Transfusion Thresholds Can Be Safely Lowered in the Hip Fracture Patient: A Consecutive Series of 1,496 Patients
Konda, Sanjit R; Parola, Rown; Perskin, Cody R; Fisher, Nina D; Ganta, Abhishek; Egol, Kenneth A
INTRODUCTION/BACKGROUND:The purpose of this study is to identify optimal threshold hemoglobin (Hgb) and hematocrit (Hct) laboratory values to transfuse hip fracture patients. METHODS:A consecutive series of hip fracture patients were reviewed for demographic, clinical, and cost data. Patients receiving an allogeneic transfusion of packed red blood cells (pRBCs) were grouped based on last Hct or Hgb (H&H) value before first transfusion. Multivariate logistic regressions of H&H quantile were performed to predict "good outcomes," a composite binary variable defined as admissions satisfying (1) no major complications, (2) length of stay below top tertile, (3) cost below median, (4) no mortality within 30 days, and (5) no readmission within 30 days. Odds ratios (OR) for "good outcomes" were calculated for each H&H quantile. RESULTS:One thousand four hundred ninety-six hip fracture patients were identified, of which 598 (40.0%) were transfused with pRBCs. Patients first transfused at Hgb values from 7.55 to 7.85 g/dL (P = 0.043, OR = 2.70) or Hct values from 22.7 to 23.8% (P = 0.048, OR = 2.63) were most likely to achieve "good outcomes." DISCUSSION/CONCLUSIONS:The decision to transfuse patients should be motivated by Hgb and Hct laboratory test results, given that transfusion timing relative to surgery has been shown to not affect outcomes among patients matched by trauma risk score. Surgeons should aim to transfuse hip fracture patients at Hgb levels between 7.55 g/dL and 7.85 g/dL or Hct levels between 22.7% and 23.8%. These transfusion thresholds have the potential to lower healthcare costs without compromising quality, ultimately resulting in less costly, efficacious care for the patient. LEVEL OF EVIDENCE/METHODS:Level III.
Nonunion of conservatively treated humeral shaft fractures is not associated with anatomic location and fracture pattern
Dedhia, Nicket; Ranson, Rachel A; Rettig, Samantha A; Konda, Sanjit R; Egol, Kenneth A
INTRODUCTION/BACKGROUND:Humeral shaft fractures make up 1-3% of all fractures and are most often treated nonoperatively; rates of union have been suggested to be greater than 85%. It has been postulated that proximal third fractures are more susceptible to nonunion development; however, current evidence is conflicting and presented in small cohorts. It is our hypothesis that anatomic site of fracture and fracture pattern are not associated with development of nonunion. MATERIALS AND METHODS/METHODS:In a retrospective cohort study, 147 consecutive patients treated nonoperatively for a humeral shaft fracture were assessed for development of nonunion during their treatment course. Their charts were reviewed for demographic and radiographic parameters such as age, sex, current tobacco use, diabetic comorbidity, fracture location, fracture pattern, AO/OTA classification, and need for intervention for nonunion. RESULTS:One hundred and forty-seven patients with 147 nonoperatively treated humeral shaft fractures were eligible for this study and included: 39 distal, 65 middle, and 43 proximal third fractures. One hundred and twenty-six patients healed their fractures by a mean 16â€‰Â±â€‰6.4Â weeks. Of the 21 patients who developed a nonunion, two were of the distal third, 10 of the middle third, and nine were of the proximal third. In a binomial logistic regression analysis, there were no differences in age, sex, tobacco use, diabetic comorbidity, fracture pattern, anatomic location, and OTA fracture classification between patients in the union and nonunion cohorts. CONCLUSIONS:Fracture pattern and anatomic location of nonoperatively treated humeral shaft fractures were not related to development of fracture nonunion.
The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy
Deemer, Alexa R; Furgiuele, David L; Ganta, Abhishek; Leucht, Philipp; Konda, Sanjit; Tejwani, Nirmal C; Egol, Kenneth A
OBJECTIVES/OBJECTIVE:To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip Block (LOH Block). DESIGN/METHODS:Retrospective. SETTING/METHODS:Level-I Trauma CenterPatients/Participants: 40 patients who presented between 11/2021 and 02/2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used. INTERVENTION/METHODS:Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve (FN) and accessory obturator nerve (AON). MAIN OUTCOME MEASUREMENTS/METHODS:Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates. RESULTS:A total of 120 patients (40 each: general, spinal, LOH block) were compared. The cohorts were similar in age, race, BMI, gender, CCI, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block group (p<0.05). Total OR time and anesthesia time were shortest for the LOH block cohort (p<0.05). Patients in the LOH block cohort also had lower post-operative pain scores (p<0.05). Length of hospital stay was shortest for patients in the LOH block cohort (p<0.05), and at time of discharge, patients in the LOH block cohort ambulated the furthest (p<0.05). No differences were found in regards to anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates. CONCLUSIONS:The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly requiring surgery. In addition, this block may decrease post-operative pain and length of hospital stay, and also allow for greater ambulation in the early post-operative period for hip fracture patients. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Improving Cephalad Lag Screw Placement in the Femoral Head During Cephalomedullary Nailing Using a Novel Augmented Reality System
Konda, Sanjit R; Solasz, Sara; Derken, Meghan; Ganta, Abhishek; Egol, Kenneth A
OBJECTIVES/OBJECTIVE:To measure the effect of a novel augmented reality software designed to aid in lag screw placement into the femoral head for cephalomedullary nails. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Single level I trauma center. PATIENTS/METHODS:Between November 2017 and December 2020, 114 consecutive patients with a hip fracture that underwent repair with a cephalomedullary nail by one of two orthopedic trauma surgeons were reviewed. Fracture classifications included OTA/AO 31-A1, 31-A2, 31-A3, and 31-B3. INTERVENTION/METHODS:The first 57 patients underwent fracture repair without the software (control) and the subsequent 57 patients underwent repair with use of the augmented reality software (AR). MAIN OUTCOME MEASUREMENTS/METHODS:Tip apex distance (TAD) and femoral head zone (AP: superior, center, inferior; Lateral: anterior, center, posterior) were measured using standardized techniques. RESULTS:The mean TAD was lower for the AR vs. control cohort (10.7Â±2.9 mm vs 15.4Â±3.8 mm; p<0.001). TAD <10mm for AR vs. control: 25 (43.9%) vs. 3 (5.3%), p<0.001. TAD <15mm for AR vs. control: 50 (87.7%) vs. 44 (77.2%), p<0.001. On the AP view center position was achieved in 50.9% vs. 7.0% of cases for the AR vs. control cohort, respectively. On the lateral view, center position was achieved in 68.4% vs. 12.3% of cases for the AR vs. control cohort, respectively. CONCLUSION/CONCLUSIONS:This study suggests that use of the novel augmented reality software for assistance in lag screw positioning within the femoral head improves overall TAD and ability to achieve the center-center position.
Bi, Andrew S; Fisher, Nina D; Parola, Rown; Ganta, Abhishek; Egol, Kenneth A; Konda, Sanjit R
Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care "Value"
Meltzer-Bruhn, Ariana T; Esper, Garrett W; Herbosa, Christopher G; Konda, Sanjit R; Egol, Kenneth A
BACKGROUND:Value is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNF) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF). METHODS:Between October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement (CJR) bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, post-operative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-square or T-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA, 63% HA) and 132 (69%) patients discharged to SNF (14% THA, 86% HA). Patients discharged to SNF were older (p<0.01), had lower Risk Assessment and Prediction Tool (RAPT) scores (p<0.01), had higher comorbidity scores (p=0.011), and had longer post-hospitalization care (p<0.01). RESULTS:There were no differences in rates of inpatient minor complications (p=0.520), inpatient major complications (p=0.119), Intensive Care Unit (ICU) admissions (p=0.193) or readmissions within 30 (p=0.690) and 90 days (p=0.176). Costs of care at a SNF was higher than HHS (p<0.01). In multivariate regressions, a lower RAPT score was associated with discharge to SNF (OR 0.69, 95% CI 0.58-0.83, p<0.001). CONCLUSION/CONCLUSIONS:Among CJR bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.
No Differences Between White and Non-White Patients in Terms of Care Quality Metrics, Complications, and Death After Hip Fracture Surgery When Standardized Care Pathways are Used
Parola, Rown; Neal, William H; Konda, Sanjit R; Ganta, Abhishek; Egol, Kenneth A
BACKGROUND:Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking. QUESTIONS/PURPOSES/OBJECTIVE:(1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway? METHODS:In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 Â± 10 years and 427 non-White patients who were 64% (271) female with mean age 80 Â± 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially relevant confounding variables. Multivariable regression analyses were used to control for important baseline between-group differences to (1) determine the correlation of White and non-White race on mortality, inpatient complications, intensive care unit (ICU) admissions, and discharge disposition and (2) assess the correlation of gender, socioeconomic status, insurance payor, and the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) trauma risk score with these quality measures and outcomes. RESULTS:After controlling for gender, insurer, socioeconomic status and STTGMA trauma risk score, we found that non-White patients had similar or improved care in terms of mortality and rates of delayed surgery, ICU admission, major complications, and discharge location in the setting of the standardized care pathway. Non-White race was not associated with inpatient (odds ratio 1.1 [95% CI 0.40 to 2.73]; p > 0.99), 30-day (OR 1.0 [95% CI 0.48 to 1.83]; p > 0.99) or 1-year mortality (OR 0.9 [95% CI 0.57 to 1.33]; p > 0.99). Non-White race was not associated with delay to surgery beyond 2 days (OR = 1.1 [95% CI 0.79 to 1.38]; p > 0.99). Non-White race was associated with less frequent ICU admissions (OR 0.6 [95% CI 0.42 to 0.85]; p = 0.03) and fewer major complications (OR 0.5 [95% CI 0.35 to 0.83]; p = 0.047). Non-White race was not associated with discharge to skilled nursing facility (OR 1.0 [95% CI 0.78 to 1.30]; p > 0.99), acute rehabilitation facility (OR 1.0 [95% CI 0.66 to 1.41]; p > 0.99), or home (OR 0.9 [95% CI 0.68 to 1.29]; p > 0.99). Controlled factors other than White versus non-White race were associated with mortality, discharge location, ICU admission, and major complication rate. Notably, the STTGMA trauma risk score was correlated with all endpoints. CONCLUSION/CONCLUSIONS:In the context of a hip fracture care pathway that reduces variability from time of presentation through discharge, no differences in mortality, time to surgery, complications, and discharge disposition rates were observed beween White and non-White patients after controlling for baseline differences including trauma risk score. The pathway detailed in this study is one iteration that the authors encourage surgeons to customize and trial at their institutions, with the goal of providing equitable care to patients with hip fractures and reducing healthcare disparities. Future investigations should aim to elucidate the impact of standardized trauma care pathways through the use of the STTGMA trauma risk score as a controlled confounder or randomized trials in comparing standardized to individualized, surgeon-specific care. LEVEL OF EVIDENCE/METHODS:Level III, therapeutic study.
Adaptive Risk Modeling: Improving Risk Assessment of Geriatric Hip Fracture Patients Throughout their Hospitalization
Esper, Garrett W; Meltzer-Bruhn, Ariana T; Ganta, Abhishek; Egol, Kenneth A; Konda, Sanjit R
INTRODUCTION/BACKGROUND:The purpose of this study was twofold: 1. To assess how adaptive modeling, accounting for development of inpatient complications, affects the predictive capacity of the risk tool to predict inpatient mortality for a cohort of geriatric hip fracture patients. 2. To compare how risk triaging of secondary outcomes is affected by adaptive modeling. We hypothesize that adaptive modeling will improve the predictive capacity of the model and improve the ability to risk triage secondary outcomes. METHODS:and comparative analyses were conducted. RESULTS:experienced the highest rate of mortality, readmission, ICU admission, with longer lengths of stay and higher hospital costs. DISCUSSION/CONCLUSIONS:can better identify patients at risk for developing complications whose mortality and readmission risk profile increase significantly, allowing their new risk classification to inform higher levels of care. While this may increase length of stay and total costs, it may improve outcomes in both the short and long-term. LEVEL OF EVIDENCE/METHODS:III.
Observational prospective unblinded case-control study to evaluate the effect of the Gamma3® distal targeting system for long nails on radiation exposure and time for distal screw placement
Konda, Sanjit R; Maseda, Meghan; Leucht, Philipp; Tejwani, Nirmal; Ganta, Abhishek; Egol, Kenneth A
PURPOSE/OBJECTIVE:To determine if the DTS decreases radiation exposure (primary outcome measure), fluoroscopy time (secondary outcome measure), and time to distal screw placement (secondary outcome measure) compared to the freehand "perfect circles" method when used for locking of cephalomedullary nails in the treatment of femur fractures METHODS: Fifty-eight patients with hip or femoral shaft fractures that were treated with a long cephalomedullary nail were enrolled in this study. Cohorts were determined based on the method of distal interlocking screw placement into either the "Perfect Circles" or "Distal Targeting" cohort. Time from cephalad screw placement to placement of final distal interlocking screw (seconds), radiation exposure (mGy), and fluoroscopy time (seconds) were compared between groups. Hospital quality measures were compared between cohorts. RESULTS:Use of the DTS resulted in 77% (4.3x) lower radiation exposure (p < 0.001), 64% (2.7x) lower fluoroscopy time (p < 0.001), and 60% (1.7x) lower intraoperative time from end of cephalad screw placement to end of distal interlocking screw placement (p < 0.001) compared to the freehand "perfect circles" method. There was no difference in 30-day or 90-day complication rates between cohorts. CONCLUSION/CONCLUSIONS:The Stryker Gamma3® Distal Targeting System is a safe, effective and efficient alternative to the freehand "perfect circles" method.
COVID-19 Vaccination Improved Outcomes in the Treatment of Geriatric Hip Fractures Between December 2020 and January 2022
Konda, Sanjit R; Meltzer Bruhn, Ariana T; Esper, Garrett W; Solasz, Sara J; Ganta, Abhishek; Egol, Kenneth A
INTRODUCTION/UNASSIGNED:Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture. METHODS/UNASSIGNED:-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination. RESULTS/UNASSIGNED: 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications. DISCUSSION/UNASSIGNED:In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.