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The Effect of Obstructive Sleep Apnea on Venous Thromboembolism Risk in Patients Undergoing Total Joint Arthroplasty

Tang, Alex; Aggarwal, Vinay K; Yoon, Richard S; Liporace, Frank A; Schwarzkopf, Ran
INTRODUCTION:Obstructive sleep apnea (OSA) is a known risk factor for venous thromboembolism (VTE), defined as pulmonary embolism (PE) or deep vein thrombosis (DVT); however, little is known about its effect on VTE rates after total joint arthroplasty (TJA). This study sought to determine whether patients with OSA who undergo TJA are at greater risk for developing VTE versus those without OSA. METHODS:A retrospective analysis was conducted on 12,963 consecutive primary TJA patients at a single institution from 2016 to 2019. Patient demographic data were collected through query of the electronic medical record, and patients with a previous history of OSA and VTE within a 90-day postoperative period were captured using the International Classification of Disease, 10th revision diagnosis and procedure codes. RESULTS:Nine hundred thirty-five patients with OSA were identified. PE (0.6% versus 0.24%, P = 0.023) and DVT (0.1% versus 0.04%, P = 0.37) rates were greater for patients with OSA. A multivariate logistic regression revealed that patients with OSA had a higher odds of PE (odds ratio [OR] 3.821, P = 0.023), but not DVT (OR 1.971, P = 0.563) when accounting for significant demographic differences. Female sex and total knee arthroplasty were also associated with a higher odds of PE (OR 3.453 for sex, P = 0.05; OR 3.243 for surgery type, P = 0.041), but not DVT (OR 2.042 for sex, P = 0.534; OR 1.941 for surgery type, P = 0.565). CONCLUSION:Female patients with OSA may be at greater risk for VTE, specifically PE, after total knee arthroplasty. More attention toward screening procedures, perioperative monitoring protocols, and VTE prophylaxis may be warranted in populations at risk.
PMCID:9022776
PMID: 35442925
ISSN: 2474-7661
CID: 5216882

Are Arthroplasty Procedures Really Better in the Treatment of Complex Proximal Humerus Fractures? A Comprehensive Meta-Analysis and Systematic Review

Pizzo, Richard A; Gianakos, Arianna L; Haring, Richard Sterling; Gage, Mark J; Stevens, Nicole M; Liporace, Frank A; Yoon, Richard S
OBJECTIVE:A meta-analysis and systematic review was performed to compare outcomes of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) for complex proximal humerus fractures. Data sources: MEDLINE, Embase, and Cochrane Library databases were screened. Search terms included reverse total shoulder arthroplasty, open reduction internal fixation, hemiarthroplasty, and proximal humerus fracture. STUDY SELECTION:English-language studies published within the past 15 years evaluating outcomes of ORIF, rTSA, or HA for complex proximal humerus fractures with minimum of 1-year follow-up were included, resulting in 51 studies with 3064 total patients. Review articles, basic science studies, biomechanical studies, and cadaveric studies were excluded. DATA EXTRACTION:The methodological quality of evidence was assessed using the Jadad scale and methodological index for nonrandomized studies. DATA SYNTHESIS:Demographic data were compared using the χ2 test. Mean data were weighted by study size and used to calculate composite mean values and confidence intervals. Continuous data were compared using the Metan module with fixed effects. Count data were compared using the Kruskal-Wallis test. Alpha was set at 0.05 for all tests. CONCLUSIONS:Patients undergoing rTSA had lower risks of complication (relative risk 0.41) and reoperation (relative risk 0.28) than HA patients. rTSA resulted in higher Constant scores (standard mean difference 0.63) and improved active forward flexion when compared with HA (standard mean difference 0.76). Pooled mean data demonstrated better outcome scores and active forward flexion of ORIF versus HA and rTSA, although the patients were younger and had more simple fracture patterns. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
PMID: 33079841
ISSN: 1531-2291
CID: 4809802

Impact of Surrounding Canal Size on Time to Union After Intramedullary Nailing of Femur Fractures: Are 10-mm Nails All We Need?

Yoon, Richard S; Adams, Donald M; Seigerman, Daniel A; Lim, Philip K; Donegan, Derek J; Liporace, Frank A
OBJECTIVE:To determine whether intramedullary nail (IMN) size and its relation to the canal diameter [nail-canal (NC) diameter] impacts the union rate or time to union in the treatment of femoral shaft fractures. DESIGN/METHODS:Retrospective review. SETTING/METHODS:Two Level 1 and 1 Level 2 trauma centers. PATIENTS/METHODS:Two hundred eighty-seven patients met the criteria and were included in the study. INTERVENTION/METHODS:Patients were treated with either an antegrade or retrograde IMN. Comparisons were first performed comparing 10- versus 11- versus 13-mm nails. Patients were then divided into 3 groups based on the difference between the size of the femoral canal at the isthmus and the IMN (NC diameter). Group 1: <1.0 mm, group 2: >1.0 and <2.0 mm, and group 3: >2.0 mm. MAIN OUTCOME MEASUREMENTS/METHODS:Nonunion rates, mean time to union. RESULTS:Two hundred eighty-seven patients with a minimum of 12-month follow-up, who were treated with size with IMN for femoral shaft fractures, were assessed for fracture characteristics, time to union, and union rate. When comparing IMN size, no statistical difference was found when comparing time to union or overall union rate. When comparing NC diameter, no significant difference was found in union rate and time to union when comparing between the groups. CONCLUSION/CONCLUSIONS:Similar rate of union and time to union were exhibited regardless of nail size or NC diameter. This can correlate to the standard utilization of a reamed, titanium 10-mm IMN with 5.0-mm interlocking screws in the treatment of femoral shaft fractures, offering potentially less reaming, shorter operative times, and removing unnecessary stock from inventory. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
PMID: 31652189
ISSN: 1531-2291
CID: 5054552

Risk factors for liposomal bupivacaine resistance after total hip or knee arthroplasties: a retrospective observational cohort in 237 patients

Buzin, Scott; Gianakos, Arianna L; Li, Deborah; Viola, Anthony; Elkattawy, Sherif; Keller, David M; Yoon, Richard S; Liporace, Frank A
PURPOSE/OBJECTIVE:Liposomal bupivacaine demonstrated promise decreasing postoperative pain in total hip and total knee arthroplasty (THA/TKA). Some randomized trials have shown non-superior results; however, confounding variables were not accounted for in such analyses. This study attempts to determine risk factors associated with failure of pain management in patients receiving liposomal bupivacaine. METHODS:Postoperative pain scores were collected following primary or revision arthroplasties between January 2016 and December 2017. Retrospective analysis of institutional total joint quality and outcomes registry was screened and patients undergoing primary or revision arthroplasties who completed a multi-modal pain management including liposomal bupivacaine were included in the study. Patients with a history of infection/deviated from the institutional pain management protocol were excluded. RESULTS:A total of 237 patients were included for analysis. Younger patients less than 64 years old had significantly higher pain scores between 0 and 12 h and > 24 h. Active smokers had significantly higher pain scores between 0 and 6 h and > 24 h. Patients with a history of opioid use/pain management had significantly higher pain scores at 6-12 h and 24-48 h. Regression analysis indicated risk factors for resistance to liposomal bupivacaine are younger patients less than 64 years old, those undergoing primary THA, and patients with a history of smoking/pain management/opioid use. CONCLUSION/CONCLUSIONS:We identify risk factors for resistance to liposomal bupivacaine, which include younger age less than 64 years old, history of smoking/pain management/opioid use. Future studies should use these risk factors as exclusion criteria when using liposomal bupivacaine or initiating any randomized trials regarding efficacy.
PMCID:6990520
PMID: 32015758
ISSN: 1754-9493
CID: 5262252

Maximizing outcomes in the treatment of radial head fractures

Swensen, Stephanie J; Tyagi, Vineet; Uquillas, Carlos; Shakked, Rachel J; Yoon, Richard S; Liporace, Frank A
The radial head plays a critical role in the stability of the elbow joint and its range of motion. Injuries may occur across a spectrum of severity, ranging from low energy non-displaced fractures to high energy comminuted fractures. Multiple classification systems exist to help characterize radial head fractures and their associated injuries, as well as to guide treatment strategies. Depending on the type of fracture, non-operative management may be possible if early range of motion is initiated. Other options include open reduction and internal fixation or excision followed by arthroplasty. A lateral approach is typically used for adequate surgical exposure. Controversy still remains regarding operative management of more severe fractures, but studies have shown good outcomes after radial head replacement for these fractures. We will review the current treatments available for radial head fractures, highlighting gaps in knowledge, as well as providing recommendations for the care of these injuries.Level of evidence: Level V.
PMCID:6431334
PMID: 30904970
ISSN: 1590-9999
CID: 3789532

Can preoperative nasal cultures of Staphylococcus aureus predict infectious complications or outcomes following repair of fracture nonunion?

Taormina, David P; Konda, Sanjit R; Liporace, Frank A; Egol, Kenneth A
INTRODUCTION: Much has been studied with reference to methicillin resistant Staphylococcus aureus (MRSA) and methicillin sensitive S. aureus (MSSA) colonization and associated outcomes and comorbidities. In the area of Orthopedic surgery, literature predominantly comes from the field of arthroplasty. Little is known about outcomes of fracture and Orthopedic trauma patients in the setting of S. aureus colonization. We believe that MRSA/MSSA colonization in and of itself may be a weak marker for generally poor protoplasm, potentially with complex medical history including previous hospitalization or rehab placement. This milieu of risk factors may or may not contribute to poorer outcomes after fracture and fracture nonunion surgery. The purpose of this study is to determine if nasal swabbing for S. aureus (MRSA or MSSA) carriage can predict operative culture, complications, or outcomes following fracture nonunion surgery. METHODS: Sixty-two consecutive patients undergoing surgery for fracture nonunion were prospectively followed. Data analyses were performed using grouped MRSA and MSSA carriers (Staphylococcus carriers: SC). Outcomes analyzed included time to healing, need for additional surgery, and persistent nonunion. RESULTS: Twenty-six percent of patients (16/62) were identified as MSSA carriers, an additional 6.5% (4/62) carried MRSA. Follow-up of at least 12-months was obtained on 90% (56/62) of patients. White blood cell counts, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values did not differ between SCs and non-carriers pre-operatively. Carriers were just as likely as non-carriers to culture positively for any pathogen at the time of surgery. Although SC's were three times as likely as non-carriers to grow S. aureus (15% vs. 5%), this difference did not reach statistical significance (p=0.3). Post-operative wound complications, antibiotic use, pain at follow-up and progression to healing did not differ between groups. CONCLUSIONS: Ultimately, pre-operative nasal swabbing for S. aureus is a simple and non-invasive diagnostic tool with prognostic implications in patients undergoing fracture nonunion surgery. This study found that MRSA and MSSA colonized patients with fracture nonunion of long bones do not have an increased association with positive cultures or a predisposition towards greater post-operative infectious complications.
PMID: 29100874
ISSN: 1876-035x
CID: 2765702

Management of Bone Defects in Orthopedic Trauma

Gage, Mark; Liporace, Frank; Egol, Kenneth; McLaurin, Toni
Treatment of traumatic bone defects is dictated by a multitude of clinical factors including the defect size, patient comorbidities, soft tissue condition, and the possibility of infection present in the defect. With a variety of treatment strategies described, it is critical to choose the approach that will maximize outcomes in addressing this difficult problem. When addressing small-scale defects, bone grafting is the primary treatment. For large-scale defects, there are two major options to consider: induced membrane technique and distraction osteogenesis. Choosing between these two techniques should be based on the associated soft tissue injury, the local vascularity, and the possibility of residual infection. This review will focus on the current management principles and strategies in the treatment of bone defects after orthopedic trauma and the existing literature to support each of these treatment options.
PMID: 29537950
ISSN: 2328-5273
CID: 3005462

Strategies for Management of Periprosthetic Joint Infection

Riesgo, Aldo; Liporace, Frank
Periprosthetic joint infection (PJI) is one of the most catastrophic and difficult to manage complications following total hip and total knee arthroplasty. As the number of total joint arthroplasties continues to increase, the burden of PJI will continue to further strain resources. As such, orthopedic surgeons consider four principles crucial in appropriately managing difficult or complex cases of PJI: identification, debridement, antibiotics, and patience. Indications and techniques for nonoperative treatment, debridement with implant retention, and one- and two-stage exchange arthroplasty are reviewed. Despite optimal care, a subset of patients will experience failure and the role of resection, fusion, and amputation is discussed. Understanding appropriate patient selection, pathogens, and improved surgical techniques should form the basis of managing PJI.
PMID: 29537958
ISSN: 2328-5273
CID: 3005502

Treatment of Spinopelvic Dissociation: A Critical Analysis Review

Kaye, Ian David; Yoon, Richard S; Stickney, William; Snavely, Joseph; Vaccaro, Alexander R; Liporace, Frank A
PMID: 29381571
ISSN: 2329-9185
CID: 3040332

What's new in ankle fractures

Toth, Matthew J; Yoon, Richard S; Liporace, Frank A; Koval, Kenneth J
The diagnosis and treatment of ankle fractures has evolved considerably over the past two decades. Recent topics of interest have included indications for operative treatment of isolated lateral malleolus fractures, need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing. In this update, we concisely review these topics and what to expect in the future literature.
PMID: 28826651
ISSN: 1879-0267
CID: 3069992