Does a delay to surgery for preoperative echocardiogram affect outcomes in patients with hip fracture?

Introduction: Delay to surgery >24 hours has been shown to correlate with mortality rates in patients with hip fracture when left untreated. Many of these patients have multiple comorbidities, including aortic stenosis (AS), and undergo workup for operative clearance, which may delay time to surgery. The purpose of this study was to examine whether preoperative echocardiogram workup affects time to surgery, complications, and mortality after operative fixation for hip fracture. Methods: Our institutional hip fracture registry was retrospectively reviewed for inclusion over a 3-year period. Patients who had a preoperative echocardiogram (yECHO) for operative clearance were compared with those who did not (nECHO). Demographic data, time to surgery, overall complication rate, and mortality at 30 days, 90 days, and 1 year were collected. Results: Two cohorts consisted of 136 yECHO patients (45.8%) and 161 nECHO patients (54.2%). Thirty-two yECHO patients (23.5%) had AS. Patients in the yECHO cohort were more likely to have a complication for any cause compared with nECHO patients (25.7% vs. 10.6%, P = 0.01) and have a higher mortality rate at 1 year (38.9% vs. 17.4%, P = 0.001). There was no association found between AS and all-cause complication (P = 0.54) or 30-day (P = 0.13) or 90-day mortality rates (P = 0.79). However, patients with AS had a significantly higher mortality rate at 1 year (45.8% vs. 25.1%, P = 0.03). Conclusion: This study reinforces the benefits of ensuring less than a 24-hour time to surgery in the setting of a hip fracture and identifies an area of preoperative management that can be further optimized to prevent unnecessary prolongation in time to surgery. Patients with known aortic stenosis are not associated with increased 30-day or 90-day mortality or all-cause complications. Surgical delays in the yECHO cohort were attributed to preoperative medical assessments, including echocardiograms and the management of comorbidities. Therefore, the selective utilization of preoperative echocardiograms is needed and should be reserved to ensure they have a definitive role in guiding the perioperative care of patients with hip fracture. Level of Evidence: III.

Comparison of Outcomes After Reverse Total Shoulder Arthroplasty in Patients With Proximal Humerus Fractures Versus Rotator Cuff Arthropathy.

INTRODUCTION: Indications for reverse total shoulder arthroplasty (rTSA) has expanded to encompass complex proximal humerus fractures (PHFs) in recent years. The purpose of this study was to report and assess whether PHF patients treated with rTSA could achieve similar functional outcomes and short-term survivorship to patients who underwent rTSA for rotator cuff arthropathy (RTCA). METHODS: All consecutive patients with a preoperative diagnosis of PHF or RTCA, 18 years or older, treated with rTSA at a single academic institution between 2018 and 2020 with a minimum 2-year follow-up were retrospectively reviewed. Primary outcomes were survivorship defined as revision surgery or implant failure analyzed using the Kaplan-Meier survival curve, and functional outcomes, which included Quick Disabilities of the Arm, Shoulder, and Hand, and range of motion (ROM) were compared at multiple follow-up time points up to 2 years. Secondary outcomes were patient demographics, comorbidities, surgical data, length of hospital stay, and discharge disposition. RESULTS: A total of 48 patients were included: 21 patients (44%) were diagnosed with PHF and 27 patients (56%) had RTCA. The Kaplan-Meier survival rate estimates at 3 years were 90.5% in the PHF group and 85.2% in the RTCA group. No differences in revision surgery rates between the two groups (P = 0.68) or survivorship (P = 0.63) were found. ROM was significantly lower at subsequent follow-up time points in multiple planes (P < 0.05). A greater proportion of patients in the PHF group received cement for humeral implant fixation compared with the RTCA group (48% versus 7%, P = 0.002). The mean length of hospital stay was longer in PHF patients compared with RTCA patients (2.9 ± 3.8 days versus 1.6 ± 1.8 days, P = 0.13), and a significantly lower proportion of PHF patients were discharged home (67% versus 96%, P = 0.015). CONCLUSION: The rTSA implant survivorship at 3 years for both PHF and RTCA patients show comparable results. At the 2-year follow-up, RTCA patients treated with rTSA were found to have better ROM compared with PHF patients.

Direct versus indirect posterior malleolar fixation in the treatment of trimalleolar ankle fractures: Is there a difference in outcomes?

Purpose: The purpose of this study was to examine the differences in functional outcomes between direct and indirect surgical fixation methods of the posterior malleolus in the setting of trimalleolar fractures and identify any variables affecting patient outcomes. Methods: Primary outcomes were evaluated by PROMIS scores for short-term outcomes regarding total pain (TP) and total function (TF) comparing 40 patients with direct fixation with 77 with indirect fixation. Continuous variables were analyzed using t tests for parametric variables and the Mann-Whitney U test for nonparametric variables. Categorical variables were analyzed using a χ2 test. Univariate and multivariate linear regression models were performed to analyze factors that affect outcomes of TP and TF. Results: There was no difference in TP or TF between groups (P = 0.65 vs. P = 0.19). On univariate linear regression for TP, BMI, incidence of complication, tobacco use, and open injury showed significance in increasing pain levels with open injuries providing the greatest effect (coef = 11.8). On multivariate analysis, BMI, incidence of complication, open injury, and tourniquet time all significantly increased pain. For TF, univariate analysis showed age, BMI, incidence of complication, and diabetes to decrease function, and use of external fixator and tourniquet time increased function. In the multivariate model, increased BMI, open injuries, and increasing tourniquet time all decreased TF while use of an external fixator increased TF. Conclusion: This study showed no difference in TP and TF using the PROMIS outcome scores when comparing direct fixation versus indirect fixation under univariate and multivariate models. Level of Evidence: Therapeutic III.

Bone Marrow Aspirate Concentrate as a Reliable Adjunct in Tibiotalocalcanal Fusion: A Radiographic Modified RUST Score Analysis.

BACKGROUND: Tibiotalar and subtalar arthritis requiring tibiotalocalcaneal (TTC) fusion can be technically challenging and is dependent on reliable fusion for a good clinical outcome. Initial data regarding bone marrow aspirate concentrate (BMAC) has shown promise in use as an aide in both fracture and fusion healing. The purpose of this study is to determine the outcomes in TTC fusion when utilizing BMAC as an adjunct. METHODS: Twenty consecutive patients who underwent TTC fusion with BMAC adjunct between March 2013 and November 2017 were retrospectively screened for inclusion. Patients were included regardless of comorbidities or risk factors for non-union, and only excluded if they did not have a minimum of 12 months of clinical and/or radiographic chart data. Follow-up was obtained at regular intervals of 6 weeks, 3 months, 6 months and 1 year. Modified RUST scores were applied to grade bony union in a blinded fashion by two orthopedic trauma fellowship-trained surgeons and agreement was assessed via intraclass correlation coefficient (ICC). RESULTS: Twenty patients were screened and 12 met inclusion criteria for analysis. Majority were male (66.6%) at a mean age of 55.4 years and they were all treated via TTC fusion for a diagnosis of tibiotalar and subtalar arthritis. There were no postoperative complications and no reoperations in this cohort; no donor site morbidity was associated with BMAC. By the 3-month follow-up timepoint, all but one patient received a minimum modified RUST score of 10 indicating bony union (ICC 0.91); by the 6-month time point (ICC 0.94), all 12 patients were deemed united. CONCLUSION: BMAC as an adjunct in the setting of TTC fusion is a safe treatment option that can promote reliable, consistent bony fusion with minimal complications.

Tranexamic acid lowers transfusion requirements and hospital length of stay following revision total hip or knee arthroplasty.

BACKGROUD: Intravenous tranexamic acid (TXA) has been shown to reduce blood loss in patients undergoing total joint arthroplasty without systemic complications. There is limited evidence of its effectiveness in revision procedures. This study evaluated intravenous TXA effect on blood loss, transfusion rates, and length of hospital stay in revision joint replacement. METHODS: One-hundred revision total joint arthroplasty patients were retrospectively reviewed [44 revision total hip arthroplasty (THA) and 54 revision total knee arthroplasty (TKA)] who underwent surgery from 2013 to 2016. Fifty-four revision joint patients (23 THA and 31 TKA) received intravenous TXA intra-operatively, while 46 revision joint patients (23 THA/TKA) did not. Primary outcome measures were blood loss, transfusion rates, and length of hospital stay. RESULTS: The mean blood loss difference between revision THA patients who received TXA vs. not receiving TXA was 180ml in revision THA patients (p < .005). Mean length of hospital stay was 6 days in non-TXA vs. 3 days in TXA patients (p < .001). Eighteen patients received transfusions in the non-TXA revision TKA group compared to nine patients in the TXA revision TKA group (p < .001). Average length of hospital stay was 5 days in the non-TXA revision TKA group compared to 3 days in the TXA revision TKA group (p < .003). There was no increased risk of thromboembolic complications in TXA groups for either procedure. CONCLUSIONS: Intravenous TXA reduced length of hospital stay in both revision cohorts, decreased blood loss in revision THA and decreased the rate of transfusion in revision TKA without an increase in thromboembolic complications. LEVEL OF EVIDENCE: Level III (Case-control study).

Pilon Fractures: Challenges and Solutions.

Pilon fractures include a wide range of complexity. The timing and type of definitive fixation is dictated by the soft tissue injury and energy imparted to the fracture. One should have a low threshold for staged protocols and delayed definitive fixation to avoid complications. Proper radiographs and advanced imaging should be obtained for an exacting diagnosis and preoperative planning. Diligent management of the soft tissue and anatomic restoration of the articular surface, length, rotation, and axial alignment with stable fixation to the diaphysis should be obtained once feasible. Intramedullary implants with percutaneous articular fixation for simple or extra-articular patterns provide good results with little soft tissue insult in the zone of injury. Minimally invasive plate osteosynthesis techniques can help mitigate some concerns with soft tissue compromise while obtaining good articular alignment. Locking or conventional plating with lag screw fixation is used for complex articular injuries with or without fibular fixation. External fixators are generally used for temporizing measures but can be utilized as definitive fixation when indicated. There is a role for acute fusion in severely comminuted, osteoporotic, or arthritic fractures in patients with poor healing potential. This article outlines the diagnostic workup and treatment of these vexing injuries with solutions to challenges that arise.