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Siddiq BS, Dean MC, Gillinov SM, Lee JS, Dowley KS, Cherian NJ, Martin SD. Biceps tenotomy vs. tenodesis: an ACS-NSQIP analysis of postoperative outcomes and utilization trends. JSES Int 2024; 8:828-836. [PMID: 39035668 PMCID: PMC11258841 DOI: 10.1016/j.jseint.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Background While studies have assessed comparative rates of restoration of shoulder function and alleviation of symptoms, comparative systemic postoperative complication rates between biceps tenotomy and tenodesis have yet to be assessed. The purpose of the present study was to use a national administrative database to perform a comprehensive investigation into 30-day complication rates after biceps tenotomy versus tenodesis, thus providing valuable insights for informed decision-making by clinicians and patients regarding the optimal surgical approach for pathologies of the long head of the biceps tendon. Methods The National Surgical Quality Improvement Program database was queried to analyze postoperative complication rates and metrics associated with biceps tenotomy and tenodesis. Patient data spanning from 2012 to 2021 was extracted, with relevant variables assessed to identify and compare these two surgical approaches. Adjusted and unadjusted analyses were utilized to analyze patient demographics, comorbidities, operative times, lengths of stay, readmissions, adverse events, and yearly surgical volume, along with trends in usage, across cohorts. Results Of 11,527 total patients, 264 (2.29%), 6826 (59.22%), and 4437 (38.49%) underwent tenotomy, tenodesis with open repair, and tenodesis with arthroscopic repair, respectively. Tenotomy operative times ([mean ± SD]: 66.25 ± 44.76 minutes) were shorter than those for open tenodesis (78.83 ± 41.82) and arthroscopic tenodesis (75.98 ± 40.16). Conversely, tenotomy patients had longer hospital days (0.88 ± 4.86 days) relative to open tenodesis (.08 ± 1.55) and arthroscopic tenodesis (.12 ± 2.70). Multivariable logistic regression controlling for demographics and comorbidities demonstrated that patients undergoing tenodesis were less likely to be readmitted (adjusted odds ratio [AOR]: 0.42, 95% confidence interval [CI]: 0.17-0.98, P = .050) or sustain serious adverse events (AOR: 0.27, 95% CI: 0.13-0.57, P < .001), but equally likely to sustain minor adverse events (AOR: 0.87, CI: 0.21-3.68, P = .850), compared with patients undergoing tenotomy. Lastly, comparing utilization rates from 2012 to 2021 revealed a significant decrease in the proportion of tenotomy (from 6.2% to 1.0%) compared to open tenodesis (from 41.0% to 57.3%) and arthroscopic tenodesis (52.8% to 41.64%; P trend = .001). Conclusion To our knowledge, this is the first large national database study investigating postoperative complication rates between the various surgical treatments for pathologies of the long head of the biceps tendon. Our results suggest that tenodesis yields fewer serious adverse events and lower readmission rates than tenotomy. We also found a shorter operative time for tenotomy. These findings support the increased utilization of tenodesis relative to tenotomy in recent years.
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Affiliation(s)
- Bilal S. Siddiq
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael C. Dean
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen M. Gillinov
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan S. Lee
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kieran S. Dowley
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Nathan J. Cherian
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Orthopaedic Surgery, University of Nebraska, Omaha, NE, USA
| | - Scott D. Martin
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Sund A, Dybvik E, Gjertsen JE. Orthopaedic surgeons' ability to detect pathologic hip fractures: review of 1484 fractures reported to the Norwegian Hip Fracture Register. J Orthop Surg Res 2023; 18:832. [PMID: 37925444 PMCID: PMC10625282 DOI: 10.1186/s13018-023-04336-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/01/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND The proximal femur is the most common location of metastases in the appendicular skeleton. Data on pathologic hip fractures, however, are sparse despite it is the most frequently operated pathologic fracture. The aim of this study was to investigate the ability of orthopaedic surgeons to identify pathologic hip fractures in an acute setting and secondly to validate the underlying cause of the pathologic fractures reported to Norwegian Hip Fracture Register (NHFR). METHODS In the NHFR dataset between 2005 and 2019, we identified 1484 fractures reported to be pathologic possibly secondary to a malignancy. These fractures were thoroughly validated by reviewing X-rays, the patient journal, the operation description for date, side, why there had been suspicion of pathologic fracture, and implant choice. Pathology reports were reviewed once a biopsy had been performed. Based on this validation, information in the NHFR was corrected, whenever necessary. RESULTS Of the 1484 fractures possible secondary to malignancy, 485 (32.7%) were not a pathologic fracture. When reviewing the 999 validated pathologic fractures, 15 patients had a pathologic fracture secondary to a benign lesion. The remaining 984 patients had a pathologic fracture secondary to malignancy. The underlying diagnosis reported was corrected in 442 of the 999 patients. The true rate of pathologic hip fractures secondary to malignancy in our material was 0.8%, and most patients had underlying prostate (30%), breast (20%), or lung (17%) cancer. CONCLUSION Orthopaedic surgeons in Norway failed to report correct data on pathologic fractures and the corresponding cancer diagnosis in an acute setting in many patients. The corrected data on pathologic fractures in the NHFR from 2005 to 2019 can now be a valid resource for further studies on the subject.
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Affiliation(s)
- Anders Sund
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.
| | - Eva Dybvik
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Jan-Erik Gjertsen
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
- Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Varady NH, Amen TB, Rudisill SS, Adcock K, Bovonratwet P, Ast MP. Same-Day Discharge Total Knee Arthroplasty in Octogenarians. J Arthroplasty 2023; 38:96-100. [PMID: 35985540 DOI: 10.1016/j.arth.2022.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/03/2022] [Accepted: 08/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND One of the most important aspects of the transition to outpatient (OP) arthroplasty is patient selection, with guidance traditionally recommending that OP total knee arthroplasty (TKA) be reserved for patients <80 years old. However, there are limited data as to whether older age should really be considered a contraindication to OP-TKA. The purpose of this study is to assess the risk of complications and readmissions following OP-TKA in patients ≥80 years old. METHODS This is a retrospective, propensity-matched cohort study of the National Surgical Quality Improvement Program database from 2011 to 2019. Patients ≥80 years undergoing OP (same-day discharge) TKA were propensity matched to patients ≥80 years undergoing inpatient (IP) TKA based on age, gender, race, body mass index, American Society of Anesthesiologists classification, functional status, smoking status, anesthetic type, and medical comorbidities. There were 1,418 patients (709 IPs and 709 OPs) included. All baseline factors were successfully matched between IP-TKA versus OP-TKA (P ≥ .18 for all). Thirty-day complications, readmissions, reoperations, and mortality were subsequently analyzed. RESULTS Thirty-day readmission rates were identical between patients undergoing IP-TKA and OP-TKA (3.5% versus 3.5%, P = 1.0). Similarly, there was no significant difference in the incidence of major complications (2.7% versus 2.0%, P = .38), reoperations (1.3% versus 0.8%, P = .44), or mortalities (0.3% versus 0.3%, P = 1.0) within 30 days. CONCLUSION Octogenarians undergoing OP-TKA had comparable complication rates to similar patients undergoing IP-TKA. OP-TKA can be performed safely in select octogenarians and age ≥80 years likely does not need to be a uniform contraindication to OP-TKA.
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Affiliation(s)
- Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York; Department of Orthopaedic Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Troy B Amen
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York; Department of Orthopaedic Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
| | | | - Kelson Adcock
- University of Washington Medical Center, Seattle, Washington
| | - Patawut Bovonratwet
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York; Department of Orthopaedic Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Michael P Ast
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York; Department of Orthopaedic Surgery, NewYork-Presbyterian/Weill Cornell Medical Center, New York, New York
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Surgical Management and Outcomes following Pathologic Hip Fracture—Results from a Propensity Matching Analysis of the Registry for Geriatric Trauma of the German Trauma Society. Medicina (B Aires) 2022; 58:medicina58070871. [PMID: 35888590 PMCID: PMC9322375 DOI: 10.3390/medicina58070871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: The outcomes of patients with pathologic hip fractures remain unclear. Data from a large international geriatric trauma registry were analyzed to examine the outcomes of patients with pathologic hip fractures compared with patients with typical osteoporotic hip fractures. Materials and Methods: Data from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie (DGU)) (ATR-DGU) were analyzed. All patients treated surgically for osteoporotic or pathologic hip fractures were included in this analysis. Across both fracture types, a 2:1 optimal propensity score matching and multivariate logistic regression analysis were conducted. In-house mortality rate and mortality at the 120-day follow-up, as well as mobility after 7 and 120 days, reoperation rate, discharge management from the hospital and readmission rate to the hospital until the 120-day follow-up were analyzed as outcome parameters for the underlying fracture type—pathologic or osteoporotic. Results: A total of 29,541 cases met the inclusion criteria. Of the patients included, 29,330 suffered from osteoporotic fractures, and 211 suffered from pathologic fractures. Multivariate logistic regression analysis revealed no differences between the two fracture types in terms of mortality during the acute hospital stay, reoperation during the initial acute hospital stay, walking ability after seven days and the likelihood of being discharged back home. Walking ability and hospital readmission remained insignificant at the 120-day follow-up as well. However, the odds of passing away within the first 120 days were significantly higher for patients suffering from pathologic hip fractures (OR: 3.07; p = 0.003). Conclusions: Surgical treatment of pathologic hip fractures was marked by a more frequent use of arthroplasty in per- and subtrochanteric fractures. Furthermore, the mortality rate among patients suffering from pathologic hip fractures was elevated in the midterm. The complication rate, as indicated by the rate of readmission to the hospital and the necessity for reoperation, remained unaffected.
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Eberlin CT, Varady NH, Kucharik MP, Naessig SA, Best MJ, Martin SD. Comparison of perioperative complications following surgical treatment of shoulder instability. JSES Int 2022; 6:355-361. [PMID: 35572454 PMCID: PMC9091785 DOI: 10.1016/j.jseint.2022.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Surgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow. Methods This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time. Results This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (P trend < .001). Conclusion In addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.
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Affiliation(s)
- Christopher T. Eberlin
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Nathan H. Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Michael P. Kucharik
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Sara A. Naessig
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Matthew J. Best
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Scott D. Martin
- Department of Orthopaedic Surgery, Sports Medicine Center, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
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Kucharik MP, Varady NH, Best MJ, Rudisill SS, Naessig SA, Eberlin CT, Martin SD. Comparison of outpatient vs. inpatient anatomic total shoulder arthroplasty: a propensity score–matched analysis of 20,035 procedures. JSES Int 2021; 6:15-20. [PMID: 35141670 PMCID: PMC8811397 DOI: 10.1016/j.jseint.2021.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background As the proportion of anatomic total shoulder arthroplasty (aTSA) operations performed at outpatient surgical sites continues to increase, it is important to evaluate the clinical implications of this evolution in care. Methods Patients who underwent TSA for glenohumeral osteoarthritis from 2007 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Demographic data and 30-day outcomes were collected, and patients were separated into inpatient and outpatient (defined as same day discharge) groups. To control for confounding variables, a propensity score–matching algorithm was utilized. Outcomes included 30-day adverse events, readmission, and operative time. Results A total of 20,035 patients who underwent aTSA between 2007 and 2019 were identified: 18,707 inpatient aTSAs and 1328 outpatient aTSAs. On matching, there were no significant differences in patient characteristics between inpatient and outpatient cohorts. Patients who underwent outpatient aTSA were less likely to experience a serious adverse event when compared with their matched inpatient aTSA counterparts (outpatient: 1.1% vs. inpatient: 2.1%, P = .03). Outpatient aTSA was associated with similar rates of all specific individual complications and readmissions (1.5% vs. 1.9%, P = .31). Conclusion When compared with a propensity score–matched cohort of inpatient counterparts, the present study found outpatient aTSA was associated with significantly reduced severe adverse events and similar readmission rates. These findings support the growing use of outpatient aTSA in appropriately selected patients.
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Affiliation(s)
- Michael P. Kucharik
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
- Corresponding author: Michael P. Kucharik, BS, BS Sports Medicine Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, 175 Cambridge Street, Suite 400, Boston, MA 02114, USA.
| | - Nathan H. Varady
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Matthew J. Best
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
| | | | - Sara A. Naessig
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
| | - Christopher T. Eberlin
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
| | - Scott D. Martin
- Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital, Mass General Brigham Integrated Health Care System, Boston, MA, USA
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Amen TB, Varady NH, Birir A, Hayden BL, Chen AF. Morbidity and mortality of surgically treated pathologic humerus fractures compared to native humerus fractures. J Shoulder Elbow Surg 2021; 30:1873-1880. [PMID: 33220410 DOI: 10.1016/j.jse.2020.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite an increasing prevalence of patients sustaining pathologic fractures of neoplastic origin, few studies have investigated 30-day postoperative complication profiles after surgical treatment of pathologic humerus fractures. The purposes of this study were to use a large nationally representative database to determine short-term complication profiles after surgical treatment of pathologic humerus fractures and assess how these complications compared with more commonly studied native humerus fractures. METHODS Using the National Surgical Quality Improvement Program database, we identified 30,866 patients who underwent surgical treatment for either pathologic (n = 449) or native humerus fractures (n = 30,417) from 2007 to 2017. Thirty-day postoperative complication profiles were ascertained and compared between the 2 groups using χ2 analyses. Three logistic regression models were then performed to determine which complications were primarily attributable to the pathologic fracture itself vs. the increased comorbidity burden faced by these patients. RESULTS Patients with pathologic humerus fractures experienced significantly higher rates of death (6.0% vs. 0.3%, P < .001), serious adverse events (12.2% vs. 3.7%, P < .001), minor complications (15.8% vs. 4.8%, P < .001), extended postoperative lengths of stay (42.3% vs. 21.3%, P < .001), discharge to facilities (22.3% vs. 13.5%, P < .001), and readmissions (14.8% vs. 3.4%, P < .001) compared with patients with native humerus fractures. With respect to specific complications, patients with pathologic fractures were at significantly higher risk of pulmonary complications (1.3% vs. 0.3%, P < .001), renal complications (0.7% vs. 0.2%, P = .007), thromboembolic complications (1.6% vs. 0.6%, P = .01), and transfusions (15.1% vs. 4.1%, P < .001). CONCLUSION After surgical treatment, patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures, suggesting that guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin. These findings have significant implications for preoperative patient counseling and may be used to negotiate higher reimbursement rates for these patients given a significantly higher morbidity and mortality than was previously described in literature. Postoperatively, orthopedic surgeons should closely monitor patients with pathologic humerus fractures for deep vein thrombosis, renal complications, and pulmonary complications, use blood-sparing techniques, and employ a multidisciplinary approach to help manage and prevent a more heterogeneous profile of postsurgical complications.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aseal Birir
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brett L Hayden
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Willoughby JE, Baker JF. Survival analysis after intramedullary stabilization for metastatic disease of the femur: prognostic value of common laboratory parameters. ANZ J Surg 2020; 91:179-183. [PMID: 33084167 DOI: 10.1111/ans.16395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/15/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Metastatic disease of the femur confers significant morbidity and with improved survival due to advances in oncological treatment the prevalence in increasing. The aim of this study was to report on the outcomes of intramedullary stabilization for metastatic disease of the femoral shaft in a New Zealand centre and identify predictors of mortality. METHODS Ten-year retrospective review of clinical and radiographic records of patients treated with intramedullary stabilization for metastatic disease of the femur from a single tertiary referral hospital. Data on demographics, clinical and radiographic disease, laboratory markers, complications and mortality were collected. Univariate and multivariate analyses were used to determine predictors of mortality. RESULTS A total of 82 patients were reviewed (median age 72.5 years; 51% female). The most common primary tumour type was breast cancer (33%). Mortality rate was 15% and 77% at 30 days and 1 year, respectively. Multivariate analysis determined higher albumin (hazard ratio (HR) 0.51; P = 0.014) and higher Karnofsky Performance Score (HR 0.95; P < 0.001) were associated with reduced mortality risk; higher platelet count (HR 2.14; P = 0.009) and higher platelet : lymphocyte ratio (HR 1.87; P = 0.027) were associated with increased mortality risk. CONCLUSIONS Mortality rates were similar to those reported in other regions. Simple laboratory markers including serum albumin, platelet count and the platelet : lymphocyte ratio can aid clinicians in providing prognosis with surgical intervention.
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Affiliation(s)
| | - Joseph F Baker
- Department of Orthopaedic Surgery, Waikato Hospital, Hamilton, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand
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Meynard P, Seguineau A, Laumonerie P, Fabre T, Foltran D, Niglis L, Descamps J, Bouthors C, Lebaron M, Szymanski C, Sailhan F, Bonnevialle P. Surgical management of proximal femoral metastasis: Fixation or hip replacement? A 309 case series. Orthop Traumatol Surg Res 2020; 106:1013-1023. [PMID: 32778439 DOI: 10.1016/j.otsr.2020.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/04/2020] [Accepted: 05/13/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The proximal femur is the most frequent operative site for metastasis, but there is no consensus between internal fixation and hip replacement. The present multicenter retrospective observational study sought: (1) to compare early clinical results between internal fixation and hip replacement for proximal femoral metastasis (PFM), and (2) to assess events affecting survival. HYPOTHESIS The study hypothesis was that internal fixation and hip replacement give comparable clinical results, operative site complications rates and survival. MATERIAL AND METHODS The series comprised 309 cases, 10 of which were bilateral, in 182 females and 117 males, with a mean age of 67.2±11.5 years and 62.5±13.2 years, respectively. Primaries were mainly breast (118; 38.2%), lung (85; 25.5%) or kidney (40; 12.9%). PFM was revelatory in 114 cases (36.9%). There was visceral involvement in 142 patients (46%), multiple peripheral bone involvement in 212 (68.6%), and spinal involvement in 134 (43.4%). There were 124 pathologic fractures (40%), 51 of which were revelatory. Metastases were cervicocephalic in 135 cases (43.7%), metaphyseal in 166 (53.7%) and both in 8 (2.6%). PFM was osteolytic in 90% of cases, managed by hip replacement in 161 cases and internal fixation in 148 (12 screwed plates, 136 nails). Seventy-seven patients had postoperative radiation therapy. RESULTS After hip replacement (n=144), walking was normal in 35 cases (24.3%), impaired but unassisted in 53 (36.8%), with 1 forearm crutch in 24 (16.6%), 2 crutches or a frame in 26 (18%), and impossible in 6 (4.1%). After nailing (n=125), results were respectively 38 (30.4%), 47 (37.6%), 15 (12%), 18 (14.4) and 7 (5.6%). Recovery of normal walking capacity did not significantly differ according to technique (p=0.162); nor did pain or function. Recovery of normal walking capacity was better after preventive surgery (p<0.001). Perioperative complications comprised: 10 cases of severe blood loss, 7 pulmonary embolisms, 6 digestive hemorrhages, and 5 lung infections. Secondarily, there were 11 infections (7 after hip replacement, 2 after nailing, 2 after plate fixation), 7 progressive osteolyses and 5 fractures. Complications rates were significantly higher with plate fixation, with no difference between nailing and hip replacement. Survival did not significantly differ between hip replacement (12 months [95% CI: 7-19]), nailing (7 months [95% CI: 6-11]) and plate fixation (16 months [95% CI: 6-not calculable]). CONCLUSIONS Clinical results and survival were comparable between hip replacement and nailing, confirming the study hypothesis, in agreement with the literature. Each technique has its indications. Patients with severely impaired walking capacity benefited greatly from surgery. The importance of preventive surgery was highlighted. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Pierre Meynard
- Centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33076 Bordeaux cedex, France.
| | - Arthur Seguineau
- Centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33076 Bordeaux cedex, France
| | - Pierre Laumonerie
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse cedex, France
| | - Thierry Fabre
- Centre hospitalier universitaire de Bordeaux, place Amélie Raba-Léon, 33076 Bordeaux cedex, France
| | - Deborah Foltran
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse cedex, France
| | - Lucas Niglis
- Service d'orthopédie traumatologie, hôpital de Hautepierre, avenue Molière, 67200 Strasbourg, France
| | - Jules Descamps
- Service d'orthopédie, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Charlie Bouthors
- Service de chirurgie orthopédique et traumatologie et du Rachis, hôpital Kremlin-Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Marie Lebaron
- Service de chirurgie orthopédique et traumatologie, hôpital Nord, chemin des Bourrely, 13015 Marseille, France
| | - Christophe Szymanski
- Service de chirurgie orthopédique et traumatologie, hôpital Salengro, avenue du Professeur-Emile-Laine, 59037 Lille, France
| | - Fréderic Sailhan
- Service d'orthopédie, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Paul Bonnevialle
- Département universitaire d'orthopédie traumatologie, hôpital Pierre-Paul-Riquet, place Baylac, 31052 Toulouse cedex, France
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- Société française de chirurgie orthopédique et traumatologique (SoFCOT), 56, rue Boissonade, 75014 Paris, France
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Ehne J, Tsagozis P. Current concepts in the surgical treatment of skeletal metastases. World J Orthop 2020; 11:319-327. [PMID: 32908816 PMCID: PMC7441493 DOI: 10.5312/wjo.v11.i7.319] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/20/2020] [Accepted: 05/30/2020] [Indexed: 02/06/2023] Open
Abstract
Symptomatic metastatic bone disease affects a large proportion of patients with malignant tumours and significantly impairs patients’ quality of life. There are still controversies regarding both surgical indications and methods, mainly because of the relatively few high-quality studies in this field. Generally, prosthetic reconstruction has been shown to result in fewer implant failures and should be preferred in patients with a good prognosis. Survival estimation tools should be used as part of preoperative planning. Adjuvant treatment, which relies on radiotherapy and inhibition of osteoclast function may also offer symptomatic relief and prevent implant failure. In this review we discuss the epidemiology, indications for surgery, preoperative planning, surgical techniques and adjuvant treatment of metastatic bone disease.
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Affiliation(s)
- Jessica Ehne
- Department of Orthopedic Surgery, Karolinska University Hospital, Solna 171 76, Sweden
| | - Panagiotis Tsagozis
- Department of Orthopedic Surgery, Karolinska University Hospital, Solna 171 76, Sweden
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Amen TB, Varady NH, Hayden BL, Chen AF. Pathologic Versus Native Hip Fractures: Comparing 30-day Mortality and Short-term Complication Profiles. J Arthroplasty 2020; 35:1194-1199. [PMID: 31987688 DOI: 10.1016/j.arth.2020.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 12/30/2019] [Accepted: 01/05/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND A large body of research on native hip fractures has resulted in several evidence-based guidelines aimed at improving postsurgical care for these patients. In contrast, there is a paucity of data on pathologic hip fractures, and whether native hip fracture protocols are generalizable to this population is unknown. The purpose of this study was to compare mortality rates and complication profiles between patients with pathologic and native hip fractures. METHODS Using the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database, we identified patients who underwent surgical treatment for pathologic and native hip fractures from 2007 to 2017 and 2601 matched pairs were identified using propensity scoring. Baseline covariates were controlled for, and rates of 30-day postoperative complications and mortality were compared using McNemar's test. RESULTS Pathologic hip fracture patients experienced significantly higher rates of death (6.3% vs 4.3%, P < .001), serious adverse events (17.3% vs 13.5%, P < .001), minor complications (34.3% vs 29.1%, P < .001), extended postoperative lengths of stay (30.2% vs 25.9%, P < .001), readmissions (11.9% vs 8.4%, P < .001), thromboembolic complications (3.0% vs 1.6%, P < .001), and perioperative transfusions (31.5% vs 26.4%, P < .001) compared to native hip fracture patients. CONCLUSION Pathologic hip fractures result in significantly higher complication rates than native hip fractures after surgical treatment, suggesting that guidelines for native hip fractures may not be generalizable for pathologic hip fractures. Orthopedic surgeons should closely monitor these patients for deep vein thrombosis, utilize blood sparing techniques, and employ a multidisciplinary approach to help manage and prevent a more heterogenous profile of postsurgical complications.
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Affiliation(s)
- Troy B Amen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brett L Hayden
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Is Delayed Time to Surgery Associated with Increased Short-term Complications in Patients with Pathologic Hip Fractures? Clin Orthop Relat Res 2020; 478:607-615. [PMID: 31702689 PMCID: PMC7145067 DOI: 10.1097/corr.0000000000001038] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed time to surgery of at least 2 days after hospital arrival is well known to be associated with increased complications after standard hip fracture surgery; whether this association is present for pathologic hip fractures, however, is unknown. QUESTIONS/PURPOSES (1) After controlling for differences in patient characteristics, is delayed time to surgery (at least 2 days) for patients with pathologic hip fractures independently associated with increased complications compared with early surgery (fewer than 2 days)? (2) What preoperative factors are independently associated with major complications and mortality after surgery for pathologic hip fractures? METHODS A retrospective study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database of pathologic hip fractures (including femoral neck, trochanteric, and subtrochanteric fractures) from 2007 to 2017. This database was chosen over other databases given the high-quality preoperative medical history and postoperative complication (including readmissions, reoperations, and mortality) data collected from patient medical records through the thirtieth postoperative day. Patients were identified using Common Procedural Terminology codes for hip fracture treatment (THA, hemiarthroplasty, proximal femur replacement, intramedullary nail, and plate and screw fixation) with associated operative diagnoses for pathologic fractures as identified with International Classification of Diseases codes. A total of 2627 patients with pathologic hip fractures were included in this study; 65% (1714) had surgery within 2 days and 35% (913) had surgery after that time. Patient demographics, hospitalization information, and 30-day postoperative complications were recorded. Differences in characteristics between patients who underwent surgery in the early and delayed time periods were assessed with chi-square tests for categorical variables and t-tests for continuous variables. Delayed-surgery patients were more medically complex at the time of admission than early-surgery patients, including having higher American Society of Anesthesiologists classification (mean ± SD 3.18 ± 0.61 versus 2.94 ± 0.60; p < 0.001) and prevalence of advanced, "disseminated" cancer (53% versus 39%; p < 0.001). Propensity-adjusted multivariable logistic regression analyses were performed to assess the effect of delayed time to surgery alone on the various outcome measures. Additional independent risk factors for major complications and mortality were identified using backwards stepwise regressions. RESULTS After controlling for baseline factors, the only outcome associated with delayed surgery was extended postoperative length of stay (odds ratio 1.94 [95% CI 1.62 to 2.33]; p < 0.001). Delayed surgery was not associated with any postoperative complications, including major complications (OR 1.23 [95% CI 0.94 to 1.6]; p = 0.13), pulmonary complications (OR 1.24 [95% CI 0.83 to 1.86]; p = 0.29), and mortality (OR 1.26 [95% CI 0.91 to 1.76]; p = 0.16). Histories of chronic obstructive pulmonary disease (OR 2.48), congestive heart failure (OR 2.64), and disseminated cancer (OR 1.68) were associated with an increased risk of major complications, while dependent functional status (OR 2.27), advanced American Society of Anesthesiologists class (IV+ versus I-II, OR 4.81), and disseminated cancer were associated with an increased risk of mortality (OR 2.2; p ≤ 0.002 for all). CONCLUSIONS After controlling for baseline patient factors, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic hip fractures. These results are in contrast to the traditional dogma for standard hip fractures that surgery within 2 days of hospital arrival is associated with reduced complications. Although surgery should not be delayed needlessly, if the surgeon feels that additional time could benefit the patient, the results of this study suggest surgeons should not expedite surgery because of the risk of surgical delay observed for standard hip fractures. LEVEL OF EVIDENCE Level III, therapeutic study.
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