Association of Bleeding Disorders and Risk of Complications Following Open Reduction and Internal Fixation of the Ankle.

BACKGROUND: Open reduction and internal fixation (ORIF) of the ankle is a common procedure performed to correct ankle fractures in many different patient populations. Diabetes, peripheral vascular disease, and osteoporosis have been identified as risk factors for postoperative complications following surgery for ankle fractures. To date, there have not been any studies evaluating postoperative outcomes in patients with bleeding disorders undergoing operative treatment for ankle fractures. The aim of this study was to determine the postoperative complication rate following ORIF of the ankle in patients with a bleeding disorder vs those without a bleeding disorder. METHODS: From 2006 to 2018, patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. Patients who underwent either inpatient or outpatient ORIF of the ankle were included in this study. In this analysis, demographics, medical comorbidities, and postoperative complications variables were assessed between the 2 cohorts. Bivariate and multivariate analyses were performed. RESULTS: Of 10 306 patients undergoing operative treatment for ankle fracture, 9909 patients (96.1%) had no bleeding disorder whereas 397 patients (3.9%) had a bleeding disorder. Following adjustment on multivariate analysis, compared to patients who did not have a bleeding disorder, those with a bleeding disorder had an increased risk of any postoperative complications (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.05-2.08, P = .024), requirement for postoperative blood transfusion (OR 2.86, 95% CI 1.53-5.36, P = .001), and extended length of hospital stay greater than 5 days (OR 1.46, 95% CI 1.10-1.93, P = .010). CONCLUSION: Patients with bleeding disorders are associated with increased risk of postoperative complications following ORIF for ankle fractures. Determining patient risk factors and creating optimal preoperative and perioperative management plans in patients with bleeding disorders undergoing ORIF can be beneficial in reducing postoperative complications, improving patient outcomes, and reducing overall morbidity. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Differences in 30-day complications associated with total ankle arthroplasty and ankle arthrodesis: A matched cohort study.

BACKGROUND: The objective of this study was to identify whether total ankle arthroplasty (TAA) was associated with greater risk for 30-day complications and/or greater financial burden in comparison to ankle arthrodesis (AA). METHODS: The PearlDiver Patient Records Database was queried to identify all patients who underwent an arthroscopic/open AA or TAA from 2006 to 2013. The two cohorts were then matched in a 1:1 manner to control for comorbidities and demographics. Postoperative complications were compared between the two cohorts, in addition to the associated costs with respect to each procedure. RESULTS: No significant differences in risk for postoperative complications were noted between the two procedures with the numbers available. Significant differences were demonstrated in total length of hospital stay (LOS), with a mean of 2.13 days for the TAA cohort and 2.42 days for the AA cohort (p < 0.001). Higher mean total hospital costs were noted for TAA (x¯ = $62,416.62) compared to AA (x¯ = $37,737.43, p < 0.001); however, TAA was associated with a higher mean total reimbursement (x¯ = $12,254.43) than AA (x¯ = $7915.72, p < 0.001). CONCLUSION: With no notable differences in 30-day complication rates, TAA remains a viable alternative to AA in the appropriately selected patient and provides the ability to preserve tibiotalar motion resulting in superior functional scores. Additionally, TAA demonstrated higher total costs to implant, but also greater reimbursement, in line with the recent literature suggesting TAA to be a cost-effective alternative to AA. LEVEL OF EVIDENCE: III Retrospective study.

Cannulated Lag Screw Fixation of Displaced Lateral Humeral Condyle Fractures Is Associated With Lower Rates of Open Reduction and Infection Than Pin Fixation.

BACKGROUND: Open reduction/internal fixation remains the most common way to surgically stabilize displaced pediatric lateral humeral condyle fractures, but closed reduction and internal fixation is being increasingly used. Our goal was to compare the clinical and functional results of treating displaced pediatric lateral humeral condylar fractures with traditional smooth or threaded pin fixation versus single cannulated screw fixation. METHODS: From 1998 through 2012, the lateral humeral condyle fractures of 48 patients were treated with pin fixation (22 patients, until 2006) or cannulated, partially threaded screw fixation (26 patients, from 2006 onward). In each, closed reduction with percutaneous fixation was attempted first, followed by open reduction if anatomic reduction was not achieved. For the pin and screw groups, preoperative maximum radiographic displacement averaged 8.4 mm (range, 3.8 to 18.4 mm) and 6.3 mm (range, 2.2 to 15.5 mm), respectively; follow-up averaged 4.3 months (range, 1.5 to 20 mo) and 10.3 months (range, 2 to 30 mo), respectively. We reviewed preoperative and postoperative images and all follow-up clinical examination findings; serially assessed initial displacement, Baumann and carrying angles, range of motion limitations, and clinical alignment; evaluated functional results via the system of Hardacre and colleagues; and investigated all complications. RESULTS: Open reduction was required in 73% (16/22) and 15% (4/26) of the pin and screw groups, respectively (P<0.001). All fractures were reduced to <1 mm postoperative displacement. Postoperative immobilization averaged 5.9 weeks (range, 4 to 11 wk) and 4.5 weeks (range, 3 to 8 wk) for the pin and screw groups, respectively. The only significant difference in complications was the infection rate: 5 (1 deep) in the pin group and none in the screw group (P<0.05). CONCLUSIONS: Closed reduction and percutaneous 4.5-mm lag screw fixation of displaced pediatric lateral humeral condyle fractures is safe and reliable, enabling a higher rate of closed reduction, significantly lower infection rate, and earlier mobilization than traditional pin fixation. LEVEL OF EVIDENCE: Level III-Therapeutic.

BMP Use and the Risk of Revision Surgery After Long Posterolateral Fusions in the Elderly.

STUDY DESIGN: Retrospective database review. OBJECTIVE OF THE STUDY: The objective of the study was to assess whether bone morphogenetic protein (BMP) decreases the risk of revision surgery in elderly patients treated with 3-7 level or 8 or greater level fusions. SUMMARY OF BACKGROUND DATA: Revision spine surgery in the elderly is a complex undertaking, highlighting the importance of discovering methods to decrease the risk of repeat procedures. The role of BMP in modulating risk of future revision surgery is not well studied in the elderly. MATERIALS AND METHODS: The PearlDiver database (2005-2012) was queried for elderly adult spinal deformity patients treated with a primary thoracolumbar posterolateral fusion of 3 or more levels. To compare how BMP modifies revision surgery rates in 3-7 level versus 8 level or greater fusions, 4 mutually exclusive cohorts were created and matched to one another: 1043 patients treated with 8 or greater level fusions with BMP; 1111 patients with 8 or greater level fusions without BMP; 2813 patients with 3-7 level fusions with BMP; and 4770 patients with 3-7 level fusions without BMP. Revision and complication rates were compared. Complications included seroma formation, heterotopic ossification, and postoperative neuritis within 90 days. RESULTS: Patients treated with BMP during an 8 or greater level fusion were significantly less likely to require a revision surgery than matched controls (relative risk, 0.75, P=0.015). BMP use was not associated with a decreased risk of revision surgery in 3-7 level fusions (relative risk, 0.89, P=0.20). Patients treated with BMP during 3-7 level fusions were significantly less likely to develop any of the assessed complications (P=0.02). There were no other significant differences in pairwise comparisons of subcohorts of each of the fusion lengths. CONCLUSIONS: BMP use decreases revision rates in elderly adult spinal deformity patients treated with 8 or greater level fusions, but not in those treated with 3-7 level fusions. LEVEL OF EVIDENCE: Level III.

Posterior tibial tendon dysfunction in the adult: current concepts.

The management of posterior tibial tendon dysfunction in adults has evolved substantially, and controversy persists regarding a specific recommended algorithm for treatment. The current focus is on early diagnosis and treatment of this disorder with joint-sparing surgeries, such as corrective osteotomies and tendon transfers, when nonsurgical modalities have been exhausted. It is helpful to be familiar with the pertinent pathophysiology and diagnostic pearls associated with posterior tibial tendon dysfunction, its treatment options, pertinent literature, and technique tips for the procedures currently being used.

Outcomes of acute Achilles tendon rupture repair with bone marrow aspirate concentrate augmentation.

PURPOSE: Optimal treatment of acute Achilles tendon ruptures remains controversial. Positive results using stem-cell-bearing concentrates have been reported with other soft-tissue repairs, but no studies exist on outcomes of bone marrow aspirate concentrate (BMAC) augmentation in primary Achilles tendon repair. METHODS: We reviewed patients with sport-related Achilles tendon ruptures treated via open repair augmented with BMAC injection from 2009 to 2011. Data on operative complications, strength, range of motion, rerupture, calf circumference and functional improvement through progressive return to sport and the Achilles tendon Total Rupture Score (ATRS) were analysed. RESULTS: A total of 27 patients (28 tendons) treated with open repair and BMAC injection were identified (mean age 38.3 ± 9.6 years). At mean follow-up of 29.7 ± 6.1 months, there were no reruptures. Walking without a boot was at 1.8 ± 0.7 months, participation in light activity was at 3.4 ± 1.8 months and 92% (25 of 27) of patients returned to their sport at 5.9 ± 1.8 months. Mean ATRS at final follow-up was 91 (range 72-100) points. One case of superficial wound dehiscence healed with local wound care. No soft-tissue masses, bone formation or tumors were observed in the operative extremity. CONCLUSIONS: Excellent results, including no re-ruptures and early mobilisation, were observed in this small cohort with open Achilles tendon repair augmented by BMAC. No adverse outcomes of biologic treatment were observed with this protocol. The efficacy of BMAC in the operative repair of acute Achilles tendon ruptures warrants further study. LEVEL OF EVIDENCE: IV - Therapeutic.

Influence of podiatry on orthopedic surgery at a level I trauma center.

Level I trauma centers frequently see trauma at or below the ankle, which requires consultation with the orthopedic surgery department. However, as podiatry programs begin to firmly establish themselves in more Level I trauma centers, their consultations increase, ultimately taking those once seen by orthopedic surgery. A review of the literature demonstrates that this paradigm shift has yet to be discussed. The purpose of this study was to determine how many, if any, lower extremity fracture consultations a newly developed podiatry program would take from the orthopedic surgery department. A retrospective review was performed of emergency department records from January 2007 to December 2011. Seventeen different emergency department diagnoses were used to search the database. Ultimately, each patient's emergency department course was researched. Several trends were noted. First, if trauma surgery was involved, only the orthopedic surgery department was consulted for any injuries at or below the ankle. Second, the emergency department tended to consult the podiatry program only between the hours of 8 am and 6 pm. Third, as the podiatry program became more established, their number of consultations increased yearly, and, coincidentally, the orthopedic surgery department's consultations decreased. Finally, high-energy traumas involved only the orthopedic surgery department. Whether the orthopedic surgery department or podiatry program is consulted regarding trauma surgery is likely hospital dependent.

Changing trends in cervical spine fusions in patients with rheumatoid arthritis.

STUDY DESIGN: Retrospective data analysis. OBJECTIVE: To compare the trends in primary cervical spine fusion procedures in patients with rheumatoid arthritis (RA) against those in the general population. SUMMARY OF BACKGROUND DATA: RA severely impacts multiple joints in the body and can result in substantial deformity and functional impairment. Cervical spine involvement is common. In the past decade, treatment for RA has changed substantially with the introduction of biologically based, disease-modifying antirheumatic medications. Recent literature has shown decreasing rates of total joint arthroplasty in patients with RA. METHODS: Cases of cervical spine fusion in the general population and in patients with RA were identified from the Nationwide Inpatient Sample from 1992 through 2008. US population counts were obtained from the Census Bureau. Data were analyzed with computer software (significance, P < 0.05 for all analyses). Linear regression models were used to describe national rates of cervical spine fusion in patients with and without RA. RESULTS: There was a marked increase in the number of cervical fusion procedures in the studied population. Over time, the incidence of atlantoaxial fusion increased in the general population (P < 0.01) and decreased in patients with RA (P < 0.01). Compared with the general population, patients with RA had a significantly lower rate of increase in the incidence of posterior cervical fusion (P < 0.01) and a significantly higher rate of increase in the incidence of anterior cervical fusion (P < 0.01). CONCLUSION: In the US, the absolute number of primary cervical fusion procedures from 1992 through 2008 increased in the general population and in patients with RA. However, the patients with RA had a significantly lower incidence of undergoing atlantoaxial and posterior cervical surgical procedures than did the general population. LEVEL OF EVIDENCE: 2.

Upper-extremity peripheral nerve blocks in the perioperative pain management of orthopaedic patients: AAOS exhibit selection.

BACKGROUND: Over the past twenty-five years, peripheral nerve blocks have become increasingly common for the management of perioperative pain of the upper extremity. Several factors have led to increasing acceptance and use of these peripheral nerve blocks, including a greater awareness and measurement of patient pain and a greater emphasis on decreasing the duration of hospital stays and associated costs. METHODS: We present a review of peripheral nerve blocks for procedures involving the upper extremity, including indications, contraindications, anatomy and technique, expected clinical outcomes and the associated levels of evidence, cost-effectiveness, and complications. We reviewed the scientific literature for studies on the effectiveness of peripheral nerve blocks for orthopaedic procedures involving the upper extremity. Particular attention was directed at the most commonly used nerve blocks, the levels of evidence supporting their use, and emerging technologies such as ultrasonographic guidance. RESULTS: Peripheral nerve blocks for upper-extremity procedures improve postoperative pain control and patient satisfaction, can be administered safely, and have a low complication rate. They are also associated with enhanced participation in postoperative rehabilitation, decreased hospital stays, and decreased costs. There are increasingly higher levels of evidence in the literature to support the use of peripheral nerve blocks in a wide variety of orthopaedic procedures ranging from the shoulder to the hand. CONCLUSIONS: The use of peripheral nerve blocks in upper-extremity surgery is common. To actively participate with the patient and anesthesiologist to ensure the best possible outcomes, the orthopaedic surgeon must be well informed regarding the benefits and limitations of this modality.

Postoperative death associated with a reverse prosthesis.

The mortality rate after total shoulder arthroplasty, and specifically after reverse total shoulder arthroplasty, has not received much attention in the literature. Although complications of the reverse total shoulder arthroplasty are well known, fatalities secondary to complications related to the unique features of the reverse prosthesis have not, to our knowledge, been previously reported. We report the case of an elderly man who developed shoulder instability after the implantation of a reverse prosthesis followed by disassociation of the glenosphere from the baseplate. After a reoperation to revise and reassemble the components, he developed an infected shoulder and sepsis, and subsequently died from the complications of sepsis. This death represents a perioperative mortality rate of 0.5% in our series of 190 cases. The mortality rate after reverse total shoulder seems to be similar to that after standard total shoulder arthroplasty.

Prevalence of Allograft Contamination During Intraoperative Processing for Spinal Deformity Correction Surgery.

STUDY DESIGN: Prospective study. OBJECTIVES: To prospectively evaluate bone allografts during spinal fusion surgery for 1) the rate of contamination as a result of perioperative preparation, and 2) the types of bacterial organisms that may be transmitted through the contaminated bone allograft. SUMMARY OF BACKGROUND DATA: Bone allografts are routinely used to enhance spinal arthrodesis procedures. Ready availability and lack of donor site morbidity make them valuable alternatives to iliac crest bone grafts. Reports of disease transmission of such organisms as hepatitis C, the human immunodeficiency virus, and a variety of bacterial pathogens through allograft bone implants raise concerns for patient and practitioner safety. METHODS: Our study population consisted of 50 consecutive (20 male and 30 female) patients (mean age at surgery, 15 years; range, 3-51 years) undergoing spinal deformity correction from May 2010 through October 2010, by 1 surgeon at 1 institution. The mean operative time was 297 minutes (range, 81-444 minutes), and the most commonly fused spinal levels were T5 to L4. During the procedure, the researchers prospectively obtained intraoperative microbial culture swabs from a container with freeze-dried allograft and from an empty identical control container. Aerobic and anaerobic bacterial culture growth was assessed for 7 days postoperatively. Each patient was observed for 6 weeks after surgery to ascertain any evidence of surgical-site infection. RESULTS: Microbial cultures showed bacterial growth in 4 cases: 1 allograft specimen (day 4, very light Staphylococcus aureus) and 3 control specimens (day 3, very light Enterococcus; day 4, very light S aureus; and day 6, Propionibacterium acnes). No patient showed signs of infection in the perioperative or 6-week postoperative period. CONCLUSIONS: Intraoperative allograft preparation is not a major source of bone allograft contamination during spinal surgery.

Lower-extremity peripheral nerve blocks in the perioperative pain management of orthopaedic patients: AAOS exhibit selection.

BACKGROUND: The utilization of peripheral nerve blocks in orthopaedic surgery has paralleled the rise in the number of ambulatory surgical procedures performed. Optimization of pain control in the perioperative orthopaedic patient contributes to improved patient satisfaction, early mobilization, decreased length of hospitalization, and decreased associated hospital and patient costs. Our purpose was to provide a concise, pertinent review of the use of peripheral nerve blocks in various orthopaedic procedures of the lower extremity, with specific focus on procedural anatomy, indications, patient outcome measures, and complications. METHODS: We reviewed the literature and reference textbooks on commonly performed lower-extremity peripheral nerve block procedures in orthopaedic surgery, focusing on those most commonly used. RESULTS: The use of lower-extremity peripheral nerve blocks is a safe and effective approach to perioperative pain management. Different techniques and timing can have an important impact on patient satisfaction, and each technique has specific indications and complications. For major hip surgery, one of the most commonly used is the lumbar plexus block, which can result in early mobilization, reduced postoperative pain, and decreased opioid-associated adverse events. Associated complications include epidural spread of anesthesia, retroperitoneal hematoma formation, and postoperative falls. For arthroscopic and open knee procedures, the femoral nerve block is frequently used adjunctively. It provides improved early postoperative pain control, early mobilization with therapy, and increased patient satisfaction compared with intra-articular or intravenous opioids alone; it also provides cost savings. However, some studies have shown no significant difference in outcome measures compared with intra-articular opioids alone for arthroscopic anterior cruciate ligament reconstruction. Associated complications include nerve injury, intravascular injection, and postoperative falls. CONCLUSIONS: The use of peripheral nerve blocks in lower-extremity surgery is becoming a mainstay of perioperative pain management strategy.

Postoperative incentive spirometry use.

The authors hypothesized that the use of incentive spirometry by orthopedic patients is less than the recommended level and is affected by patient-related factors and type of surgery. To determine its postoperative use, the authors prospectively surveyed all patients in their institution's general orthopedic ward who had undergone elective spine surgery or total knee or hip arthroplasty during a consecutive 3-month period in 2010, excluding patients with postoperative delirium or requiring a monitored bed. All 182 patients (74 men, 108 women; average age, 64.5 years; range, 32-88 years; spine group, n=55; arthroplasty group, n=127), per protocol, received preoperative spirometry education by a licensed respiratory therapist (recommended use, 10 times hourly) and reinforcement education by nurses. Patients were asked twice daily (morning and evening) regarding their spirometry use during the previous 1-hour period by a registered nurse on postoperative days 1 through 3. All data were collected by the same 2 nurses using the same standardized questionnaire. Spirometry use was correlated with surgery type, postoperative day/time, and patient's age and sex. Student's t test, Spearman test, and one-way analysis of variance were used to compare differences (P<.05). Spirometry use averaged 4.1 times per hour (range, 0-10 times). No statistical correlations were found between spirometry use and age. Sex did not influence spirometry use. The arthroplasty group reported significantly higher use than did the spine group: 4.3 and 3.5 times per hour, respectively. Mean use increased significantly between postoperative days 1, 2, and 3.

Total joint arthroplasty in patients with rheumatoid arthritis: a United States experience from 1992 through 2005.

To determine whether total joint arthroplasty (TJA) for patients with rheumatoid arthritis (RA) is decreasing, we collected Nationwide Inpatient Sample database information (1992 through 2005) on (1) the number of primary TJAs for all patient diagnoses, (2) the number of primary TJAs for patients with RA, and (3) distribution of age and sex in both groups. To account for population growth, a given year's arthroplasty estimate was normalized against its population. The trends over time were analyzed using a multivariable Poisson regression model (significance, P < .05). We found that the number of primary TJA procedures increased in the general and RA populations but that, after adjusting for population growth, age, and sex, the rate was significantly lower in patients with RA.

Management and prevention of recurrent clostridium difficile infection in patients after total joint arthroplasty: a review.

Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea in elderly patients, accounting for 15% to 25% of all cases of antibiotic-induced diarrhea in those patients. Virulent forms of this organism have developed, increasing the associated morbidity, mortality, and complication rates. The average patient undergoing total joint arthroplasty is at particular risk of CDI because of advanced age, the use of prophylactic antibiotic coverage in the perioperative period, multiple comorbid conditions, and length of hospital stay. In addition, patients who have had one CDI are at risk of another; the rate of recurrent CDI (RCDI) is 15% to 30%. To review the available information on RCDI, we conducted an extensive literature search, focusing on its epidemiology and the management strategies for its treatment and prevention. We found the management of RCDI is a controversial topic, with as yet no consensus regarding specific treatment guidelines. Several experienced clinicians have published suggested treatment algorithms, but they are based on anecdotal experience. With regard to the prevention of RCDI, the literature is scarce, and currently, the only effective strategies remain judicious use of perioperative antibiotics and appropriate implementation of infection control procedures. There are several vaccination medications that are currently being studied but are not yet ready for clinical use. We agree with the approach to management of RCDI that has been proposed in several articles, that is, on confirmation of a first recurrence of CDI by a stool toxin assay and clinical symptoms, a 14-day course of metronidazole or vancomycin; for a second recurrence, a tapered-pulsed course of vancomycin; and, for 3 or more recurrences, a repeat course of the tapered-pulsed vancomycin and adjunctive Saccharomyces boulardii or cholestyramine.