Mortality Risk Assessment of Total Knee Arthroplasty and Related Surgery After Percutaneous Coronary Intervention

Background: The optimal antiplatelet therapy (APT) treatment strategy after Coronary Artery Stenting (CAS) in non-cardiac surgery, such as total knee arthroplasty (TKA) or urgent TKA-related surgery remains unknown. Methods: We built a decision tree model to examine the mortality outcomes of two alternative strategies for APT after CAS use in the perioperative period namely, continuous use and discontinuation. Results: If surgery was performed in the first month after CAS placement, discontinuing APT led to an estimated 30-day post TKA mortality of 10.5%, compared to 1.0% in a strategy with continuous APT use. Mortality with both strategies decreased with longer intervals. Conclusion: Our model demonstrated that APT discontinuation in patients undergoing TKA or urgent TKA related surgery after CAS placement might lead to greater 30-day mortality up to one year

Factors associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome

Introduction: The objective of this study is to determine factors associated with myonecrosis at the time of fasciotomy in patients with acute leg compartment syndrome. Methods: A retrospective cohort study was conducted of 546 patients with acute leg compartment syndrome treated with fasciotomies from January 2000 to June 2015 at two tertiary trauma centers. The main outcome measurement was clinical myonecrosis diagnosed by the treating surgeon at the time of fasciotomy. Results: Eighty-two patients (15.0%) with acute leg compartment syndrome had myonecrosis at time of fasciotomy. Multivariable logistic regression analyses showed that younger age (p = 0.004) and diabetes mellitus (p < 0.001) were associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome. Serum creatine kinase at presentation greater than 2405 U/L was found to be associated with myonecrosis at time of fasciotomy in post hoc analysis (p < 0.001). Conclusions: Myonecrosis is associated with patient-related factors. Younger age by 10 years is associated with a 1.3 times increase and diabetes mellitus with a 3-time increase in the odds of myonecrosis. Serum creatine kinase at presentation greater than 2405 U/L denotes an almost 3 times increase in odds of myonecrosis and may be useful for preoperative counseling

Survivorship and Complications of the Distal Femoral Osteotomy

Objectives: Distal femoral osteotomy (DFO) is a useful procedure in the young patient with symptomatic unicompartmental osteoarthritis and valgus malalignment to avoid or postpone knee arthroplasty. Distal femoral osteotomy can be technically demanding and various complications are reported in the literature. Our retrospective study aims to evaluate the outcomes and analyze survivorship of the distal femoral osteotomy until eventual conversion to knee arthroplasty. Methods: We performed a retrospective review of 78 open-wedge distal femoral osteotomies done on 74 patients at our institution between 2001 and 2011. The average patient age at surgery is 33 ± 11 years with mean BMI of 28 ± 6. All surgeries were performed by two of the senior authors and 60.3% were done in conjunction with cartilage repair procedures such as autologous chondrocyte implantation and osteochondral graft transfer. Other associated procedures included lateral release, tibial tubercle osteotomy, quadricepsplasty and ACL reconstruction. The average follow-up duration was 43 ± 31 months and the need for further procedures (such as arthroscopic adhesiolysis, hardware removal, revision osteotomy and eventual progression to arthroplasty) was identified with relation to complications. Statistical analyses for survivorship were performed using MedCalc for Windows, version 12.5 (MedCalc Software, Ostend, Belgium). Results: Of the 71 patients who followed -up beyond six months post-operatively, seven eventually converted to total knee arthroplasty (9.9%). The most common complication was hardware pain (20.5%) followed by arthrofibrosis (12.8%). All cases of arthrofibrosis were noted to have had intra-articular surgical manipulation for associated procedures such as cartilage repair. Other less common complications included hardware failure (3.8%), septic arthritis (3.8%) and nonunion (2.6%). Osteotomy hardware removal was performed in fourteen cases (17.9%). Kaplan - Meier survivorship analysis estimates mean survival time of 123 ± 8 months (with 95% confidence interval of 107 - 138) and survival probability at 10 years follow-up is estimated at 78%. Conclusion: Distal femoral osteotomy is an acceptable surgical option for the young patient with severe unicompartmental knee osteoarthritis and malalignment. Its combination with various cartilage repair procedures has been shown to further improve outcomes. Careful selection of each surgical candidate is necessary to ensure maximum benefit. The unloading osteotomy is especially useful in the young, active patient as an adjunct procedure for cartilage repair. However, osteoarthritis continues to progress and multiple arthroscopic or open procedures may be required despite a successful osteotomy. When performed at the optimal time in a carefully selected patient, distal femoral osteotomy can provide adequate joint function for many years until arthroplasty becomes inevitable

Risk factors for death and amputation in acute leg compartment syndrome

Introduction: The primary objective of this study is to determine whether time from injury to fasciotomy is associated with increased risk for death or limb amputation in patients with acute leg compartment syndrome. The secondary objective of this study is to identify other risk factors for death or limb amputation in patients with acute leg compartment syndrome. Methods: In an institutional review board approved retrospective study, we identified 546 patients with acute compartment syndrome of 558 legs treated with fasciotomies from January 2000 to June 2015 at two Level I trauma centers. Our primary outcome measures were death and limb amputation during inpatient hospital admission. Electronic medical records were analyzed for patient-related factors and treatment-related factors. Bivariate analyses were used to screen for variables associated with our primary outcome measures, and explanatory variables with a p value below 0.05 were included in our multivariable logistic regression analyses. Results: In-hospital death occurred in 6.6% and in-hospital limb amputation occurred in 9.5% of acute leg compartment syndrome patients. Neither death nor limb amputation was found to be associated with time from injury to fasciotomy. Multivariable logistic regression analyses showed that older age (p = 0.03), higher modified Charlson Comorbidity Index (p = 0.009), higher potassium (p = 0.02), lower hemoglobin (p = 0.002), and higher lactate (p < 0.001) were associated with death, and diabetes mellitus (p = 0.05), no compartment pressure measurement (p = 0.009), higher PTT (p = 0.03), and lower albumin (p = 0.01) were associated with limb amputation. Conclusions: Time to fasciotomy is not found to be associated with death or limb amputation in acute leg compartment syndrome. Death and limb amputation are associated with patient-related factors and injury severity. Level of evidence: Level III Prognostic

Recurrent Septic Arthritis Due to Achromobacter xylosoxidans in a Patient With Granulomatosis With Polyangiitis

We report a case of recurrent Achromobacter xylosoxidans infections including bacteremia, sepsis, septic joints and endocarditis in a 72 year old female with granulomatosis with polyangiitis. Achromobacter xylosoxidans is a gram negative bacteria increasingly identified in immunocompromised patients. Surgical and medical therapy may need to be combined

Factors Associated With Poor Outcomes in Acute Forearm Compartment Syndrome

Background: There is limited literature on risk stratification of patients with acute forearm compartment syndrome. The primary objective of this study was to identify factors associated with poor outcomes in patients with acute forearm compartment syndrome. Methods: We retrospectively identified 130 patients with acute compartment syndrome of 130 forearms treated with fasciotomies from January 2000 to June 2015 at 2 Level 1 trauma centers. Poor outcome was defined as a composite variable, including: (1) death; (2) limb amputation; (3) persistent neurological deficit; and (4) contracture. Patient- and treatment-related variables were collected. Bivariate analyses were used to screen for variables associated with poor outcome, and explanatory variables with a value of P <.05 were included in our multivariable logistic regression analyses. Results: Of the 130 patients, 43 (33%) with acute forearm compartment syndrome had poor outcomes, including 5 deaths, 5 limb amputations, 21 persistent neurological deficits, and 31 contractures. Multivariable logistic regression analyses showed that elevated serum creatine kinase at presentation (P <.05) was associated with poor outcomes in patients with acute forearm compartment syndrome. Receiver operating characteristic curve analysis showed that a serum creatine kinase cutoff of 300 U/L yields 92% sensitivity and a serum creatine kinase cutoff of 10 000 U/L yields 95% specificity for poor outcomes in acute forearm compartment syndrome. Conclusions: Elevated creatine kinase levels above 300 U/L are a useful screening test for the highest risk patients with acute forearm compartment syndrome. Levels above 10 000 U/L may play a role in informed consent and counseling regarding expectations