United States

Introduction
In the United States, deep vein thrombosis (DVT) and pulmonary embolism (PE) rank high in terms of preventable hospital deaths. Victims of trauma are at a higher risk of developing thromboembolic complications. The aim of this study is to compare the incidence of DVT/PE in trauma patients before and after a June 2022 policy intervention to continue prophylactic anticoagulation at an academic trauma center.

Methods
A retrospective review was conducted to compare DVT/PE rates in trauma patients requiring surgery from January 1, 2018, through December 31, 2023. Clinical information relating to trauma date, surgery date, injury type, anticoagulant administration, DVT/PE development, and death, if applicable, was obtained from patient charts.

Results
DVT/PE development was 14.553 times more likely pre-policy change when anticoagulation was held prior to surgery compared to post-policy change when anticoagulation was administered before surgery (X2 (3, N=374) =14.553, p=.002).

Conclusions
Findings suggest that DVT/PE rates have significantly decreased post policy change. Limitations include the presence of comorbidities in patients, varying trauma mechanisms and injury severity, and missing documentation. 

Authors
1. Armarion Stegall
2. John T. Watson, MD
3. Heidi Israel, PhD
4. Letitia Bradford, MD, FAAOS, FACS, Nth Dimensions

Affiliations
1. Mercer University School of Medicine, Columbus, GA
2. Saint Louis University, St. Louis, MO
3. Nth Dimensions


AMA Research Challenge 2024 

Harmless Bleeding: Assessing the Impact of Preoperative Anticoagulant Continuation on DVT/PE Rates in Trauma Patients

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Intro: Compartment syndrome, a surgical emergency, often requires fasciotomy within 6-8 hours of diagnosis. Prophylactic fasciotomy can also be considered in patients with a high risk of developing compartment syndrome. Current guidelines are unclear as to the impact of fasciotomy timing on patient outcomes. This study investigates the relationship between fasciotomy timing and rates of amputation and infection.

Methods: Data from 2017-2021 was accessed through the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP). ICD-10 codes were then used to quantify fasciotomy procedures, limb amputations, and infection rates.

Results: 22,004 patients analyzed in the TQIP database underwent fasciotomy. Of the fasciotomies performed there were 1,625 (5.35%) corresponding amputations. Rate of amputations were significantly lower in patients where fasciotomies were performed 1-4 hours compared to 4-8 hours (p<0.0001, OR=0.6088, 95% Cl=0.5180 to 0.7156) after presentation. There was no significant change in rate of amputation from 4-24 hours only, showing a significant increase after 48 hours. Deep surgical site infection rates showed a similar decrease from the 1-4 hour to the 4–8-hour time frame (p=0.0354, OR=0.6794, 95% Cl=0.4742 to 0.9736) with a significant increase after 12 hours (p=0.0283, OR=1.823, 95% Cl=1.095 to 3.033).

Conclusion: Although there was no significant correlation with fasciotomy timing and amputation within the first 24 hours, there was a significant increase in deep SSI and sepsis rates after the 8-hour time frame, suggesting that fasciotomy be performed within 4-8 hours of presentation. Interestingly, fasciotomy within the first 4 hours showed significantly elevated risk of both amputation and infection. This could be due to an increased injury severity, thus increasing the patient’s risk of further morbidity early in the hospital stay. This shows that initial management of patients requiring fasciotomy within the first 4 hours provides opportunities for more optimal outcomes in the future.

Implications of Emergent Fasciotomy Timing on Limb Salvage and Infection: 
A Trauma Quality Improvement Program (TQIP) Study

Introduction:
A challenge for orthopedic surgeons dealing with post-traumatic osteoarthritis of the elbow is a therapeutic procedure that maintains good mobility and functionality. Interposition Arthroplasty is a conservative procedure to alleviate arthritis and increase range of motion in a stiff elbow. This is achieved by placing graft tissues in the joint space of the elbow creating a false, but more mobile joint. It is especially popular in the younger, high demand population who desire a high functioning elbow that a total elbow arthroplasty would limit in regard to weight-bearing exercises and activities of daily living. 

Methods:
Through our institutions elbow pathology database, we were able to review records of patients who have received an Interposition Arthroplasty procedure from 2020-2024. We reviewed past medical history, comorbidities, time of injury, intraoperative complications, postoperative complications, pre/post operation x-rays, range of motion, and follow-up. 


Results:
There were 8 (3 female and 5 male) patients in this study who underwent the corrective surgery. The average age of the patient was 36 with a standard deviation of 12 years. The average follow -up time has been 5.44 months with a standard deviation of 7.85 months. 3 postoperative complications were reported which include elbow contracture with significant scarring adhesion, elbow pain, and broken medial plate involving another procedure (internal joint stabilizer).


Discussion/Conclusion:
Interposition arthroplasty serves as a viable substitute for total elbow arthroplasty, especially for younger patients needing a robust and functional elbow for everyday tasks and professional activities. It is imperative for more research to develop in this area of orthopedic surgery to improve the procedure's effectiveness and longevity for the patient’s desired elbow function. 


Interposition Arthroplasty of the Elbow for Post-Traumatic Injury Patients

Introduction: It is estimated that 58.5 million US adults have arthritis. Osteoarthritis (OA) is the most common form. Current American Academy of Orthopedic Surgeons (AAOS) treatment recommendations include conservative management (education, rest, activity modification, physical therapy (PT)) and medications (acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), knee injections) with a recommendation against opioids and if conservative care is no longer helpful, knee replacement surgery is the next course of action. 

Objective: To describe the current population and treatment trends in patients with symptomatic knee osteoarthritis.

Methods: A quality assurance project was completed to define the knee OA population in a private practice, and how their treatment aligns with AAOS guidelines and recommendations. Medical records were reviewed to identify patients and their age, gender, body mass index (BMI), numeric rating pain score (NRS) 0-10, where 0 means no pain and 10 is worst, and previous and present treatments. Treatments were evaluated against current non-arthroplasty and surgical AAOS Evidenced-based Clinical Treatment Guidelines. 

Results: Two hundred ninety-two radiographically confirmed OA patients (35% male, 65% female) who are currently following up with the practice were analyzed. The average age and BMI were 69 and 32, respectively. Most commonly reported symptom was pain with an average score of 7. There were more patients (67%) with unilateral knee OA than bilateral knee OA. Over the counter medications (Acetaminophen, 25%, NSAIDs, i.e., Ibuprofen and Naproxen, 54%) were the most common treatment. Prescription NSAIDs (i.e., diclofenac, meloxicam) at 27% and opioids at less than 1% were used. Knee injections significantly delayed time to surgery since presentation (p<.05) with a mean of 411 days using injections (95% CI, 323 – 498) and visco-supplementation knee injections significantly delayed surgery compared to only corticosteroid knee injections (p<.05) with a mean of 579 days using visco-supplementation (95% CI, 400 – 757).

Discussion: Nearly half of patients had PT and 86% received knee injections (steroids, visco-supplementation). At the time of review, 28% underwent total knee arthroplasty. Knee injections were able to delay a patient’s time between presentation and surgery, with visco-supplementation delaying the time to a greater degree than corticosteroids. 

Conclusion: Advanced age (greater than 65 years old) and obesity (BMI greater than 30) was common in this predominantly female population. Knee pain was the primary symptom at initial consultation. Rest, activity modification, oral medications, physical therapy, and knee injections were commonly used to treat OA. The results show conservative treatment options were exhausted prior to total knee arthroplasty.

Knee Osteoarthritis: A Snapshot of An Affected Population, their Symptoms and Treatment Options

Background: Osteochondritis dissecans of the capitellum is a common condition in adolescent overhead athletes, causing pain during physical activity, limited motion range, and functional impairments. While its exact cause is not fully understood, repetitive microtrauma and reduced blood supply are thought to contribute to lesion development. Traditional surgeries for unstable OCD lesions often fail to restore cartilage or subchondral bone, potentially leading to further joint problems. Osteochondral autograft transfers have emerged as a promising alternative that aims to both restore osteochondral structure and improve sports-related outcomes. This study examines the long-term impact of OATs on capitellar OCD lesions with the hypothesis that such interventions can prevent long-term elbow disability and facilitate a return to athletic activities
Hypothesis: We hypothesize osteochondral autologous transplantation surgery (OATS) provides long-term pain relief and maintains elbow function in adolescent athletes with capitellar osteochondritis dissecans (OCD) lesions.
Methods: A retrospective review of patients who underwent OATS between 2009 and 2023 was performed. Patients were identified by CPT code. Clinical assessment and surgeries were performed at a single institution by a single orthopaedic surgeon. Demographic data, preoperative clinical information, radiographic assessments, intraoperative findings, and postoperative outcomes were collected. Clinical and radiographic evaluations were performed, and preoperative MRI was analyzed. Intraoperative data, including graft dimensions and histopathology, were recorded. Postoperative data included MRI, complications, range of motion, return to sports, and patient satisfaction.
Results: 17 patients (15 males, 2 females) met inclusion criteria, with a mean follow-up duration of 62 months (range 12-170). The average age at time of surgery was 14 years old (±3, range 11-19). All but one patient presented with involvement of the dominant arm. All patients were athletes, with 15 competing at the elite level and 2 at the recreational level. Baseball was the most prevalent sport among these athletes. Preoperatively, every patient reported pain, and 6 of them present with a limited range of motion. The average passive pre-operative arc of motion increased from 127° ± 19 (range 80-150), with 136° of flexion and 8.9° of extension. All patients had undergone nonsurgical treatment involving rest and immobilization, and four had previously received surgical treatment at outside institutions. Intraoperatively, 4 patients had loose bodies. Synovial biopsies, performed in all cases, revealed papillary hypertrophy in 53% and mucoid/myxomatous degeneration in 59% of patients. A single osteochondral plug was used in each surgery. Postoperatively, there were no instances of instability or infections. The average passive arc of motion improved to 136.5°, consisting of 139° flexion and 3.2° extension. All athletes resumed sports activities, although one elite athlete did not return to the previous competitive level in the same sport. Additionally, one patient underwent a subsequent contracture release due to stiffness. No sign or evidence of decline in function was observed throughout the follow-up period.
Summary: 
• This study has identified synovial inflammation as a component of this disease process. 
• OATS has proven to be an effective treatment for capitellar OCD in adolescent athletes. 
• The restoration of osteochondral architecture provides both short-term and long-term elbow pain relief and restoration of high-level function.


Long-Term Outcomes of Osteochondral Autologous Transplantation Surgery in Adolescent Athletes with Capitellar Osteochondritis Dissecans

Abstract Title
Nationwide Surgical Trends in Distal Radius Fixation in Medicare Beneficiaries: Increased Utilization by Plastic Surgeons and Subspecialty Hand Surgeons

Background
In recent years, several randomized controlled trials have been published concerning the treatment of distal radius fractures (DRFs) in elderly patients. It remains unclear to what extent these studies have influenced clinical practice among different surgical specialties. This study aims to investigate both overarching trends and specialty-specific patterns in the surgical management of DRFs within the Medicare population.

Methods
Utilizing data from the Centers for Medicare & Medicaid Services, between 2013 and 2022, all claims associated with surgical management of DRFs were identified (Current Procedural Terminology [CPT] codes: 25606, 25607, 25608, and 25609). The results were further categorized based on primary operator type (general orthopedist, general plastics, general surgeon, subspecialty hand surgeon) and place of service (inpatient, outpatient, other).

Results
A total of 101,857 DRFs requiring surgical intervention were identified. Over a span of 10 years, the overall rate of distal radius fracture interventions (DRFIs) declined from 29.5 to 26.1 per 100,000 individuals, representing a 12% decrease. During this period, the utilization of closed reduction percutaneous pinning experienced a substantial 63% decrease, dropping from 4.8 to 1.8 per 100,000. Conversely, open treatment for distal radial intra-articular fractures of three or more fragments saw an 11% increase in utilization, rising from 10.0 to 11.1 per 100,000. After correction for the number of claims, general orthopedic and general surgeons experienced a notable decrease in utilization for DRFIs, 22% and 6% respectively, However, plastic surgeons and hand surgeons saw an increase in utilization for DRFIs, 74% and 13% respectively, over the same 10-year period. Additionally, there was an increasing shift towards outpatient DRFIs, with an 11% increase, whereas inpatient and other experienced a 17% and 36% decrease, respectively.

Conclusion
Between 2013 and 2022, there has been a notable decline in surgical interventions for distal radius fractures (DRFIs) within the Medicare population. While general orthopedic surgeons traditionally led the provision of DRFIs, recent trends indicate a shifting landscape. We observe a diminishing procedure share among general orthopedic surgeons and general surgeons, accompanied by a rising utilization of plastic surgeons and hand surgeons in addressing DRFIs.


Nationwide Surgical Trends in Distal Radius Fixation in Medicare Beneficiaries: Increased Utilization by Plastic Surgeons and Subspecialty Hand Surgeons

Background: Ankle fractures are one of the most common fractures that occur in the United States with an estimated incidence of 4.22/10,000 per year. Trimalleolar ankle fractures make up about 7% of all ankle fractures, but these fractures traditionally have worse recovery outcomes as well as a risk of future osteoarthritis. Surgical repair of the ankle after this type of fracture requires the reduction of the malleoli and stabilization of the syndesmosis. However, postoperative complications from this type of fracture include restricted mobility, pain, swelling, and limitation to activities of daily living. Smoking and nicotine use are well described in the literature to increase the risk of bone loss, decrease bone mineral density, and delay the union of fracture sites. The purpose of this study is to evaluate specific postoperative complications between nicotine- and non-nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fracture.

Methods: TriNetX, a global health database with de-identified patient information, was used and analyzed for this study. Cohort A was defined as patients who had surgical open treatment of trimalleolar ankle fractures with or without fixation (Current Procedural Terminology [CPT]: 27822, 27823) and had a dependence to nicotine (International Classification of Diseases, Tenth Revision, code: F17.2). Cohort B was defined as patients who had surgical open treatment of trimalleolar ankle fractures but did not have a dependence to nicotine. Data were gathered from healthcare organizations over the past 20 years. All post-diagnostic complications were analyzed between 1 and 120 days after the surgical open treatment of trimalleolar ankle fractures.

Results: 4,827 patients in cohort A were propensity matched with 25,467 patients in cohort B for age at the event, ethnicity, race, sex, type 2 diabetes mellitus, and body mass index. Nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fractures experienced a higher associated risk for numerous post-operative complications. When compared to non-dependent patients, nicotine-dependent patients had an increased risk for wound disruption (risk ratio [RR] 1.656, 95% confidence interval [CI] 1.28 – 2.14) and infection (RR 1.836, 95% CI 1.5 – 2.25) following a procedure within 120 days post open treatment of trimalleolar ankle fractures. Instances of avascular necrosis, deep vein thrombosis, pulmonary embolism, and revision surgeries were found not to be statistically different between the two cohorts.

Conclusion: This propensity-matched study showed that nicotine-dependent patients who were surgically treated with open treatment of trimalleolar ankle fractures were correlated with an increased risk for wound disruption and infection compared to their non-nicotine-dependent counterparts.

Nicotine Dependence on Postoperative Complications in Trimalleolar Ankle Fractures

Background
Body mass index (BMI) cutoffs are frequently implemented for total knee arthroplasty (TKA) candidates. However, recent data in primary TKA suggest obese patients have greater improvement in patient-reported outcome measures (PROMs) and no difference in postoperative complications when utilizing standardized medical optimization protocols. This study evaluated the influence of BMI on PROMs following revision TKA using these optimization protocols. The null hypothesis of the study was there would be no difference in PROMs based on BMI following revision TKA.

Methods
Between 2010 and 2022, 572 consecutive revision TKAs were retrospectively reviewed. All patients underwent risk assessment and medical clearance prior to surgery by a designated internal medicine specialist. Cases were dichotomized into two BMI groups, ≥35kg/m2 and <35kg/m2 (range, 20 to 65kg/m2). Activity level, pain, function, and satisfaction were compared between groups, controlling for multiple comorbidities and case characteristics. The BMI ≥35kg/m2 group was younger; had a higher prevalence of depression/anxiety and pre-revision narcotics; and worse pre-revision PROMs (P≤0.090). Multivariate statistical analysis was performed with P<0.05 as significant.

Results
Patients with a BMI ≥35 demonstrated greater improvement in their Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and experienced less pain when walking and climbing stairs (P≤0.071) over an average of 2.0 years. A higher percentage of patients in the BMI ≥35 group also achieved Minimal Clinically Important Differences (MCIDs) for PROMs (46-67% compared to 59-70%). Moreover, the BMI ≥35 group reported higher satisfaction levels (72.2% versus 66.5%, P=0.254), and more patients indicated that their knee 'always' feels normal (28.4% versus 19.8%, P=0.149). 
The groups did not differ by the indication for revision surgery or the number of components revised (P≥0.108). However, those who needed revision due to aseptic loosening showed significantly greater improvements in PROMs. There was no difference in the rate of re-revisions between the two groups for aseptic loosening or infection.

Conclusion
Despite being more debilitated preoperatively, revision TKA patients with a BMI ≥35 experienced greater improvements in PROMs compared to patients with lower BMIs, independent of revision indication. Given the significant improvements in PROMs with appropriate perioperative optimization, obese patients should not be restricted access to revision TKA when appropriately indicated.

Obesity is Associated With Greater Improvement in Patient-Reported Outcomes Following Revision Total Knee Arthroplasty

Background
The safety of outpatient versus inpatient total hip arthroplasty (THA) in the higher BMI population has not been described. The current study compared 90-day complications and 5-year revisions in patients following primary THA in the outpatient versus inpatient settings with BMI ≥ 35 kg/m2, a “high-risk” group as defined by prior studies.

Methods 
In this case-control study, adult patients with BMI ≥ 35 kg/m2 undergoing primary THA from 2010 to October 2022 were identified in the PearlDiver Mariner165 orthopedics database. Patients diagnosed with infection, trauma, or neoplasm of the hip within 90 days prior to surgery were excluded. Patients were categorized by service location of THA: inpatient or outpatient. 90-day postoperative adverse events were compared between groups with multivariable logistic regression controlling for age, sex, and Elixhauser Comorbidity Index (ECI). With Bonferroni correction, significance was established at P < 0.004. 5-year revision rates were compared with logrank test.

Results
Of high-BMI patients undergoing THA, 39,396 were inpatient and 11,505 were outpatient. These groups were exact matched 1:1 on age, sex, and ECI, yielding 11,455 patients in each matched group. Multivariate analysis demonstrated that outpatient THA was associated with lower 90-day odds ratios (ORs) for: deep vein thrombosis (OR: 0.47), pulmonary embolism (OR: 0.63), surgical site infection (OR: 0.69), and readmissions (OR: 0.40), in addition to multiple minor adverse events (P < 0.001 for each). Outpatient THA in the study population was not associated with differences in 90-day hip-related adverse events (dislocation, fracture) or 5-year all-cause revisions (P = 0.5).

Conclusion
Compared to inpatient THA, outpatient THA for those with BMI ≥ 35 kg/m2 was associated with lower odds of various severe and minor 90-day adverse events, with similar short-term hip-related outcome measures and 5-year revision rates. These findings are encouraging when considering performing outpatient THA in obese patients.

Outpatient Total Hip Arthroplasty Is Safe in High BMI Patients

Background
Total hip arthroplasty (THA) utilization is increasing significantly. Despite this, it is unknown whether patients have increasing interest in THA, and what patients search online regarding THA. Google Trends provides the relative search volume (RSV) regarding any search term. Therefore, we performed this study utilizing Google Trends to determine whether public interest in THA is increased, and to identify which THA search terms have the most engagement.

Methods
A longitudinal study on United States public interest in THA was performed with Google Trends from January 2013 – December 2022. 50 Google search terms were identified, for which the mean RSV was obtained and compared. RSV ranges from 0 – 100 and represents interest in a search term during at a specific point during the selected timeframe; 0 indicates negligible interest while 100 indicates maximal interest. Linear regression was used with yearly volume to determine if RSV increased significantly over time. We compared the rates of change for various pairs of search terms using an interaction model.

Results
Between 2013–2022, the mean RSV for “hip replacement” increased significantly [2013: 57; 2022: 92; p < 0.001], indicating increasing public interest in THA. Additionally, when comparing 50 search terms about THA, “hip replacement pain” and “hip replacement recovery” had significantly higher mean RSVs than other terms, and the ten highest mean RSV terms also included “hip replacement cost”, “hip replacement therapy”, “hip replacement precautions”, “hip replacement approach”, “how long does hip replacement take”, “hip replacement fracture”, “hip replacement infection”, and “hip replacement rehab” (65 vs 61 vs 20 vs 15 vs 14 vs 12 vs 11 vs 11 vs 10 vs 8; p < 0.001). The mean RSV significantly increased over the last decade for “hip replacement pain” [2013: 44; 2022: 88; p < 0.001] and “hip replacement recovery” [2013: 50; 2022: 73; p < 0.001]. The rate of change of these two terms was significantly more positive over time than all other terms.

Conclusion
Public interest in THA has significantly increased during the past decade, correlating with the increasing volume of THA being performed. Patients have interest in many topics about THA, with pain and recovery having the largest increase in search volume over time. Other topics such as cost, therapy, surgical length/approach, and complications were also commonly searched. Patient information resources should ensure to include these variety of topics to meet changing patient interests.

Patients Have Increasing Interest In Total Hip Arthroplasty In The United States

Introduction. Postoperative pain control is critical in orthopedic surgery. While efficacious analgesics, opiates have rapid tolerance and addictive potential. Metamizole is a non-opioid analgesic primarily inhibiting COX-3, commonly used in Europe and South America, but banned in the U.S. due to concerns about agranulocytosis risk. However, large meta-analyses have not shown significant agranulocytosis when compared to other analgesics. The purpose of this review is to assess the analgesic efficacy of metamizole and potential use in orthopedic surgery.
Methods. An electronic review was conducted of PubMed, Web of Science, Cochrane, Embase, and OVID Medline in October 2023. Studies for inclusion were limited to those in which metamizole use was a primary focus, patients were undergoing orthopedic surgery, studies in human patients, and studies reporting in the English language.
Results. 1,112 studies were identified and 15 (1.3%) met inclusion criteria. The use of metamizole as a single agent or in combination therapy was described to be superior or non-inferior to alternative analgesics in 10 (66.7%) studies. Metamizole decreased rescue analgesia in 5 (33.3%) articles. No patients experienced agranulocytosis.
Conclusions. Metamizole was efficaciously non-inferior to other non-opioid analgesics by demonstrating an opioid sparing effect in over a third of included studies. Metamizole did not have significant differences in incidence or severity of side effects and no cases of agranulocytosis were seen across all studies. These results indicate the potential for metamizole as analgesia in the setting of orthopedic surgery. Future studies should focus on larger cohorts to continue to assess efficacy and risk of agranulocytosis.


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