BackgroundCompared to the posterior approach, the anterior approach to total hip arthroplasty (THA) offers the potential for an accelerated recovery secondary to less dissection and therefore less pain in the immediate postoperative period. This offers potential financial benefit through a reduction in length of stay. This study retrospectively reviewed 98 anterior approach and 69 posterior approach THA cases (N = 167) to compare perioperative outcomes and cost-effectiveness.MethodsPatients who underwent anterior approach THA were discharged sooner than those who underwent posterior approach THA.ResultsThe anterior approach was also less expensive per patient than the posterior approach. Overall, differences in perioperative outcomes between these approaches to THA are less robust than previously reported. There is a significant difference in operative cost between these surgical approaches.ConclusionsAlthough there are many sources for this difference in cost, the predominant contributor is surgeon implant preference.

Introduction: In hip fracture patients with elevated international normalized ratios (INRs), the risks of delaying surgery for correction of INR are controversial. We examined the association of (1) preoperative INR values and (2) surgical delay with postoperative complications after intramedullary nailing of hip fractures. Methods: Using the National Surgical Quality Improvement Program database, we retrospectively identified patients that underwent intramedullary nailing for hip fractures from 2005 to 2016. Patients aged older than 55 years with preoperative INR recorded ≤1 day before surgery were included. Patients were stratified into five cohorts—(1) INR ≤ 1.0, (2) 1 < INR ≤ 1.25 (INR [1 to 1.25]), (3) 1.25 < INR ≤ 1.5 (INR [1.25 to 1.5]), (4) 1.5 < INR ≤ 2.0 (INR [1.5 to 2.0]), and (5) INR > 2.0. The primary outcomes of interest were postoperative bleeding requiring transfusion, surgical site infection, and 30-day mortality. Multivariate regression analysis was done to adjust for potential confounding variables. Results: In total, 15,323 patients were included in this analysis. Adjusting for potential confounders, INR [1 to 1.25], INR [1.25 to 1.5], and INR [1.5 to 2.0] were associated with increased mortality (adjusted odds ratio [aOR]: 1.501, P < 0.001; aOR: 2.226, P < 0.001; aOR: 2.524, P < 0.001, respectively) and surgical delay >48 hours (aOR: 1.655, P < 0.001; aOR: 3.434, P < 0.001; aOR: 2.382, P < 0.001, respectively). The INR > 2.0 cohort was not associated with mortality (P = 0.181) or surgical delay (P = 0.529). Surgical delay was associated with mortality (aOR: 1.531, P = 0.004). The INR > 2.0 cohort was associated with increased rate of transfusions (aOR: 1.388, P = 0.039). Conclusion: Elevated preoperative INR value within 1 day of surgery between 1.0 and 2.0 was associated with increased risk of 30-day mortality and surgical delay >48 hour, which may represent attempts at INR correction. An INR greater than 2.0 was not associated with mortality or surgical delay but was associated with increased transfusions. Surgical delay was independently associated with increased risk of 30-day mortality. We therefore recommend that INR reversal be attempted but not delay surgical fixation of geriatric hip fractures over 48 hours and counsel patients and their families regarding the risks of surgery with elevated INR. Level of Evidence: Prognostic-level III/retrospective cohort study

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Objective: To determine the prevalence of positive screening for posttraumatic stress disorder (PTSD) amongst trauma patients. Design: Prospective, longitudinal study. Setting: Single urban US level 1 trauma center. Patients and methods: Four hundred fifty-two adult trauma patients were administered the PTSD checklist for DSM-V (PCL-5) survey upon posthospital outpatient clinic visit. This included 300 men (66%) and 152 women with mean age 43.8 years and mean Injury Severity Score (ISS) 11.3, with 83% having fractures of the pelvis and/or extremities. Medical and injury related variables were recorded. Multivariate logistic regression analysis was performed to identify factors predictive of screening positive for PTSD. Main outcome measurement: Prevalence and risk factors for screening positive for PTSD amongst the trauma patient population. Results: Twenty-six percent of trauma patients screened positive for PTSD after mean 86 days following injury. These patients were younger (35 vs 46 years old, P < 0.001) and more commonly African American (56% vs 43% Caucasian, P < 0.001). Pedestrians struck by motor vehicles (OR 4.70, P = 0.040) and victims of crime (OR 4.12, P = 0.013) were more likely to screen positive. Psychiatric history, injury severity (ISS), and injury type did not predict positive screening. Conclusion: One-in-four patients suffering traumatic injuries screened positive for PTSD suggesting the prevalence of PTSD among trauma patients far exceeds that of the general population. Predictive factors included victims of crime and pedestrians struck by motor vehicles. Screening measures are needed in orthopaedic trauma surgery clinics to refer these at-risk patients for proper evaluation and treatment. Level of evidence: Prognostic; Level II