Not All Patients Need Supervised Physical Therapy After Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

Although postoperative physical therapy (PT) has long been considered essential to successful total knee arthroplasty (TKA) recovery, recent literature has suggested that unsupervised home exercise regimens may offer similar benefits to formal supervised sessions. We aimed to compare objectively measured physical function and subjective patient-reported outcomes (PROs) between primary TKA patients who received formal supervised physical therapy sessions and those who received unsupervised home exercise regimens after discharge. Six electronic databases were queried to identify randomized controlled trials comparing supervised physical therapy to unsupervised home exercise regimens in primary TKA patients after discharge. Outcomes of interest included change from baseline in objective measures (knee flexion range of motion (ROM), lower extremity strength, and aerobic capacity) and PROs (physical function and quality of life scores). These outcomes were subdivided into short-term (surgery; closest data point to three months is used if multiple measurements were made in this time period) and long-term (≥6 months from surgery; closest data point to 12 months is used if multiple measurements were made in this time period) assessments. A total of 1,884 cases performed in 11 studies were included in this review. There were no significant differences between cohorts with regard to short-term knee flexion ROM (p = 0.7), lower extremity strength (p = 0.6), or patient-reported quality of life (p = 0.5), as well as long-term knee flexion ROM (p = 0.7), patient-reported quality of life (p = 0.2), or patient-reported physical outcome scores (p = 0.3). A small difference in short-term patient-reported physical outcomes was observed in favor of the supervised cohort (standardized mean difference (SMD): 0.3 (95% confidence interval (CI): 0.01, 0.6); I2 = 82%; p = 0.04). Formal supervised physical therapy regimens do not confer clinically significant benefits over unsupervised home exercise regimens following primary TKA. The routine use of supervised physical therapy after discharge may not be warranted. Further study is needed to determine the subset of patients that may benefit from supervised care

Comparing five equations to calculate estimated glomerular filtration rate to predict acute kidney injury following total joint arthroplasty.

BACKGROUND: Acute kidney injury (AKI) following total joint arthroplasty (TJA) is associated with increased morbidity and mortality. Estimated glomerular filtration rate (eGFR) is used as an indicator of renal function. The purpose of this study was (1) to assess each of the five equations that are used in calculating eGFR, and (2) to evaluate which equation may best predict AKI in patients following TJA. METHODS: The National Surgical Quality Improvement Program (NSQIP) was queried for all 497,261 cases of TJA performed from 2012 to 2019 with complete data. The Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Cockcroft-Gault, Mayo quadratic, and Chronic Kidney Disease Epidemiology Collaboration equations were used to calculate preoperative eGFR. Two cohorts were created based on the development of postoperative AKI and were compared based on demographic and preoperative factors. Multivariate regression analysis was used to assess for independent associations between preoperative eGFR and postoperative renal failure for each equation. The Akaike information criterion (AIC) was used to evaluate predictive ability of the five equations. RESULTS: Seven hundred seventy-seven (0.16%) patients experienced AKI after TJA. The Cockcroft-Gault equation yielded the highest mean eGFR (98.6 ± 32.7), while the Re-expressed MDRD II equation yielded the lowest mean eGFR (75.1 ± 28.8). Multivariate regression analysis demonstrated that a decrease in preoperative eGFR was independently associated with an increased risk of developing postoperative AKI in all five equations. The AIC was the lowest in the Mayo equation. CONCLUSIONS: Preoperative decrease in eGFR was independently associated with increased risk of postoperative AKI in all five equations. The Mayo equation was most predictive of the development of postoperative AKI following TJA. The mayo equation best identified patients with the highest risk of postoperative AKI, which may help providers make decisions on perioperative management in these patients

Comparison of Estimated Glomerular Filtration Rate Using Five Equations to Predict Acute Kidney Injury Following Hip Fracture Surgery

Introduction: Hip fractures are a common injury and a source of disability and mortality in the aging population. Acute kidney injury (AKI) is a common and potentially serious complication following hip fracture surgery. Estimated glomerular filtration rate (eGFR) is used as an indicator of renal function. Several equations are commonly used to calculate eGFR. The purpose of this study was 1) to evaluate the agreement between five equations in calculating eGFR, and 2) to confirm which equation can best predict AKI in patients undergoing hip fracture surgery. Methods: 146,702 cases of surgical stabilization of hip fracture were queried from the National Surgical Quality Improvement Program (NSQIP) from 2012 to 2019. Preoperative eGFR was calculated using the Cockcroft-Gault, Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Chronic Kidney Disease Epidemiology Collaboration, and Mayo quadratic (Mayo) equations. The primary outcome measure was AKI. Cases were stratified into two cohorts based on the development of postoperative AKI. These cohorts were compared based on demographic and preoperative factors. Multivariate regression analysis was used to evaluate independent associations between preoperative eGFR and postoperative renal outcomes. Results: Six hundred ninety-nine (0.73%) patients acquired AKI after hip fracture surgery. The Mayo equation yielded the highest mean eGFR (83.8 ± 23.6), while the Re-expressed MDRD II equation yielded the lowest mean eGFR (68.3 ± 35.6). Multivariate regression analysis showed that a decrease in preoperative eGFR was independently associated with an increased risk of postoperative AKI in all five equations. The Akaike information criterion (AIC) was the lowest in the Mayo equation (5116). Conclusions: Preoperative decrease in eGFR in all five equations was independently associated with increased risk of postoperative AKI. The Mayo equation had the highest predictive ability of acquiring postoperative AKI following hip fracture surgery

Unsupervised Home Exercises Versus Formal Physical Therapy After Primary Total Hip Arthroplasty: A Systematic Review

Historically, postoperative exercise and physical therapy (PT) have been viewed as crucial to a successful outcome following primary total hip arthroplasty (THA). This systematic review and meta-analysis aimed to assess differences in both short- and long-term objective and self-reported measures between primary THA patients with formal supervised physical therapy versus unsupervised home exercises after discharge. A search was conducted of six electronic databases from inception to December 14, 2020, for randomized controlled trials (RCTs) comparing changes from baseline in lower extremity strength (LES), aerobic capacity, and self-reported physical function and quality of life (QoL) between supervised and unsupervised physical therapy/exercise regimens following primary THA. Outcomes were separated into short-term (surgery, closest to 3 months) and long-term (≥6 months from surgery, closest to 12 months) measures. Meta-analyses were performed when possible and reported in standardized mean differences (SMDs) with 95% confidence intervals (CI). Seven studies (N=398) were included for review. No significant differences were observed with regard to lower extremity strength (p=0.85), aerobic capacity (p=0.98), or short-term quality of life scores (p=0.18). Although patients in supervised physical therapy demonstrated improved short-term self-reported outcomes compared to those performing unsupervised exercises, this was represented by a small effect size (SMD 0.23 [95% CI, 0.02-0.44]; p=0.04). No differences were observed between groups regarding long-term lower extremity strength (p=0.24), physical outcome scores (p=0.37), or quality of life (p=0.14). The routine use of supervised physical therapy may not provide any clinically significant benefit over unsupervised exercises following primary THA. These results suggest that providers should reconsider the routine use of supervised physical therapy after discharge

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration

BACKGROUND: Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery. AIM: To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients. METHODS: In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of \u3c 7 g/dL hemoglobin in asymptomatic patients and \u3c 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P \u3c 0.05. RESULTS: Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P \u3c 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P \u3c 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring \u3e 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort. CONCLUSION: The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery

Predictors of Hospice Discharge Following Surgical Fixation of Hip Fracture

Introduction: Each year, over 300,000 people over the age of 65 are hospitalized for hip fractures, and even with co-management of patients perioperatively with a geriatric team, hip fractures in the elderly are associated with significant morbidity and mortality. Given the extreme morbidity and mortality faced by elderly patients in the post-injury period, recommendations have been put forth for the integration of palliative and even hospice care, to help improve patients’ quality of life. Our objectives were to 1) determine the proportion of patients discharged to hospice following hip fracture surgery and their 30-day mortality rates of these patients, and 2) identify the independent predictors of discharge to hospice. Methods: We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) for all hip fractures surgeries between the years of 2016 and 2018. Included cases were stratified into two cohorts: cases involving a discharge to hospice and non-hospice discharge. Variables assessed included patient demographics, comorbidities, perioperative characteristics, and postoperative outcomes. Differences between hospice and non-hospice patients were compared using chi-squared analysis or Fisher\u27s exact test for categorical variables and Student’s t-tests for continuous variables. A binary logistic regression model was used to assess independent predictors of hospice discharge with 30-day mortality. Results: Overall, 31,531 operatively treated hip fractures were identified, of which 281 (0.9%) involved a discharge to hospice. Patients discharged to hospice had a 67% 30-day mortality rate in comparison to 5.6% of patients not discharged to hospice (p \u3c 0.001). Disseminated cancer, dependent functional status, \u3e10% weight loss over six months preoperatively, and preoperative cognitive deficit were the strongest predictors of hospice discharge with 30-day mortality following hip fracture surgery. Conclusions: Current hospice utilization in hip fracture patients remains low, but 30-day mortality in these patients is high. An awareness of the associations between patient characteristics and discharge to hospice with 30-day mortality is important for surgeons to consider when discussing postoperative expectations and outcomes with these patients

Evaluation of the Posterior Tilt Angle in Predicting Failure of Nondisplaced Femoral Neck Fractures After Internal Fixation: A Systematic Review

OBJECTIVE: This systematic review and meta-analysis aimed to evaluate the posterior tilt angle (PTA) in predicting treatment failure after internal fixation of nondisplaced femoral neck fractures as graded by the Garden classification, which is based solely on anterior-posterior radiographic evaluation. DATA SOURCES: A search was conducted of all published literature in the following databases from inception to December 20, 2021: PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov. STUDY SELECTION: We included English-language randomized controlled trials, prospective and retrospective cohort studies that reported malunion/nonunion, avascular necrosis, fixation failure, or reoperations in patients with nondisplaced femoral neck fractures treated with internal fixation who were evaluated for PTA using either lateral radiograph or computed tomography (CT). DATA EXTRACTION: All abstract, screening, and quality appraisal was conducted independently by two authors. Data from included studies was extracted manually and summarized. The Methodological Index for Non-Randomized Studies criteria was used for quality appraisal. DATA SYNTHESIS: Odds ratios (OR) with 95% confidence intervals (CI) were calculated for treatment failure, defined as nonunion/malunion, AVN, fixation failure, or reoperation, in cases involving preoperative PTA ≥20 degrees andp\u3c0.05. RESULTS: Nondisplaced femoral fractures with PTA\u3e20 degrees had a 24% rate of treatment failure compared to 12% for those(OR, 3.21 [95% CI, 1.95-5.28]; p\u3c0.001). CONCLUSION: PTA is a predictor of treatment failure in nondisplaced femoral neck fractures treated with internal fixation. Nondisplaced femoral neck fractures with a PTA \u3e20 degrees may warrant alternative treatment modalities. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence

Prognostic Value of Posterior Tilt Angle in Determining Outcome of Internal Fixation of Nondisplaced Femoral Neck Fractures

INTRODUCTION: As the population continues to age there is expected to be an increase in prevalence of femoral neck fractures. The standard tool for guiding treatment decisions in femoral neck fractures is the Garden Classification, which is based around the severity of displacement. Garden I and II fractures display minimal displacement and suggest internal fixation as the preferred surgical option rather than arthroplasty. Recent literature indicates the rate of revision surgery following internal fixation of Garden I and II fractures is approximately 20%. Originally proposed by Palm et al, Posterior Tilt Angle (PTA) is a radiographic measurement that evaluates the severity of angulation at the site of femoral neck fracture. Measured on a lateral radiograph of the hip, the PTA consists of the angle between the mid-column line and the radius column line. Palm suggested the PTA has prognostic value in determining the outcome of internal fixation of femoral neck fractures, with 20 degrees being the cut off angle. The goal of this systematic review is to determine association between preoperative PTA and the risk of failure after internal fixation of nondisplaced femoral neck fractures. METHODS: This systematic review was conducted following PRISMA guidelines. Quality appraisal was conducted using the MINORS criteria and all data from the included studies was manually extracted and summarized. Outcomes of interest included development of malunion, nonunion, avascular necrosis, loss of fixation, and reoperation requirement. A full text review of 40 studies was conducted after inclusion and exclusion criteria were applied and a total of 17 studies were included in the systematic review. RESULTS: Treatment failure was observed in 14% of cases. PTA ≥20° had a failure rate of 24%, compared to 12% for \u3c20° (p\u3c0.001). Among studies reporting continuous values for PTA, those with failure were found to have 8.2° larger PTA (p=0.003). CONCLUSION: The Posterior Tilt Angle is a useful measurement in predicting internal fixation failure of Garden I and II femoral neck fractures. There is a significantly higher rate of failure for internal fixation when the PTA is greater than 20 degrees. In these cases, arthroplasty may be a better treatment option. Study of PTA as a continuous variable is recommended to determine the true critical value

Fusion versus fixation in complex comminuted C3-type tibial pilon fractures: a systematic review.

BACKGROUND: Comminuted intra-articular tibial pilon fractures can be challenging to manage, with high revision rates and poor functional outcomes. This study reviewed [1] treatment, complications, and clinical outcomes in studies of complex comminuted tibial pilon fractures (type AO43-C3); and [2] primary ankle arthrodesis as a management option for these types of complex injuries. METHODS: A systematic literature search was performed on PubMed from 1990 to 2020 to determine complications and outcomes after staged fracture fixation and primary ankle joint arthrodesis for comminuted C3-type tibial pilon fractures. The search was conducted in compliance with the PRISMA guidelines, using the following MeSH terms: tibial pilon / pilon fracture / plafond fracture / distal tibial / 43-C3 / ankle fracture / ankle fusion / primary ankle arthrodesis / pilon fracture staged / pilon external fixation and pilon open reduction internal fixation. Inclusion criteria were restricted to original articles in English language on adult patients ≥18 years of age. Eligibility criteria for retrieved publications were determined using a PICO approach (population, intervention/exposure, comparison, outcomes). Weighted analysis was used to compare treatment groups on time to definitive treatment, follow-up time, range of motion, fracture classification, and complications. RESULTS: The systematic literature review using the defined MeSH terms yielded 72 original articles. Of these, 13 articles met the eligibility criteria based on the PICO statements, of which 8 publications investigated the outcomes of a staged fixation approach in 308 cumulative patients, and 5 articles focused on primary ankle arthrodesis in 69 cumulative patients. For staged treatment, the mean wound complication rate was 14.6%, and the malunion/nonunion rate was 9.9%. For primary arthrodesis, the mean wound complication rate was 2.9%, and the malunion/nonunion rate was 2.9%. After risk stratification for fracture type and severity, the small cumulative cohort of patients included in the primary arthrodesis publications did not provide sufficient power to determine a clinically relevant difference in complications and long-term patient outcomes compared to the staged surgical fixation group. CONCLUSIONS: At present, there is insufficient evidence in the published literature to provide guidance towards consideration of ankle arthrodesis for complex comminuted C3-type tibial pilon fractures, compared to the standard treatment by staged surgical fracture fixation