scispace - formally typeset
Search or ask a question

Showing papers in "Journal of Bone and Joint Surgery, American Volume in 2017"


Journal ArticleDOI
TL;DR: Reporting of PRP preparation protocols in clinical studies is highly inconsistent, and the majority of studies did not provide sufficient information to allow the protocol to be reproduced, which does not enable comparison of the PRP products being delivered to patients.
Abstract: Background:Platelet-rich plasma (PRP) is a blood-derived preparation whose use has grown exponentially in orthopaedic practice. However, there remains an unclear understanding of the biological properties and effects of PRP on musculoskeletal healing. Heterogeneous processing methods, unstandardized

295 citations


Journal ArticleDOI
TL;DR: The GAP score is a new pelvic-incidence-based proportional method of analyzing the sagittal plane that predicts mechanical complications in patients undergoing surgery for adult spinal deformity and may decrease the prevalence of mechanical complications.
Abstract: Background:The restoration of normal sagittal alignment is a critical goal in adult spinal deformity surgery to achieve favorable outcomes and prevent mechanical complications. Schwab sagittal modifiers have been accepted as targets for appropriate alignment, but addressing these targets does not al

287 citations


Journal ArticleDOI
TL;DR: Hip arthroscopy for FAI with labral debridement or repair resulted in significant improvements in the patient-reported outcomes and satisfaction of patients who did not eventually require THA.
Abstract: Background:Studies have demonstrated hip arthroscopy to be an effective treatment for femoroacetabular impingement (FAI) with associated labral tears. The purposes of this study were to report 10-year outcomes and hip survival following hip arthroscopy for FAI and to compare labral debridement with

255 citations


Journal ArticleDOI
TL;DR: Despite a high arthroplasty survival rate and good long-term clinical results, RTSA outcomes showed deterioration when compared with medium-term results, probably related to patient aging coupled with bone erosion and/or deltoid impairment over time.
Abstract: BACKGROUND Despite the increasing numbers of reverse total shoulder arthroplasty (RTSA) procedures, the long-term results have been rarely reported. We previously reported early outcomes of a cohort of patients treated with a Grammont-style RTSA. The purpose of this study was to evaluate the outcomes after a minimum of 10 years, and to document prosthetic survival and complications. METHODS Clinical outcome assessment was based on the absolute and relative Constant scores and the active range of motion. Radiographic evaluations of scapular notching, tuberosity osteolysis, and periprosthetic radiolucent lines were done as well. Complications and revisions were compiled, and a Kaplan-Meier survival analysis was performed. RESULTS The original report included the outcomes for 186 patients (191 RTSAs) who had been followed for a mean of 40 months. In the present study, in which the mean duration of follow-up was 150 months, follow-up clinical evaluations were available for 84 patients (87 prostheses) and radiographic assessments were available for 64 patients (67 prostheses). Seventy-seven patients (79 prostheses) had died before the 10-year follow-up, and 17 patients (17 prostheses) had been lost to follow-up. The mean absolute and relative Constant scores (and standard deviations) were 55 ± 16 points and 86 ± 26 points, respectively, with both having decreased significantly compared with the scores at the medium-term follow-up evaluation (at a minimum of 2 years) (p < 0.001 and p = 0.025, respectively). Forty-nine shoulders (73%) exhibited scapular notching. Forty-seven complications (29%) were recorded, with 10 cases (10%) occurring after 2 years. Sixteen (12%) of the original patients underwent revision surgery. The 10-year overall prosthetic survival rate using revision as the end point was 93%. CONCLUSIONS Despite a high arthroplasty survival rate and good long-term clinical results, RTSA outcomes showed deterioration when compared with medium-term results. The cause of this decrease is probably related to patient aging coupled with bone erosion and/or deltoid impairment over time. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

248 citations


Journal ArticleDOI
TL;DR: Serum D-dimer outperformed both ESR and serum CRP, with a sensitivity and specificity of 89% and a specificity of 93%, and may have a great utility for determining the optimal timing of reimplantation.
Abstract: Background:Despite the availability of a battery of tests, the diagnosis of periprosthetic joint infection (PJI) continues to be challenging. Serum D-dimer assessment is a widely available test that detects fibrinolytic activities that occur during infection. We hypothesized that patients with PJI m

228 citations


Journal ArticleDOI
TL;DR: In this article, the authors reviewed articles published between 1996 and 2005 pertaining to anatomic total shoulder arthroplasty (TSA) and revealed 414 complication events after 2,810 total shoulder replacements (a rate of 14.7%).
Abstract: In 2006, we reviewed articles published between 1996 and 2005 pertaining to anatomic total shoulder arthroplasty (TSA); that analysis revealed 414 complication events after 2,810 total shoulder replacements (a rate of 14.7%)[1][1]. Component loosening accounted for 161 (39%) of the 414 complications

227 citations


Journal ArticleDOI
TL;DR: With demographic characteristics showing an upward trend in the utilization of joint arthroplasty, including a shift toward younger population groups, reduction in length of stay remains an important target for procedure-level cost containment under emerging payment models.
Abstract: Background Utilization of total knee and hip arthroplasty has greatly increased in the past decade in the United States; these are among the most expensive procedures in patients with Medicare. Advances in surgical techniques, anesthesia, and care pathways decrease hospital length of stay. We examined how trends in hospital cost were altered by decreases in length of stay. Methods Procedure, demographic, and economic data were collected on 6.4 million admissions for total knee arthroplasty and 2.8 million admissions for total hip arthroplasty from 2002 to 2013 using the National (Nationwide) Inpatient Sample, a component of the Healthcare Cost and Utilization Project. Trends in mean hospital costs and their association with length of stay were estimated using inflation-adjusted, survey-weighted generalized linear regression models, controlling for patient demographic characteristics and comorbidity. Results From 2002 to 2013, the length of stay decreased from a mean time of 4.06 to 2.97 days for total knee arthroplasty and from 4.06 to 2.75 days for total hip arthroplasty. During the same time period, the mean hospital cost for total knee arthroplasty increased from $14,988 (95% confidence interval [CI], $14,927 to $15,049) in 2002 to $22,837 (95% CI, $22,765 to $22,910) in 2013 (an overall increase of $7,849 or 52.4%). The mean hospital cost for total hip arthroplasty increased from $15,792 (95% CI, $15,706 to $15,878) in 2002 to $23,650 (95% CI, $23,544 to $23,755) in 2013 (an increase of $7,858 or 49.8%). If length of stay were set at the 2002 mean, the growth in cost for total knee arthroplasty would have been 70.8% instead of 52.4% as observed, and the growth in cost for total hip arthroplasty would have been 67.4% instead of 49.8% as observed. Conclusions Hospital costs for joint replacement increased from 2002 to 2013, but were attenuated by reducing inpatient length of stay. With demographic characteristics showing an upward trend in the utilization of joint arthroplasty, including a shift toward younger population groups, reduction in length of stay remains an important target for procedure-level cost containment under emerging payment models.

191 citations


Journal ArticleDOI
TL;DR: Time to return to sport was the only significant predictor of a second ACL injury, with a slower return being protective (hazard ratio per month, 0.87), and within this population, an earlier return toSport is predictive of aSecond ACL injury.
Abstract: BACKGROUND Anterior cruciate ligament (ACL) graft failure and contralateral ACL tears are more frequent in children and adolescents than adults. The reasons for higher subsequent injury rates in this population are incompletely understood. METHODS We analyzed a continuous cohort of patients who were <18 years of age. Subjects underwent isolated, primary ACL reconstruction with autograft between 2006 and January 1, 2014, and had a minimum 2-year follow-up. Return-to-sport characteristics were described, and multivariable Cox regression modeling was used to identify predictors of a second ACL injury. Candidate variables included patient factors (age, sex, physeal status, tibial slope, notch width index), surgical characteristics (graft type, surgical technique), measures of recovery (time to return to sport, duration of physical therapy), and patients' preoperative and postoperative sports involvement (primary and secondary sports, number of sports). RESULTS A total of 112 subjects met inclusion criteria; of these patients, 85 (76%) had complete follow-up data and were analyzed. The mean age (and standard deviation) was 13.9 ± 2.1 years (range, 6 to 17 years); 77% had open physes. The mean follow-up was 48.3 ± 15.3 months. Seventy-seven patients (91%) returned to sports, and 84% returned to the same sport. The mean Marx activity score at the time of the latest follow-up was 13.7 ± 3.5 points. Patients were involved in fewer sports after ACL reconstruction, 1.48 ± 0.92 compared with 1.83 ± 1.01 sports before reconstruction (p = 0.002). Sixteen patients (19%) sustained an ACL graft rupture, 11 patients (13%) sustained a contralateral ACL tear, and 1 of these patients (1%) sustained both. The overall prevalence of a second ACL injury was 32%. Time to return to sport was the only significant predictor of a second ACL injury, with a slower return being protective (hazard ratio per month, 0.87 [95% confidence interval, 0.73 to 0.99]; p = 0.04). CONCLUSIONS Pediatric athletes return to sports at a high rate (91%) after ACL reconstruction. Unfortunately, the prevalence of a second ACL injury is high at 32%. Within this population, an earlier return to sport is predictive of a second ACL injury. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

174 citations


Journal ArticleDOI
TL;DR: Minimum reporting requirements for clinical studies evaluating PRP and MSCs are developed using Delphi consensus methods and expert consensus on the inclusion of each item within minimum reporting guidelines is established.
Abstract: Background:A comprehensive approach to the evaluation of biologic therapies for musculoskeletal conditions is required to guide appropriate future use. Clinical studies evaluating platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) are limited by inadequate reporting of scientific details c

164 citations


Journal ArticleDOI
TL;DR: RTSA in patients younger than 60 years leads to substantial subjective and functional improvement without clinical deterioration beyond 10 years, and it is associated with a substantial complication rate, and complications compromise ultimate subjective and objective outcomes.
Abstract: BACKGROUND: There has been serious concern regarding the longevity and durability of outcomes of reverse total shoulder arthroplasty (RTSA) in younger patients. It was the purpose of this study to analyze long-term outcomes and complications of RTSA for irreparable rotator cuff tears in patients younger than 60 years. METHODS: Twenty patients (23 shoulders) with a mean age of 57 years (range, 47 to 59 years) were evaluated at a mean of 11.7 years (range, 8 to 19 years) after RTSA. Fifteen shoulders (65%) had undergone previous non-arthroplasty surgery. Longitudinal clinical and radiographic outcomes were assessed. RESULTS: At the time of final follow-up, the mean absolute and relative preoperative Constant score (CS) (and standard deviation) had improved from 24 ± 9 to 59 ± 19 points (p < 0.001) and from 29% ± 11% to 69% ± 21% (p < 0.001), respectively. The mean Subjective Shoulder Value (SSV) had increased from 20% ± 13% to 71% ± 27% (p < 0.001). There were also significant improvements in the mean active anterior elevation (from 64° to 117°), active abduction (from 58° to 111°), pain scores, and strength (all p ≤ 0.001). Clinical outcomes did not significantly deteriorate beyond 10 years and the functional results of patients with previous surgical procedures were not significantly inferior to the results of those with primary RTSA. The grade of, and number of patients with, radiographically apparent notching increased over time; the mean relative CS was lower in patients in whom the notching was grade 2 or higher (57%) than it was in those with no or grade-1 notching (81%; p = 0.006). Nine (39%) had ≥1 complication, with 2 failed RTSAs (9%). CONCLUSIONS: RTSA in patients younger than 60 years leads to substantial subjective and functional improvement without clinical deterioration beyond 10 years. It is associated with a substantial complication rate, and complications compromise ultimate subjective and objective outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

160 citations


Journal ArticleDOI
TL;DR: Patients who used opioids prior to TKA obtained less pain relief from the operation, and Clinicians should consider limiting pre-TKA opioid prescriptions to optimize the benefits of TKA.
Abstract: Background:There is growing concern about the use of opioids prior to total knee arthroplasty (TKA), and research has suggested that preoperative opioid use may lead to worse pain outcomes following surgery We evaluated the pain relief achieved by TKA in patients who had and those who had not used

Journal ArticleDOI
TL;DR: Long-term opioid use prior to TKA was associated with an increased risk of knee revision during the first year after TKA among predominantly male patients treated in the VA system and the hazard was not significant in the analysis of its association with knee manipulation.
Abstract: Background:Opioid use is endemic in the U.S. and is associated with morbidity and mortality. The impact of long-term opioid use on joint-replacement outcomes remains unknown. We tested the hypothesis that use of opioids is associated with adverse outcomes after total knee arthroplasty (TKA).Methods:

Journal ArticleDOI
TL;DR: A systematic review and meta-analysis of synovial fluid biomarkers found that leukocyte count, PMN, CRP, &agr;-defensin, LE, IL-6, and IL-8 all demonstrated high sensitivity for diagnosing PJI, with &agR;- defensin being the best synovials marker based on the highest log DOR.
Abstract: Background:The search for a single standard reference test for determining periprosthetic joint infection (PJI) through analysis of synovial fluid has yielded numerous biomarkers as potential candidates. The purpose of the present systematic review and meta-analysis was to evaluate the diagnostic ac

Journal ArticleDOI
TL;DR: This large, prospective cohort study demonstrated the clinical success of contemporary PAO surgery for the treatment of symptomatic acetabular dysplasia, and patient and disease characteristics demonstrated predictive value that should be considered in surgical decision-making.
Abstract: Background:Current literature describing the periacetabular osteotomy (PAO) is mostly limited to retrospective case series. Larger, prospective cohort studies are needed to provide better clinical evidence regarding this procedure. The goals of the current study were to (1) report minimum 2-year pat

Journal ArticleDOI
TL;DR: The results indicate that spine surgery among opioid-naive patients is not a major driver of long-term prescription opioid use, and Socioeconomic status and pre-existing mental health disorders may be factors associated with sustained opioid use following spine surgery.
Abstract: Background There is a growing concern that the use of prescription opioids following surgical interventions, including spine surgery, may predispose patients to chronic opioid use and abuse. We sought to estimate the proportion of patients using opioids up to 1 year after discharge following common spinal surgical procedures and to identify factors associated with sustained opioid use. Methods This study utilized 2006 to 2014 data from TRICARE insurance claims obtained from the Military Health System Data Repository. Adults who underwent 1 of 4 common spinal surgical procedures (discectomy, decompression, lumbar posterolateral arthrodesis, or lumbar interbody arthrodesis) were identified. Patients with a history of opioid use in the 6 months preceding surgery were excluded. Posterolateral arthrodesis and interbody arthrodesis were considered procedures of high intensity, and discectomy and decompression, low intensity. Covariates included demographic factors, preoperative diagnoses, comorbidities, postoperative complications, and mental health disorders. Risk-adjusted Cox proportional hazard models were used to evaluate the time to opioid discontinuation. Results This study included 9,991 patients. Eighty-four percent filled at least 1 opioid prescription on discharge. At 30 days following discharge, 8% continued opioid use; at 3 months, 1% continued use; and at 6 months, 0.1%. In the adjusted analysis, the low-intensity surgical procedures were associated with a higher likelihood of discontinuing opioid use (discectomy: hazard ratio [HR] = 1.43, 95% confidence interval [CI] = 1.36 to 1.50; and decompression: HR = 1.34, 95% CI = 1.25 to 1.43). Depression (HR = 0.84, 95% CI = 0.77 to 0.90) was significantly associated with a decreased likelihood of discontinuing opioid use (p Conclusions By 6 months following discharge, nearly all patients had discontinued opioid use after spine surgery. As only 0.1% of the patients continued opioid use at 6 months following surgery, these results indicate that spine surgery among opioid-naive patients is not a major driver of long-term prescription opioid use. Socioeconomic status and pre-existing mental health disorders may be factors associated with sustained opioid use following spine surgery. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Journal ArticleDOI
TL;DR: Direct HU measurement from diagnostic CT scans has the potential to be used opportunistically for osteoporosis screening, but in its current state it is not ready for clinical implementation.
Abstract: Background:The purpose of this study was to determine the clinical opportunities for the use of computed tomography (CT) imaging for inferring bone quality and to critically analyze the correlation between dual x-ray absorptiometry (DXA) and diagnostic CT as reported in the literatureMethods:A syst

Journal ArticleDOI
TL;DR: For patients with a diaphyseal fracture of the clavicle displaced at least 1 shaft width, plate fixation improves the chances that the bone will heal; however, the rate of patients who need a second operation is considerable.
Abstract: Background: The use of operative treatment for clavicular fractures is increasing, despite varying results in previous studies. The aim of this study was to compare plate fixation and nonoperative treatment for displaced midshaft clavicular fractures with respect to nonunion, adverse events, and shoulder function. Methods: In this multicenter, prospective, randomized controlled trial, patients between 18 and 60 years old with a displaced midshaft clavicular fracture were randomized between nonoperative treatment and open reduction with internal plate fixation. The primary outcome was evidence of nonunion at 1 year. Other outcomes were secondary operations, arm function as measured with the Constant shoulder score and Disabilities of the Arm, Shoulder and Hand (DASH) score, pain, cosmetic results, and general health status. Outcomes were recorded at 6 weeks, 3 months, and 1 year following trauma. Results: One hundred and sixty patients were randomized. The rate of nonunion was significantly higher in the nonoperatively treated group than in the operatively treated group (23.1% compared with 2.4%; p < 0.0001), as was the rate of nonunion for which secondary plate fixation was performed (12.9% compared with 1.2%; p = 0.006). The rate of secondary operations was 27.4% in the operatively treated group (16.7% for elective plate removal) and 17.1% in the nonoperatively treated group (p = 0.18). Nineteen percent of the patients in the operatively treated group had persistent loss of sensation around the scar. No difference was found between the groups with respect to the Constant and DASH scores at all time points. Conclusions: For patients with a diaphyseal fracture of the clavicle displaced at least 1 shaft width, plate fixation improves the chances that the bone will heal; however, the rate of patients who need a second operation is considerable. In addition, the procedure does not improve shoulder function or general symptoms, and it does not decrease limitations compared with nonoperative treatment in a sling. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Journal ArticleDOI
TL;DR: In this paper, the authors investigated the current trends in ambulatory total shoulder arthroplasty in the United States; to characterize the rate of postoperative complications, hospital readmission, and risk factors associated with readmission.
Abstract: BACKGROUND There have been few studies that have evaluated ambulatory total shoulder arthroplasty. The objectives of the present study were to investigate the current trends in ambulatory total shoulder arthroplasty in the United States; to characterize the rate of postoperative complications, hospital readmission, and risk factors associated with readmission; and to conduct a cost analysis comparing ambulatory total shoulder arthroplasty with matched inpatient total shoulder arthroplasty. METHODS A national insurance database was queried for patients who underwent anatomic total shoulder arthroplasty between the fourth quarter of 2010 and 2014. Patients undergoing ambulatory total shoulder arthroplasty and a matched group of patients undergoing inpatient total shoulder arthroplasty were identified. Complications were assessed for both groups. Risk factors for readmission within 90 days postoperatively were examined. The costs up to 30 days postoperatively were evaluated for patients who underwent ambulatory total shoulder arthroplasty and controls. RESULTS Included in the study were 706 patients who underwent ambulatory total shoulder arthroplasty. From the fourth quarter of 2010 to 2014, the yearly incidence of ambulatory total shoulder arthroplasty doubled. In the study, 4,459 patients who underwent inpatient total shoulder arthroplasty were matched to patients who underwent ambulatory total shoulder arthroplasty. In no instances were any complications present at a significantly higher rate in the patients who underwent ambulatory total shoulder arthroplasty. The rate of readmission was not significantly different (p > 0.05) between the 2 cohorts. The patients undergoing ambulatory total shoulder arthroplasty had significantly lower costs (p < 0.0001) at $14,722 compared with the matched controls at $18,336 in numerous itemized cost categories as well as costs related to diagnosis-related groups. CONCLUSIONS In appropriately selected patients, ambulatory total shoulder arthroplasty is a viable and safe practice model. Ambulatory total shoulder arthroplasty also offers significant cost savings compared with inpatient total shoulder arthroplasty in matched patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Journal ArticleDOI
TL;DR: It is suggested that loading of the foot causes significant 3-D displacement not only at the TMT joint but also at the other joints of the first ray in patients who have hallux valgus.
Abstract: Background:Some physicians report that patients with hallux valgus have hypermobility at the tarsometatarsal (TMT) joint of the first ray and 3-dimensional (3-D) deformity. With use of non-weight-bearing and weight-bearing computed tomography (CT), we evaluated the 3-D mobility of each joint of the

Journal ArticleDOI
TL;DR: WB images better demonstrated the severity of osseous derangement in patients with flexible adult acquired flatfoot deformity, and are obtainable using high-resolution cone-beam CT.
Abstract: In this study, we tested the hypothesis that, when compared with non-weight bearing (NWB) measurements, weight bearing (WB) measurements on cone beam computed tomography (CBCT) images can better demonstrate adult-acquired flatfoot deformity (AAFD) We included 12 men and 8 women (mean age, 52 years; range, 20–88) with flexible AAFD Eighteen of 19 measurements were different between WB and NWB CBCT images, with more pronounced deformities in the WB images In conclusion, measurements analogous to traditional AAFD radiographic measurements are obtainable using CBCT Compared with NWB images, WB images better demonstrated the severity of bony derangement in patients with flexible AAFD

Journal ArticleDOI
TL;DR: In this paper, the role of teriparatide administration on patient outcomes following interbody fusion was evaluated in a multicenter, prospective randomized study, where patients were randomly allocated to receive either weekly terraparatide, administered subcutaneously starting at week 1, for 6 months post-operatively (the terparamaratide arm), or no terparamarkide (the control arm). Blinded radiographic evaluations were performed using dynamic radiography and computed tomography (CT).
Abstract: BACKGROUND For elderly patients, posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) is usually performed to treat lumbar degenerative diseases. However, some patients exhibit pseudarthrosis following such procedures. The anabolic agent teriparatide is an approved treatment for promoting bone formation in osteoporotic patients. Our multicenter, prospective randomized study assessed the role of once-weekly teriparatide administration on patient outcomes following interbody fusion. METHODS Patients were females who were ≥50 years of age, had a bone mineral density (BMD) of <80% of the sex-matched young adult mean and/or previous spinal compression or femoral fractures, and had lumbar degenerative disease. Patients were randomly allocated to receive either weekly teriparatide, administered subcutaneously starting at week 1, for 6 months postoperatively (the teriparatide arm), or no teriparatide (the control arm). Blinded radiographic evaluations were performed using dynamic radiography and computed tomography (CT) and assessed by modified intention-to-treat analysis and per-protocol analysis. Clinical and neurological symptoms were evaluated using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOA-BPEQ) and the Oswestry Disability Index (ODI). RESULTS Seventy-five patients were randomized to treatment, and 66 patients completed treatment. At 4 months postoperatively, bone fusion in the 2 center CT slices was significantly higher in the teriparatide arm compared with the control arm in the age-adjusted modified intention-to-treat analysis and was significantly higher at 6 months in the per-protocol analysis. Radiographic examinations showed no disc-space narrowing and no intervertebral disc instability. JOA-BPEQ and ODI results were improved postoperatively in both treatment arms. CONCLUSIONS Weekly administration of teriparatide promoted bone formation at the surgical fusion site and decreased bone resorption, as indicated by bone metabolic marker results, within the early postoperative period. Our findings suggest that combining lumbar interbody fusion and teriparatide treatment may be an effective option for managing lumbar degenerative disease in elderly patients. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Journal ArticleDOI
TL;DR: Hypoalbuminemia is a powerful independent risk factor for mortality following a surgical procedure for geriatric hip fracture, and data suggest that further investigation into postoperative nutritional supplementation is warranted to decrease the risk of complications.
Abstract: BACKGROUND Serum albumin level is the most well-established serum marker of malnutrition, with a serum albumin concentration <3.5 g/dL considered to be suggestive of malnutrition. The purpose of this study was to test if serum albumin level is associated with death, specific postoperative complications (e.g., pneumonia), length of hospital stay, and readmission following a surgical procedure for geriatric hip fracture. METHODS A retrospective cohort study of geriatric patients (≥65 years of age) undergoing a hip fracture surgical procedure as part of the American College of Surgeons National Surgical Quality Improvement Program was conducted. Outcomes were compared between patients with and without hypoalbuminemia. All comparisons were adjusted for baseline and procedural differences between populations, and patients with missing serum albumin concentration were included in analyses using a missing data indicator. RESULTS There were 29,377 geriatric patients undergoing a hip fracture surgical procedure who met inclusion criteria; of these patients, 17,651 (60.1%) had serum albumin available for analysis. The prevalence of hypoalbuminemia was 45.9%. Following adjustment for baseline and procedural characteristics, the risk of death was inversely associated with serum albumin concentration as a continuous variable (adjusted relative risk, 0.59 [95% confidence interval (CI), 0.53 to 0.65]; p < 0.001). In comparison with patients with normal albumin concentration, patients with hypoalbuminemia had higher rates of death (9.94% compared with 5.53% [adjusted relative risk, 1.52 (95% CI, 1.37 to 1.70); p < 0.001]), sepsis (1.19% compared with 0.53% [adjusted relative risk, 1.92 (95% CI, 1.36 to 2.72); p < 0.001]), and unplanned intubation (2.64% compared with 1.47% [adjusted relative risk, 1.51 (95% CI, 1.21 to 1.88); p < 0.001]). The mean length of stay (and standard deviation) was longer among patients with hypoalbuminemia at 5.67 ± 4.68 days compared with those without hypoalbuminemia at 4.99 ± 3.95 days; the adjusted difference was 0.50 day (95% CI, 0.38 to 0.63 day; p < 0.001). However, the rate of readmission did not differ (p = 0.054) between patients with hypoalbuminemia (10.91%) and those without hypoalbuminemia (9.03%); the adjusted relative risk was 1.10 (95% CI, 1.00 to 1.21). CONCLUSIONS Hypoalbuminemia is a powerful independent risk factor for mortality following a surgical procedure for geriatric hip fracture. These data suggest that further investigation into postoperative nutritional supplementation is warranted to decrease the risk of complications. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Journal ArticleDOI
TL;DR: Scholarly impact, as defined by academic productivity and scientific relevance, can be classified by the h-index and supplemented by the m and e-indices and well-defined differences in h, m, and e,indices with regard to academic rank among orthopaedic surgeons are revealed.
Abstract: Background The Hirsch index (h-index), widely considered a valuable measure of assessing academic productivity, has been studied in various medical and surgical specialties and has shown strong associations between higher h-indices and academic promotion, as well as with National Institutes of Health (NIH) awards. Additionally, the m-index and e-index may complement the h-index in this assessment of merit. The purpose of this study was to investigate the relationship between the h, m, and e-indices and academic rank for 2,061 academic orthopaedic surgeons in the United States. Methods The h-indices of faculty members from 120 academic orthopaedic surgery residency programs were organized and calculated using the Scopus and Google Scholar databases. Additionally, m-index and e-index scores were calculated from Google Scholar. After application of exclusion criteria, 2,061 academic orthopaedic surgeons were included. Results Academic rank (assistant professor, associate professor, professor, and chair) increases as mean h-index, m-index, and e-index scores increase. Among 976 assistant professors, 504 associate professors, 461 professors, and 120 chairs, mean h, m, and e-indices increased with each academic rank. In the comparison of male and female surgeons, there was no significant difference in h, m, or e-index scores, with the exception of increased h-index scores among male assistant professors. Conclusions Scholarly impact, as defined by academic productivity and scientific relevance, can be classified by the h-index and supplemented by the m and e-indices. This study has revealed well-defined differences in h, m, and e-indices with regard to academic rank among orthopaedic surgeons. Although the h, m, and e-indices may be of value as adjunct assessment devices for scholarly merit, careful consideration of their limitations must be maintained.

Journal ArticleDOI
TL;DR: Patients treated with multiple doses of intravenous and topical TXA without a tourniquet had less hidden blood loss, a lower ratio of postoperative knee swelling, less post operative knee pain, lower levels of inflammatory biomarkers, better early knee function, and even better early satisfaction than those treated with a tarantula.
Abstract: Background:Tourniquet use during primary total knee arthroplasty is thought to reduce intraoperative blood loss and improve visibility. Our goal was to investigate whether tourniquet use is necessary for controlling intraoperative blood loss when alternatives such as tranexamic acid (TXA) are availa

Journal ArticleDOI
TL;DR: This study demonstrates that low-dose aspirin is not inferior to high- dose aspirin for venous thromboembolism prophylaxis following total joint arthroplasty and is associated with fewer gastrointestinal side effects.
Abstract: Background: Aspirin is a safe and effective prophylaxis for the prevention of venous thromboembolism following total joint arthroplasty. The optimal dose of aspirin prophylaxis is unknown. Our hypothesis was that lower-dose aspirin is as effective as higher-dose aspirin for the prevention of venous thromboembolism and is associated with fewer gastrointestinal side effects. Methods: In a prospective, crossover study, we analyzed 4,651 primary total joint arthroplasty cases performed from July 2013 to June 2015. For 4 weeks, 3,192 patients received enteric-coated 325-mg aspirin twice daily (the 325-mg aspirin group) and 1,459 patients received 81-mg aspirin twice daily (the 81-mg aspirin group). There were no significant differences (p > 0.05) in sex, body mass index, or Charlson Comorbidity Index between the two patient populations. Recorded complications occurring within 90 days postoperatively included symptomatic venous thromboembolism (deep venous thrombosis and pulmonary embolism), gastrointestinal complications, acute periprosthetic joint infection, and death. Results: The incidence of venous thromboembolism of 0.1% (95% confidence interval [CI], 0% to 0.3%) in the 81-mg aspirin group (1 with deep venous thrombosis and 1 with pulmonary embolism) was not significantly different (p = 0.345) from 0.3% (95% CI, 0.1% to 0.6%) in the 325-mg aspirin group (7 with deep venous thrombosis and 5 with pulmonary embolism). The incidence of gastrointestinal bleeding or ulceration of 0.3% (95% CI, 0% to 0.5%) in the 81-mg aspirin group was slightly, but not significantly (p = 0.66), lower than the 0.4% (95% CI, 0.2% to 0.6%) in the 325-mg aspirin group. The incidence of acute periprosthetic joint infection was 0.2% (95% CI, 0% to 0.4%) in the 81-mg aspirin group compared with 0.5% (95% CI, 0.2% to 0.7%) in the 325-mg aspirin group (p = 0.28). The 90-day mortality rate was similar in both groups at 0.1% (95% CI, 0% to 0.2%) in the 81-mg aspirin group and 0.1% (95% CI, 0% to 0.2%) in the 325-mg aspirin group (p = 0.78). Conclusions: Our study demonstrates that low-dose aspirin is not inferior to high-dose aspirin for venous thromboembolism prophylaxis following total joint arthroplasty. This is not unexpected, as the available literature demonstrates that low-dose aspirin is as effective as higher-dose aspirin in the prevention of acute coronary syndrome and cerebrovascular events. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Journal ArticleDOI
TL;DR: In this article, a retrospective review of 478 consecutive early revision total hip arthroplasty (THA) procedures performed within 5 years after the primary THAs at 3 academic centers from 2011 through 2014 was carried out.
Abstract: Background The direct anterior approach for total hip arthroplasty (THA) is marketed with claims of superiority over other approaches. Femoral exposure can be technically challenging and potentially lead to early failure. We examined whether surgical approach is associated with early THA failure. Methods A retrospective review of 478 consecutive early revision THAs performed within 5 years after the primary THAs at 3 academic centers from 2011 through 2014 was carried out. Exclusion criteria resulted in a final analysis sample of 342 early-failure THAs. The surgical approach of the primary operation that was revised, the time to the revision, and the etiology of the failure leading to the revision were documented. Results Analysis of the revisions due to early femoral failure showed them to be more common in patients who had undergone the direct anterior approach (57/112; 50.9%) than in those treated with the direct lateral (39/112; 34.8%) or the posterior (16/112; 14.3%) approach (p = 0.001). In multivariate regression analysis controlling for age, sex, laterality, Dorr bone type, body mass index (BMI) at revision, bilateral procedure (yes/no), and femoral stem type, the direct anterior approach remained a significant predictor of early femoral failure (p = 0.007). The majority of early revisions due to instability were associated with the posterior (19/40; 47.5%) or direct anterior (15/40; 37.5%) approach (p = 0.001 for the comparison with the direct lateral approach [6/40; 15.0%]). Conclusions Despite claims of earlier recovery and improved outcomes with the direct anterior approach for THA, our findings indicate that that approach may confer a greater risk of early femoral failure and, along with the posterior approach, confer a greater risk of early instability compared with the direct lateral approach. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Journal ArticleDOI
TL;DR: No difference was found between TBW and plate fixation in the patient-reported outcome at 1 year following surgery, and the complication rate was higher following TBW fixation and was due to a higher rate of implant removal in symptomatic patients.
Abstract: BACKGROUND The aim of this single-center, single-blinded, prospective randomized trial was to compare the outcomes of tension-band wire (TBW) and plate fixation for simple isolated, displaced fractures of the olecranon. METHODS We performed a prospective randomized trial involving 67 patients who were ≥16 to <75 years of age and had an acute isolated, displaced fracture of the olecranon. Patients were randomized to either TBW (n = 34) or plate fixation (n = 33) and were evaluated at 6 weeks, 3 months, 6 months, and 1 year following surgery. The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year. RESULTS The baseline demographic and fracture characteristics of the 2 groups were comparable, except for age, which was lower in the TBW group. The 1-year follow-up rate was 85% (n = 57), with 84% (n = 56) completing the DASH. There was a significant improvement in the DASH score over the 1-year period following surgery (p < 0.001). At 1 year, the DASH score for the TBW group (12.8) did not differ significantly from that of the plate group (8.5) (p = 0.315). The groups also did not differ significantly in terms of range of motion, the Broberg and Morrey score, the Mayo Elbow Score, or the DASH at all assessment points over the 1 year (all p ≥ 0.05). Complication rates were significantly higher in the TBW group (63% compared with 38%; p = 0.042), predominantly because of a significantly higher rate of metalwork removal in symptomatic patients (50.0% compared with 22%; p = 0.021). Four infections occurred, all in the plate group (0% versus 13%; p = 0.114), as did 3 revision surgeries (0% versus 9.4%; p = 0.238). CONCLUSIONS Among active patients with a simple isolated, displaced fracture of the olecranon, no difference was found between TBW and plate fixation in the patient-reported outcome at 1 year following surgery. The complication rate was higher following TBW fixation and was due to a higher rate of implant removal in symptomatic patients. However, the more serious complications of infection and the need for revision surgery occurred exclusively following plate fixation in this trial. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Journal ArticleDOI
TL;DR: No significant differences in overall postoperative complications or readmission were found between matched cohorts of patients who underwent same-day and inpatient hip and knee arthroplasties, although inpatients had a higher rate of thromboembolic events and same- day patients had aHigher rate of reoperation.
Abstract: Background:Discharge from the hospital on the day of (same-day) hip and knee arthroplasties has become more common; however, to our knowledge, few studies have compared morbidity between same-day and inpatient surgical procedures. The aims of this study were to compare matched cohorts of patients wh

Journal ArticleDOI
TL;DR: Although at 3 months there was no evidence that surgery had reduced the rate of nonunion of displaced midshaft clavicle fractures, at 9 months nonoperative treatment had led to a significantly higher nonunion rate, which should be considered for patients who sustain this common injury.
Abstract: Background: The treatment of displaced midshaft clavicle fractures remains controversial. Methods: We undertook a multicenter randomized controlled trial to compare effectiveness and safety between nonoperative management and ORIF (open reduction and internal fixation) for displaced midshaft clavicle fractures in adults. Three hundred and one eligible adult patients were randomized to 1 of the 2 treatment groups and followed at 6 weeks, 3 months, and 9 months after recruitment. The primary outcome was the rate of radiographically evident nonunion at 3 months following treatment. Secondary outcomes were the rate of radiographically evident nonunion at 9 months, limb function measured using the Constant-Murley Score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and patient satisfaction. Results: There was no difference in the proportion of patients with radiographic evidence of nonunion at 3 months between the operative (28%) and nonoperative (27%) groups, whereas at 9 months the proportion with nonunion was significantly lower (p < 0.001) in the operative group (0.8%) than in the nonoperative group (11%). The DASH and ConstantMurley scores and patient satisfaction were all significantly better in the operative group than in the nonoperative group at 6 weeks and 3 months. Conclusions: Although at 3 months there was no evidence that surgery had reduced the rate of nonunion of displaced midshaft clavicle fractures, at 9 months nonoperative treatment had led to a significantly higher nonunion rate (11% compared with <1%). The rate of secondary surgical intervention during the trial period was 12 (11%) of the 147 patients in the nonoperative group. ORIF is a safe and reliable intervention with superior early functional outcomes and should be considered for patients who sustain this common injury. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Journal ArticleDOI
TL;DR: The purpose of this article was to communicate the lessons that were learned about using videoconference interviews for evaluating and selecting adult reconstruction fellows.
Abstract: Background In 2017, approximately 90% of U.S. orthopaedic residents chose to participate in orthopaedic fellowships. The process of applying and interviewing for an orthopaedic fellowship is expensive and time-consuming for both orthopaedic residents and orthopaedic residency programs. Considerable physician man-hours are allocated to fellowship interviews and the match ranking process, and there are unintended consequences of time away from work for the resident and his or her training program. To reduce time and cost allocated to fellowship interviews, we implemented videoconference interviews for our adult reconstruction fellowship. The purpose of this article was to communicate the lessons that we learned about this innovation. Methods Candidates and faculty who participated in videoconference interviews for our adult reconstruction fellowship during 2015 through 2017 were surveyed to learn more about the utility and acceptance of videoconference interviewing. Results Eighty-five percent of the 47 videoconference interview candidates who responded to our survey believed that the videoconference interviews gave them a satisfactory understanding of our adult reconstruction fellowship; 85% of candidates stated that the fellowship manual and the videoconference interviews gave them a satisfactory understanding of our fellowship; 89% of candidates stated that the videoconference interview met their expectations; 85% of candidates believed that the videoconference interviews allowed them to present themselves to the program to their satisfaction; and 81% of candidates were comfortable ranking our program after the videoconference interviews. Furthermore, there was universal gratitude in the subjective comments for the convenience and low cost of the videoconference interviews. However, we are concerned that 15% of the candidates did not believe that they had the opportunity to present themselves to their satisfaction with videoconference interviews; 19% of applicants were not comfortable ranking our program after a videoconference interviews; 34% of videoconference interview candidates stated that the videoconference interviews had an unfavorable impact on their ranking of our program; and 30% of candidates believed that the videoconference interview was not a good format for fellowship interviews. Conclusions This review presents what we learned about using videoconference interviews for evaluating and selecting adult reconstruction fellows. The role of videoconference interviews for selecting adult reconstruction fellows remains to be determined.