Valentin Antoci

Role of Preoperative Computed Tomography Scans in Operative Planning for Malleolar Ankle Fractures

Background: There remains no consensus regarding the role of computed tomography (CT) scans in preoperative planning for malleolar ankle fractures. The aim of this study was to determine the role of preoperative CT scans on operative planning in these fractures. Methods: A retrospective analysis was performed on 100 consecutive patients treated at our institution for malleolar ankle fractures (AO type 44) with both preoperative radiographs and CT scans. Six study participants reviewed available radiographs and formulated an operative (or nonoperative) plan including positioning, operative approach, and fixation. Participants then analyzed CT scans of the same fractures, deciding whether (and how) they would alter operative strategy. Characteristics of fractures and radiographs were correlated with changes in operative strategy. Results: Operative strategy was notably changed in 24% of cases after CT review, with strong intraclass correlation (0.733). Common changes included alterations in medial malleolar (21%) or posterior malleolar (15%) fixation and fixation of an occult anterolateral plafond fracture (9%). Notable predictors of changes in operative strategy included trimalleolar over unimalleolar fractures (29% vs 10% rate of change), preoperative dislocation over no dislocation (31% vs 20%), the presence of only radiographs with overlying plaster versus fractures with at least 1 set of radiographs without plaster (25% vs 14%), and suprasyndesmotic versus trans- and infra-syndesmotic fractures (40% vs 20% and 4%, respectively). Conclusions: CT scans may be useful adjuncts in preoperative planning for malleolar ankle fractures, most notably in fracture dislocations, cases in which all available radiographs are obscured by plaster, trimalleolar fractures, and suprasyndesmotic fractures. Level of Evidence: Level III, retrospective comparative study.

What is the Fate of Total Hip Arthroplasty (THA) Acetabular Component Orientation When Evaluated in the Standing Position

This retrospective study measured the change of the acetabular component orientation between supine and standing radiographs in 113 THA patients and identified the associated anatomical parameters that may help direct pre-operative planning. The mean change of the acetabular component inclination and version from supine to standing was 4.6° and 5.9° respectively (P<0.0001), with 49 (43%) hips showing inclination change >5° and 69 (53%) hips showing version change >5°. Twelve (43%) of 28 malpositioned cups became well-positioned and 26 (31%) of 85 well-positioned cups became malpositioned upon standing. Changes in inclination were associated with leg length discrepancy and pelvic obliquity; and changes in version were associated with pelvic tilt and pelvic incidence. Standing position and patient factors should be considered when defining optimal acetabular orientation.

Utility of Serum Inflammatory and Synovial Fluid Counts in the Diagnosis of Infection in Taper Corrosion of Dual Taper Modular Stems.

BACKGROUNDnAn accurate diagnosis of periprosthetic joint infection (PJI) is critical as treatment of the infected total hip arthroplasty differs from aseptic failure. The clinical presentation of PJI may mimic symptoms of taper corrosion. Our aim was to evaluate the utility of serum inflammatory markers and synovial fluid white blood cell (WBC)/differential counts in diagnosis of PJI in failed dual taper total hip arthroplasty due to taper corrosion.nnnMETHODSnWe retrospectively reviewed 62 dual taper modular stem patients who underwent revision surgery for symptomatic adverse local tissue reaction due to taper corrosion. All patients had preoperative hip synovial aspirations, serum inflammatory markers, metal ion levels, and intraoperative cultures. Using Musculoskeletal Infection Society PJI criteria, we divided the cohort into infected and noninfected groups. Receiver-operating characteristic curves were constructed to determine the relationship and optimal cutoff values for erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and synovial fluid counts.nnnRESULTSnInfection group had significantly higher mean ESR (Pxa0= .002), CRP (Pxa0= .01), synovial fluid WBC (Pxa0< .001), and neutrophil percentage (Pxa0= .02). Cobalt levels were significantly elevated in noninfection group (Pxa0= .02). Using receiver-operating characteristic curve analysis, the most ideal tests for diagnosis of PJI were synovial fluid WBC (area under the curvexa0= 86%, optimal cutoff 730 WBC/uL) and neutrophil percentage (area under the curvexa0= 83%, optimal cutoff 65%). ESR and CRP thresholds of 22 mm/h and 3 mg/L demonstrated 57% sensitivity and 95% specificity and 29% sensitivity and 93% specificity for detection of PJI, respectively.nnnCONCLUSIONnOur study suggests that ESR and CRP are useful in excluding PJI in dual taper modular implants with corrosion, whereas both synovial WBC count and neutrophil percentage are useful markers for diagnosing infection.

Effects of Obesity on Health Related Quality of Life Following Total Hip Arthroplasty.

Obesity is known to negatively impact health related quality of life (HRQoL). Although non-disease specific tools have been used to study HRQoL after THA in obese patients, these do not directly measure health utility improvements. All 435 THA patients in the current study, regardless of BMI, reported improvement in HRQoL as measured by EQ-5D, a universal, standardized, non-disease specific preference-based instrument. These data suggest obese patients value their quality of life improvement following THA as much as non-obese patients. Furthermore, the increased activity level observed following THA in obese patients suggests obese patients may also obtain non-disease specific benefits of a more active lifestyle. This information is important for future assessments of value and cost-effectiveness of THA in the obese population.

Relevance of adjacent joint imaging in the evaluation of ankle fractures.

BACKGROUNDnRoutinely obtaining adjacent joint radiographs when evaluating patients with ankle fractures may be of limited clinical utility and an unnecessary burden, particularly in the absence of clinical suspicion for concomitant injuries.nnnMETHODSnOne thousand, three hundred and seventy patients who sustained ankle fractures over a 5-year period presenting to two level 1 trauma centers were identified. Medical records were retrospectively reviewed for demographics, physical examination findings, and radiographic information. Analyses included descriptive statistics along with sensitivity and predictive value calculations for the presence of adjacent joint fracture.nnnRESULTSnAdjacent joint imaging (n=1045 radiographs) of either the knee or foot was obtained in 873 patients (63.7%). Of those, 75/761 patients (9.9%) demonstrated additional fractures proximal to the ankle joint, most commonly of the proximal fibula. Twenty-two of 284 (7.7%) demonstrated additional fractures distal to the ankle joint, most commonly of the metatarsals. Tenderness to palpation demonstrated sensitivities of 0.92 and 0.77 and positive predictive values of 0.94 and 0.89 for the presence of proximal and distal fractures, respectively. Additionally, 19/22 (86.4%) of patients sustaining foot fractures had their injury detectable on initial ankle X-rays. Overall, only 5.5% (75/1370) of patients sustained fractures proximal to the ankle and only 0.2% (3/1370) of patients had additional foot fractures not evident on initial ankle X-rays.nnnCONCLUSIONnThe addition of adjacent joint imaging for the evaluation of patients sustaining ankle fractures is low yield. As such, patient history, physical examination, and clinical suspicion should direct the need for additional X-rays.nnnLEVEL OF EVIDENCEnLevel IV.

Top-Out Removal of Well-Fixed Dual-Taper Femoral Stems: Surgical Technique and Radiographic Risk Factors.

BACKGROUNDnContemporary dual-taper modular femoral neck-stem designs have been associated with taper corrosion-related adverse local tissue reaction (ALTR) requiring revision surgery and stem removal. Extended trochanteric osteotomy is recognized as the workhorse procedure for revision hip surgery. The aim of our study is to describe our top-out stem removal surgical technique and identify preoperative radiographic risk factors associated with periprosthetic fractures when using this technique.nnnMETHODSnThis is a single-center, single-surgeon, retrospective case series. Operative and clinic records were reviewed for patients with dual-taper modular femoral neck-stem junction who underwent revision surgery for taper tribocorrosion-related ALTR.nnnRESULTSnEighty-three patients (36 men and 47 women; mean age, 61.8 ± 10.3; body mass index, 30.2 ± 8.6) were revised using the top-out technique. Significant improvements in postoperative Harris hip score (Pxa0= .004), EuroQol 5-dimension questionnaire (EQ-5D; P < .001), and EQ-5D US-adjusted scores (Pxa0< .001) were observed at 19-months follow-up. Our study reports periprosthetic fracture incidence of 14% and reoperation rate of 7%. Periprosthetic fractures were positively correlated with radiographic parameters such as overhang distance (Rxa0= 0.376; Pxa0= .002) and overhang ratio (Rxa0= 0.312; Pxa0= .01) and negatively correlated with radiographic implant medial calcar prominence (Rxa0=xa0-0.299; Pxa0= .01).nnnCONCLUSIONnRemoval of well-fixed femoral components can be challenging, and the burden of revision surgery for taper tribocorrosion-related ALTR of these femoral stems is likely to rise. A top-out technique with systematic preoperative planning with radiographs provides a viable, alternative surgical option to remove well-fixed femoral component while preserving the femoral bony envelope.

Incentive Spirometry Adherence: A National Survey of Provider Perspectives

BACKGROUND: Patient adherence is a critical factor for success of patient-administered therapies, including incentive spirometry (IS). Patient adherence with IS is not known, so we sought to evaluate providers perspectives on the current state of IS adherence and elucidate possible factors hindering patient adherence. METHODS: Respiratory therapists (RTs) and nurses across the United States were surveyed via social media and online newsletters. Surveys were distributed to the relevant national RT and nursing societies: the American Association for Respiratory Care, the Academy of Medical-Surgical Nurses, the American Society of Peri-Anesthesia Nurses, and the American Association of Critical-Care Nurses. RESULTS: Responses from 1,681 (83.8% completion rate) RTs and nurses were received. The clear majority of all providers agreed that patient adherence is poor (86.0%; 1,416 of 1,647 respondents) and should be improved (95.4%; 1,551 of 1,626 respondents). Providers believe that IS adherence is hindered by various factors. The most common reasons cited were that patients forget to use their ISs (83.5%; 1,404 of 1,681 respondents), do not use them effectively (74.4%; 1,251 of 1,681 respondents), and do not use them frequently enough (70.7%; 1,188 of 1,681 respondents). CONCLUSIONS: These findings from a large national survey of health care providers highlight the need for improved IS adherence and indicate that patient forgetfulness may be a large contributor to nonadherence. Efforts aimed at improving IS adherence are warranted.

Perspectives on Incentive Spirometry Utility and Patient Protocols

BACKGROUND: Incentive spirometry (IS) is widely used to prevent postoperative pulmonary complications, despite limited clinical effectiveness data and a lack of standardized use protocols. We sought to evaluate health care professionals perspectives on IS effectiveness and use procedures. METHODS: An online survey was distributed via social media and newsletters to relevant national nursing and respiratory care societies. Attitudes concerning IS were compared between the American Association for Respiratory Care (AARC) and the nursing societies. RESULTS: A total of 1,681 responses (83.8% completion rate) were received. The clear majority of these respondents agreed that IS is essential to patient care (92.7%), improves pulmonary function (92.0%), improves inspiratory capacity (93.0%), helps to prevent (96.6%) and to reverse (90.0%) atelectasis, helps to prevent (92.5%) and to reverse (68.4%) pneumonia, and is as effective as early ambulation (74.0%), deep-breathing exercises (88.2%), and directed coughing (79.8%). Furthermore, most health care professionals believed that IS should be used routinely preoperatively (78.1%) and postoperatively (91.1%), used every hour (59.8%), used for an average of 9.6 (95% CI 9.3–9.9) breaths per session, used to achieve breath holds of 7.8 (95% CI 7.4–8.2) s, used to reach an initial target inspiratory volume of 1,288.5 (95% CI 1,253.8–1,323.2) mL, and used to achieve a daily inspiratory volume improvement of 525.6 (95% CI 489.8–561.4) mL. Of all respondents, 89.6% believed they received adequate IS education and training. Respondents from the AARC endorsed significantly less agreement relative to the nursing societies on most parameters for IS utility. CONCLUSIONS: There was a major discrepancy between health care professionals beliefs and the published clinical effectiveness data supporting IS. Despite reported adequate education on IS, variability in what health care professionals believed to be appropriate use underscores the literatures lack of standardization and evidence for specific use procedures.

Total Hip Arthroplasty for the Treatment of Failed Acetabular Fractures

There is an increasing prevalence of older patients with acetabular fractures and high conversion rate of operatively and nonoperatively treated geriatric acetabular fractures to total hip arthroplasty. These cases should be approached as a revision total hip arthroplasty with many similar challenges including previous hardware, scarring, heterotopic ossification, malunion, nonunion, acetabular bone loss, avascular necrosis of the femoral head, and potential occult infection. The patient should undergo a detailed physical examination documenting gait, neurovascular status of the lower extremity, leg-length discrepancy, and previous surgical incisions. Imaging should consist of AP pelvis, AP and lateral of affected hip, Judet radiographs, and CT scan of the pelvis with 3-D reconstruction. Review of preoperative radiographs and CT scan will allow templating and evaluation of the leg-length discrepancy, heterotopic ossification, previous hardware placement, bone stock, and acetabular defects. Prior to surgery it is important to rule out occult infection of previously failed ORIF of acetabular fractures. A complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) should be obtained. If a high index of suspicion for infection remains, then a hip aspiration should be obtained and sent for cell count with differential and culture. The decision regarding surgical approach is often dictated by surgeon’s preferred approach, previous surgical approach used, retained hardware, location of heterotopic ossification removal, and acetabular defects that need to be addressed. These cases have unique challenges related to optimal acetabular cup fixation and stability often requiring structural bone graft, antiprotrusio cage, jumbo cup with distraction, or combined ORIF. There is a high risk of complications compared to primary total hip arthroplasty including increased risk of dislocation, infection, and heterotopic ossification and decreased survivorship of implants. As a result, total hip arthroplasty after failed acetabular fracture should be performed in specialized centers with adult reconstruction and orthopedic trauma specialists.

Sarcopenia as a Risk Factor for Prosthetic Infection After Total Hip or Knee Arthroplasty

BACKGROUNDnSarcopenia, an age-related loss of muscle mass and function, has been previously linked to an increased risk of morbidity, mortality, and infection after a variety of surgical procedures. This study is the first to evaluate the impact of the psoas-lumbar vertebral index (PLVI), a validated marker for central sarcopenia, on determining post-arthroplasty infection status.nnnMETHODSnThis is a case-control, retrospective review of 30 patients with prosthetic joint infection (PJI) diagnosed by the Musculoskeletal Infection Society criteria compared to 69 control patients who underwent a total hip or knee arthroplasty. All patients had a recent computed tomography scan of the abdomen/pelvis to calculate the PLVI. PLVI was evaluated alongside age, gender, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, and smoking status to determine the predictive value for infection.nnnRESULTSnNotably, the infected group had a large, significant difference in their average PLVI (0.736 vs 0.963, P < .001). The patients PLVI was a predictor of infection status, with a higher PLVI being protective against infection (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.109-0.715, Pxa0= .008). Additional predictors of infection status were higher American Society of Anesthesiologists score (OR 10.634, 95% CI 3.112-36.345, P < .001) and Charlson Comorbidity Index (OR 1.438, 95% CI 1.155-1.791, Pxa0= .001). Multivariate, binary logistic regression analysis confirmed that PLVI was a significant independent predictor of infection status (Bxa0=xa0-0.685, Pxa0= .039).nnnCONCLUSIONnPLVI, a marker for central sarcopenia, was demonstrated to be a risk factor for PJI. Further research and consideration of sarcopenia as a screening and optimizable risk factor for total joint arthroplasty must be explored.