Inclusion was limited to functionally independent patients with Mayo type II fractures and minimum 12-month follow-up. We assessed clinical outcomes including range of motion; Disabilities of the Arm, Shoulder and Hand score; and Mayo Elbow Performance Score. RESULTS: Twenty-two patients with a mean follow-up period of 31.8 months (range, 12-71 months) were included in the study. All patients indicated satisfactory outcomes. The mean Mayo Elbow Performance Score was 95.5 (range, 70-100), and the mean Disabilities of the Arm, Shoulder and Hand score was 3.1 (range, 0-18.3). The mean total arc of elbow flexion was 145° (range, 134°-158°), and the mean total arc of forearm rotation was 175° (range, 160°-180°). There were no hardware-related complications. The overall complication rate was 4.5% (1 of 22) as significant heterotopic ossification developed in 1 patient, requiring contracture release. CONCLUSION: The Olecranon Sled is a reliable and well-tolerated implant for the treatment of olecranon fractures. This device results in excellent functional outcomes and may obviate hardware removal.

Atraumatic segmental atypical femur fracture secondary to bisphosphonate use: A case report.

Atypical femur fractures as a result of long term bisphosphonate use are characterized by several unique radiographic features. We describe an atypical femur fracture treated by cephalomedullary nail with a previously undescribed segmental fracture pattern. Other than 1.5 years of bisphosphonate use the patient did not have any other risk factors known to cause atypical femur fractures. Judicious bisphosphonate use as well as increased awareness of the associated complications may help reduce the rate of bisphosphonate associated atypical femur fractures.

Intramedullary Nail Fixation of Atypical Femur Fractures With Bone Marrow Aspirate Concentrate Leads to Faster Union: A Case-Control Study.

OBJECTIVES: To evaluate bone marrow aspirate concentrate (BMAC) use in the treatment of AFF. DESIGN: Retrospective case control. SETTING: Level 1 trauma center. PATIENTS: Complete AFF, defined according to American Society of Bone and Mineral Research (ASBMR) criteria, from September 2009 to April 2015 with minimum 1-year follow-up. INTERVENTION: Operative treatment with antegrade intramedullary nails. Beginning June 2014, BMAC from the ipsilateral iliac crest was added to all AFFs. MAIN OUTCOME MEASUREMENTS: Time to union as determined by a blinded panel of 3 attending orthopaedic surgeons, union rates, complications. RESULTS: Thirty-five patients with 36 AFFs were reviewed, of which 33 AFFs were included and 11 received BMAC. Alendronate was the most commonly prescribed bisphosphonate, with a similar mean duration of use in controls and BMAC cases (5.6 versus 6 years, P = 0.79). BMAC use significantly decreased time to union (3.5 versus 6.8 months, P = 0.004). Varus malreduction was associated with a significant delay in union (9.7 versus 4.7 months, P = 0.04). Overall, 1 year union rate was 86.2% and nonsignificantly higher in BMAC compared with controls (100.0% versus 77.3%, P = 0.11). Multivariate analysis revealed BMAC and varus malreduction as independent predictors of time to union. There were no complications related to BMAC use. CONCLUSION: Our findings support intramedullary nailing of AFFs as an effective treatment option with a low surgical complication rate and highlight the importance of avoiding varus malreduction. BMAC use significantly reduced time to fracture union without an increase in surgical complication rates. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for and timing of adverse events after total shoulder arthroplasty.

BACKGROUND: Total shoulder arthroplasty (TSA) is a likely target for future bundled payment initiatives, necessitating accurate preoperative risk stratification. The purpose of this study was to identify risk factors for unplanned readmission and severe adverse events, to risk stratify TSA patients based on these risk factors, and to assess timing of complications after TSA. METHODS: Data were collected from patients undergoing TSA from 2009 to 2014 in the American College of Surgeons National Surgical Quality Improvement Program. Bivariate and multivariate analyses of risk factors for severe adverse events or readmission were assessed. Patients were risk stratified, and timing of severe adverse events and cause of readmission were evaluated. RESULTS: The analysis included 5801 TSA patients; 146 (2.5%) suffered severe adverse events, and 158 (2.7%) had a 30-day unplanned readmission. The most common severe adverse events were reoperation (40%), thrombolic event (deep venous thrombosis or pulmonary embolism; 14%), cardiac event (10%), and death (8.2%). Pneumonia (8.9%) and thrombolic event (7.6%) were the most common medically related causes, whereas dislocation (7.6%) and postoperative infection or wound complication (5.1%) were the most common surgical causes for readmission. Multivariate analysis identified inflammatory arthritis (P = .026), male gender (P = .019), age (P < .001), functional status (P = .024), and American Society of Anesthesiologists class 3/4 (P = .01) as independent predictors for unplanned 30-day readmission and all but inflammatory arthritis for severe adverse events (P ≤ .05 for all). Patients with ≥3 risk factors had an 11.56 (P = .002) and 3.43 (P = .013) times increased odds of unplanned readmission and severe adverse events occurring within 2 weeks after surgery, respectively, compared with patients with 0 risk factors. CONCLUSIONS: Patients at high risk of TSA complications and readmission should be identified preoperatively to improve outcomes and to lower costs. Bundled payment initiatives must account for both patient- and procedure-related risk factors.

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures.

INTRODUCTION: The purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation. METHODS: A total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection. RESULTS: Forty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142±17.0° and AER was 41±13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2±20.0 and average Constant score was 72.7±17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p=0.297) or varus collapse (p=0.95) were not associated with an increased likelihood of sustaining a complication. CONCLUSIONS: Follow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.

Nonoperative Versus Operative Treatment of Displaced Ankle Fractures in Diabetics.

BACKGROUND: Diabetes is a risk factor for complications related to displaced ankle fractures. Limited literature exists comparing complication rates in nonoperative versus operative treatment of displaced ankle fractures in diabetics. No study has highlighted the natural history of nonoperative treatment of displaced ankle fractures in diabetics. METHODS: We retrospectively reviewed all adult ankle fractures from September 2011 through December 2014. Inclusion was limited to ambulatory adults (>18 years) with closed, displaced (widened mortise) ankle fractures with diabetes mellitus. Nonoperative treatment consisted of closed reduction and casting. Fractures were classified according to the Lauge-Hansen and AO-Weber classification systems. All operative fractures underwent open reduction internal fixation (ORIF) within 3 weeks of injury. Functional outcomes and complication rates were compared. Of 28 displaced diabetic ankle fractures, 20 were treated nonoperatively (closed reduction and casting) and 8 operatively (ORIF within 3 weeks of injury). Mean follow-up was 7 months (range 3-18 months). RESULTS: Age, insulin-dependent diabetes, and AO type B fracture rate were similar in nonoperative and operative cohorts, but fracture dislocation rate was significantly higher among operative fractures (87.5% vs 40%; P = .04). Nonoperative treatment was associated with a 21-fold increased odds of complication compared with operative treatment (75% vs 12.5%, OR 21.0, P = .004). Complication rate following unintended ORIF for persistent nonunion or malunion in nonoperatively treated patients was significantly greater compared with immediate ORIF (100% vs 12.5%, P = .005). CONCLUSION: Nonoperative treatment of displaced diabetic ankle fractures was associated with unacceptably high complication rates when compared to operative treatment. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Simplified Frailty Index as a Predictor of Adverse Outcomes in Total Hip and Knee Arthroplasty.

BACKGROUND: The modified frailty index (mFI) has been shown to predict adverse outcomes in multiple nonorthopedic surgical specialties. This study aimed to assess whether mFI is a predictor of adverse events in patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Patients who underwent THA and TKA from 2005-2012 were identified in the National Surgical Quality Improvement Program database. mFI was calculated for each patient using 15 variables found in National Surgical Quality Improvement Program. Bivariate and multivariate analyses of postoperative adverse events, including Clavien-Dindo grade IV complications, were performed. RESULTS: A total of 14,583 THA and 25,223 TKA patients were included for analysis. The mean (standard deviation, range) mFIs were 0.083 (0.080, 0-0.55) for THA and 0.097 (0.080, 0-0.64) for TKA cohorts. On bivariate analyses, incidence of Clavien-Dindo grade IV complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), hospital-acquired conditions (surgical site infection, venous thromboembolism, and urinary tract infection), any complications, and mortality increased significantly with increase in mFI (P < .0001 for all). Adjusting for demographics, age ≥ 75, body mass index ≥40, American Society of Anesthesiologists class ≥4, and nonclean wound status, mFI ≥0.45 was shown to be the strongest independent predictor of Clavien-Dindo grade IV complications for both THA and TKA cohorts with odds ratios of 5.140 and 4.183, respectively. CONCLUSION: mFI ≥0.45 is an independent predictor of Clavien-Dindo grade IV complications in TKA/THA patients with greater odds ratios than age >75, body mass index ≥40, American Society of Anesthesiologists class ≥4. mFI should be considered for risk stratifying joint arthroplasty patients preoperatively and perhaps determining immediate postoperative destination.

Discharge Destination After Revision Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes and Placement Risk Factors.

BACKGROUND: Given the rising incidence of revision total joint arthroplasty (RJR), bundled payments will likely be applied to RJR in the near future. This study aimed to compare postdischarge adverse events by discharge destination, identify risk factors for discharge placement, and stratify RJR patients based on these risk factors to identify the most appropriate discharge destination. METHODS: Patients that underwent revision total hip or knee arthroplasty from 2011 to 2013 were identified in the American College of Surgeon's National Surgical Quality Improvement Program database. Analysis of risk factors was assessed using preoperative and intraoperative variables. RESULTS: A total of 9973 RJR patients from 2011 to 2013 were included for analysis. The most common discharge destination included home (66%), skilled nursing facility (SNF; 23%), and inpatient rehabilitation facility (IRF; 11%). Bivariate analysis revealed higher rate of postdischarge 30-day severe adverse events (6.1% vs 4.1%, P < .001) and unplanned readmissions (9.3% vs 6.1%, P < .001) in nonhome vs home patients. In multivariate analysis, SNF and IRF patients were 1.30 and 1.51 times more likely to suffer an unplanned 30-day readmission relative to home patients (P ≤ .01), respectively. After stratifying patients by number of significant risk factors and discharge destination, IRF patients consistently had significantly higher rates of unplanned 30-day readmission than home patients (P ≤ .05). CONCLUSION: RJR patients who are discharged to SNF or IRF have significantly increased risk for unplanned readmissions as compared with patients discharged home. Across risk levels, home discharge destination (when feasible) is the optimal strategy compared with IRF, although the distinction between SNF and home is less clear.

Outcomes, complications, utilization trends, and risk factors for primary and revision total elbow replacement.

BACKGROUND: Using a validated database, 30-day complications of primary and revision total elbow arthroplasty (TEA) were analyzed to identify risk factors of adverse events. METHODS: Primary and revision TEAs from 2007 to 2013 were identified in the National Surgical Quality Improvement Program database. Bivariate and multivariate analyses of risk factors for 30-day adverse events were assessed using preoperative and intraoperative variables. RESULTS: The study reviewed 189 primary and 53 revision TEA patients. Fracture (34%), osteoarthritis (24%), and rheumatoid arthritis (23%) were the most common indications for TEA. Adverse event rate was similar in primary and revision TEA (12% vs. 15%; P = .49), and infectious complications occurred in 3.2% of primary TEAs and 7.5% of revision TEAs (P = .23). Bivariate analysis of risk factors for 30-day adverse events identified dependent functional status in primary TEA (P = .03) and age in revision TEA (P = .02). Multivariate analysis of primary TEA revealed that adverse events were significantly less likely with rheumatoid arthritis compared with osteoarthritis etiology (odds ratio, 0.15; P = .02), and smoking was associated with an increased chance of infection (odds ratio, 6.96; P = .03). Revision TEA was not associated with an increased 30-day adverse event or infection rate compared with primary TEA in multivariate analysis. Among primary and revision TEA patients, dependent functional status (P = .02) and hypertension (P = .04) were independent predictors for adverse events. CONCLUSION: Modifiable risk factors should be addressed before TEA to limit postoperative complications as well as cost. The risk of short-term complications after revision TEA is comparable to that of primary TEA.