Faculty Bibliography

Background/UNASSIGNED:Sutures and staples are the mainstay wound closure techniques in total joint arthroplasty. Newer techniques such as zipper devices and novel skin adhesives have emerged because of their potential to decrease operative time and possibly minimize complications. The aim of this study is to compare these newer techniques against conventional sutures with respect to wound complications, closure time, and costs. Methods/UNASSIGNED:A single-center randomized control trial was conducted on 160 patients (52 zipper, 55 suture, 53 mesh) who underwent primary total hip or knee arthroplasty between February 2017 and May 2018. Patients were divided into 3 closure groups: zipper device, monofilament suture plus adhesive, and monofilament plus polyester mesh with adhesive. The primary endpoint was closure time (superficial skin layer). Secondarily we collected perioperative complication rates, including infection, persistent (14-day) wound drainage, 90-day readmission, and emergency room visit rates as well as compared material costs. Results/UNASSIGNED:There were no differences in baseline characteristics between groups for age, body mass index, and American Society of Anesthesiologists classification. There was a trend toward decreased time to closure for the suture group. There were no significant differences between groups for our secondary endpoint, complications. Conclusions/UNASSIGNED:Our study shows that the suture group trended toward shorter closure time but suggests that each of the closure methods after total joint arthroplasty has equivalent complication rates. With small differences in closure time and no significant differences in complications, the decision to use one wound closure device or technique over another should be driven by institutional costs and provider familiarity.

Background  Pisiform dislocations are an extremely rare injury. There are reports in the literature of isolated dislocations, but to our knowledge there are no reports of distal radius fractures with associated pisiform dislocations. Methods and Results  We present two cases of isolated pisiform dislocation and distal radius fracture in the adult population. Both patients were managed conservatively with closed reduction in both the distal radius and pisiform, and subsequently achieved good pain relief and progressive return of wrist function. Conclusion  For adult patients with distal radius fractures and an associated pisiform dislocation, successful closed reduction and immobilization can result in symptomatic improvement and return of function.

Osseous metastases are common in advanced cancer stages. The tibia is the appendicular skeleton bone affected third most often. However, tibial metastases are not well described. We conducted a retrospective descriptive single-institution study of patients with evidence of tibial metastatic disease in order to better characterize tibial metastases in their anatomical distribution and histology, and to describe their clinical presentation and surgical management. Using proprietary research software, we searched pathology and radiology reports and cross-referenced results with Current Procedural Terminology procedure codes to identify patients with metastatic lesions of the tibia. We then reviewed these patients' medical records and reviewed and verified all available imaging. We reviewed the medical records of 36 patients (20 females, 16 males) with 43 affected tibiae. Mean age was 63.5 years. Of 12 different primary neoplasms, the most common were prostate, breast, and lung cancers. The proximal tibia was the region most commonly affected, followed by the diaphysis. Of 6 impending fractures, 3 were treated with intramedullary nail, 2 with total knee megaprosthesis, and 1 with total knee arthroplasty. Of 2 pathologic fractures, 1 was treated with intramedullary nail and 1 with periarticular locking plate. Almost all identified patients (88.9%) had other metastatic lesions. Almost half (47.2%) of patients presented with symptomatic tibia lesions. Mean time from diagnosis of malignancy to tibial metastasis was 1282 days (range, 0-3708 days). Metastases to the tibia are uncommon but often require surgical intervention. Fixation technique should be selected on a case-by-case basis, and patients should be treated by a multidisciplinary team. Patients with known malignancy and tibial pain should undergo a work-up for tibia lesions.

INTRODUCTION/BACKGROUND:Frailty is a clinical state of increased vulnerability resulting from aging-associated decline in physiologic reserve. Hip fractures are serious fall injuries that affect our aging population. We retrospectively sought to study the effect of frailty on postoperative outcomes after Total Hip Arthroplasty (THA) and Hemiarthroplasty (HA) for femoral neck fracture in a national data set. METHODS:National Surgical Quality Improvement Project dataset (NSQIP) was queried to identify THA and HA for a primary diagnosis femoral neck fracture using ICD-9 codes. Frailty was assessed using the modified frailty index (mFI) derived from the Canadian Study of Health and Aging. The primary outcome was 30-day mortality and secondary outcomes were 30-day morbidity and failure to rescue (FTR). We used multivariate logistic regression to estimate odds ratio for outcomes while controlling for confounders. RESULTS:Of 3121 patients, mean age of patients was 77.34 ± 9.8 years. The overall 30-day mortality was 6.4% (3.2%-THA and 7.2%-HA). One or more severe complications (Clavien-Dindo class-IV) occurred in 7.1% patients (6.7%-THA vs.7.2%-HA). Adjusted odds ratios (ORs) for mortality in the group with the higher than median frailty score were 2 (95%CI, 1.4-3.7) after HA and 3.9 (95%CI, 1.3-11.1) after THA. Similarly, in separate multivariate analysis for Clavien-Dindo Class-IV complications and failure to rescue 1.6 times (CI95% 1.15-2.25) and 2.1 times (CI95% 1.12-3.93) higher odds were noted in above median frailty group. CONCLUSIONS:mFI is an independent predictor of mortality among patients undergoing HA and THA for femoral neck fracture beyond traditional risk factors such as age, ASA class, and other comorbidities. LEVELS OF EVIDENCE/METHODS:Level II.

BACKGROUND:The risk of venous thromboembolism (VTE) in patients undergoing intramedullary nailing for skeletal metastatic disease is currently undefined. The purpose of our study was to determine the risk of thromboembolic events, to define the risk factors for VTE, and to define the rate of wound complications in this population. METHODS:A retrospective review of surgical databases at three National Cancer Institute (NCI)-designated cancer centers identified 287 patients with a total of 336 impending or pathologic long-bone fractures that were stabilized with intramedullary nailing between February 2001 and April 2013. Statistical analysis was performed utilizing multivariable logistic regression and Fisher exact tests. RESULTS:The overall rate of VTE was twenty-four (7.1%) of the 336; thirteen (3.9%) were pulmonary embolism (PE), and eleven (3.3%), deep venous thrombosis (DVT). In two patients, adequate anticoagulation data were not available. We found no significant relationship between the type of anticoagulant used and VTE. There was a significant positive correlation found between lung-cancer histology and the development of VTE (p < 0.001) or PE (p < 0.001). The absence of radiation therapy approached significance (p = 0.06) with respect to decreased overall VTE risk. Wound complications were documented for 11 (3.3%) of the operations. CONCLUSIONS:There is a high rate of VTE among those with skeletal metastatic disease who undergo intramedullary nailing, even while receiving postoperative thromboembolic prophylaxis. Current anticoagulation protocols may be inadequate. Wound-complication risk with anticoagulant use in this population is low and should not be a deterrent to adequate anticoagulant use for this population.