Robert P. Runner

The frail fail: Increased mortality and post-operative complications in orthopaedic trauma patients

OBJECTIVE The burgeoning elderly population calls for a robust tool to identify patients with increased risk of mortality and morbidity. This paper investigates the utility of the MFI as a predictor of morbidity and mortality in orthopaedic trauma patients. DESIGN Retrospective review of the NSQIP database to identify patients age 60 and above who underwent surgery for pelvis and lower extremity fractures between 2005 and 2014. MAIN OUTCOMES AND MEASURES For each patient, an MFI score was calculated using NSQIP variables. The relationship between the MFI score and 30-day mortality and morbidity was determined using chi-square analysis. MFI was compared to age, American Society of Anesthesiologists physical status classification, and wound classifications in multiple logistic regression. RESULTS Study sample consisted of 36,424 patients with 27.8% male with an average age of 79.5 years (SD 9.3). MFI ranged from 0 to 0.82 with mean MFI of 0.12 (SD 0.09). Mortality increased from 2.7% to 13.2% and readmission increased from 5.5% to 18.8% with increasing MFI score. The rate of any complication increased from 30.1% to 38.6%. Length of hospital stay increased from 5.3days (±5.5days) to 9.1days (±7.2days) between MFI score 0 and 0.45+. There was a stronger association between 30-day mortality and MFI (aOR for MFI 0.45+: 2.6, 95% CI: 1.7-3.9) compared to age (aOR for age: 1.1, 95% CI: 1.1-1.1) and ASA (aOR 2.5, 95% CI: 2.3-2.7). CONCLUSIONS AND RELEVANCE MFI was a significant predictor of morbidity and mortality in orthopaedic trauma patients. The use of MFI can provide an individualized risk assessment tool that can be used by an interdisciplinary team for perioperative counseling and to improve outcomes.

Value of a Dedicated Saturday Orthopaedic Trauma Operating Room.

Objectives: To determine the effect of an additional scheduled operative day on length of stay, distribution of caseload, waiting time to surgery, and direct variable hospital costs. Design: Retrospective chart review. Setting: Urban level 1 trauma center. Patients: Consecutive operative tibia and femur fractures admitted from November 1, 2009, to October 31, 2011. Intervention: Addition of a dedicated Saturday orthopaedic trauma operating room. Main Outcome Measurements: Length of stay, distribution of caseload, and waiting time to surgery. Results: The overall length of stay for all trauma patients admitted with femur or tibia fractures was significantly reduced by 2.7 days from a mean of 14.0–11.3 days (P value 0.018). Additionally, there was a trend toward shorter waiting time to surgery (average reduction of 25.1 hours) for patients admitted on a Friday (48.6 vs. 23.5 hours, P value 0.06). Furthermore, there was an increase in the number of cases performed on Saturdays by 59% (6.2% of the total caseload), whereas the originally disproportionally high number of cases on Mondays was appropriately reduced by 33% (6.7% of the total caseload). The estimated direct variable cost savings per year for the hospital was

Anthropometric Computed Tomography Reconstruction Identifies Risk Factors for Cortical Perforation in Revision Total Hip Arthroplasty

1.13 million. Conclusions: Overall, these findings support the continuation of a dedicated Saturday orthopaedic trauma operating room and can provide the foundation for other departments with similar circumstances to negotiate for more dedicated operative time on weekends to improve efficiency. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Gross Trunnion Failure of a Cobalt-Chromium Femoral Head on a Titanium Stem at Midterm Follow-up

BACKGROUND The incidence of revision hip arthroplasty is increasing with nearly 100,000 annual procedures expected in the near future. Many surgeons use straight modular tapered stems in revisions; however, complications of periprosthetic fracture and cortical perforation occur, resulting in poor outcomes. Our objective was to identify patient demographics and femoral characteristics that predispose patients to cortical perforation when using the straight modular stems. METHODS We used a computed tomography database and modeling software to identify patient demographics and morphologic femoral characteristics that predispose patients to cortical perforation during revision hip arthroplasty. Overall, 561 femurs from patients of various backgrounds were used, and statistical analysis was performed via the 2-sample t test. RESULTS Decreased patient height (mean 163.0 vs 168.8 cm), radius of curvature (818 vs 939 mm), anterior-posterior (8.5 vs 13.8 mm) and medial-lateral (7.9 vs 11.3 mm) width of the isthmus, and distance of the isthmus from the greater trochanter (179 vs 186 mm) were all statistically significant risk factors for cortical perforation (P < .05). CONCLUSION This study identifies several patient-specific risk factors for cortical perforation during revision hip arthroplasty using straight modular tapered stems and highlights the importance of preoperative planning especially in patients with shorter stature, proximal location of the femoral isthmus, narrow femoral canal, and smaller radius of curvature. Also, when using a mid-length modular tapered stem without an extended trochanteric osteotomy, consideration should be given to using a kinked stem to avoid anterior cortical perforation.

Quadriceps Strength Deficits After a Femoral Nerve Block Versus Adductor Canal Block for Anterior Cruciate Ligament Reconstruction: A Prospective, Single-Blinded, Randomized Trial

Case:Three patients underwent uncomplicated primary total hip arthroplasty with cobalt-chromium femoral heads (36+5 mm) on titanium V40 tapers. At 6 to 9 years of follow-up, severe effects of corrosion at the trunnion were noted in all 3 patients, along with elevated levels of serum cobalt ions and normal levels of serum chromium ions. Gross trunnion failure, apparently caused by corrosion, required femoral stem revision in all of the patients. Conclusion:Decreased neck diameter, longer trunnion length, and large-sized cobalt-chromium heads are possible contributors to early failure after primary total hip arthroplasty due to trunnionosis. Surgeons should be mindful of trunnionosis as a cause of pain and a mechanism of failure following total hip arthroplasty, and serum metal ions should be monitored in these patients.

Femoral neuropathy following direct anterior total hip arthroplasty: an anatomic review and case series†

Background: Peripheral nerve blocks, particularly femoral nerve blocks (FNBs), are commonly performed for anterior cruciate ligament (ACL) reconstruction. However, associated quadriceps muscle weakness after FNBs is well described and may occur for up to 6 months postoperatively. The adductor canal block (ACB) has emerged as a viable alternative to the FNB, theoretically causing less quadriceps weakness during the immediate postoperative period, as it bypasses the majority of the motor fibers of the femoral nerve that branch off proximal to the adductor canal. Purpose/Hypothesis: This study sought to identify if a difference in quadriceps strength exists after an ACB or FNB for ACL reconstruction beyond the immediate postoperative period. Beyond the immediate postoperative period, we anticipated no difference in quadriceps strength between patients who received ACBs or FNBs for ACL reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 102 patients undergoing primary ACL reconstruction using a variety of graft types were enrolled between November 2015 and April 2016. All patients were randomized to receive an ACB or FNB before surgery, and the surgeon was blinded to the block type. All patients underwent aggressive rehabilitation without functional bracing postoperatively. The time to the first straight-leg raise was reported by the patient. Isokinetic strength testing was performed at 3 and 6 months postoperatively. Results: Data for 73 patients were analyzed. There was no significant difference in patient demographics of age, body mass index, sex, or tourniquet time between the FNB (n = 35) and ACB (n = 38) groups. The mean time to the first straight-leg raise was similar, at 13.1 ± 1.0 hours for the FNB group and 15.5 ± 1.2 hours for the ACB group (P = .134). The mean extension torque at 60 deg/s increased significantly for both the ACB (53.7% ± 3.4% to 68.3% ± 2.9%; P = .008) and the FNB (53.3% ± 3.3% to 68.5% ± 4.1%; P = .006) groups from 3 to 6 months postoperatively. There was also no significant difference in mean extension torque at 60 deg/s or 180 deg/s between the FNB and ACB groups at 3 and 6 months. There were no significant differences in postoperative complications (infection, arthrofibrosis, retear) between groups. Conclusion: Although prior studies have shown immediate postoperative benefits of ACBs compared with FNBs, with a faster return of quadriceps strength, in the current study there was no statistically or clinically significant difference in quadriceps strength at 3 and 6 months postoperatively in patients who received ACBs or FNBs for ACL reconstruction.

Disparities in follow-up care for ballistic and non-ballistic long bone lower extremity fractures

Abstract The popularity of the direct anterior approach for total hip arthroplasty (THA) has dramatically increased in recent years. Many patients request this muscle sparing approach for the theorized benefits of quicker recovery and reduced post-operative pain. Femoral nerve injury is a rare, yet serious complication following the anterior approach for THA. During the 7-year period from 2008 to 2016, 1756 patients underwent primary THA with a direct anterior approach by a single senior surgeon for end-stage osteoarthritis. Six (0.34%) of these patients had a post-operative femoral nerve palsy. We aim to discuss anatomic considerations, risk factors, and a timeline of severity and recovery for femoral nerve palsy following direct anterior THA in six patients.

Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries

OBJECTIVES To describe differences in follow-up compliance and emergency department (ED) visits between ballistic and non-ballistic operative lower extremity fracture patients. DESIGN Retrospective study. SETTING Urban level 1 trauma center. PATIENTS/PARTICIPANTS Patients age ≥18 years with ≥1 tibia or femur fractures treated with ORIF or intramedullary nailing (IMN) between September 1, 2013 and August 31, 2015. MAIN OUTCOME MEASURE A compliance fraction calculated as ([number of attended follow-up visits] / [number of attended follow-up visits + number of missed follow-up visits]) and ED visits in the post-operative period. RESULTS 612 patients were studied. Patients with ballistic lower extremity fractures had a younger mean age (30.8 years v. 41.6 years; p < 0.0001); a shorter length of stay (5.00 days v. 8.00 days; p < 0.0001); and were more likely to be male (92.6% v. 68%; p < 0.0001) and African-American (90.1% v. 63.1%; p < 0.0001) when compared to non-ballistic long bone injuries. Increased follow-up compliance (defined as a compliance fraction ≥0.75) was associated with having a non-ballistic fracture (OR 1.73, 1.13-2.64; p = 0.01), not having an ED visit (OR 2.08, 1.30-3.33; p = 0.002), and being female (OR 1.82, 1.27-2.61; p = 0.001). Increased ED utilization (≥ 1 ED visit) was associated with ballistic mechanism (OR 1.95, 1.20-3.16; p = 0.006), a low follow-up compliance fraction (OR 2.08, 1.30-3.33; p = 0.0019), homelessness (OR 3.91, 1.53-9.98; p = 0.006), and African-American race (OR 2.26, 1.26-4.05; p = 0.05). Scheduling a specific follow-up visit on the discharge summary did not predict higher compliance (OR 1.51, 0.98-2.33; p = 0.06). Conversely, the lack of a specific follow-up visit scheduled on the discharge summary did not predict ED utilization (OR 0.63, 0.34-1.17; p = 0.14). CONCLUSION The results of this study demonstrate that increased utilization of the ED was associated with ballistic fractures, homelessness, decreased clinic compliance, and African American race. Furthermore, patients with non-ballistic injuries, women, and those without any ED visit were more likely to have higher outpatient clinic compliance.

Unusual presentation of failed metal-on-metal total hip arthroplasty with features of neoplastic process

BACKGROUND As morbidity and mortality from traumatic orthopaedic injuries continues to rise, increased research is being conducted on how to best predict complications in at risk patients. Recently, frailty indices have been validated in a variety of surgical subspecialties as predictors of morbidity and mortality. However, the vast majority of research has been conducted on geriatric patient populations, with little evidence on patients who are chronologically young. The purpose of this study was to evaluate the role of a modified frailty index (mFI) in predicting mortality and complications after pelvis, acetabulum, and lower extremity trauma in patients of all ages. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2014 for all patients who underwent surgery for pelvis, acetabulum, and lower extremity trauma. The sample size was divided into geriatric (age ≥ 60) and young (age < 60) cohorts. The mFI score was calculated for each patient. Bivariate analysis was performed using logistic regression and a chi-square test to determine the relationship between mFI and both primary and secondary outcomes while adjusting for age. Univariate analysis and multivariate analyses were performed. All analyses were done using SAS 9.4 (Cary, NC) and a p < 0.05 was considered significant. RESULTS 56,241 patients were identified to have undergone surgery for pelvis, acetabulum, or lower extremity trauma. 28% of patients were identified under the age of 60. In the young cohort, mFI was a strong predictor of thirty-day mortality (OR 11.02, 95% CI 6.26-19.39, p < 0.001). With regards to Clavien-Dindo grade IV complications, MFI is also a strong predictor in the young cohort (OR 28.82, 95% CI 16.05-51.77, p < 0.001). CONCLUSION AND RELEVANCE The mFI score was a significant predictor of morbidity and mortality in chronologically young orthopaedic trauma patients. The use of the mFI score can provide an individualized risk assessment to interdisciplinary teams for perioperative counseling and to improve outcomes.

Renal failure after placement of an articulating, antibiotic impregnated polymethylmethacrlyate hip spacer

Metal-on-metal (MoM) total hip arthroplasty (THA) is associated with increased incidence of failure from metallosis, adverse tissue reactions, and the formation of pseudotumors. This case highlights a 53-year-old female with an enlarging painful thigh mass 12 years status post MoM THA. Radiographs and advanced imaging revealed an atypical mass with cortical bone destruction and spiculation, concerning for periprosthetic malignancy. Open frozen section biopsy was performed before undergoing revision THA in a single episode of care. This case illustrates that massive pseudotumors can be locally aggressive causing significant femoral bone destruction and may mimic malignancy. It is important that orthopaedic surgeons, radiologists and pathologists understand the relative infrequency of periprosthetic malignancy in MoM THA to mitigate patient concerns, misdiagnosis, and allow for an evidence based discussion when treating massive pseudotumors.