Faculty Bibliography

The treatment of hip fractures in the elderly represents a major public health priority and a source of ongoing debate among orthopaedic surgeons and anesthesiologists. Most of these injuries are treated with surgery in an expedient fashion. From the surgical perspective, there are certain special considerations in this population including osteoporosis, pre-existing arthritis, age, activity level, and overall health that contribute to the type of surgical fixation performed. Open reduction and internal fixation versus arthroplasty remain the two major categories of treatment. While the indications and treatment algorithms still remain controversial, the overall goal for these patients is early mobilization and prevention of morbidity and mortality. The use of preoperative, regional anesthesia has aided in this effort. The purpose of this review article is to examine the various treatment modalities for hip fractures in the elderly and discuss the most recent evidence in the face of a rapidly aging population.

Tibial plateau fractures are common in the elderly population following a low-energy mechanism. Initial evaluation includes an assessment of the soft tissues and surrounding ligaments. Most fractures involve articular depression leading to joint incongruity. Treatment of these fractures may be complicated by osteoporosis, osteoarthritis, and medical comorbidities. Optimal reconstruction should restore the mechanical axis, provide a stable construct for mobilization, and reestablish articular congruity. This is accomplished through a variety of internal or external fixation techniques or with acute arthroplasty. Regardless of the treatment modality, particular focus on preservation and maintenance of the soft tissue envelope is paramount.

INTRODUCTION/BACKGROUND:Healthcare providers are increasingly searching for ways to provide cost-efficient, high-quality care. Previous studies on evaluating cost used estimated cost-to-charge ratios, which are inherently inaccurate. The purpose of this study was to quantify actual direct cost savings from performing pediatric orthopaedic sports day surgery at an ambulatory surgery center (ASC) compared with a university-based children's hospital (UH). METHODS:Custom-scripted accounting software was queried for line-item costs for a period of 3 fiscal years (fiscal year 2012 to fiscal year 2014) for eight day surgery procedures at both a UH and a hospital-owned ASC. Hospital-experienced direct costs were compared while controlling for surgeon, concomitant procedures, age, sex, and body mass index. RESULTS:One thousand twenty-one procedures were analyzed. Using multiple linear regression analysis, direct cost savings at the ASC ranged from 17% to 43% for seven of eight procedures. Eighty percent of the cost savings was attributed to time (mean, 64 minutes/case; P < 0.001) and 20% was attributed to supply utilization (P < 0.001). Of the time savings in the operating room, 73% (mean, 47 minutes; P < 0.001) was attributed to the surgical factors whereas 27% (17 minutes; P < 0.001) was attributed to anesthesia factors. CONCLUSIONS:Performing day surgery at an ASC, compared with a UH, saves 17% to 43% from the hospital's perspective, which was largely driven by surgical and anesthesia-related time expenditures in the operating room. LEVEL OF EVIDENCE/METHODS:Level II.

Femoral bone loss is a complex problem in revision total hip arthroplasty. The Paprosky classification is used when determining the degree and location of bone loss. Meticulous operative planning is essential where severe bone loss is a concern. One must correctly identify the bone loss pattern, safely remove the existing components, and proceed with the proper reconstruction technique based on the pattern of bone loss. This article discusses the etiology and classification of bone loss, clinical and radiographic evaluation, components of effective preoperative planning, and clinical results of various treatment options with a focus on more severe bone loss patterns.

We retrospectively reviewed 1012 consecutive patients undergoing elective primary hip and knee arthroplasties to identify risk factors associated with postoperative complications. A total of 70 complications (6.9%) requiring additional physician interventions occurred following surgery and 59 (84%) occurred past 24 hours postoperatively. Independent multivariate risk factors for developing late (>24 hours) complications included COPD (adjusted OR 4.16), CHF (adjusted OR 9.71), CAD (adjusted OR 2.80), and cirrhosis (adjusted OR 8.43). These results suggest that most major medical complications requiring additional physician interventions occur greater than 24 hours following primary THA/TKA. Patients with history of COPD, CHF, CAD, and cirrhosis should not undergo short stay or outpatient TJA.

PURPOSE/OBJECTIVE:The pivot shift test (PST) is a complex, multiplanar maneuver used to assess rotatory instability of the knee. The grading is subjective due to the broad range of examination techniques and lack of tibiofemoral motion quantification. The goal of this study was to develop and evaluate a mechanized device for quantitative assessment of the PST. METHODS:We constructed a mechanized pivot shifter (MPS). In five cadaveric hip-to-toes specimens, the anterior cruciate ligament was resected. We used a surgical navigation system for acquisition of the tibiofemoral motion path during the PST. Two sets of measurements were obtained for the MPS and for two examiners performing the manual technique. RESULTS:Mean lateral compartment translation magnitudes for each MPS measurement were 13.5 mm (σ = 6.7) and 13.6 mm (σ = 6.7). For examiner 1, 14.9 mm (σ = 6.5) and 15.7 mm (σ = 6.3). For examiner 2, 16.9 mm (σ = 6.3) and 16.1 mm (σ = 5.2). Differences were not significant (n.s.). The MPS had narrower limits of agreement than both examiner 1 and examiner 2. CONCLUSION/CONCLUSIONS:The MPS demonstrated no significant differences in the tibiofemoral translation magnitudes compared to the manual technique. It resulted in better test-retest reliability and more consistent measurements of tibiofemoral translation when compared to manual PST. The high repeatability factor conferred by the MPS is a clinical advantage.