Orthopedics

Huddleston, J. I., 3rd, A. De, H. Jaffri, J. W. Barrington, P. J. Duwelius and B. D. Springer (2021). “Cementless Fixation Is Associated With Increased Risk of Early and All-Time Revision After Hemiarthroplasty But Not After THA for Femoral Neck Fracture: Results From the American Joint Replacement Registry.” Clin Orthop Relat Res 479(10): 2194-2202.

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BACKGROUND: Despite ample evidence supporting cemented femoral fixation for both hemiarthroplasty and THA for surgical treatment of displaced femoral neck fractures, cementless fixation is the preferred fixation method in the United States. To our knowledge, no nationally representative registry from the United States has compared revision rates by fixation for this surgical treatment. QUESTION/PURPOSE: After controlling for relevant confounding variables, is femoral fixation method (cemented or cementless) in hemiarthroplasty or THA for femoral neck fracture associated with a greater risk of (1) all-cause revision or (2) revision for periprosthetic fracture? METHODS: Patients with Medicare insurance who had femoral neck fractures treated with hemiarthroplasty or THA reported in the American Joint Replacement Registry database from 2012 to 2017 and Centers for Medicare and Medicaid Services claims data from 2012 to 2017 were analyzed in this retrospective, large-database study. Of the 37,201 hemiarthroplasties, 42% (15,748) used cemented fixation and 58% (21,453) used cementless fixation. Of the 7732 THAs, 20% (1511) used cemented stem fixation and 80% (6221) used cementless stem fixation. For both the hemiarthroplasty and THA cohorts, most patients were women and had cementless femoral fixation. Early revision was defined as a procedure that occurred less than 90 days from the index procedure. All patients submitted to the registry were included in the analysis. Patient follow-up was limited to the study period. No patients were lost to follow-up. Due to inherent limitations with the registry, we did not compare medical complications, including deaths attributed directly to cemented fixation. A logistic regression model including the index arthroplasty, age, gender, stem fixation method, hospital size, hospital teaching affiliation, and Charlson comorbidity index score was used to determine associations between the index procedure and revision rates. RESULTS: For the hemiarthroplasty cohort, risk factors for any revision were cementless stem fixation (odds ratio 1.42 [95% confidence interval 1.20 to 1.68]; p < 0.001), younger age (OR 0.96 [95% CI 0.95 to 0.97]; p < 0.001), and higher Charlson comorbidity index (OR 1.06 [95% CI 1.02 to 1.11]; p = 0.004). Risk factors for early revision were cementless stem fixation (OR 1.77 [95% CI 1.43 to 2.20]; p < 0.001), younger age (OR 0.98 [95% CI 0.97 to 0.99]; p < 0.001), and higher Charlson comorbidity index (OR 1.09 [95% CI 1.04 to 1.15]; p < 0.001). Risk factors for revision due to periprosthetic fracture were cementless fixation (OR 6.19 [95% CI 3.08 to 12.42]; p < 0.001) and higher Charlson comorbidity index (OR 1.16 [95% CI 1.06 to 1.28]; p = 0.002). Risk factors for early revision due to periprosthetic fracture were cementless fixation (OR 7.38 [95% CI 3.17 to 17.17]; p < 0.001), major teaching hospital (OR 2.10 [95% CI 1.08 to 4.10]; p = 0.03), and higher Charlson comorbidity index (OR 1.20 [95% CI 1.09 to 1.33]; p < 0.001). For the THA cohort, there were no associations. CONCLUSION: These data suggest that cemented fixation should be the preferred technique for most patients with displaced femoral neck fractures treated with hemiarthroplasty. The fact that stem fixation method did not affect revision rates for those patients with displaced femoral neck fractures treated with THA may be due to current practice patterns in the United States. LEVEL OF EVIDENCE: Level III, therapeutic study.

Villarreal, J. V., N. Shibuya and D. C. Jupiter (2021). “Thromboprophylaxis and Bleeding Complications in Orthopedic and Trauma Patients: A Systematic Review.” J Foot Ankle Surg 60(5): 1014-1022.

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This systematic review was conducted to investigate the effects of currently used chemoprophylactic modalities to assess concerns regarding their usage. Preventive benefits of thromboprophylaxis were weighed against potential complications in orthopedic and trauma patients. The Ovid MEDLINE® database was used to identify relevant studies. The authors independently screened the initial study articles by title and abstract, eliminating articles not dealing with venous thromboembolism (VTE) chemoprophylaxis in orthopedic or trauma populations. The remaining articles were assessed for eligibility through full-text analysis. The analyzed studies within this review suggested that Factor X(a) inhibitors and direct oral anticoagulants hold promise as safe and potentially more effective thromboprophylactic entities when compared to low molecular weight heparin in trauma and orthopedic patients. Thromboprophylaxis had little to no effect on major bleeding incidence, although we could not definitively conclude there was no effect on overall bleeding. Early thromboprophylaxis, especially when identifiable risk factors are present, can improve VTE prevention without changing major bleeding rates. Additionally, we could not conclude whether extended prophylaxis affects VTE incidence, although it seemed to have no effect on major bleeding. Finally, we determined that thromboprophylaxis in the lower extremity trauma population is questionable without the presence of underlying risk factors.

Lo, E. Y., C. Melton, J. Rizkalla, T. Majekodunmi and S. G. Krishnan (2021). “Complex Shoulder Girdle Stabilization Using Allograft Capsular Reconstruction and Pectoralis Major Transfer: A Case Report.” JBJS Case Connect 11(3).

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CASE: A 21-year-old woman with a history of multiple failed surgical and conservative management for recurrent involuntary shoulder instability presented with 1-year history of shoulder pain. Physical examination demonstrated intractable static anterior glenohumeral instability, deficient capsular tissue, with reducible scapular winging secondary to long thoracic nerve palsy. Allograft capsular reconstruction and open split pectoralis major tendon transfer were performed to salvage shoulder motion and stabilize her shoulder girdle. CONCLUSION: This report presents a novel repair option for intractable shoulder instability and scapular winging. Surgeons should recognize potential causes of shoulder instability and familiarize themselves with multiple stabilization techniques as potential salvage options before glenohumeral fusion.

Huddleston, J. I., 3rd, A. De, H. Jaffri, J. W. Barrington, P. J. Duwelius and B. D. Springer (2021). “Cementless Fixation Is Associated With Increased Risk of Early and All-Time Revision After Hemiarthroplasty But Not After THA for Femoral Neck Fracture: Results From the American Joint Replacement Registry.” Clin Orthop Relat Res Aug 16. [Epub ahead of print].

Full text of this article.

BACKGROUND: Despite ample evidence supporting cemented femoral fixation for both hemiarthroplasty and THA for surgical treatment of displaced femoral neck fractures, cementless fixation is the preferred fixation method in the United States. To our knowledge, no nationally representative registry from the United States has compared revision rates by fixation for this surgical treatment. QUESTION/PURPOSE: After controlling for relevant confounding variables, is femoral fixation method (cemented or cementless) in hemiarthroplasty or THA for femoral neck fracture associated with a greater risk of (1) all-cause revision or (2) revision for periprosthetic fracture? METHODS: Patients with Medicare insurance who had femoral neck fractures treated with hemiarthroplasty or THA reported in the American Joint Replacement Registry database from 2012 to 2017 and Centers for Medicare and Medicaid Services claims data from 2012 to 2017 were analyzed in this retrospective, large-database study. Of the 37,201 hemiarthroplasties, 42% (15,748) used cemented fixation and 58% (21,453) used cementless fixation. Of the 7732 THAs, 20% (1511) used cemented stem fixation and 80% (6221) used cementless stem fixation. For both the hemiarthroplasty and THA cohorts, most patients were women and had cementless femoral fixation. Early revision was defined as a procedure that occurred less than 90 days from the index procedure. All patients submitted to the registry were included in the analysis. Patient follow-up was limited to the study period. No patients were lost to follow-up. Due to inherent limitations with the registry, we did not compare medical complications, including deaths attributed directly to cemented fixation. A logistic regression model including the index arthroplasty, age, gender, stem fixation method, hospital size, hospital teaching affiliation, and Charlson comorbidity index score was used to determine associations between the index procedure and revision rates. RESULTS: For the hemiarthroplasty cohort, risk factors for any revision were cementless stem fixation (odds ratio 1.42 [95% confidence interval 1.20 to 1.68]; p < 0.001), younger age (OR 0.96 [95% CI 0.95 to 0.97]; p < 0.001), and higher Charlson comorbidity index (OR 1.06 [95% CI 1.02 to 1.11]; p = 0.004). Risk factors for early revision were cementless stem fixation (OR 1.77 [95% CI 1.43 to 2.20]; p < 0.001), younger age (OR 0.98 [95% CI 0.97 to 0.99]; p < 0.001), and higher Charlson comorbidity index (OR 1.09 [95% CI 1.04 to 1.15]; p < 0.001). Risk factors for revision due to periprosthetic fracture were cementless fixation (OR 6.19 [95% CI 3.08 to 12.42]; p < 0.001) and higher Charlson comorbidity index (OR 1.16 [95% CI 1.06 to 1.28]; p = 0.002). Risk factors for early revision due to periprosthetic fracture were cementless fixation (OR 7.38 [95% CI 3.17 to 17.17]; p < 0.001), major teaching hospital (OR 2.10 [95% CI 1.08 to 4.10]; p = 0.03), and higher Charlson comorbidity index (OR 1.20 [95% CI 1.09 to 1.33]; p < 0.001). For the THA cohort, there were no associations. CONCLUSION: These data suggest that cemented fixation should be the preferred technique for most patients with displaced femoral neck fractures treated with hemiarthroplasty. The fact that stem fixation method did not affect revision rates for those patients with displaced femoral neck fractures treated with THA may be due to current practice patterns in the United States. LEVEL OF EVIDENCE: Level III, therapeutic study.

O’Toole, R.V., Joshi, M., Carlini, A.R., Murray, C.K., Allen, L.E., Huang, Y., Scharfstein, D.O., O’Hara, N.N., Gary, J.L., Bosse, M.J., Castillo, R.C., Bishop, J.A., Weaver, M.J., Firoozabadi, R., Hsu, J.R., Karunakar, M.A., Seymour, R.B., Sims, S.H., Churchill, C., Brennan, M.L., Gonzales, G., Reilly, R.M., Zura, R.D., Howes, C.R., Mir, H.R., Wagstrom, E.A., Westberg, J., Gaski, G.E., Kempton, L.B., Natoli, R.M., Sorkin, A.T., Virkus, W.W., Hill, L.C., Hymes, R.A., Holzman, M., Malekzadeh, A.S., Schulman, J.E., Ramsey, L., Cuff, J.A.N., Haaser, S., Osgood, G.M., Shafiq, B., Laljani, V., Lee, O.C., Krause, P.C., Rowe, C.J., Hilliard, C.L., Morandi, M.M., Mullins, A., Achor, T.S., Choo, A.M., Munz, J.W., Boutte, S.J., Vallier, H.A., Breslin, M.A., Frisch, H.M., Kaufman, A.M., Large, T.M., LeCroy, C.M., Riggsbee, C., Smith, C.S., Crickard, C.V., Phieffer, L.S., Sheridan, E., Jones, C.B., Sietsema, D.L., Reid, J.S., Ringenbach, K., Hayda, R., Evans, A.R., Crisco, M.J., Rivera, J.C., Osborn, P.M., Kimmel, J., Stawicki, S.P., Nwachuku, C.O., Wojda, T.R., Rehman, S., Donnelly, J.M., Caroom, C., Jenkins, M.D., Boulton, C.L., Costales, T.G., LeBrun, C.T., Manson, T.T., Mascarenhas, D.C., Nascone, J.W., Pollak, A.N., Sciadini, M.F., Slobogean, G.P., Berger, P.Z., Connelly, D.W., Degani, Y., Howe, A.L., Marinos, D.P., Montalvo, R.N., Reahl, G.B., Schoonover, C.D., Schroder, L.K., Vang, S., Bergin, P.F., Graves, M.L., Russell, G.V., Spitler, C.A., Hydrick, J.M., Teague, D., Ertl, W., Hickerson, L.E., Moloney, G.B., Weinlein, J.C., Zelle, B.A., Agarwal, A., Karia, R.A., Sathy, A.K., Au, B., Maroto, M., Sanders, D., Higgins, T.F., Haller, J.M., Rothberg, D.L., Weiss, D.B., Yarboro, S.R., McVey, E.D., Lester-Ballard, V., Goodspeed, D., Lang, G.J., Whiting, P.S., Siy, A.B., Obremskey, W.T., Jahangir, A.A., Attum, B., Burgos, E.J., Molina, C.S., Rodriguez-Buitrago, A., Gajari, V., Trochez, K.M., Halvorson, J.J., Miller, A.N., Goodman, J.B., Holden, M.B., McAndrew, C.M., Gardner, M.J., Ricci, W.M., Spraggs-Hughes, A., Collins, S.C., Taylor, T.J. and Zadnik, M. (2021). “Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial.” JAMA Surg 156(5): e207259.

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IMPORTANCE: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. OBJECTIVE: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. DESIGN, SETTING, AND PARTICIPANTS: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. INTERVENTIONS: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. MAIN OUTCOMES AND MEASURES: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. RESULTS: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. CONCLUSIONS AND RELEVANCE: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02227446.