1. The Influence of CT Imaging on Treatment of Periprosthetic Proximal Femur Fractures
Purpose
Periprosthetic femur fractures (PPFF) are often complex injuries requiring expertise in fracture care and arthroplasty surgery. The preoperative planning is frequently complemented with computerized tomography (CT) imaging to assess the fracture pattern and its relation to the femoral implant. How this CT imaging influences treatment of these injuries is not well defined. The goal of this study is to determine the utility of CT imaging in treatment of PPFFs.
Methods
A series of 17 PPFF cases were selected with known stem stability by intra-operative evaluation. Three trauma and 3 arthroplasty surgeons viewed the radiographs and CT imaging and completed a questionnaire inquiring about their Vancouver classification diagnosis and surgical treatment plan. Fleiss and Cohen kappa were used to compare inter- and intra-observer reliability.
Results
The interobserver kappa values (k) in diagnosis were 0.371 without and 0.348 with CT. The interobserver reliability in treatment were 0.254 without and 0.336 with CT. When using Landis and Koch criteria Arthoplasty had a higher agreement on both diagnosis and treatment. For intraobserver reliability, the average k for diagnosis was 0.818 and for treatment was 0.671. Eleven diagnostic (10%) and 24 treatment changes (24%) were made based on the CT evaluation. The majority of treatment changes involved adding or removing a plate, and the majority of diagnostic changes involved switching from Vancouver A to B1 and Vancouver B2 to B3.
Conclusion
While CT imaging influenced the diagnosis and treatment of PPFFs, it did not increase agreement among trauma or arthroplasty surgeons. Arthroplasty surgeons relied on CT more to guide both their treatment and diagnosis and had higher interobserver agreement compared to trauma surgeons. Our results suggests fracture extension and bone quality are better evaluated by CT and that CTs do help guide treatment of these injuries.
2. Hip Fracture Fixation Requiring Angioembolization
Purpose
Hip fractures are common orthopaedic injuries. They frequently require surgical intervention. Postoperative anemia secondary to blood loss is a known complication. We present a case series discussing postoperative angioembolization in 7 patients following orthopaedic intervention secondary to falls and hip fractures. Treatment included cephalomedullary nailing and hemiarthroplasty (femoral necks). This study aims at identifying prudent intraoperative techniques crucial to limiting anemia secondary to blood loss. Furthermore, our purpose is to add to the literature regarding optimization of hemodynamic stability in orthopedic patients that have sustained long-bone fractures.
Methods
Data from 2016 to 2021 was collected via an EMR review. “Angioembolization” and “embolization” procedure terms with associated misspellings were used. 301 cases of angioembolization resulted from this search. 7 of those were following hip fractures. Additionally, the total number of hip fractures resulted during the same timeframe was 3188.
Results
The mean age of patients requiring embolization was 76 years old. Mean time to embolization was 3.7 days, with a range of 1-7 days. Mean number of blood transfusions was 5.8 units, with a range of 2-10 units. Mean hemoglobin level prior to embolization consultation was 6.3, with a range of 5.3-6.8. All patients had normal platelets on presentation, but four out of the seven were on documented anticoagulation/antiplatelet. Of the CMN procedures requiring embolization, seventy-five percent required a reduction aid including collinear clamps, ball spike, or bone hook.
Conclusion
The collected cases highlight the importance of prudent intraoperative technique. Clamp placement and use of surgical instrumentation are factors that could be considered in higher-powered studies. Furthermore, attention to intraoperative blood loss is crucial when patients are managed by a multi- service team. When postoperative complications require team-based interventions, such as angioembolization, attention to these details can correlate to improved patient outcomes. In considering postoperative procedures, correction of hematologic abnormalities and use of tranexamic acid may also help in decreasing patient care risks.
3. Comparative Analysis of Unicompartmental Total Knee Arthroplasty and High Tibial Osteotomy: Time to Total Knee Arthroplasty and Other Outcome Measures
Purpose
There is no consensus on whether unicompartmental arthroplasty (UKA) or high tibial osteotomy (HTO) is superior for unicompartmental arthritis. While there are studies comparing revision and complication rates, none matched a large number of patients undergoing HTO and UKA in the United States and compared these outcomes. We investigated TKA conversion rate and the complications following HTO or UKA.
Methods
This retrospective study queried the PearlDiver database of all patients undergoing UKA and HTO using CPT codes between January 2011 and January 2020. We compared propensity-matched populations based on age, gender, Charlson Comorbidity Index, and Elixhauser Comorbidity Index to compare odds of complications, TKA conversion, and drug use between UKA and HTO groups. Two-independent sample t-test for unequal variances and test of significance were performed.
Results
We found 32,583 UKA patients and 816 HTO patients. Each matched group had 535 patients. One-year complication showed higher risk of pneumonia, hematoma, infection, and mechanical complications among HTO patients. UKA patients used narcotics on average of 10.3 days compared to 9.1 days among HTO patients (p<0.01). UKA conversion rates were 4.1%, 5.4%, 7.7%, and 9.2% at one-, two-, five-, and ten-year intervals. HTO conversion rates were less than 2% at one- and two-year intervals, 3.4% at five-year and 4.5% at ten-year intervals. This difference was statistically significant at five- and ten-year intervals (p<0.01).
Conclusion
Using large matched cohorts, HTO’s are converted to TKA’s later than UKA’s in short- to mid-term follow-up, and HTO patients used opioids for shorter duration. This information can be utilized when counseling patients and deciding what treatment option is best for patients with unicompartmental arthritis.
4. Rate of secondary surgery and implant removal following superior, pre-contoured plating of mid-shaft clavicle fractures
Purpose
Surgical fixation of midshaft clavicle fractures with a single 3.5mm superior clavicular plate has previously been thought to be associated with a high rate of hardware removal due to symptomatic or irritating hardware. Because of this, dual plating techniques have been proposed in an attempt to decrease the amount of symptoms associated with the hardware. However, dual plating systems have theoretical disadvantages as well, including increased cost and increased dissection resulting in potential weakness of the pectoralis major. At our institution, we use a single 3.5mm superior plate construct. Anecdotally, our patients do not seem to complain of symptomatic hardware at the same rate as that reported in the literature. Our purpose is to define the rate of symptomatic hardware removal for all midshaft clavicle fractures from 2014 through 2018.
Methods
We retrospectively reviewed the electronic medical record of our institution by searching for all patients from 2014 to 2018 with surgeries performed by two fellowship trained orthopaedic trauma surgeons under the CPT code 23515 (open reduction internal fixation of midshaft clavicle fracture), 23485 (non-union of midshaft clavicle fracture), and 20680 (removal of hardware). For patients who resulted from this search we then recorded the patient’s age, gender, laterality, mechanism of injury, open vs closed injury, smoking status, length of surgery, if additional surgery on the clavicle had been performed, and if the hardware was still in place. If removal of hardware was documented, we recorded the documented reason for hardware removal. We then contacted every patient in our search results by the telephone number listed in their medical record to confirm hardware still in place and to administer ASES (American Society of Shoulder and Elbow Surgeons) and QuickDASH shoulder function scores. For patients who did not answer their listed contact telephone number, multiple attempts on separate days were made and any emergency contacts were also attempted to be reached. Patients who did not have midshaft clavicle fractures, patients who were surgically treated with options other than the superior 3.5mm plate, and patients with surgeries not performed by Drs. Brennan and Stahl were excluded. Patients who did not answer the telephone call but had documented hardware removal were included in the total number of hardware removal patients.
Results
The CPT code search revealed 158 patients. Fourteen of these patients met exclusion criteria. Four patients were deceased. Forty-eight patients were unable to be reached by phone. One patient was unable to be reached but was included in our rate analysis due to documented hardware removal. Two patients were reached but declined to participate. Eighty nine patients (61.8%) were reached and agreed to participate. Average follow up was 4.09 years (1494 days). Five patients (5.56%) underwent hardware removal. Removal was for symptomatic or irritating hardware in two of these patients (2.22%). One patient had non-union, one had a peri-prosthetic fracture, and one had a superficial blister concerning for infection. There were zero documented infections.
Conclusion
In our series, our rate of symptomatic hardware removal was 2.22%, well below the reported removal rates. The rate of hardware removal for any reason was also well below the reported removal rates. Our data shows that the rate of hardware removal for prominent symptomatic superior clavicular plates may be significantly lower than previously reported. Midshaft clavicle fractures may adequately be treated with a single superior plate and the additional cost and additional dissection of a two plate fixation system may be avoided.
5. Utilizing WHOOP Inc’s Continuous Physiological Monitoring (CPM) Device to Measure Residents’ Intraoperative Maximum Heart Rate (MHR) and Average Heart Rate (AHR) while Performing Primary Total Joint Arthroplasty
Purpose (No limit. However, a succinct purpose is useful)
To analyze and compare resident intraoperative MHR and AHR over the course of a 3 month arthroplasty rotation.
Methods
1 Post Graduate Year 2 (PGY2) orthopedic surgery resident and 2 PGY 4 orthopedic surgery residents were voluntarily recruited to wear a WHOOP Inc. CPM intraoperatively during primary total hip (THA) and knee arthroplasty (TKA) . The average heart rate and maximum heart rate was recorded during each procedure performed over the 3 month rotation.
Results
All testing across the three months was performed based on the data’s distribution where appropriate Wilcoxon Rank Sum Test was used to compare the average of AHR and MHR between residents. Over the course of a 3 month rotation, the difference in the mean of between residents of the AHR and MHR was deemed to be statistically significant. Results are as follows:
THA
PGY2
Avg HR 112.33 Max HR 161.53 PGY4
Avg HR 89.4 Max HR 119.89 P-value
.004
.002
TKA
PGY2
Average HR 106.31 Max HR 133.46 PGY4
Average HR 85.2 Max HR 106.6 P-value
.0001
.0001
Conclusion
Even though the sample size is small, the difference in AHR and MHR between PGY2 and PGY4 residents performing primary arthroplasty over the course of a 3 month rotation is significant. Resident preparedness for practice is currently measured via subjective staff evaluations, milestones, and virtual simulations. The use of CPM in residents has not been studied extensively and may provide objective data for insight into resident preparedness for orthopedic surgical procedures.
6. Factors Influencing Compliance to Follow-Up Visits in Orthopaedic Surgery
Purpose
Orthopaedic procedures require post-operative follow-up to maximize recovery. Missed appointments and noncompliance primarily depend on patient-related factors, and can result in detrimental effects on patient health and increase healthcare costs. This study investigates the relationship between patient post-operative visit attendance and the distance traveled to receive care.
Methods
A retrospective review of all surgeries performed by a single orthopaedic surgeon in 2019 at Level 1 trauma center was completed. We excluded patients who underwent another subsequent procedure. Distance to care and time traveled were determined by the patient’s address and the clinic address using Google Maps API. Other variables that may impact attendance at follow-up visits were also collected. Univariate and multivariate logistic regression was performed with purposeful selection.
Results
We identified 518 patients, of which 32 (6%) did not attend their first scheduled follow-up appointment. An additional 47 (10%) did not attend their second follow-up. In total, 79 (15%) patients did not attend one of their appointments (effective no-show rate of 8%). Younger age, male sex, Black or African American race, self-pay, Medicaid insurance, accident insurance, and increased distance were individual predictors of missing an appointment. In the final multivariate logistic regression model male sex (OR 1.74), Black or African American race (OR 2.78), self-pay (OR 3.39), Worker’s Compensation (OR 0.19), Medicaid (OR 3.33), and distance from clinic per 10 miles (OR 1.03) predicted missing an appointment. Native American heritage perfectly predicted attendance.
Conclusion
Several nonmodifiable patient factors predict patient noncompliance in attending orthopaedic post- operative visits. When patients are considered at high risk of being lost to follow-up, there may be an opportunity to implement procedures or actions which may improve follow-up rate, patient outcomes, minimize patient costs, and maximize profitability for the hospital.
7. Is Duration of External Fixator Placement associated with Positive Reaming Cultures
Purpose
Temporary stabilization of long bones with external fixators is commonly done prior to definitive fixation with an intramedullary nail (IMN), especially in a damage control setting. With prolonged time in external fixation, complications such as pin-site infections may occur which may increase the risk of future infections, nonunions, and further surgeries. However, there is no current data which defines the length of external fixator application and resultant colonization of medullary canals, and subsequent infection risk after IMN. Our study aims to determine if an association exists between the duration of external fixation and positive reaming cultures at the time of definitive fixation with intramedullary nailing.
Methods
Our study included all patients older than 16 years of age who underwent intramedullary nailing of the femur or tibia after external fixation between November 2021 to January 2023. Patients were excluded if their procedures were performed by outside surgeons or if reaming cultures were not sent during the definitive procedure. Patients with positive reaming cultures were given a short course of oral antibiotics.
Results
A total of 70 long bones in 56 patients were included in the study. There was no significant difference in the number of open (25) versus closed (45) fractures in the group. There were 7 positive reaming cultures and 63 were negative. There was no significant difference between duration of external fixator placement and positive reaming cultures. When categorized into subgroups by duration of external fixator placement, there was no significant difference in positive culture rates at less than 7 days, between 7-14 days, and greater than 14 days.
Conclusion
To date, our study has found no significant difference between positive reaming cultures and duration of external fixator application. This suggests that a “pin-site holiday” may be unnecessary prior to intramedullary nailing; however, further studies are needed to determine the clinical significance of positive reaming cultures. Future directions include whether patients with positive reaming cultures have an increased risk of complications such as infection or nonunion. Additionally, we will evaluate if infection rates have been significantly affected after the introduction of this protocol at our institution.
8. Rapid Sequence MRI vs CT Capsular Width Sign For Detection Of Occult Femoral Neck Fractures Associated With Femoral Shaft Fractures
Purpose
Ipsilateral occult femoral neck fractures (IFNF) are an injury associated with high energy femoral shaft fractures. The current “Gold Standard” for diagnosing IFNF is MRI with both the highest sensitivity and specificity. In 2020 the CT capsular sign was proposed as another modality to detect these fractures. The CT capsular sign involves measuring the hip capsule distention on an axial CT cut when viewed in a soft tissue window. A difference between the contralateral hip capsule and the injured side of 1mm or greater was deemed positive for an association with IFNF. The aim of this study was to compare the efficacy of CT Capsular Width Sign with a proven modality of Rapid Sequence MRI developed at UT Houston in diagnosing IFNF.
Methods
The EMR was queried for patients with CPT codes 27506, 27235, and 27236. Of these patients, those aged greater than 18, with both a CT scan and MRI were included. Patients with bilateral femoral shaft fractures or ipsilateral acetabulum/pelvis pathology were excluded. There were 217 patients who met all inclusion/exclusion criteria. Of those 217 patients, there were 21 patients with MRI positive for IFNF. The CT capsular sign was measured using the technique outlined by Park et al., the “side-to-side difference of capsular distension, which was the distance between the anterior capsular border and the tangential line drawn from the intertrochanteric crest—where the anterior hip capsule was attached—to the femoral head.” A difference of greater than 1 mm is considered positive.
Results
Of the 21 MRI positive for IFNF, only 7 had a positive CT capsular sign (33%). 14 patients had a falsely negative CT capsular sign (66.7%). Two patients with false negative signs had a capsule on the uninjured extremity at least 1 mm greater than on the injured extremity. In one patient, the MRI also identified subtle, occult inferior and superior pubic rami fractures.
Conclusion
When compared to rapid sequence MRI, CT capsular sign demonstrated a high rate of false negatives. This leads to the concern that this sign is not a reliable method to diagnose IFNF, and may not be not be useful in isolation to guide operative treatment.
9. Efficacy of Intravenous Acetaminophen in Postoperative Geriatric Hip Fracture Patients
Purpose (No limit. However, a succinct purpose is useful)
Hip fractures are among the most commonly treated orthopedic injuries in geriatric patients and represent a significant cost to the community and health care system. We sought to study the effects of postop intravenous acetaminophen (IVA) on total postop opioid use, immediate postop opioid use in the first three postop days, pain scales, and hospital length of stay for patients undergoing operative fixation for hip fracture.
Methods
This was a retrospective cohort study of hip fractures managed by a single surgeon at one level I trauma center, one level III trauma center, and one level IV trauma center. 117 patients older than 65 years of age treated for hip fractures with an intramedullary implant (n=54), total hip arthroplasty (n=17), hemiarthroplasty (n=44), or percutaneous femoral neck fixation (n=2) were included. Exclusion criteria included polytrauma, periprosthetic fracture, and non-orthopedic complications or comorbidities resulting in a prolonged hospital stay.
Results
56 patients received no postop IVA. 61 patients received 1 to 6 grams of IVA. Postop pain scores for postop days zero (2.9 +/- 2.4 vs. 3.2 +/- 3.0, p = 0.46), one (3.3 +/- 2.2 vs. 3.7 +/- 2.5, p = 0.45), two (3.4 +/- 2.4 vs. 3.7 +/- 2.4, p = 0.39), three (2.8 +/- 2.1 vs. 3.5 +/- 2.5, p = 0.32) were slightly higher in the IVA group. Total postop inpatient morphine milliequivalents (MME) (53.2 MME +/- 54.7 vs. 41.5 MME +/- 63.6, p = 0.20), immediate postop MME (31.9 MME +/- 45.2 vs. 28.3 MME +/- 42.9, p = 0.29) and length of stay (6.6 days +/- 3.7 vs. 5.1 days +/- 2.3, p = 0.02) were lower in the IVA group.
Conclusion
Verbal postop pain scores were slightly higher in the IVA group. Total opioid use and immediate postop opioid use was decreased and length of stay was significantly reduced by over one day. Intravenous acetaminophen may decrease duration of inpatient admissions and opioid use for postop geriatric hip fracture patients.
10. Intrailiac Osteotomy with Superior Lateral Outcropping of Bone: A Previously Undescribed Procedure for Hip Subluxation in Cerebral Palsy
Purpose (No limit. However, a succinct purpose is useful)
Surgical treatment of hip subluxation in cerebral palsy typically involves proximal femoral osteotomy with or without concurrent supraacetabular pelvic osteotomy. The literature lacks data on isolated pelvic osteotomy for this condition. Additionally, we present a novel procedure for augmenting our pelvic osteotomies for additional femoral coverage, the superior lateral outcropping of bone.
Methods
In this retrospective case series, all patients were included for whom a single surgeon at a single institution performed pelvic osteotomy with adjunctive superior lateral outcropping of bone for the treatment of hip subluxation in cerebral palsy over a 12 year period. Patients with less than 2 years radiographic follow up were excluded, as were patients with frank dislocation preoperatively. On each case were collected multiple data, including radiographic measurements of migration percentage and acetabular index preoperatively, immediately postoperatively, and at last available radiograph. Paired t- tests were performed to confirm a significant difference between preoperative and postoperative measurements. Surgical failure was defined as either (1) any subsequent hip or pelvic procedure other than simple myotendinous lengthening or alcohol neurolysis, or (2) final migration percentage of greater than 50%.
Results
33 hips (23 patients, 13 male) were included. Mean age at surgery was 7 years. Mean time to follow up was 49 months. Migration percentage of the hips improved from an average 44% preoperatively to 25% at first postoperative measurement and 22% at final follow-up, and acetabular index improved from an average 27 degrees preoperatively to 15 degrees at first postoperative measurement and 17 degrees at final follow-up. No hips met failure criteria of repeat surgery other than myotendinous lengthening, but two presented with a migration percentage of greater than 50% at final follow up, giving us a failure rate of 6%.
Conclusion
We present a novel procedure, using techniques adapted from others well-established, which appears to provide safe and successful outcomes for our given indication, hip subluxation in cerebral palsy. Our clinical results compare favorable to those in the literature for isolated proximal femoral osteotomy for similar patient populations.