Mortality in Older Patients with Breast Cancer Undergoing Breast Surgery: How Low is “Low Risk”?

Background

Breast surgery carries a low risk of postoperative mortality. For older patients with multiple comorbidities, even low-risk procedures can confer some increased perioperative risk. We sought to identify factors associated with postoperative mortality in breast cancer patients ≥70 years to create a nomogram for predicting risk of death within 90 days.

Methods

Patients diagnosed with nonmetastatic invasive breast cancer (2010–2016) were selected from the National Cancer Database. Unadjusted OS was estimated using the Kaplan–Meier method. Multivariate logistic regression was used to estimate the association of age and surgery with 90-day mortality and to build a predictive nomogram.

Results

Among surgical patients ≥70 years, unadjusted 90-day mortality increased with increasing age (70–74 = 0.4% vs. ≥85 = 1.6%), comorbidity score (0 = 0.5% vs. ≥3 = 2.7%), and disease stage (I = 0.4% vs. III = 2.7%; all p < 0.001). After adjustment, death within 90 days of surgery was associated with higher age (≥85 vs. 70–74: odds ratio [OR] 3.16, 95% confidence interval [CI] 2.74–3.65), comorbidity score (≥3 vs. 0: OR 4.79, 95% CI 3.89–5.89), and disease stage (III vs. I: OR 4.30, 95% CI 3.69–5.00). Based on these findings, seven variables (age, gender, comorbidity score, facility type, facility location, clinical stage, and surgery type) were selected to build a nomogram; estimates of risk of death within 90 days ranged from <1 to >30%.

Conclusions

Breast operations remain relatively low-risk procedures for older patients with breast cancer, but select factors can be used to estimate the risk of postoperative mortality to guide surgical decision-making among older women.

     

Early versus delayed fixation of pelvic ring fractures

This retrospective study reports outcomes, after early and delayed surgical stabilization of fractures of the pelvic ring, in terms of pulmonary complications, length of hospital stay, and cost of hospitalization. The hospital course of 151 patients admitted to an academic teaching hospital who sustained acute fractures of the pelvic ring between June 1996 and December 2000 was reviewed. Patient demographics, Injury Severity Score (ISS), timing of operative fixation, and the incidence of pulmonary complications were analyzed. Radiographs were reviewed and fractures classified according to the modified Tile system. Tile fracture types B and C patients who underwent fixation within 1 week of injury (n = 71) were compared to those in whom surgery was delayed (n = 28). Adjusting for the ISS, early-repair patients had a lower risk of pulmonary complications (RR = 0.49, 95% CI = 0.25-0.96), a reduced length of hospital stay (12.2 vs. 20.5 days; P = 0.0005), and overall reduced cost of care (57,084 dollars vs. 158,625 dollars; P = 0.0317). Pelvic ring fixation within the first week of injury results in significantly reduced incidence of pulmonary complication, hospital stay, and cost of care regardless of injury severity. The coordinated team approach to insure prompt resuscitation, stabilization, and operative fixation results in more optimal patient outcomes.     

Timing of surgery for internal fixation of intracapsular hip fractures and complications at 1 year; a 32 year clinical study of 2,366 patients at a single center

BackgroundTiming of hip fracture surgery for the internal fixation of an intracapsular fracture remains controversial and few studies to date have been able to determine the optimum time to surgery in minimizing osteonecrosis and non-union with intracapsular fractures after fixation.MethodsUsing a local hip fracture database managed by the senior author over a 32 year period, those who underwent osteosynthesis following intracapsular fractures were assessed for risk of development of non-union and osteonecrosis. Multivariate regression analysis was performed focusing on factors that were predictive of complications. Patient demographics, time from injury to surgery, fixation method, fracture pattern and complications at one year were reported. The primary outcome was whether delay to surgery contributed to risk of complications, defined as non-union or osteonecrosis. Secondary outcomes assessed the contribution of other factors to these complications.Results2,366 patients were identified with an average age of 74.7 years and 66.5% were female. 1189 (50.3%) of fractures were displaced. 481 (20.3%) had a complication at one year following fixation. 78 (3.3%) were fixed by DHS, 6 (0.3%) by cephalomedullary nail, (1257) 53.1% by cannulated screws and 1025 (43.3%) by Targon® screw. Multivariate regression revealed no significant correlation between delay to surgery and complication rates (OR 0.99, 95% CI 0.99, 1.01, p = 0.55). Significant variables include female sex (OR 2.03, 95% CI 1.58, 2.62, p<0.0001), fracture displacement (OR 4.8, 95% CI 3.79, 6.14, p<0.0001), independent mobility (OR 0.64, 95% CI 0.47, 0.87, p = 0.004) and use of Targon® screws compared to parallel screws (OR 0.61, 95% CI 0.48, 0.76, p<0.0001).ConclusionsOur study demonstrates no relationship between timing of surgery for fixation of intracapsular fracture and complication rates. Female sex and fracture displacement increased risk of complications whereas independent mobility and use of Targon® screw device in comparison to parallel screws were protective against non-union but not avascular necrosis.     

Impact of anesthesia technique on the incidence of major complications after open aortic abdominal surgery: a cohort study

Study ObjectiveTo determine the risk factors of perioperative complications and the impact of intrathecal morphine (ITM) in major vascular surgery.DesignRetrospective analysis of a prospective cohort.SettingsOperating room, intensive care unit, and Postanesthesia Care Unit of a university hospital.MeasurementsData from 595 consecutive patients who underwent open abdominal aortic surgery between January 1997 and December 2011 were reviewed. Data were stratified into three groups based on the analgesia technique delivered: systemic analgesia (Goup SA), thoracic epidural analgesia (Group TEA), and intrathecal morphine (Group ITM). Preoperative patient characteristics, perioperative anesthetic and medical interventions, and major nonsurgical complications were recorded.Main ResultsPatients managed with ITM (n=248) and those given thoracic epidural analgesia (n=70) required lower doses of intravenous (IV) sufentanil intraoperatively and were extubated sooner than those who received systemic analgesia (n=270). Total inhospital mortality was 2.9%, and 24.4% of patients experienced at least one major complication during their hospital stay. Intrathecal morphine was associated with a lower risk of postoperative morbidity (OR 0.51, 95% CI 0.28 - 0.89), particularly pulmonary complications (OR 0.54, 95% CI 0.31 - 0.93) and renal dysfunction (OR 0.52, 95% CI 0.29 - 0.97). Other predictors of nonsurgical complications were ASA physical status 3 and 4 (OR 1.94, 95% CI 1.07 - 3.52), preoperative renal dysfunction (OR 1.61, 95% CI 1.01 - 2.58), prolonged surgical time (OR 1.78, 95% CI 1.16 - 2.78), and the need for blood transfusion (OR 1.77, 95% CI 1.05 - 2.99).ConclusionsThis single-center study showed a decreased risk of major nonsurgical complications in patients who received neuraxial analgesia after abdominal aortic surgery.     

Clavicular Tunnel Complications after Coracoclavicular Reconstruction in Acute Acromioclavicular Dislocation: Coracoid Loop versus Coracoid Tunnel Fixation

BackgroundThe purpose of this study was to compare clavicular tunnel complications after coracoclavicular (CC) reconstruction between a coracoid loop fixation group and a coracoid tunnel fixation group. We hypothesized that clavicular tunnel complications would be more common in the coracoid loop group.MethodsThis retrospective study evaluated 24 patients who underwent CC reconstruction using coracoid tunnel fixation (n = 14) and coracoid loop fixation (n = 10). Radiographic measurements included the CC distance and clavicular tunnel diameter. Clavicular tunnel complications such as tunnel widening and clavicular tunnel fractures were investigated. Clinical outcomes were assessed using the American Shoulder and Elbow Surgeons Shoulder score and the University of California at Los Angeles Shoulder score.ResultsThe mean follow-up period was 17.5 months (range, 11–38 months). The final clavicular tunnel diameter and the increase in the clavicular tunnel diameter in millimeter and percentage were significantly greater in the coracoid loop group than in the coracoid tunnel group (all p < 0.05). Clavicular tunnel widening more than 100% was found in 5 patients, all belonging to the coracoid loop group. Clavicular tunnel fractures occurred in 3 patients (all in the coracoid loop group). Fracture was associated with severe tunnel widening (more than 100% increase). The mean value of the final clavicular tunnel diameter in patients with fractures was significantly larger than that in patients without (12.7 ± 3.3 mm vs. 8.4 ± 1.5 mm, p = 0.016).ConclusionsClavicular tunnel complications such as significant tunnel widening and fractures after CC reconstructions in acromioclavicular dislocations were common with the coracoid loop fixation technique. A greater clavicular tunnel widening and resultantly enlarged tunnel diameter might increase the risk of fracture through the clavicular tunnel.     

Postoperative complications of S2AI versus iliac screw in spinopelvic fixation: a meta-analysis and recent trends review

BACKGROUND CONTEXTIliac screw constructs have been a major advancement in spinopelvic fixation demonstrating superior biomechanics as compared with earlier pelvic spanning constructs. However, drawbacks such as screw site prominence and wound complication have led to the development of a lower profile S2AI iliac screw.PURPOSEIn this study, we aimed to study the differences in complication rates between the traditional iliac and S2AI fixations via a pooled analysis of the available head-to-head comparisons between S2AI and iliac screws. We also aimed to study the iliac screw complications trend over the years particularly with reference to recent modifications in its screw insertion techniques.STUDY DESIGNA meta-analysis with attention to the comparison of patients who underwent iliac screws and S2AI screws was conducted.METHODSThe following databases were utilized: PubMed, Scopus, Web of Science, Embase, and Cochrane Central Register of Controlled Trials database. Using the search terms: iliac, iliac bolts, S2AI, sacral 2 alar iliac, sacral two alar iliac, reviewers independently selected eligible studies, analyzed data and evaluated the risk of bias. Data analysis was conducted using RevMan 5.3 software.RESULTA total of 215 articles were identified, with 6 clinical studies directly comparing outcomes of S2AI pelvic fixation versus iliac screw fixation. A total of 477 patients were included, of which 255 patients (53.5%) underwent S2AI screw and 222 (46.5%) underwent iliac screw fixation. Our pooled analysis favored S2AI screws with regards to postoperative complications of screw prominence (odds ratio [OR]=5.99, 95% confidence interval [CI]=2.168–16.523, p<.001), screw loosening (OR=3.36, 95% CI=1.415–7.998, p=.006), implant breakage (OR=2.30, 95% CI=1.189–4.443, p=.013), and revision surgery (OR=7.84, 95% CI=3.224–19.080, p<.001). Although there was a trend toward more wound complications in conventional iliac screw techniques when compared with S2AI, it was not statistically significant.CONCLUSIONSpinopelvic fixation is an evolving technique. The results from this study showed that S2AI screws with a lower profile have made a significant impact in reducing complications associated with conventional iliac screws. With recent entry point modification and further advancement in the conventional iliac screw technique, such as the “subcrestal iliac screw technique” which reduces the iliac screw complication rate but avoids S2AI-associated SIJ violation. Further studies may be needed to investigate whether these newer iliac screw techniques can narrow the difference in complication rates between iliac screws and S2AI screw techniques.     

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Surgical treatment of dislocated 3 and 4-segment fractures of the proximal humerus]

Twenty-eight three- and four-segment fractures of the proximal humerus were treated by plate fixation (n = 22), screw or Kirschner wire stabilization (n = 5), and primary endoprothesis (n = 1). There were no early postoperative complications. Fourteen months after the operation, 80% of the patients examined showed good results; 4 cases had poor results. In comparison to other reports our results are positive and support plate fixation as the method of choice in these situations.     

Prior Nonarthroplasty Surgery Increases Risk of Complication in Primary Total Knee Arthroplasty

BackgroundPrior ipsilateral knee surgery may increase the risk for complications after total knee arthroplasty (TKA). It remains unclear if the extent of previous surgery affects those risks disparately. The purpose of this study is to evaluate prior nonarthroplasty bony procedure (BP) and soft tissue only procedure (STP) as a potential risk factor for complications after TKA and determine the association with charges or reimbursement of the primary TKA.MethodsPatients who underwent primary TKA with previous knee surgery were identified using a national Medicare database and matched 1:5 to controls without prior knee surgery. Rates of postoperative medical and surgical complications were calculated in addition to hospital-associated charges and reimbursements. Logistic regression analysis was used to control for confounding factors.ResultsPatients who underwent BP (n = 835) had increased risk of readmission (58.6% vs 45.3%, odds ratio (OR) 1.72, 95% confidence interval (CI) 1.59-1.85, P < .001) and emergency room visits (14.5% vs 10.4%, OR 1.44, 95% CI 1.29-1.61, P = .001). Patients who underwent STP (n = 6766) had increased risk of readmission (58.1% vs 45.2%, OR 1.69, 95% CI 1.64-1.73, P < .001), emergency room visits (12.6% vs 0.7%, OR 1.33, 1.28-1.39, P < .001), revision (1.8% vs 1.4%, OR 1.33, 95% CI 1.21-1.47, P = .006), cerebrovascular accident (2.3% vs 1.7%, OR 1.33, 95% CI 1.22-1.46, P = .002), and venous thromboembolism (3.8% vs 3.2%, OR 1.21, 95% CI 1.13-1.29, P = .009). Prior surgery was associated with increased charges and reimbursements.ConclusionPrior ipsilateral knee surgery is associated with significantly increased risks of postoperative complications after primary TKA. Interestingly, previous STP but not BP increased the risk of short-term revision and venous thromboembolism.     

Complications digestives sévères après chirurgie cardiaque sous circulation extracorporelle

PURPOSE: To determine the incidence, circumstances of occurrence and evolution of gastrointestinal complications after cardiac surgery with extracorporeal circulation (ECC). METHODS: Retrospective chart study of gastrointestinal complications in 6.281 patients undergoing ECC between january 1994 and December 1997. RESULTS: Sixty patients developed 68 gastrointestinal complications (1%). Complications included: upper gastrointestinal bleeding (n = 23), intestinal ischemia (n = 19), cholecystitis (n = 7), pancreatitis (n = 6), and paralytic ileus (n = 16). The incidence of these complications was low after coronary artery (0.4%) or valvular surgery (0.8%) and high after cardiac transplantation (6%) and after surgery for acute aortic dissection (9%). Compared with a control population, patients with gastrointestinal complication had a higher Parsonnet score (29 +/- 15 vs 13 +/- 12 points; P = 0.002), were more frequently operated upon as an emergency (40/60, 66% vs 1120/6221, 18%; P = 0.01), underwent ECC of longer duration (114 +/- 66 vs 74 +/- 42 min; P = 0.01), and presented more frequently with low cardiac output after surgery (45/60, 75% vs 435/6221, 7%; P = 0.001). The mortality rate after gastrointestinal complications was 52%. The major factor associated with mortality was the occurrence of sepsis (OR = 38.7). Other factors were: renal failure (OR = 7.9), age > 75 yr (OR = 3.5), mechanical ventilation for more than seven days (OR = 2.7), associated cerebral damage (OR = 3.9). CONCLUSION: Gastrointestinal complications after ECC occur in high risk surgical patients. These complications are frequently associated with other complications leading to a high mortality rate.     

Male sex,Gustillo-Anderson type III open fracture and definitive external fixation are risk factors for a return to the or following the surgical management of geriatric low energy open ankle fractures

IntroductionOpen ankle fractures in geriatric (age > 60 years) patients are a source of significant morbidity and mortality. Surgical management includes plate and screw fixation (ORIF), retrograde hindfoot nail (HFN), definitive external fixation (ex-fix) and below knee amputation. However, each modality poses unique challenges for this population. We sought to identify predictors of unplanned OR and short-term mortality after geriatric open ankle fractures managed by our service.Materials and methodsIn an IRB-approved protocol, we evaluated patients over 60 years of age managed for a low energy open ankle/distal tibia pilon fracture by trauma fellowship-trained surgeons from a single academic department that covers two level I trauma centers. Our primary outcome was an unplanned return to the OR. Secondary outcomes were a 90-day “event”, defined as an all-cause hospital readmission or mortality, and 1-year mortality. Differences with a p-value < 0.1 measured on univariate analysis were evaluated using a multivariable logistic regression to identify independent outcome predictors.ResultsA total of 113 (60 ORIF, 36 HFN, 11 ex-fix, 6 amputations) were performed. Cohort mean age was 75.2 ± 9.8 years, and 31 patients (27.4%) were male. Mean age-adjusted charlson comorbidity index was 5.5 ± 2.0. Significant independent predictors of an unplanned return to the OR were male sex (OR 4.4, 95% CI 1.3 to 15.4), Gustilo Type III open fracture (OR 4.9, 95% CI 1.5 to 17.5) and ex-fix (OR 15.6, 95% CI 2.7 to 126.3). Independent predictors of a 90-day “event” were walker/minimal ambulation (OR 3.5, 95% CI 1.3 to 10.4), surgical site infection (OR 4.8, 95% CI 1.8 to 13.8) and reduced BMI (OR 0.9, 95% CI 0.9 – 0.99), while independent predictors of 1-year mortality were age (OR 1.1, 95% CI 1.003 to 1.2), ACCI (OR 1.4, 95% CI 1.02 to 2.0) and walker/minimal ambulator (OR 7.5, 95% CI 1.7 to 53)ConclusionsHost factors, particularly pre-operative mobility, were most predictive of 90-day event and 1-year mortality. Only definitive external fixation was found to influence patient morbidity as a significant predictor of unplanned OR. However, no surgical modality had any influence on short-term readmission or survival.     

Association between use of enhanced recovery after surgery protocols and postoperative complications in colorectal surgery in Europe: The EuroPOWER international observational study

Study objectiveAssess the relationship between the Enhanced Recovery After Surgery (ERAS®) pathway and routine care and 30-day postoperative outcomes.DesignProspective cohort study.SettingEuropean centers (185 hospitals) across 21 countries.PatientsA total of 2841 adult patients undergoing elective colorectal surgery. Each hospital had a 1-month recruitment period between October 2019 and September 2020.InterventionsRoutine perioperative care.MeasurementsTwenty-four components of the ERAS pathway were assessed in all patients regardless of whether they were treated in a formal ERAS pathway. A multivariable and multilevel logistic regression model was used to adjust for baseline risk factors, ERAS elements and country-based differences.ResultsA total of 1835 patients (65%) received perioperative care at a self-declared ERAS center, 474 (16.7%) developed moderate-to-severe postoperative complications, and 63 patients died (2.2%). There was no difference in the primary outcome between patients who were or were not treated in self-declared ERAS centers (17.1% vs. 16%; OR 1.00; 95%CI, 0.79–1.27; P = 0.986). Hospital stay was shorter among patients treated in self-declared ERAS centers (6 [5–9] vs. 8 [6–10] days; OR 0.82; 95%CI, 0.78–0.87; P < 0.001). Median adherence to 24 ERAS elements was 57% [48%–65%]. Adherence to ERAS-pathway quartiles (≥65% vs. <48%) suggested that patients with the highest adherence rates experienced a lower risk of moderate-to-severe complications (15.9% vs. 17.8%; OR 0.71; 95%CI, 0.53–0.96; P = 0.027), lower risk of death (0.3% vs. 2.9%; OR 0.10; 95%CI, 0.02–0.42; P = 0.002) and shorter hospital stay (6 [4–8] vs. 7 [5–10] days; OR 0.74; 95%CI, 0.69–0.79; P < 0.001).ConclusionsTreatment in a self-declared ERAS center does not improve outcome after colorectal surgery. Increased adherence to the ERAS pathway is associated with a significant reduction in overall postoperative complications, lower risk of moderate-to-severe complications, shorter length of hospital stay and lower 30-day mortality.     

Mono-segmental percutaneous screw fixation in the management of AoSpine thoracolumbar type B fracture in patients with ankylosing spondylitis: A new treatment

PurposeTo assess the viability and effectiveness of mono-segmental percutaneous screw fixation in the treatment of unstable type B thoracolumbar fracture due to ankylosing spondylitis.MethodsWe report here all 40 patients treated by mono-segmental screw fixation in this indication, between January 2018 and January 2022, with follow-up at 3 and 9 months. Study variables comprised operating time, length of stay, fusion, stabilization quality, and peri-operative morbidity and mortality.ResultsOne patient showed early displacement of rods caused by technical error. None of the others showed secondary displacement of rods or screws. Mean age was 73 years (range 18–93), mean hospital stay 4.8 days (range 2–15), mean operative time 52 minutes (range 26–95 minutes) and mean estimated blood loss 40 ml. There were 2 deaths caused by intensive care unit complications. All patients except those in intensive care were verticalized within 24 hours after surgery. Parker score was unchanged for each patient before and after surgery and during follow-up.ConclusionMono-segmental percutaneous screw fixation in the treatment of unstable type B thoracolumbar fracture due to ankylosing spondylitis was safe and effective. This study showed that this surgery reduced length of hospital stay, operative time, blood loss and complications compared to open or extended percutaneous surgery, and allowed fast rehabilitation in this vulnerable population.     

Incidence of and Risk Factors for Screw Loosening after Iliosacral Screw Fixation for Posterior Pelvic Ring Injury

Purposes

Screw loosening is a common complication of iliosacral screw fixation, with subsequent loss of stability and fracture re-displacement. This study aimed to investigate the incidence of and risk factors for screw loosening after iliosacral screw fixation for posterior pelvic ring injury.

Methods

A total of 135 patients with posterior pelvic ring injuries who were treated with iliosacral screw fixation in our department between July 2015 and April 2021 were selected for this retrospective analysis. The possible risk factors for screw loosening were investigated using univariate and multivariate logistic regression analyses of patient demographics and trauma-related and iatrogenic variables, including age, sex, body mass index, Osteoporosis Self-Assessment Tool for Asians (OSTA) index, mechanism of injury, Young–Burgess classification, site of injury, type of injury, type of screw, mode of fixation, numbers of guidewire adjustments, accuracy of screw position, and quality of fracture reduction.

Results

The incidence of screw loosening was 15.6% (n = 21). The mean duration for screw loosening was 3.2 ± 1.5 months after operation. Univariate analysis results showed that the Young–Burgess classification, type of injury, site of injury, type of screw, mode of fixation, and OSTA index might be related to screw loosening (p < 0.05). According to the multivariate logistic regression, vertical shear injuries (Odds ratios [OR] 9.80, 95% Confidence intervals [CI] [1.96–73.28], p = 0.008), type of injury (OR 0.25, 95% CI [0.13–0.79], p = 0.027), common screws (OR 6.94, 95% CI [1.53–31.40], p = 0.012), screws insertion only at the level of the first sacral segment (S1) (OR 8.79, 95% CI [1.18–65.46], p = 0.034), injury site located in the medial sacral foramina (OR 6.28, 95% CI [1.16–34.06], p = 0.033), and lower OSTA index [OR 0.41, 95% CI [0.24–0.71], p = 0.001] were significantly related to screw loosening.

Conclusions

Vertical shear injuries, sacral fractures, injury site located in the medial sacral foramina, and lower OSTA index are significantly associated with the postoperative occurrence of screw loosening. Transiliac–transsacral screw fixation and screws insertion both at the level of the S1 and second sacral segment can prevent screw loosening.     

Results and outcomes after operative treatment of high-energy tibial plafond fractures

BACKGROUND: The purposes of this study were to evaluate the clinical and radiographic results and the functional outcomes after operative treatment of tibial plafond fractures treated with internal or external fixation. METHODS: A retrospective review identified 76 patients with 79 fractures (OTA 43-B or 43-C) of the tibial plafond. Their average age was 45 years. Twenty-one fractures (27%) were open, and 43 (54%) were type 43-C3. Five were type 43-B1, four were 43-B2, two were 43-B3, 15 were 43-C1, and 10 were 43-C2. Patients were treated with open reduction and internal fixation (ORIF) (n = 63) or limited open articular reduction and wire ring external fixation (EF) (n = 16). Tibial fixation was performed at a mean of 7.6 days after injury, with staged reconstruction in 56 fractures (71%). Bone graft was used initially in 32 fractures (41%). Early and late complications, secondary procedures, and radiographic evidence of post-traumatic arthritis were evaluated. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were administered. RESULTS: Seventy-nine fractures were followed clinically and radiographically for a mean of 26 (range 24 to 38) months, and 33 patients completed outcomes questionnaires at a mean of 98 months after surgery. Early complications included two superficial wound problems and three deep infections. Late complications included two nonunions and four malunions. Thirty-one fractures (39%) developed post-traumatic arthritis. Complications occurred after six of 21 open fractures and after 11 of 43 type C3 fractures (p = 0.007). Patients treated with EF more frequently had type C3 fractures (88% versus 46%, p = 0.004) compared with patients treated with ORIF. The EF patients developed more complications (six of 16, p = 0.007) and post-traumatic arthritis (11 of 16, p = 0.01) when compared with ORIF. Patients treated with EF (88% were type C3 fractures) had lower FFI and MFA scores. The greatest impairment in outcome was noted after type C3 fractures, regardless of the method of treatment. CONCLUSIONS: Tibial plafond fractures are difficult to manage and may have serious complications. We identified more complications, more secondary procedures, and worse outcomes in patients with articular and metaphyseal comminution (type C3). ORIF was associated with fewer complications and less post-traumatic arthritis when compared to EF, possibly reflecting a selection bias for open injuries and more severely comminuted fractures to be managed with EF. ORIF with appropriate soft tissue handling resulted in acceptable results in most patients. Severely damaged soft tissues and highly comminuted C3 fractures may be safely treated with EF. Loss of function and progression to post-traumatic arthritis are common after tibial plafond fractures. Assessment of long-term results and the efficacy of additional reconstructive procedures will refine the treatment algorithms for these fractures.     

Early post-operative outcomes of plate versus nail fixation for humeral shaft fractures

IntroductionThis study was designed to measure early postoperative outcomes of plate vs. nail fixation for humeral shaft fractures.Patients and methodsPatients ≥18 years who underwent plate or nail fixation for low-energy humeral shaft fractures between 2005–2016 were identified from the National Surgical Quality Improvement Program (NSQIP). Multivariable regression was used to compare postoperative outcomes using propensity score adjustment to account for differences between fixation groups. Variables included in the propensity score were age, American Society of Anesthesiologists (ASA) class, hypertension, steroid use, cancer, functional status, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and sex.ResultsPlate fixation was used in 1418 patients (70.6%), while nail fixation was used in 591 (29.4%). Patients undergoing nail fixation were more likely to be older, have a higher American Society of Anesthesiologists (ASA) class, and have comorbidities. Mean operative time was statistically longer in the plate fixation group (130 +/−62 min vs. 102 +/−54 min). After propensity score adjustment, type of fixation was not a significant predictor of major or minor complications, length of stay, or readmission. However, nail fixation was a significant predictor of mortality following propensity score adjustment (OR 3.15, 95% Confidence interval 1.26–7.85).ConclusionPatients undergoing intramedullary nail fixation tended to be older patients with more comorbidities, suggesting that surgeons are selecting nail fixation in patients who may not be ideal surgical candidates. Although LOS, complications, and readmission rates were higher in the nail group, this difference was not statistically significant following propensity score adjustment. However, nail fixation remained an independent predictor of 30-day mortality following adjustment. This suggests that nail fixation may not be a safer surgical option in patients with multiple medical co-morbidities and low-energy humeral shaft fractures.     

Fixation method for treatment of unstable distal clavicle fracture: systematic review and network meta-analysis

Surgical management is recommended for unstable distal clavicle fractures. A variety of methods have been previously reported, but there is no current consensus regarding which method is most suitable. Therefore, we have conducted a systematic review and network meta-analysis to compare postoperative shoulder function and complications between different fixation methods to identify which class of fixation is best for unstable distal clavicle fractures. We searched the literature systematically using eligibility criteria of all comparative studies that compared postoperative outcomes of coracoclavicular fixation (tight rope, screw or endobutton), hook plating, plate and screws, tension band wiring and transacromial pinning fixation for unstable distal clavicle fractures from PubMed, EMBASE, and Scopus databases up to February 10, 2018. Two reviewers independently extracted data. A network meta-analysis was applied to combine direct and indirect evidence and to estimate the relative effects of the treatment options. The probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Ten comparative studies (n?=?505 patients) with one RCT study (n?=?42) met the inclusion criteria. Intervention included coracoclavicular fixation (n?=?111 patients), hook plating (n?=?300 patients), plate and screws (n?=?41 patients), tension band wiring (n?=?81 patients) and transacromial pinning (n?=?14 patients). A network meta-analysis showed that CM scores of coracoclavicular fixation were significantly higher when compared to hook plate and tension band wiring, with pooled mean of 2.98 (95% CI 0.05–5.91) and 7.11 (95% CI 3.04–11.18). For UCLA, CC fixation and plate and screw fixation had significantly higher scores compared to hook plating fixation with a mean score 2.22 (95% CI 0.44–3.99) and 3.20 (95% CI 0.28–6.12), respectively. In terms of complications, plate and screw fixation had lower risk with RRs of 0.63 (95% CI 0.20–1.98), 0.37 (95% CI 0.19–0.72), 0.11 (95% CI 0.04–0.30) and 0.02 (95% CI 0.002–0.16) when compared to coracoclavicular fixation, hook plating, tension band wiring and transacromial pinning. The SUCRA probabilities of CC fixation were in the first rank with 96.8% for CMS, while plate and screw fixation were in the first rank with 67.7 and 93.8% for UCLA score and complications. We recommend using plate and screw and CC fixation as the first- and second-line treatment of unstable distal clavicle fractures. As the quality of studies for this meta-analysis was not high, larger and higher-quality randomized controlled trials are required to confirm these conclusions for informed clinical decision making.     

Surgical site infection is a major risk factor of pseudarthrosis in adult spinal deformity surgery

BACKGROUND CONTEXTDespite the evidence in appendicular skeletal surgery, the effect of infection on spinal fusion remains unclear, particularly after Adult Spinal Deformity (ASD) surgery.PURPOSEThe purpose of this study was to determine the impact of surgical site infection (SSI) in ASD surgery fusion rates and its association with other risks factors of pseudarthrosis.STUDY DESIGNWe conducted an international multicenter retrospective study on a prospective cohort of patients operated for spinal deformity.PATIENT SAMPLEA total of 956 patients were included (762 females and 194 males).OUTCOME MEASURESPatient's preoperative characteristics, pre and postoperative spinopelvic parameters, surgical variables, postoperative complications and were recorded. Surgical site infections were asserted in case of clinical signs associated with positive surgical samples. Each case was treated with surgical reintervention for debridement and irrigation. Presence of pseudarthrosis was defined by the association of clinical symptoms and radiological signs of nonfusion (either direct evidence on CT-scan or indirect radiographic clues such as screw loosening, rod breakage, screw pull out or loss of correction). Each iterative surgical intervention was collected.METHODSUnivariate and multivariate analysis with logistic regression models were performed to evaluate the role of risk factors of pseudarthrosis.RESULTSNine hundred fifty-six surgical ASD patients with more than two years of follow-up were included in the study. 65 of these patients were treated for SSI (6.8%), 138 for pseudarthrosis (14.4%), and 28 patients for both SSI and pseudarthrosis.On multivariate analysis, SSI was found to be a major risk factor of pseudarthrosis (OR=4.4; 95% CI=2.4,7.9) as well as other known risks factors: BMI (OR=1.1; 95% CI=1.0,1.1), smoking (OR=1.6; 95% CI=1.1,2.9), performance of Smith-Petersen osteotomy (OR = 1.6; 95% CI 1.0,2.6), number of vertebrae instrumented (OR=1.1; 95% CI=1.1,1.2) and the caudal level of fusion, with a distal exponential increment of the risk (OR max for S1=6, 95% CI=1.9,18.6).CONCLUSIONSSI significantly increases the risk of pseudarthrosis with an OR of 4.4.     

What Is the Relative Effectiveness of the Various Surgical Treatment Options for Distal Radius Fractures? A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

BackgroundMany acceptable treatment options exist for distal radius fractures (DRFs); however, a simultaneous comparison of all methods is difficult using conventional study designs.Questions/purposesWe performed a network meta-analysis of randomized controlled trials (RCTs) on DRF treatment to answer the following questions: Compared with nonoperative treatment, (1) which intervention is associated with the best 1-year functional outcome? (2) Which intervention is associated with the lowest risk of overall complications? (3) Which intervention is associated with the lowest risk of complications requiring operation?MethodsTen databases were searched from inception to July 25, 2019. Search and analysis reporting adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Included studies were English-language RCTs that assessed at least one surgical treatment arm for adult patients with displaced DRFs, with less than 20% loss to follow-up. We excluded RCTs reporting on patients with open fractures, extensive bone loss, or ipsilateral upper extremity polytrauma. Seventy RCTs (n = 4789 patients) were included. Treatments compared were the volar locking plate, bridging external fixation, nonbridging external fixation, dynamic external fixation, percutaneous pinning, intramedullary fixation, dorsal plating, fragment-specific plating, and nonoperative treatment. Subgroup analyses were conducted for intraarticular fractures, extraarticular fractures, and patients with an average age greater than 60 years. Mean (range) patient age was 59 years (56 to 63) and was similar across all treatment groups except for dynamic external fixation (44 years) and fragment-specific plating (47 years). Distribution of intraarticular and extraarticular fractures was approximately equal among the treatment groups other than that for intramedullary fixation (73% extraarticular), fragment-specific plating (66% intraarticular) [13, 70], and dorsal plating (100% intraarticular). Outcomes were the DASH score at 1 year, total complications, and reoperation. The minimum clinically important different (MCID) for the DASH score was set at 10 points. The analysis was performed using Bayesian methodology with random-effects models. Rank orders were generated using surface under the cumulative ranking curve values. Evidence quality was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology. Most studies had a low risk of bias due to randomization and low rates of incomplete follow-up, unclear risk of bias due to selective reporting, and high risk of bias due to lack of patient and assessor blinding. Studies assessing bridging external fixation and/or nonoperative treatment arms had a higher overall risk of bias while studies with volar plating and/or percutaneous pinning treatment arms had a lower risk of bias.ResultsAcross all patients, there were no clinically important differences in terms of the DASH score at 1 year; although differences were found, all were less than the MCID of 10 points. Volar plating was ranked the highest for DASH score at 1 year (mean difference -7.34 [95% credible interval -11 to -3.7) while intramedullary fixation, with low-quality evidence, also showed improvement in DASH score (mean difference -7.75 [95% CI -14.6 to -0.56]). The subgroup analysis revealed that only locked volar plating was favored over nonoperative treatment for patients older than 60 years of age (mean difference -6.4 [95% CI -11 to -2.1]) and for those with intraarticular fractures (mean difference -8.4 [95% CI -15 to -2.0]). However, its clinical importance was uncertain as the MCID was not met. Among all patients, intramedullary fixation (odds ratio 0.09 [95% CI 0.02 to 0.84]) and locked volar plating (OR 0.14 [95% CI 0.05 to 0.39]) were associated with a lower complication risk compared with nonoperative treatment. For intraarticular fractures, volar plating was the only treatment associated with a lower risk of complications than nonoperative treatment (OR 0.021 [95% CI < 0.01 to 0.50]). For extraarticular fractures, only nonbridging external fixation was associated with a lower risk of complications than nonoperative treatment (OR 0.011 [95% CI < 0.01 to 0.65]), although the quality of evidence was low. Among all patients, the risk of complications requiring operation was lower with intramedullary fixation (OR 0.06 [95% CI < 0.01 to 0.85) than with nonoperative treatment, but no treatment was favored over nonoperative treatment when analyzed by subgroups.ConclusionWe found no clinically important differences favoring any surgical treatment option with respect to 1-year functional outcome. However, relative to the other options, volar plating was associated with a lower complication risk, particularly in patients with intraarticular fractures, while nonbridging external fixation was associated with a lower complication risk in patients with extraarticular fractures. For patients older than 60 years of age, nonoperative treatment may still be the preferred option because there is no reliable evidence showing a consistent decrease in complications or complications requiring operation among the other treatment options. Particularly in this age group, the decision to expose patients to even a single surgery should be made with caution.Level of EvidenceLevel I, therapeutic study.     

Fewer reoperations after posterolateral plate positioning compared with lateral plate positioning in ankle fractures—a retrospective study on 453 AO/OTA 44-B injuries

IntroductionAnkle fractures are commonly treated by open reduction and internal fixation with plate and screws. Unplanned return to theatre is common, in many cases to extract prominent osteosynthesis material from the lateral malleolus as swelling subsides. We hypothesised that patients operated with a posterolateral plate placement on the lateral malleolus would have fewer reoperations, and fewer complications, compared to patients with a lateral plate placement.Materials and MethodsFrom a prospectively collected database of all orthopaedic surgery performed at our institution, we identified 664 ankle fractures undergoing plate fixation between 2008-01-01 and 2012-04-30. Radiographs were analysed to only include AO/OTA 44-B-fractures (n = 453), and to define study groups based on plate positioning. Hospital files were assessed to identify possible confounding factors, and any unplanned reoperation or complication. Complications were classified according to Dindo-Clavien.ResultsThe risk of reoperation was 13% after posterolateral plating, compared with 24% after lateral plating; absolute risk reduction 10% (95% CI: 2.5–18), p = 0.02. After adjusting for possible confounders, the odds ratio of undergoing reoperation after lateral plating was 2.2 (95% CI: 1.17–4.1), p = 0.01. The two surgical methods did not differ with regard to complication frequency: 31% vs 34%, p = 0.6, but complications following lateral plate fixation were more serious, p = 0.03. Plate positioning depended on surgeon preference.DiscussionThe two studied methods are both considered standard treatment of ankle fractures, and relatively simple surgical procedures. High rates of secondary surgery after plate fixation have been reported, but no study comparing plate positioning has been previously published to our knowledge. AO Sweden has recently switched to teaching posterolateral plating in group exercises during the AO Basic Fracture Surgery course, based on the belief that it may be safer than lateral plating. Our findings support this change in practice.ConclusionsPosterolateral plate positioning on the lateral malleolus in AO/OTA 44-B-fractures may be preferential to lateral plate positioning, due to a large difference in unplanned secondary surgery.