Short-Term Morbidity and Mortality after Distal Femur Open Reduction Internal Fixation in the Geriatric Population.

OBJECTIVE: Distal femur fractures remain a significant cause of morbidity and mortality for elderly patients. There is a lack of large population studies investigating short-term outcomes after distal femur c in elderly patients. The purpose of this study is to assess the incidence of and risk factors for various short-term outcomes after distal femur open reduction internal fixation (ORIF) in the geriatric population. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database was used to identify all primary distal femur ORIF cases in patients 60+ years old between January 1, 2015 and December 31, 2020 using Current Procedural Terminology (CPT) codes 27511, 27513, and 27514. Demographic, medical, and surgical variables were extracted for all patients. Propensity score matching was used to match cases in the two age groups based on various demographic and medical comorbidity variables. Several 30-day outcome measures were compared between the 60-79-year-old and 80+-year-old groups both before and after matching. Subsequent multivariate logistic regression was used to identify independent risk factors for 30-day outcome measures in the matched cohort. RESULTS: A total of 2913 patients were included in the final cohort: 1711 patients in the 60-79-year-old group and 1202 patients in the 80+-year-old group. Most patients were female (n = 2385; 81.9%). Prior to matching, the older group had a higher incidence of 30-day mortality (1.9% vs. 6.2%), readmission (3.7% vs. 9.7%, p = 0.024), and non-home discharge (74.3% vs. 89.5%, p < 0.001). Additionally, the older group had a higher rate of blood loss requiring transfusion (30.9% vs. 42.3%, p < 0.001) and medical complications (10.4% vs. 16.4%, p < 0.001), including myocardial infarction (0.7% vs. 2.7%, p < 0.001), pneumonia (2.7% vs. 4.6%, p = 0.008), and urinary tract infection (4.1% vs. 6.1%, p = 0.0188). After matching, the older group consistently had a higher incidence of mortality, non-home-discharge, blood loss requiring transfusion, and myocardial infarction. Various independent risk factors were identified for 30-day morbidity and mortality, including American Society of Anesthesiologists (ASA) classification, body mass index (BMI) status, operative duration, and certain medical comorbidities. CONCLUSION: Geriatric patients undergoing distal femur ORIF are at significant risk for 30-day morbidity and mortality. After matching, octogenarians and older patients specifically are at increased risk for mortality, non-home discharge, and surgical complications compared to patients aged 60-79 years old. Multiple factors, such as BMI status, ASA classification, operative time, and certain medical comorbidities, are independently associated with poor 30-day outcomes.

Shoulder Pain in a Pediatric Throwing Athlete.

Pediatric avulsion fractures most commonly occur at sites of secondary ossification and are often associated with chronic stress from repetitive movements. Because of a variety of risk factors, youth athletes place higher stress on ossification centers, and their activities may predispose them to injury. This case report describes a 12-year-old female softball player who presented with pain at the distal acromion, worsened by her overhead throwing motion. Further questioning revealed improper throwing mechanics placing extenuated stress on the shoulder. Plain radiograph imaging showed an avulsion fracture of the distal acromion; conservative management with decreased mobilization and cessation of activity was recommended. Reimaging four weeks later revealed a bone-on-bone healing, and the patient was gradually allowed to return to function. This report's discussion details the unusual location for a common injury, the mechanism of injury, an association of throwing mechanics with a shoulder injury, and recommended treatment strategies for pediatric avulsion fractures.

Osseointegration reduces aseptic loosening of primary distal femoral implants in pediatric and adolescent osteosarcoma patients: a retrospective clinical and radiographic study.

AIM: The challenge of distal femoral replacement (DFR) longevity remains a priority for orthopaedic oncologists as the overall survival and activity level of young patients with osteosarcoma continues to improve. This study hypothesized that increased extracortical osseointegration at the bone-implant shoulder (i.e., where the metal implant shaft abuts the femur) will improve stress transfer adjacent to the implant, as evidenced by reduced cortical bone loss, radiolucent line progression and implant failure in young patients (< 20 years) following DFR surgery. METHODS: Twenty-nine patients of mean age 13.09 ± 0.56 years received a primary DFR. The clinical outcome of 11 CPS®, 10 GMRS®, 5 Stanmore® and 3 Repiphysis® implants was evaluated over a mean follow-up period of 4.25 ± 0.55 years. The osseous response to a bone-implant shoulder composed of either a hydroxyapatite-coated grooved ingrowth collar (Stanmore®), a porous metal coating (GMRS®) or a polished metal surface (Repiphysis®) was quantified radiographically. RESULTS: All (100.0%) of the Stanmore® implants, 90.0% of GMRS®, 81.8% of CPS® and 33.3% of the Repiphysis® implants survived. Significantly increased extracortical bone and osseointegration were measured adjacent to the Stanmore® bone-implant shoulder when compared with the GMRS® and Repiphysis® implants (p < 0.0001 in both cases). Significantly decreased cortical loss was identified in the Stanmore® group (p = 0.005, GMRS® and p < 0.0001, Repiphysis®) and at 3 years, the progression of radiolucent lines adjacent to the intramedullarly stem was reduced when compared with the GMRS® and Repiphysis® implants (p = 0.012 and 0.026, respectively). CONCLUSIONS: Implants designed to augment osseointegration at the bone-implant shoulder may be critical in reducing short- (≤ 2 years) to mid- (≤ 5 years) term aseptic loosening in this vulnerable DFR patient group. Further longer-term studies are required to confirm these preliminary findings.

Two-Stage Total Knee Arthroplasty Revision With Extended Antibiotic Spacer Use.

Despite the many benefits of total knee arthroplasty (TKA) in the treatment of degenerative arthritis, infection of the total knee prosthesis presents a dangerous post-operative complication affecting 0.5-1.9% of all cases. Infection after the first three post-operative weeks is treated with either one or two-stage revision operations involving the removal of all prosthetic components. Two-stage revision operations are more commonly used and involve the removal of prosthetic components followed by the implantation of a cement mold infused with antibiotics (antibiotic spacer) as well as systemic antibiotic treatment for four to six weeks before prosthetic reimplantation. This case report details a TKA revision in a patient with osteoarthritis of the knee. The patient presented with an elevated erythrocyte sedimentation rate, C-reactive protein, and white blood cell count nearly two years after the primary operation and was found to have an infected total knee prosthetic. A two-stage revision was planned but due to scheduling disruption by the coronavirus disease 2019 pandemic, the second stage of the operation was delayed until 12 months after the stage one operation. The patient ambulated without pain on an antibiotic spacer for 12 months, providing information about the long-term use of spacers. This case also offers a look at a potential benefit to one-stage operations, which have been shown in the literature to have similar outcomes as two-stage operations. The patient had a medical history of psoriasis and immunosuppressive treatment with methotrexate, two risk factors for prosthetic joint infection, and may have benefited from prophylactic antibiotic therapy extending beyond the perioperative period. The goal of this case report is to detail the prolonged use of an antibiotic spacer, examine the risks and benefits of one and two-stage total knee revisions, and discuss prophylactic antibiotic use in high-risk patients following TKA.