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Frailty is a well-established risk factor in patients undergoing total knee arthroplasty (TKA). How age modifies the impact of frailty on outcomes in these patients, however, remains unknown. In this study, we aimed to describe and evaluate the applicability of a novel risk stratification tool-the age-adjusted modified Frailty Index (aamFI)-in patients undergoing TKA.A national database was queried for all patients undergoing primary TKA from 2015 to 2019. There were 271,271 patients who met inclusion criteria for this study. First, outcomes were compared between chronologically young and old frail patients. In accordance with previous studies, the 75th percentile of age of all included patients (73 years) was used as a binary cutoff. Then, frailty was classified using the novel aamFI, which constitutes the 5-item mFI with the addition of 1 point for patients ≥73 years. Multivariable logistic regressions were then used to investigate the relationship between aamFI and postoperative outcomes.Frail patients ≥73 years had a higher incidence of complications compared to frail patients73 years. There was a strong association between aamFI and complications. An aamFI of ≥3 (reference aamFI of 0) was associated with an increased odds of 30-day mortality (odds ratio [OR] 8.6, 95% CI 5.0-14.8), any complication (OR 3.1, 95% CI 2.9-3.3), deep vein thrombosis (OR 1.5, 95% CI 1.2-1.8), and nonhome discharge (OR 6.1, 95% CI 5.8-6.4; all P.001).Although frailty negatively influences outcomes following TKA in patients of all ages, chronologically old, frail patients are particularly vulnerable. The aamFI accounts for this and represents a simple, but powerful tool for stratifying risk in patients undergoing primary TKA.

Introduction Current standards recommend antibiotic prophylaxis administered after open fracture injury. The purpose of this study was to assess culture results in patients with open fracture-associated infections, hypothesizing that cultures obtained do not vary by Gustilo-Anderson (GA) classification. Methods We examined cultured bacterial species from patients with open long bone fractures that underwent irrigation and debridement at a Level 1 trauma center (2008-2016), evaluating our current and two hypothetical antibiotic protocols to assess whether they provided appropriate coverage. The antibiotic protocols included protocols 1 (cefazolin, with gentamicin added for type III fractures), 2 (vancomycin and cefepime) and 3 (ceftriaxone). Results GA classification was not associated with bacterial gram stain (P = 0.161), nor was it predictive of mono- versus polymicrobial infection (P = 0.094). Of 42 culture-positive infections, 31 were type III and 11 were type I or II fractures. 27% of the infections for type I or II fractures were caused by organisms targeted by protocol 1 (OR 0.18, 95% CI 0.04-0.82; P = 0.027). There was no difference in coverage by fracture type among protocol 2 (P = 0.771) or protocol 3 (P = 0.891). For type III fractures, protocol 2 provided 94% appropriate coverage compared to 68% and 61% coverage by protocols 1 and 3, respectively. Conclusion For open fractures complicated by infection, isolated bacterial organisms do not correlate with GA open fracture classification, suggesting that hypothetical protocol 2 should be used for all fracture types. Protocol 2’s broad coverage, across all GA fracture types, may prevent infection by organisms not covered by current antibiotic prophylaxis.

Retrospective cohort study. To compare clinical outcomes and radiographic parameters between patients treated with a posterior spinal fusion that had a lower instrumented vertebra at T11, T12, and L1. Posterior instrumented fusions are well established for treating patients with adolescent idiopathic scoliosis (AIS). Fusions limited to the thoracic spine can adequately correct a spinal deformity while preserving lumbar segmental mobility. However, fusions that end at the thoracolumbar junction have been proposed to cause adjacent segment complications. Studies comparing outcomes between patients who were treated with fusions that end at the thoracolumbar junction with varying LIVs are limited. A multicenter database was queried for patients with AIS that had Lenke Type 1 and 2 curves treated with a fusion that had an LIV at T11, T12, or L1. Coronal curve magnitude, degree of junctional kyphosis, C7–central sacral line, thoracic apical translation, and sagittal stable vertebrae were measured. Clinical and functional outcomes were assessed using the Scoliosis Research Society-22 (SRS-22) questionnaire and lumbar flexibility testing. The lower instrumented level was below the sagittal stable vertebrae in 22.7%, 40%, and 66.2% of patients in the LIV-T11, T12, and L1 groups, respectively (p

OBJECTIVES To explore the association between increased time in traction and in-hospital pulmonary complications in patients with acetabular fractures. DESIGN Retrospective. SETTING Level I trauma center. PATIENTS/PARTICIPANTS One hundred ninety consecutive patients. INTERVENTION Application of skeletal traction before fixation of acetabular fracture. MAIN OUTCOME MEASUREMENTS The primary outcome measure was pulmonary complication as defined by pulmonary embolism, pneumonia, and acute respiratory distress syndrome. Secondary outcome measures included length of intensive care unit stay (in days), total length of hospital stay (in days), deep hardware-associated infection, subsequent conversion to total hip arthroplasty, urinary tract infection, and lower-extremity deep venous thrombosis. RESULTS The mean time in traction for patients who developed a pulmonary complication was 210 hours compared with 62 hours for those who did not (P < 0.001). After controlling for Injury Severity Score, chest injury, and concomitant long bone injury requiring intramedullary nailing, the odds of developing a pulmonary complication for patients who spent longer than 120 hours in traction were over 40 times higher than those treated within 5 days (P < 0.001). The mean intensive care unit stay for patients who spent at least 120 hours in traction was 17 days compared with 5 days for those treated in less than 120 hours (P < 0.001). CONCLUSION Early definitive fixation and decreased time in skeletal traction is associated with a lower rate of complications in patients with acetabular fractures. Our results would suggest that fixation of acetabular fractures before 120 hours (5 days) confers a significant risk-reduction benefit. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The aim of this study was to evaluate the association between frailty and 30-day morbidity and mortality in patients with intertrochanteric femur fractures. Furthermore, the authors sought to identify a specific frailty index score that would help identify high-risk patients. This retrospective study evaluated 229 consecutive patients 50 years or older who presented to a single level I trauma center for surgical fixation of an intertrochanteric femur fracture. Frailty was determined using a previously validated 11-point modified frailty index (mFI) scale. Primary outcome variables included 30-day morbidity and mortality. Of the 229 patients included in this study, 82 (36%) had a postoperative complication and there were 10 (4%) mortalities. The most common complications were delirium (n=40; 17%) and acute kidney injury (n=25; 11%). Mean mFI score for those who developed a postoperative complication was 0.24 compared with 0.14 for those who did not ( P P =.006). This study demonstrates that the mFI is associated with 30-day morbidity and mortality in patients aged 50 years or older with intertrochanteric femur fractures. The authors identified an mFI score of 0.27 or more as the most robust predictor of increased 30-day morbidity and mortality following surgical fixation of intertrochanteric femur fractures. [ Orthopedics . 2019; 42(6):344–348.]

To examine the relationship of nutrition parameters with the modified frailty index (mFI) and postoperative complications in hip fracture patients.Retrospective observational cohort study.Urban, American College of Surgeons-Verified, Level-1, Trauma Center.Three hundred seventy-seven consecutive patients with isolated hip fractures.N/A.On admission, albumin and total lymphocyte count (TLC) levels and complication data were collected. Additionally, mFI scores were calculated. Statistical analysis was then used to analyze the association between frailty, malnutrition, and postoperative complications.Overall, 62.6% and 17.5% of patients were malnourished as defined by TLC of1500 cells per cubic millimeter and albumin of3.5 g/dL, respectively. Both TLC (P = 0.024; r = -0.12) and albumin (P0.001; r = -0.23) weakly correlated with frailty. Combining malnutrition and frailty revealed predictive synergy. Albumin of3.5 g/dL and mFI of ≥0.18 in the same patient resulted in a positive predictive value of 69% and a likelihood ratio of 4 (2.15-7.43) for postoperative complications. Similarly, the combination of hypoalbuminemia and frailty resulted in a positive predictive value of 23.3% and likelihood ratio of 8.52 (P0.001) for mortality.When patients are frail and malnourished, there is a risk elevation beyond that of frailty or malnutrition in isolation. This high-risk cohort can be easily identified at admission with routine laboratory values and clinical history. There is an opportunity to improve outcomes in frail hip fracture patients because malnutrition represents a potentially modifiable risk factor.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The purpose of the present study was to evaluate the prevalence of closed suction drainage after a Kocher–Langenbeck (K–L) approach for surgical fixation of acetabular fractures and to determine the impact of closed suction drainage on patient outcomes. This retrospective study reports on 171 consecutive patients that presented to a single level I trauma center for surgical fixation of an acetabular fracture. Medical records were reviewed to evaluate the use of closed suction drains. The primary outcomes measures were rate of packed red blood cell (PRBC) transfusion and length of hospital stay (LOS). Secondary outcome measures were 30-day post-operative wound complication and 1-year deep infection rates. Of the 171 patients included in this study, 140 (82%) patients were treated with drains. There was a significant association between the use of closed suction drainage and post-operative blood transfusion rate (p = 0.002). Thirty-five patients (25%) treated with drains required a post-operative blood transfusion compared to 0% in the no drain cohort. Regarding the total number of drains used, for every additional closed suction drain that was placed beyond a single drain, the odds of receiving a blood transfusion doubled (p = 0.002). Use of closed suction drainage was associated with a significantly longer LOS (p = 0.015), and no difference in wound complication or deep infection rates. The use of closed suction drains for treatment of acetabular fractures using a K–L approach is associated with increased rates of blood transfusion and increased length of hospital stay, with no impact on surgical site infection rates. The results of this study suggest against routine drain usage in acetabular surgery.

OBJECTIVES To explore the association between intraoperative hypothermia and perioperative blood loss and blood transfusion requirements in patients with operative pelvic and acetabular fractures. DESIGN Retrospective review. SETTING Single, Level 1 trauma center in Atlanta, Georgia. PATIENTS/PARTICIPANTS Three hundred seventy-four patients who underwent surgical fixation of an acetabular fracture and/or pelvic ring injury at a single Level 1 trauma center during the years 2013-2017. MAIN OUTCOME MEASURES Estimated blood loss during surgery (EBL, mL), drain output (mL) on postoperative day 1 (POD1), and rate of postoperative packed red blood cell (pRBC) transfusion (%). RESULTS A significant association was found between intraoperative hypothermia and postoperative transfusion requirement (P = 0.016). The rate of postoperative blood transfusion was 42% for patients with intraoperative hypothermia compared with 28% for controls. In a subgroup analysis of patients presenting with an admission acidosis, the rate of postoperative transfusion was significantly increased to more than 4 times as likely when intraoperative hypothermia was present, even after controlling for admission hemoglobin, Injury Severity Score, and rate of preoperative transfusion (OR 4.4; P = 0.018). CONCLUSIONS For patients with pelvic trauma who present with an admission acidosis, intraoperative hypothermia is an independent risk factor for postoperative blood transfusion. This information is clinically important given the modifiable nature of intraoperative patient temperature and the known complications and sequelae associated with increased transfusion rates. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study is to compare biomechanical properties of fully and partially threaded iliosacral screws. We hypothesise that fully threaded screws will have a higher yield force, and less deformation than partially threaded screws following axial loading. Twenty sawbone blocks were uniformly divided to simulate vertical sacral fractures. Ten blocks were affixed with fully threaded iliosacral screws in an over-drilled, lag-by-technique fashion whilst the remaining ten were fixed with partially threaded lag-by-design screws. All screws measured 7.3-mm x 145 mm, and were inserted to a 70% of calculated maximal insertional torque, ensuring uniform screw placement throughout across models. Continuous axial loads were applied to 3 constructs of each type to failure to determine baseline characteristics. Five hundred loading cycles of 500 N at 1 Hz were applied to 4 constructs of each type, and then axially loaded to failure. Force displacement curves, elastic, and plastic deformation of each construct was recorded. Fully threaded constructs had a 428% higher yield force, 61% higher stiffness, 125% higher ultimate force, and 66% lower yield deformation (p

Background:Success rates for surgical management of chronic exertional compartment syndrome (CECS) are historically lower with release of the deep posterior compartment compared with isolated anterolateral releases. At our institution, when a deep posterior compartment release is performed, we routinely examine for a separate posterior tibial muscle osseofascial sheath and release it if present.Purpose:Within the context of this surgical approach, the aim of the current study was to compare long-term patient satisfaction and activity levels in patients who underwent 2-compartment fasciotomy versus a modified 4-compartment fasciotomy for CECS.Study Design:Cohort study; Level of evidence, 3.Methods:Patients treated with fasciotomy for lower extremity CECS from 2007 to 2017 were retrospectively identified. In all patients in whom a 4-compartment fasciotomy was indicated, the tibialis posterior muscle was examined for a separate osseofascial sheath, which was released when present. Patients completed a series of validated patient-reported outcome (PRO) surveys, including the Marx activity score, Tegner activity score, 12-Item Short Form Health Survey, and Likert score for patient satisfaction.Results:Of the 48 patients who were included in this study, 34 (71%) patients with a total of 52 operative limbs responded and completed PRO surveys. The mean follow-up for the entire cohort was 5.5 ± 2.6 years. Of the 34 patients, 23 (68%) underwent 2-compartment fasciotomy and 11 (32%) underwent 4-compartment fasciotomy. Among the patients in the 4-compartment fasciotomy group, 7 (64%) were found to have a fifth compartment. No significant difference was found in any of the validated PRO measures between patients who had a 2- versus 4-compartment fasciotomy or those who underwent 4-compartment fasciotomy with or without a present fifth compartment. At a mean 5.5-year follow-up, 74% of patients who underwent a 2-compartment release reported good or excellent outcomes compared with 82% of patients who underwent our modified 4-compartment release.Conclusion:The current study, which included the longest follow-up on CECS patients in the literature, demonstrated that the addition of a release of the posterior tibial muscle fascia led to no significant difference in PRO measures between patients who underwent a 2- versus 4-compartment fasciotomy, when historically the 2-compartment fasciotomy group has had higher success rates.

Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed.To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures.This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019.Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care.Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03).The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

Background: The primary aim of this study was to investigate whether USMLE board scores correlate with the emotional intelligence of medical students. We hypothesized that higher Step 1 scores would be associated with lower emotional intelligence.Methods: This prospective study included medical students who self-reported their USMLE Step 1 score and completed a survey designed to measure their emotional intelligence. The survey was composed of a Grit Scale, a Hardiness-Resilience quiz, and the “Reading the Mind in the Eyes” quiz. For participants who completed all three instruments, a composite score was equal to the sum of the three scoresThis study was performed at Emory University School of Medicine in Atlanta, Georgia. Of the 85 medical students who were recruited to participate, 72 completed all aspects of this study (85% completion rate).Results: Pearson correlation analyses showed that grit (r=-0.105, P=0.34), hardiness-resilience (r=-0.230, P=0.04), the eye quiz (r=-0.033, P=0.79), and the composite score (r=-0.187, P=0.12) wereinversely correlated with USMLE scores. Participants who scored higher than the national average had a lower mean hardiness score compared to those who scored lower than the national average (P=0.03). Those who scored at least one standard deviation above the national average had a lowermean hardiness score (P=0.05) and a lower composite score (P=0.04).Conclusion: Higher USMLE Step 1 scores are associated with lower emotional intelligence, namely hardiness, in medical students.Keywords: EMOTIONAL INTELLIGENCE, USMLE STEP 1, HARDINESS, GRIT, RESIDENCY SELECTION

Introduction. On-call orthopedic clinicians have long speculated that daily consult volume is closely correlated with weather. While prior studies have demonstrated a relationship between weather and certain fracture types, the effect of weather on total orthopaedic consult volume has not yet been examined. The aim of this study was to investigate this relationship.Methods. We retrospectively reviewed orthopaedic consult data from 405 consecutive days at an urban, level one trauma center. The number, mechanism of injury, and type of consult were collected, along with daily weather data (temperature, wind, and precipitation). Statistical analysis was then performed to determine the relationship between weather and orthopaedic trauma consults.Results. A total of 4543 consults were received during the study period. There was a significant difference in total number of consults between months of the year (pConclusion. Weather parameters, specifically average temperature and precipitation, were found to be associated with daily orthopedic consult type and volume. Additionally, consult volume varies significantly between months of the year. Because trauma centers are often resource scarce, this is an important relationship to understand for proper resource allocation.