The successful short-term results of the ACLD group suggest ACL deficiency may not always be a contraindication to Oxford UKA as previously thought. Until long-term data is available, however, we maintain our recommendation that ACLD be considered a contraindication.
Objective: To examine the relationship of nutrition parameters with the modified frailty index (mFI) and postoperative complications in hip fracture patients. Design: Retrospective observational cohort study. Setting: Urban, American College of Surgeons–Verified, Level-1, Trauma Center. Patients/Participants: Three hundred seventy-seven consecutive patients with isolated hip fractures. Intervention: N/A. Main Outcome Measures: On admission, albumin and total lymphocyte count (TLC) levels and complication data were collected. Additionally, mFI scores were calculated. Statistical analysis was then used to analyze the association between frailty, malnutrition, and postoperative complications. Results: Overall, 62.6% and 17.5% of patients were malnourished as defined by TLC of <1500 cells per cubic millimeter and albumin of <3.5 g/dL, respectively. Both TLC (P = 0.024; r = −0.12) and albumin (P < 0.001; r = −0.23) weakly correlated with frailty. Combining malnutrition and frailty revealed predictive synergy. Albumin of <3.5 g/dL and mFI of ≥0.18 in the same patient resulted in a positive predictive value of 69% and a likelihood ratio of 4 (2.15–7.43) for postoperative complications. Similarly, the combination of hypoalbuminemia and frailty resulted in a positive predictive value of 23.3% and likelihood ratio of 8.52 (P < 0.001) for mortality. Conclusions: When patients are frail and malnourished, there is a risk elevation beyond that of frailty or malnutrition in isolation. This high-risk cohort can be easily identified at admission with routine laboratory values and clinical history. There is an opportunity to improve outcomes in frail hip fracture patients because malnutrition represents a potentially modifiable risk factor. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Objective Lateral tibiofemoral osteoarthritis (OA) is overall less common than medial tibiofemoral OA, but it is more prevalent in women. This may be explained by sex differences in hip and pelvic geometry. The aim of this study is to explore sex differences in hip and pelvic geometry and determine if such parameters are associated with the presence of compartment-specific knee OA. Methods This case-control study reports on 1,328 hips/knees from 664 participants and is an ancillary to the Multicenter Osteoarthritis Study (MOST). Of the 1,328 knees, 219 had lateral OA, 260 medial OA, and 849 no OA. Hip and pelvic measurements were taken from full-limb radiographs on the ipsilateral side of the knee of interest. After adjusting for covariates, means were compared between sexes and also between knees with medial and lateral OA versus no OA using separate regression models. Results Women were shown to have a reduced femoral offset (mean 40.9 mm vs. 45.9 mm; p=0.001) and more valgus neck-shaft angle (mean 128.4° vs. 125.9°; p<0.001) compared to men. Compared to those with no OA, knees with lateral OA were associated with a reduced femoral offset (p=0.012), increased height of hip centre (p=0.003), more valgus neck-shaft angle (p=0.042), and increased abductor angle (p=0.031). Knees with medial OA were associated with a more varus neck-shaft angle (p=0.043) and a decreased abductor angle (p=0.003). Conclusion These data suggest anatomical variations at the hip and pelvis are associated with compartment-specific knee OA and may help to explain sex differences in patterns of knee OA.
Background: Success rates for surgical management of chronic exertional compartment syndrome (CECS) are historically lower with release of the deep posterior compartment compared with isolated anterolateral releases. At our institution, when a deep posterior compartment release is performed, we routinely examine for a separate posterior tibial muscle osseofascial sheath and release it if present. Purpose: Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in patients who underwent 2-compartment fasciotomy versus a modified 4-compartment fasciotomy for CECS. Study Design: Cohort study; Level of evidence, 3. Methods: Patients treated with fasciotomy for lower extremity CECS from 2007 to 2017 were retrospectively identified. In all patients in whom a 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath, which was released when present. Patients completed a series of validated patient-reported outcome (PRO) surveys, including the Marx activity score, Tegner activity score, 12-Item Short Form Health Survey, and Likert score for patient satisfaction. Results: Of the 48 patients who were included in this study, 34 (71%) patients with a total of 52 operative limbs responded and completed PRO surveys. The mean follow-up for the entire cohort was 5.5 ± 2.6 years. Of the 34 patients, 23 (68%) underwent 2-compartment fasciotomy and 11 (32%) underwent 4-compartment fasciotomy. Among the patients in the 4-compartment fasciotomy group, 7 (64%) were found to have a fifth compartment. No significant difference was found in any of the validated PRO measures between patients who had a 2- versus 4-compartment fasciotomy or those who underwent 4-compartment fasciotomy with or without a present fifth compartment. At a mean 5.5-year follow-up, 74% of patients who underwent a 2-compartment release reported good or excellent outcomes compared with 82% of patients who underwent our modified 4-compartment release. Conclusion: The current study, which included the longest follow-up on CECS patients in the literature, demonstrated that the addition of a release of the posterior tibial muscle fascia led to no significant difference in PRO measures between patients who underwent a 2- versus 4-compartment fasciotomy, when historically the 2-compartment fasciotomy group has had higher success rates.
The aim of this study was to evaluate the association between frailty and 30-day morbidity and mortality in patients with intertrochanteric femur fractures. Furthermore, the authors sought to identify a specific frailty index score that would help identify high-risk patients. This retrospective study evaluated 229 consecutive patients 50 years or older who presented to a single level I trauma center for surgical fixation of an intertrochanteric femur fracture. Frailty was determined using a previously validated 11-point modified frailty index (mFI) scale. Primary outcome variables included 30-day morbidity and mortality. Of the 229 patients included in this study, 82 (36%) had a postoperative complication and there were 10 (4%) mortalities. The most common complications were delirium (n=40; 17%) and acute kidney injury (n=25; 11%). Mean mFI score for those who developed a postoperative complication was 0.24 compared with 0.14 for those who did not ( P <.001). The mortality rate increased from 0% for mFI of 0 to 11% for mFI of 0.27 or more. Patients with an mFI of 0.27 or more were more than 9 times as likely to have a mortality compared with patients with an mFI of less than 0.27 ( P =.006). This study demonstrates that the mFI is associated with 30-day morbidity and mortality in patients aged 50 years or older with intertrochanteric femur fractures. The authors identified an mFI score of 0.27 or more as the most robust predictor of increased 30-day morbidity and mortality following surgical fixation of intertrochanteric femur fractures. [ Orthopedics . 2019; 42(6):344–348.]
IMPORTANCE Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed. OBJECTIVE To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20°and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019. MAIN OUTCOMES AND MEASURES Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care. RESULTS Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6°(10.3°) compared with 13.9°(4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03). CONCLUSIONS AND RELEVANCE The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.
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