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Smolev E, Marchese RM, Sriram V, Lebens R, Komatsu DE, Wang ED. Is delayed time to surgery associated with increased postoperative complications in patients with pathologic humerus fractures? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:3873-3879. [PMID: 39177774 DOI: 10.1007/s00590-024-04055-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/31/2024] [Indexed: 08/24/2024]
Abstract
INTRODUCTION Delayed time to surgery, in the case of orthopedic trauma, is well known to be associated with higher morbidity and mortality, an extended duration of hospitalization, and an associated rise in overall cost. Delayed time to surgery of at least 3 days following hospital admission is associated with elevated risk of complications following surgery for a standard, non-pathologic, humeral shaft fracture. To our knowledge, it is unknown whether the same association is present for pathologic humerus fractures. The primary objective of this study was to identify risk factors, including patient characteristics, comorbidities, and postoperative complications, that are associated with delayed time to surgery following pathologic humeral fracture. METHODS All patients undergoing surgical management of pathologic humerus fractures across a 6-year period from 2015 to 2021 were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Postoperative complications were reported within 30 days of procedure. Delayed time to surgery was defined by ≥ 2 days from hospital admission to surgery. We identified a total of 248 patients, and 39.9% (n = 99) of patients had delayed time to surgery. Multivariate logistic regression adjusted for all significantly associated variables was employed to identify predictors of delayed time to surgery for pathologic humerus fractures. RESULTS The characteristics of patients significantly associated with delayed time to surgery were ASA classification ≥ 3 (p = 0.016), dependent functional status (p = 0.041), and congestive heart failure (p = 0.008). After adjusting for all significantly associated patient variables, the characteristics of patients independently associated with delayed time to surgery were non-home discharge (OR: 2.93, 95% CI 1.53-5.63; p = 0.001) and extended length of stay (OR: 2.00, 95% CI 1.06-3.77; p = 0.033). CONCLUSION Delayed time to surgery of at least 2 days was independently associated with non-home discharge and extended postoperative length of stay. After controlling for baseline patient characteristics and comorbidities, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic humeral fractures. This is in contrast to standard, non-pathologic humerus fractures in which delayed time to surgery is associated with an increased risk of postoperative complications. LEVEL OF EVIDENCE III Retrospective Cohort Comparison; Prognosis Study.
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Affiliation(s)
- Emma Smolev
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA.
- Department of Orthopaedics, Stony Brook University Hospital, HSC T-18, Room 080, Stony Brook, NY, 11794-8181, USA.
| | - Richard M Marchese
- Department of Orthopaedics, Stony Brook University Hospital, HSC T-18, Room 080, Stony Brook, NY, 11794-8181, USA
| | - Varun Sriram
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Ryan Lebens
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - David E Komatsu
- Department of Orthopaedics, Stony Brook University Hospital, HSC T-18, Room 080, Stony Brook, NY, 11794-8181, USA
| | - Edward D Wang
- Department of Orthopaedics, Stony Brook University Hospital, HSC T-18, Room 080, Stony Brook, NY, 11794-8181, USA
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Aguirre-Milachay E, León-Figueroa DA, Valladares-Garrido MJ. Clinical, laboratory, and hospital factors associated with preoperative complications in Peruvian older adults with hip fracture. PLoS One 2024; 19:e0313089. [PMID: 39495713 PMCID: PMC11534202 DOI: 10.1371/journal.pone.0313089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 10/16/2024] [Indexed: 11/06/2024] Open
Abstract
OBJECTIVES To determine the clinical, laboratory, and hospital factors associated with preoperative complications in older adults with hip fractures. METHODOLOGY Analytical observational retrospective cohort study, whose population was older adults with a diagnosis of hip fracture treated in a hospital in northern Peru, during 2017-2019. RESULTS 432 patients with a median age of 83 years (RIC: 77-88) were evaluated, with the female gender being the most prevalent (60.9%). The most common comorbidities included cardiovascular disease (68%) and diabetes (17.6%), and multimorbidity was observed in 47.2% of cases. The median number of geriatric syndromes was 2 (RIC: 1-5). The overall mortality rate was 3.2% (1.7-5.3). Analysis with the Poisson regression model found a significant association with MRC scale 3-5 degree (RR = 1.60), glucose on admission (RR = 1.01), and minimally significantly female sex (RR = 2.41). CONCLUSIONS The most commonly observed complications were infectious in nature, including pneumonia, sepsis, and urinary tract infections. The MRC scale from 3 to 5 degrees increases the risk of developing a preoperative complication; the glucose levels upon admission show a clinically irrelevant association; and in females, there is a minimally significant association in older adults with hip fractures.
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Affiliation(s)
| | | | - Mario J Valladares-Garrido
- Universidad Continental, Lima, Peru
- Oficina de Inteligencia Sanitaria, Red Prestacional EsSalud Lambayeque, Chiclayo, Peru
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Šarić Jadrijev A, Bego A, Lojpur B, Poljak D, Žaja M, Matas J, Pivalica B, Stojanović Stipić S, Čapkun V, Vukojević K, Glavina Durdov M, Bratanić A. Admission Hemoglobin Associated with Increased Mortality in Hip Fracture Surgical Patients: An Observational Study. Biomedicines 2024; 12:2041. [PMID: 39335554 PMCID: PMC11428683 DOI: 10.3390/biomedicines12092041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 09/05/2024] [Accepted: 09/06/2024] [Indexed: 09/30/2024] Open
Abstract
In hip fracture patients, who are mostly elderly, preexisting anemia can be worsened when combined with trauma and surgery. To this date, there is no unequivocal approach about transfusion thresholds. We analyzed hemoglobin (Hb) and hematocrit (Hct) levels at three time points in surgical patients with proximal femoral fractures (PFF) to see which levels were triggers for transfusions and whether transfusions were related to mortality after hospital discharge. A total of 956 patients were operated on from 1 January 2021 to 31 December 2022 at the University Hospital of Split and included in the study. There were more women (74%); 47% patients had admission Hb < 120 g/L. Transfusion was given preoperatively to 88, intraoperatively to 74 and postoperatively to 309 patients. Transfusion thresholds were as follows: Hb 84 g/L preoperatively, 99 intraoperatively and 83 postoperatively. After hospital discharge, 10.79% of patients died within the 1st month and 23% within 6 months. In the group of non-survivors, 60% of patients had admission Hb ≤ 117 g/L and the proportion of patients transfused preoperatively was two times higher. Preoperative transfusion thresholds could be set to higher levels for patients with surgically treated PFF. However, that could increase mortality even more. Further investigation is necessary.
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Affiliation(s)
- Ana Šarić Jadrijev
- Department of Anaesthesiology and Intensive Care, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
| | - Ana Bego
- Department of Anaesthesiology and Intensive Care, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
| | - Borna Lojpur
- Institute of Emergency Medicine in Split-Dalmatia County, Spinčićeva 1, 21000 Split, Croatia
| | - Dino Poljak
- Department of Surgery, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
| | - Marija Žaja
- Department of Anaesthesiology and Intensive Care, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
| | - Jakov Matas
- Priska Med Polyclinic, Kroz Smrdečac 45, 21000 Split, Croatia
| | - Božen Pivalica
- Department of Surgery, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
| | - Sanda Stojanović Stipić
- Department of Anaesthesiology and Intensive Care, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
| | - Vesna Čapkun
- Department of Anatomy, Histology and Embryology, School of Medicine, University of Split, Šoltanska 2A, 21000 Split, Croatia
| | - Katarina Vukojević
- Department of Anatomy, Histology and Embryology, School of Medicine, University of Split, Šoltanska 2A, 21000 Split, Croatia
| | - Merica Glavina Durdov
- Department of Pathology, Legal Medicine and Cytology, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
| | - Andre Bratanić
- Department of Internal Medicine, University Hospital of Split, Spinčićeva 1, 21000 Split, Croatia
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Tian Z, Hu Z, Wei Z, Meng C. Letter to the Editor: For Surgically Treated Geriatric Acetabular Fractures, Longer Duration Between Admission and Surgery Is Associated With an Increase in Postoperative Complications: A Study Using the National Trauma Data Bank. J Am Acad Orthop Surg 2024; 32:e617-e618. [PMID: 38684132 DOI: 10.5435/jaaos-d-24-00210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 05/02/2024] Open
Affiliation(s)
- Zhikang Tian
- From the Jining Medical University (Tian, Hu, and Wei), Jining, China, and the Affiliated Hospital of Jining Medical University (Meng), Jining, China
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Gonzalez MR, Karczewski D, Bedi AD, Denwood H, Lozano-Calderon SA. Neoplastic pathologic hip fractures are associated with a higher risk of post-operative bleeding and thromboembolic events. Surg Oncol 2024; 54:102076. [PMID: 38608626 DOI: 10.1016/j.suronc.2024.102076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/03/2024] [Accepted: 04/08/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION Surgical treatment of hip fractures leads to significant post-operative complications. Although pathologic fractures (PF) are associated with worse outcomes, most studies do not differentiate between etiology (neoplastic and non-neoplastic PF). We seek to compare 30-day complication rates between 1) native hip fractures and neoplastic PF, and 2) neoplastic and non-neoplastic PF. MATERIALS AND METHODS A total of 127,819 patients with hip fractures and 5104 with PF diagnosed from 2005 to 2021 were retrieved from the NSQIP database. We included 1843 patients with neoplastic PF and 3261 with non-neoplastic PF. Demographics, pre-operative labs and co-morbidities, and post-operative outcomes were analyzed. Propensity-score matching was conducted to control for confounders. RESULTS Patients with a neoplastic PF had a significantly higher rate of deep venous thrombosis (DVT) (4 % vs 1.2 %, p = 0.001) and pulmonary embolism (PE) (2.4 % vs 0.7 %, p < 0.001), than native hip fractures. Rates of post-operative bleeding were significantly higher in the neoplastic PF group (29.3 % vs 23.9 %, p < 0.001) than non-neoplastic PF. No differences in soft tissue complications were found. When comparing neoplastic and non-neoplastic PF, the former had a higher rate of PE (2.5 % vs 1.0 %, p = 0.015) and post-operative bleeding (27.6 % vs 22.0 %, p = 0.009). Unplanned readmission rates and 30-day mortality rate were also higher in the neoplastic PF group. CONCLUSION Neoplastic PF of the hip are associated with higher risk of thromboembolic event rates and post-operative bleeding than both native hip fractures and non-neoplastic PF. No differences in rates of soft tissue complications were found between groups.
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Affiliation(s)
- Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA
| | - Daniel Karczewski
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA
| | - Angad Ds Bedi
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA; Department of Orthopaedic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hayley Denwood
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA
| | - Santiago A Lozano-Calderon
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02144, USA.
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Wang LX, Guan LJ, Deng MH, Zhou LH. Risk Factors of Serious Adverse Events for Geriatric Hip Fractures: Is it the Frailty or the Timing? Geriatr Orthop Surg Rehabil 2024; 15:21514593241250165. [PMID: 38681064 PMCID: PMC11047255 DOI: 10.1177/21514593241250165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/13/2024] [Accepted: 04/02/2024] [Indexed: 05/01/2024] Open
Abstract
Objective Preoperative frailty and surgical waiting times are associated with the occurrence of adverse outcomes in patients with hip fractures. Specifically, we aimed to investigate the influence of frailty status and surgical timing on the risk of serious adverse events during hospitalization. Methods This study utilized an observational single cohort design and included patients aged ≥60 years with a primary diagnosis of hip fracture. Frailty was assessed using the chart-derived frailty index (CFI), which was calculated based on demographic and routine laboratory variables. The primary outcome of interest was the occurrence of in-hospital serious adverse events. A multivariate logistic regression model was utilized to examine the risk factors influencing outcomes. Results The study included 427 participants, with a mean age of 80.28 ± 8.13 years and 64.2% of whom were female. Patients with high CFI have more comorbidities (P < .001), lower surgical rates (P = .002), and delayed surgical times (P = .033). A total of 239 patients (56.0%) experienced serious adverse events. The high CFI group had a significantly higher occurrence of serious adverse events compared to the low CFI group (73.4% vs 48.5%, P < .001). After adjusting for surgical timing and covariates, the multivariate logistic regression analysis revealed that high frailty significantly increased the risk for serious adverse events (OR = 2.47, 95% CI 1.398-4.412), infection (OR = 1.99, 95% CI 1.146-3.446), acute heart failure (OR = 3.37, 95% CI 1.607-7.045). However, the timing of surgery did not demonstrate any association with these outcomes. In addition, after adjusting for surgical factors, high CFI remains an independent risk factor for these complications. Conclusions Frailty serves as a reliable predictor of the probability of encountering severe adverse events while hospitalized for elderly individuals with hip fractures. This method has the potential to pinpoint particular modifiable factors that necessitate intervention, whereas the impact of surgical timing remains uncertain and necessitates additional research.
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Affiliation(s)
- Ling-xiao Wang
- Department of gerontology and geriatrics, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Li-juan Guan
- Department of gerontology and geriatrics, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Ming-hong Deng
- Department of gerontology and geriatrics, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
| | - Li-hua Zhou
- Department of gerontology and geriatrics, Chengdu Fifth People’s Hospital (The Second Clinical Medical College, Affiliated Fifth People’s Hospital of Chengdu University of Traditional Chinese Medicine), Chengdu, China
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Wang Y, Jiang Q, Long H, Chen H, Wei J, Li X, Wang H, Xie D, Zeng C, Lei G. Trends and benefits of early hip arthroplasty for femoral neck fracture in China: a national cohort study. Int J Surg 2024; 110:1347-1355. [PMID: 38320106 PMCID: PMC10942226 DOI: 10.1097/js9.0000000000000794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/10/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Limited studies have examined the benefits of early arthroplasty within 48 h from admission to surgery for femoral neck fractures (FNFs). Using the national inpatient database, the authors aimed to investigate the trends in early arthroplasty within 48 h for FNFs in China and to assess its effect on in-hospital complications and 30-day readmission patterns. MATERIALS AND METHODS This was a retrospective cohort study. Patients receiving primary total hip arthroplasty (THA) or hemiarthroplasty (HA) for FNFs in the Hospital Quality Monitoring System between 2013 and 2019 were included. After adjusting for potential confounders with propensity score matching, a logistic regression model was performed to compare the differences in in-hospital complications [i.e. in-hospital death, pulmonary embolism, deep vein thrombosis (DVT), wound infection, and blood transfusion], rates and causes of 30-day readmission between early and delayed arthroplasty. RESULTS During the study period, the rate of early THA increased from 18.0 to 19.9%, and the rate of early HA increased from 14.7 to 18.4% ( P <0.001). After matching, 11 731 pairs receiving THA and 13 568 pairs receiving HA were included. Compared with delayed THA, early THA was associated with a lower risk of pulmonary embolism [odds ratio (OR) 0.51, 95% CI: 0.30-0.88], DVT (OR 0.59, 95% CI: 0.50-0.70), blood transfusion (OR 0.62, 95% CI: 0.55-0.70), 30-day readmission (OR 0.82, 95% CI: 0.70-0.95), and venous thromboembolism-related readmission (OR 0.50, 95% CI: 0.34-0.74). Similarly, early HA was associated with a lower risk of DVT (OR 0.70, 95% CI: 0.61-0.80) and blood transfusion (OR 0.74, 95% CI: 0.68-0.81) than delayed HA. CONCLUSION Despite a slight increase, the rate of early arthroplasty remained at a low level in China. Given that early arthroplasty can significantly improve prognosis, more efforts are needed to optimize the procedure and shorten the time to surgery.
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Affiliation(s)
| | | | | | - Hu Chen
- Tibet Autonomous Region People’s Hospital, Lhasa, Tibet, People’s Republic of China
| | - Jie Wei
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Health Management Center, Xiangya Hospital
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
| | - Xiaoxiao Li
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
| | - Haibo Wang
- China Standard Medical Information Research Center, Shenzhen
- Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong
| | | | - Chao Zeng
- Department of Orthopedics
- National Clinical Research Center for Geriatric Disorders
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
| | - Guanghua Lei
- Department of Orthopedics
- National Clinical Research Center for Geriatric Disorders
- Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment, Ministry of Education
- Hunan Key Laboratory of Joint Degeneration and Injury, Changsha, Hunan
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Vazquez S, Dominguez JF, Jacoby M, Rahimi M, Grant C, DelBello D, Salik I. Poor socioeconomic status is associated with delayed femoral fracture fixation in adolescent patients. Injury 2023; 54:111128. [PMID: 37875032 DOI: 10.1016/j.injury.2023.111128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/06/2023] [Accepted: 10/13/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Healthcare disparities continue to exist in pediatric orthopedic care. Femur fractures are the most common diaphyseal fracture and the leading cause of pediatric orthopedic hospitalization. Prompt time to surgical fixation of femur fractures is associated with improved outcomes. OBJECTIVE The objective of this study was to evaluate associations between socioeconomic status and timing of femoral fixation in adolescents on a nationwide level. METHODS The 2016-2020 National Inpatient Sample (NIS) database was queried using International Classification of Disease, 10th edition (ICD-10) codes for repair of femur fractures. Patients between the ages of 10 and 19 years of age with a principal diagnosis of femur fracture were selected. Patients transferred from outside hospitals were excluded. Baseline demographics and characteristics were described. Patients were categorized as poor socioeconomic status (PSES) if they were classified in the Healthcare Cost and Utilization Project's (HCUP) lowest 50th percentile median income household categories and on Medicaid insurance. The primary outcome studied was timing to femur fixation. Delayed fixation was defined as fixation occurring after 24 h of admission. Secondary outcomes included length of stay (LOS) and discharge disposition. RESULTS From 2016-2020, 10,715 adolescent patients underwent femur fracture repair throughout the United States. Of those, 765 (7.1 %) underwent late fixation. PSES and non-white race were consistently associated with late fixation, even when controlling for injury severity. Late fixation was associated with decreased rate of routine discharge (p < 0.01), increased LOS (p < 0.01) and increased total charges (p < 0.01). CONCLUSION Patients of PSES or non-white race were more likely to experience delayed femoral fracture fixation. Delayed fixation led to worse outcomes and increased healthcare resource utilization. Research studying healthcare disparities may provide insight for improved provider education, implicit bias training, and comprehensive standardization of care.
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Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, NY, USA.
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Jacoby
- Department of Anesthesiology, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Rahimi
- Department of Anesthesiology, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Christa Grant
- Department of Pediatric Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Damon DelBello
- Department of Orthopaedic Pediatric Surgery, Maria Fareri Children's Hospita, Westchester Medical Center, Valhalla, NY, USA
| | - Irim Salik
- Department of Anesthesiology, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
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Verspoor FGM, Hannink G, Parry M, Jeys L, Stevenson JD. The Importance of Awaiting Biopsy Results in Solitary Pathological Proximal Femoral Fractures : Do We Need to Biopsy Solitary Pathological Fractures? Ann Surg Oncol 2023; 30:7882-7891. [PMID: 37505350 PMCID: PMC10562502 DOI: 10.1245/s10434-023-13931-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND The optimal surgical treatment for patients presenting with (impending and complete) pathological proximal femoral fractures is predicated on prognosis. Guidelines recommend a preoperative biopsy to exclude sarcomas, however no evidence confirms a benefit. OBJECTIVE This study aimed to describe the diagnostic accuracy, morbidity and sarcoma incidence of biopsy results in these patients. MATERIAL AND METHODS All patients (n = 153) presenting with pathological proximal femoral fractures between 2000 and 2019 were retrospectively evaluated. Patients after inadvertent surgery (n = 25) were excluded. Descriptive statistics were used to evaluate the accuracy and morbidity of diagnostic biopsies. RESULTS Of 112/128 patients who underwent biopsy, nine (8%) biopsies were unreliable either due to being inconclusive (n = 5) or because the diagnosis changed after resection (n = 4). Of impending fractures, 32% fractured following needle core biopsy. Median time from diagnosis to surgery was 30 days (interquartile range 21-46). The overall biopsy positive predictive value (PPV) to differentiate between sarcoma and non-sarcoma was 1.00 (95% confidence interval [CI] 0.88-1.00). In patients with a previous malignancy (n = 24), biopsy (n = 23) identified the diagnosis in 83% (PPV 0.91, 95% CI 0.71-0.99), of whom five (24%) patients had a new diagnosis. In patients without a history of cancer (n = 61), final diagnosis included carcinomas (n = 24, 39.3%), sarcomas (n = 24, 39.3%), or hematological malignancies (n = 13, 21.3%). Biopsy (n = 58) correctly identified the diagnosis in 66% of patients (PPV 0.80, 95% CI 0.67-0.90). CONCLUSION This study confirms the importance of a preoperative biopsy in solitary pathological proximal femoral fractures due to the risk of sarcoma in patients with and without a history of cancer. However, biopsy delays the time to definite surgery, results can be inconclusive or false, and it risks completion of impending fractures.
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Affiliation(s)
- Floortje G. M. Verspoor
- Department of Oncology, Royal Orthopaedic Hospital, Birmingham, UK
- Amsterdam UMC, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michael Parry
- Department of Oncology, Royal Orthopaedic Hospital, Birmingham, UK
- Aston University, Birmingham, UK
| | - Lee Jeys
- Department of Oncology, Royal Orthopaedic Hospital, Birmingham, UK
- Aston University, Birmingham, UK
| | - Jonathan D. Stevenson
- Department of Oncology, Royal Orthopaedic Hospital, Birmingham, UK
- Aston University, Birmingham, UK
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Archer JE, Chauhan GS, Dewan V, Osman K, Thomson C, Nandra RS, Ashford RU, Cool P, Stevenson J. The British Orthopaedic Oncology Management (BOOM) audit. Bone Joint J 2023; 105-B:1115-1122. [PMID: 37777202 DOI: 10.1302/0301-620x.105b10.bjj-2023-0443.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Aims Most patients with advanced malignancy suffer bone metastases, which pose a significant challenge to orthopaedic services and burden to the health economy. This study aimed to assess adherence to the British Orthopaedic Oncology Society (BOOS)/British Orthopaedic Association (BOA) guidelines on patients with metastatic bone disease (MBD) in the UK. Methods A prospective, multicentre, national collaborative audit was designed and delivered by a trainee-led collaborative group. Data were collected over three months (1 April 2021 to 30 June 2021) for all patients presenting with MBD. A data collection tool allowed investigators at each hospital to compare practice against guidelines. Data were collated and analyzed centrally to quantify compliance from 84 hospitals in the UK for a total of 1,137 patients who were eligible for inclusion. Results A total of 846 patients with pelvic and appendicular MBD were analyzed, after excluding those with only spinal metastatic disease. A designated MBD lead was not present in 39% of centres (33/84). Adequate radiographs were not performed in 19% of patients (160/846), and 29% (247/846) did not have an up-to-date CT of thorax, abdomen, and pelvis to stage their disease. Compliance was low obtaining an oncological opinion (69%; 584/846) and prognosis estimations (38%; 223/846). Surgery was performed in 38% of patients (319/846), with the rates of up-to-date radiological investigations and oncology input with prognosis below the expected standard. Of the 25% (215/846) presenting with a solitary metastasis, a tertiary opinion from a MBD centre and biopsy was sought in 60% (130/215). Conclusion Current practice in the UK does not comply with national guidelines, especially regarding investigations prior to surgery and for patients with solitary metastases. This study highlights the need for investment and improvement in care. The recent publication of British Orthopaedic Association Standards for Trauma (BOAST) defines auditable standards to drive these improvements for this vulnerable patient group.
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Affiliation(s)
- James E Archer
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Govind S Chauhan
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Varun Dewan
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Khabab Osman
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Calum Thomson
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Rajpal S Nandra
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Robert U Ashford
- Joint Reconstruction and Oncology, University Hospitals of Leicester NHS Trust, Leicester, UK
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Paul Cool
- Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
- Medical School, Keele University, Keele, UK
| | - Jonathan Stevenson
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
- Aston Medical School, Aston University, Birmingham, UK
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11
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Zhou X, Chen XH, Li SH, Li N, Liu F, Wang HM. Effects of surgical treatment modalities on postoperative cognitive function and delirium in elderly patients with extremely unstable hip fractures. World J Psychiatry 2023; 13:533-542. [PMID: 37701542 PMCID: PMC10494770 DOI: 10.5498/wjp.v13.i8.533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/15/2023] [Accepted: 07/05/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND As the perioperative risk of elderly patients with extremely unstable hip fractures (EUHFs) is relatively high and therapeutic effect is not satisfactory, new thera-peutic strategies need to be proposed urgently to improve the efficacy and clinical outcomes of such patients. AIM To determine the influence of two surgical treatment modalities on postoperative cognitive function (CF) and delirium in elderly patients with EUHFs. METHODS A total of 60 elderly patients consecutively diagnosed with EUHF between September 2020 and January 2022 in the Chongqing University Three Gorges Hospital were included. Of them, 30 patients received conventional treatment (control group; general consultation + fracture type-guided internal fixation), and the other 30 received novel treatment (research group; perioperative multidisciplinary treatment diagnosis and treatment + individualized surgical plan + risk prediction). Information on hip function [Harris hip score (HHS)], perioperative risk of orthopedic surgery [Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM)], CF [Montreal cognitive assessment scale (MoCA)], postoperative delirium [mini-cognitive (Mini-Cog)], adverse events (AEs; internal fixation failure, infection, nonunion, malunion, and postoperative delirium), and clinical indicators [operation time (OT), postoperative hospital length of stay (HLOS), ambulation time, and intraoperative blood loss (IBL)] were collected from both groups for comparative analyses. RESULTS The HHS scores were similar between both groups. The POSSUM score at 6 mo after surgery was significantly lower in the research group compared with the control group, and MoCA and Mini-Cog scores were statistically higher. In addition, the overall postoperative complication rate was significantly lower in the research than in the control group, including reduced OT, postoperative HLOS, ambulation time, and IBL. CONCLUSION The new treatment modality has more clinical advantages over the conventional treatment, such as less IBL, faster functional recovery, more effectively optimized perioperative quality control, improved postoperative CF, mitigated postoperative delirium, and reduced operation-related AEs.
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Affiliation(s)
- Xue Zhou
- Department of Operating Room, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Xiao-Hua Chen
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Sheng-Hua Li
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Nan Li
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Feng Liu
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Hao-Ming Wang
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
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Surgical Management and Outcomes following Pathologic Hip Fracture—Results from a Propensity Matching Analysis of the Registry for Geriatric Trauma of the German Trauma Society. Medicina (B Aires) 2022; 58:medicina58070871. [PMID: 35888590 PMCID: PMC9322375 DOI: 10.3390/medicina58070871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: The outcomes of patients with pathologic hip fractures remain unclear. Data from a large international geriatric trauma registry were analyzed to examine the outcomes of patients with pathologic hip fractures compared with patients with typical osteoporotic hip fractures. Materials and Methods: Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) were analyzed. All patients treated surgically for osteoporotic or pathologic hip fractures were included in this analysis. Across both fracture types, a 2:1 optimal propensity score matching and multivariate logistic regression analysis were conducted. In-house mortality rate and mortality at the 120-day follow-up, as well as mobility after 7 and 120 days, reoperation rate, discharge management from the hospital and readmission rate to the hospital until the 120-day follow-up were analyzed as outcome parameters for the underlying fracture type—pathologic or osteoporotic. Results: A total of 29,541 cases met the inclusion criteria. Of the patients included, 29,330 suffered from osteoporotic fractures, and 211 suffered from pathologic fractures. Multivariate logistic regression analysis revealed no differences between the two fracture types in terms of mortality during the acute hospital stay, reoperation during the initial acute hospital stay, walking ability after seven days and the likelihood of being discharged back home. Walking ability and hospital readmission remained insignificant at the 120-day follow-up as well. However, the odds of passing away within the first 120 days were significantly higher for patients suffering from pathologic hip fractures (OR: 3.07; p = 0.003). Conclusions: Surgical treatment of pathologic hip fractures was marked by a more frequent use of arthroplasty in per- and subtrochanteric fractures. Furthermore, the mortality rate among patients suffering from pathologic hip fractures was elevated in the midterm. The complication rate, as indicated by the rate of readmission to the hospital and the necessity for reoperation, remained unaffected.
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13
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Varady NH, Abraham PF, Kucharik MP, Freccero DM, Smith EL, Martin SD. Comparing the Risk of Osteonecrosis of the Femoral Head Following Intra-Articular Corticosteroid and Hyaluronic Acid Injections. J Bone Joint Surg Am 2022; 104:1055-1060. [PMID: 35275891 DOI: 10.2106/jbjs.21.01043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although intra-articular corticosteroid injections (CSIs) are a cornerstone in the nonoperative management of hip pathology, recent reports have raised concerns that they may cause osteonecrosis of the femoral head (ONFH). However, these studies might have been limited by nonrepresentative patient samples. Therefore, the purpose of this study was to assess the incidence of ONFH after CSI and compare it with the incidence in a similar patient population that received a non-CSI injection. METHODS This was a retrospective propensity-matched cohort study of patients in the MarketScan database who underwent an intra-articular hip injection from 2007 to 2017. Patients receiving hip CSIs were matched 4:1 with patients receiving hip hyaluronic acid injections (HAIs) based on age, sex, geographic region, comorbidities, type of hip pathology, injection year, and baseline and follow-up time using propensity scores. The patients' first injections were identified, and the time to development of ONFH was analyzed using Kaplan-Meier curves and Cox proportional-hazards models. Patients with a history of osteonecrosis or those who received both types of injections were excluded. RESULTS A total of 3,710 patients undergoing intra-articular hip injection were included (2,968 CSIs and 742 HAIs; mean [standard deviation] age, 53.1 [9.2] years; 55.4% men). All baseline factors were successfully matched between the groups (all p > 0.57). The estimated cumulative incidence (95% confidence interval [CI]) of ONFH for CSI and HAI patients was 2.4% (1.8% to 3.1%) versus 2.1% (1.1% to 3.5%) at 1 year and 2.9% (2.2% to 3.7%) versus 3.0% (1.7% to 4.8%) at 2 years (hazard ratio, 1.05; 95% CI, 0.59 to 1.84; p = 0.88). The results held across a range of sensitivity analyses. CONCLUSIONS The incidence of ONFH after intra-articular hip injection was similar between patients who received CSIs and those who received HAIs. Although this study could not determine whether intra-articular injections themselves (regardless of the drug that was used) lead to ONFH, the results suggest that ONFH after CSI often may be due, in part, to the natural course of the underlying disease. Future randomized controlled trials are needed to definitively answer this question; in the interim, clinicians may be reassured that they may continue judicious use of CSIs as clinically indicated. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY.,Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Paul F Abraham
- Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - Michael P Kucharik
- Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
| | - David M Freccero
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts
| | - Eric L Smith
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts
| | - Scott D Martin
- Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
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14
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Eberlin CT, Varady NH, Kucharik MP, Naessig SA, Best MJ, Martin SD. Comparison of perioperative complications following surgical treatment of shoulder instability. JSES Int 2022; 6:355-361. [PMID: 35572454 PMCID: PMC9091785 DOI: 10.1016/j.jseint.2022.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Surgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow. Methods This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time. Results This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (P trend < .001). Conclusion In addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.
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Affiliation(s)
- Christopher T. Eberlin
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Nathan H. Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Michael P. Kucharik
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Sara A. Naessig
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Matthew J. Best
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Scott D. Martin
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
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15
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Raad M, Puvanesarajah V, Wang KY, McDaniel CM, Srikumaran U, Levin AS, Morris CD. Do Disparities in Wait Times to Operative Fixation for Pathologic Fractures of the Long Bones and 30-day Complications Exist Between Black and White Patients? A Study Using the NSQIP Database. Clin Orthop Relat Res 2022; 480:57-63. [PMID: 34356036 PMCID: PMC8673988 DOI: 10.1097/corr.0000000000001908] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/30/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Racial disparities in outcomes after orthopaedic surgery have been well-documented in the fields of arthroplasty, trauma, and spine surgery; however, little research has assessed differences in outcomes after surgery for oncologic musculoskeletal disease. If racial disparities exist in the treatment of patients with pathologic long bone fractures, then they should be identified and addressed to promote equity in patient care. QUESTIONS/PURPOSES (1) How do wait times between hospital admission and operative fixation for pathologic fractures of long bones differ between Black and non-Hispanic white patients, after controlling for confounding variables using propensity score matching? (2) How does the proportion of patients with 30-day postoperative complication differ between these groups after controlling for confounding variables using propensity score matching? METHODS Using the National Surgical Quality Improvement Program database, we analyzed 828 patients who underwent fixation for pathologic fractures from 2012 to 2018. This database not only provides a large enough sample of pathologic long bone fracture patients to conduct the present study, but also it contains variables such as time from hospitalization to surgery that other national databases do not. After excluding patients with incomplete data (4% of the initial cohort), 775 patients were grouped by self-reported race as Black (12% [94]) or white (88% [681]). Propensity score matching using a 1:1 nearest-neighbor match was then used to match 94 Black patients with 94 white patients according to age, gender, BMI, American Society of Anesthesiologists physical status classification, anemia, endstage renal disease, independence in performing activities of daily living, congestive heart failure, and pulmonary disease. The primary outcome of interest was the number of days between hospital admission and operative fixation, which we assessed using a Poisson regression and report as an incidence risk ratio. The secondary outcomes were the occurrences of major 30-day postoperative adverse events (failure to wean off mechanical ventilation, cerebrovascular events, renal failure, cardiovascular events, reoperation, death), minor 30-day adverse events (reintubation, wound complications, pneumonia, and thromboembolic events), and any 30-day adverse events (defined as the pooling of all adverse events, including readmissions). These outcomes were analyzed using a bivariate analysis and logistic regression with robust estimates of variance and are reported as odds ratios. Because any results on disparities rely on rigorous control of other baseline demographics, we performed this multivariable approach to ensure we were controlling for confounding variables as much as possible. RESULTS After controlling for potentially confounding variables such as age and gender, we found that Black patients had a longer mean wait time (incidence risk ratio 1.5 [95% CI 1.1 to 2.1]; p = 0.01) than white patients. After controlling for confounding variables, Black patients also had greater odds of having any postoperative adverse event (OR 2.1 [95% CI 1.1 to 3.8]; p = 0.02), including readmission (OR 3.3 [95% CI 1.5 to 7.6]; p = 0.004). CONCLUSION The racial disparities in pathologic long bone fracture care found in our study may be attributed to fundamental racial biases, as well as systemic socioeconomic disparities in the US healthcare system. Identifying and eliminating the racial, socioeconomic, and sociocultural biases that drive these disparities would improve care for patients with orthopaedic oncologic conditions. One possible way to reduce these disparities would be to implement standardized surgical care pathways for pathological long bone fractures across different institutions to minimize variation in important aspects of care, such as time to surgical fixation. Further insight is needed on the types of standardized care pathways and the implementation mechanisms that are most effective. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Kevin Y. Wang
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Claire M. McDaniel
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Adam S. Levin
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA
| | - Carol D. Morris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, The Johns Hopkins University, Baltimore, MD, USA
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16
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Kucharik MP, Varady NH, Best MJ, Rudisill SS, Naessig SA, Eberlin CT, Martin SD. Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures. JSES Int 2021; 6:15-20. [PMID: 35141670 PMCID: PMC8811397 DOI: 10.1016/j.jseint.2021.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background As the proportion of anatomic total shoulder arthroplasty (aTSA) operations performed at outpatient surgical sites continues to increase, it is important to evaluate the clinical implications of this evolution in care. Methods Patients who underwent TSA for glenohumeral osteoarthritis from 2007 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Demographic data and 30-day outcomes were collected, and patients were separated into inpatient and outpatient (defined as same day discharge) groups. To control for confounding variables, a propensity score–matching algorithm was utilized. Outcomes included 30-day adverse events, readmission, and operative time. Results A total of 20,035 patients who underwent aTSA between 2007 and 2019 were identified: 18,707 inpatient aTSAs and 1328 outpatient aTSAs. On matching, there were no significant differences in patient characteristics between inpatient and outpatient cohorts. Patients who underwent outpatient aTSA were less likely to experience a serious adverse event when compared with their matched inpatient aTSA counterparts (outpatient: 1.1% vs. inpatient: 2.1%, P = .03). Outpatient aTSA was associated with similar rates of all specific individual complications and readmissions (1.5% vs. 1.9%, P = .31). Conclusion When compared with a propensity score–matched cohort of inpatient counterparts, the present study found outpatient aTSA was associated with significantly reduced severe adverse events and similar readmission rates. These findings support the growing use of outpatient aTSA in appropriately selected patients.
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Affiliation(s)
- Michael P. Kucharik
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
- Corresponding author: Michael P. Kucharik, BS, BS Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, 175 Cambridge Street, Suite 400, Boston, MA 02114, USA.
| | - Nathan H. Varady
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Matthew J. Best
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
| | | | - Sara A. Naessig
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
| | - Christopher T. Eberlin
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
| | - Scott D. Martin
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
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Amen TB, Varady NH, Birir A, Hayden BL, Chen AF. Morbidity and mortality of surgically treated pathologic humerus fractures compared to native humerus fractures. J Shoulder Elbow Surg 2021; 30:1873-1880. [PMID: 33220410 DOI: 10.1016/j.jse.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite an increasing prevalence of patients sustaining pathologic fractures of neoplastic origin, few studies have investigated 30-day postoperative complication profiles after surgical treatment of pathologic humerus fractures. The purposes of this study were to use a large nationally representative database to determine short-term complication profiles after surgical treatment of pathologic humerus fractures and assess how these complications compared with more commonly studied native humerus fractures. METHODS Using the National Surgical Quality Improvement Program database, we identified 30,866 patients who underwent surgical treatment for either pathologic (n = 449) or native humerus fractures (n = 30,417) from 2007 to 2017. Thirty-day postoperative complication profiles were ascertained and compared between the 2 groups using χ2 analyses. Three logistic regression models were then performed to determine which complications were primarily attributable to the pathologic fracture itself vs. the increased comorbidity burden faced by these patients. RESULTS Patients with pathologic humerus fractures experienced significantly higher rates of death (6.0% vs. 0.3%, P < .001), serious adverse events (12.2% vs. 3.7%, P < .001), minor complications (15.8% vs. 4.8%, P < .001), extended postoperative lengths of stay (42.3% vs. 21.3%, P < .001), discharge to facilities (22.3% vs. 13.5%, P < .001), and readmissions (14.8% vs. 3.4%, P < .001) compared with patients with native humerus fractures. With respect to specific complications, patients with pathologic fractures were at significantly higher risk of pulmonary complications (1.3% vs. 0.3%, P < .001), renal complications (0.7% vs. 0.2%, P = .007), thromboembolic complications (1.6% vs. 0.6%, P = .01), and transfusions (15.1% vs. 4.1%, P < .001). CONCLUSION After surgical treatment, patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures, suggesting that guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin. These findings have significant implications for preoperative patient counseling and may be used to negotiate higher reimbursement rates for these patients given a significantly higher morbidity and mortality than was previously described in literature. Postoperatively, orthopedic surgeons should closely monitor patients with pathologic humerus fractures for deep vein thrombosis, renal complications, and pulmonary complications, use blood-sparing techniques, and employ a multidisciplinary approach to help manage and prevent a more heterogeneous profile of postsurgical complications.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aseal Birir
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brett L Hayden
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Sørensen MS, Colding-Rasmussen T, Horstmann PF, Hindsø K, Dehlendorff C, Johansen JS, Petersen MM. Pretreatment Plasma IL-6 and YKL-40 and Overall Survival after Surgery for Metastatic Bone Disease of the Extremities. Cancers (Basel) 2021; 13:cancers13112833. [PMID: 34200156 PMCID: PMC8201042 DOI: 10.3390/cancers13112833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Estimating postoperative survival in patients undergoing surgery for metastatic bone disease of the extremities is important in order to choose an implant that will outlive the patient. The present study suggests that plasma IL-6, reflecting the inflammatory state of the patient, is predictive for postoperative overall survival (OS). Abstract Background: Plasma IL-6 and YKL-40 are prognostic biomarkers for OS in patients with different types of solid tumors, but they have not been studied in patients before surgery of metastatic bone disease (MBD) of the extremities. The aim was to evaluate the prognostic value of plasma IL-6 and YKL-40 in patients undergoing surgery for MBD of the extremities. Patients and Methods: A prospective study included all patients undergoing surgery for MBD in the extremities at a tertiary referral center during the period 2014–2018. Preoperative blood samples from index surgery were included. IL-6 and YKL-40 concentrations in plasma were determined by commercial ELISA. A total of 232 patients (median age 66 years, IQR 58–74; female 51%) were included. Results: Cox regression analysis was performed to identify independent prognostic factors for OS. IL-6 correlated with YKL-40 (rho = 0.46, p < 0.01). In univariate analysis (log2 continuous variable) IL-6 (HR = 1.26, 95% CI 1.16–1.37), CRP (HR = 1.20, 95% CI 1.12–1.29) and YKL-40 (HR = 1.25, 95% CI 1.15–1.37) were associated with short OS. In multivariable analysis, adjusted for known risk factors for survival, only log2(IL-6) was independently associated with OS (HR = 1.24, 95% CI 1.08–1.43), whereas CRP and YKL-40 were not. Conclusion: High preoperative plasma IL-6 is an independent biomarker of short OS in patients undergoing surgery for MBD.
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Affiliation(s)
- Michala Skovlund Sørensen
- Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen Ø, Denmark; (T.C.-R.); (P.F.H.); (M.M.P.)
- Correspondence: or
| | - Thomas Colding-Rasmussen
- Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen Ø, Denmark; (T.C.-R.); (P.F.H.); (M.M.P.)
| | - Peter Frederik Horstmann
- Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen Ø, Denmark; (T.C.-R.); (P.F.H.); (M.M.P.)
| | - Klaus Hindsø
- Pediatric Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen Ø, Denmark;
| | - Christian Dehlendorff
- Statistics and Data Analysis Danish Cancer Society Research Center, 2100 Copenhagen Ø, Denmark;
| | - Julia Sidenius Johansen
- Department of Medicine, Herlev and Gentofte Hospital, Copenhagen University Hospital, 2730 Herlev, Denmark;
- Department of Oncology, Herlev and Gentofte Hospital, Copenhagen University Hospital, 2730 Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2730 Herlev, Denmark
| | - Michael Mørk Petersen
- Musculoskeletal Tumor Section, Department of Orthopedic Surgery, Rigshospitalet, University of Copenhagen, 2100 Copenhagen Ø, Denmark; (T.C.-R.); (P.F.H.); (M.M.P.)
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2730 Herlev, Denmark
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Preoperative Platelet and International Normalized Ratio Thresholds and Risk of Complications After Primary Hip Fracture Surgery. J Am Acad Orthop Surg 2021; 29:e396-e403. [PMID: 32796366 DOI: 10.5435/jaaos-d-19-00793] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 07/14/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A paucity of data exists on safe platelet and international normalized ratio (INR) thresholds for hip fracture surgery. Recent work has called into question the safety of preoperative INRs < 1.5 for total knee arthroplasty, and optimal platelet thresholds are unknown. The purpose of this study was to identify the risk of 30-day postoperative morbidity and mortality in patients with thrombocytopenia or elevated INRs undergoing hip fracture surgery. METHODS The National Surgical Quality Improvement Program database was queried for patients undergoing surgical treatment of a native hip fracture from 2012 to 2017 (N = 86,850). Patient demographic, laboratory, and complication data were collected. Patients with preoperative platelet counts or INRs within one day of surgery were included for analysis. Preoperative platelet counts and INRs were divided into four groups (<50 k/μL, ≥50 k to 100 k/μL, ≥100 k to 150 k/μL, ≥150 k/μL, and ≤1.0, >1.0 to 1.5, >1.5 to 2.0, and >2.0, respectively). Multivariable logistic regressions were used to assess the independent association between platelet count and INR on bleeding complications requiring transfusion, wound complications, reoperations, readmissions, and deaths. RESULTS A total of 72,306 and 56,027 patients were included for analysis of preoperative platelet and INR levels, respectively. In reference to platelet levels ≥150 k/μL, a notably increased risk of bleeding events was observed for patients with platelet counts ≥100 k to 150 k/μL (odds ratio [OR] 1.21, 95% confidence interval 1.15 to 1.27), ≥50 to 100 k/μL (OR 1.85, 1.69 to 2.03), and <50 k/μL (OR 1.60, 1.25 to 2.04). Decreasing platelet counts were associated with a stepwise increased risk of mortality from OR 1.12 (1.02 to 1.22) for platelet counts ≥100 k to 150 k/μL to OR 1.63 (1.41 to 1.90) and OR 1.59 (1.06 to 2.39) for platelet counts ≥50 k to 100 k/μL and <50 k/μL, respectively. Elevated INR was associated with an increased risk of reoperations, readmissions, and death (P < 0.001 for all), with largest effect sizes observed starting at INRs >1.5. DISCUSSION The results of this study suggest that preoperative platelet thresholds of <100,000/μL and INR thresholds of 1.5 serve as an important risk factor for complications after hip fracture surgery. Future work is warranted to determine whether preoperative platelet transfusions and/or INR reversal will improve outcomes for these patients. LEVEL OF EVIDENCE Prognostic Level III.
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Delayed Presentation of Patients with Hip Fractures during the COVID-19 "Stay-at-Home" Order in the Southmost Region of the United States. Adv Orthop 2021; 2021:8822004. [PMID: 33643668 PMCID: PMC7902137 DOI: 10.1155/2021/8822004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 12/12/2022] Open
Abstract
To evaluate the effects of COVID-19 and stay-at-home orders in traumatic hip fractures presentation, we conducted a retrospective chart review cohort study from March 13 to June 13 in 2020 compared to 2019 from a single-hospital Trauma Level 2 Center. Males and females, 18 years of age and older presenting with a diagnosis of displaced or nondisplaced, intracapsular, or extracapsular hip fracture, underwent standard of care—comparative analysis of the patient's characteristics and clinical outcomes. The primary study outcomes included age, sex, ethnicity, and body mass index, the onset of injury, date of arrival, payer, the primary type of injury and comorbidities, mechanism of injury, treatment received, postoperative complications, days in an intensive care unit (ICU), discharge disposition, pre- and postinjury functional status, and COVID-19 test. Age, sex, ethnicity, and body mass index were similar in the patients in 2019 compared to 2020. The patients' average age was 76 years old, 80% reported Hispanic ethnicity, and 63% of the patients were females. Most injuries (90%) occurred due to falls. On average, patients in 2020 presented 4.8 days after the injury onset as compared to 0.7 days in 2019 (p < 0.05). There was an increase in displaced fractures in 2019 compared to 2020 and an increase in patients' disposition into rehabilitation facilities compared to skilled nursing facilities. Despite the delay in presentation, length of stay, days in the ICU, or functional outcomes of the patients were not affected. Although the patients showed a delayed presentation after hip fracture, this does not appear to significantly interfere with the short-term or the 6-month mortality outcomes of the patients, suggesting the possibility of guided delayed care during times of national emergency and increased strain in hospital resources.
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Affiliation(s)
- Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Wu XD, Liu JC, Li YJ, Wang JW, Qiu GX, Huang W. The necessity of routine postoperative laboratory tests after total hip arthroplasty for hip fracture in a semi-urgent clinical setting. J Orthop Traumatol 2020; 21:19. [PMID: 33170383 PMCID: PMC7655881 DOI: 10.1186/s10195-020-00559-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background Recent studies suggest that routine postoperative laboratory tests are not necessary after primary elective total hip arthroplasty (THA). This study aims to evaluate the utility of routine postoperative laboratory tests in patients undergoing THA for hip fracture in a semi-urgent clinical setting. Materials and methods This retrospective study included 213 consecutive patients who underwent primary unilateral THA for hip fractures. Patient demographics, clinical information, and laboratory tests were obtained from the electronic medical record system. Multivariate logistic regression analysis was performed to identify risk factors associated with abnormal laboratory test-related interventions. Results A total of 207 patients (97.18%) had abnormal postoperative laboratory results, which were mainly due to anemia (190/213, 89.20%) and hypoalbuminemia (154/213, 72.30%). Overall, 54 patients (25.35%) underwent a clinical intervention, 18 patients received blood transfusion, and 42 patients received albumin supplementation. Factors associated with blood transfusion were long operative time and low preoperative hemoglobin levels. Factors associated with albumin supplementation were long operative time and low preoperative albumin levels. Of the 33 patients with abnormal postoperative creatinine levels, 7 patients underwent a clinical intervention. For electrolyte abnormalities, sodium supplementation was not given for hyponatremia, three patients received potassium supplementation, and one patient received calcium supplementation. Conclusions This study demonstrated a high incidence of abnormal postoperative laboratory tests and a significant clinical intervention rate in patients who underwent THA for hip fracture in a semi-urgent clinical setting, which indicates that routine laboratory tests after THA for hip fracture are still necessary for patients with certain risk factors. Level of Evidence Level III. Trial registration Clinical trial registry number ChiCTR1900020690.
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Affiliation(s)
- Xiang-Dong Wu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China.,Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Jia-Cheng Liu
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Yu-Jian Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Jia-Wei Wang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Gui-Xing Qiu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Wei Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China.
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Ehne J, Tsagozis P. Current concepts in the surgical treatment of skeletal metastases. World J Orthop 2020; 11:319-327. [PMID: 32908816 PMCID: PMC7441493 DOI: 10.5312/wjo.v11.i7.319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/20/2020] [Accepted: 05/30/2020] [Indexed: 02/06/2023] Open
Abstract
Symptomatic metastatic bone disease affects a large proportion of patients with malignant tumours and significantly impairs patients’ quality of life. There are still controversies regarding both surgical indications and methods, mainly because of the relatively few high-quality studies in this field. Generally, prosthetic reconstruction has been shown to result in fewer implant failures and should be preferred in patients with a good prognosis. Survival estimation tools should be used as part of preoperative planning. Adjuvant treatment, which relies on radiotherapy and inhibition of osteoclast function may also offer symptomatic relief and prevent implant failure. In this review we discuss the epidemiology, indications for surgery, preoperative planning, surgical techniques and adjuvant treatment of metastatic bone disease.
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Affiliation(s)
- Jessica Ehne
- Department of Orthopedic Surgery, Karolinska University Hospital, Solna 171 76, Sweden
| | - Panagiotis Tsagozis
- Department of Orthopedic Surgery, Karolinska University Hospital, Solna 171 76, Sweden
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