Wilke, Benjamin K.

Abstract Postoperative pain control after total knee arthroplasty (TKA) remains challenging, particularly in patients utilizing chronic opioids preoperatively. Our study aimed to evaluate the effect of regional nerve blockade on perioperative pain control outcomes after TKA in patients using or not using chronic preoperative opioids. A retrospective review of our institutional database identified 434 chronic opioid patients defined as documented ongoing use greater than 3 months prior to contemporary TKA. Patients were 1:1 matched to nonopioid users based upon age, sex, body mass index, and regional block type (single-shot adductor canal block [ACB, 29%], 3-day ACB catheter [31%], or no block [41%]). All patients underwent primary TKA using periarticular injections and contemporary multimodal pain management. Immediate and 90-day postoperative outcomes, including Knee Osteoarthritis Outcome Score, Junior (KOOS, Jr), were compared via univariate analysis among the matched cohort and regional block type among chronic opioid patients. Chronic opioid patients demonstrated higher inpatient opioid use than controls (90 vs. 65 oral morphine equivalents [OMEs], respectively, p < 0.01), but no significant differences existed in length of stay (LOS), discharge pain scores, 90-day readmission or KOOS, Jr (all p ≥ 0.05). When comparing chronic opioid patients according to block type, those receiving no block had the highest LOS (1.6 days, p < 0.01), discharge pain score (5.0, p < 0.01), and inpatient opioid use (80 OMEs, p < 0.01) compared with either ACB. The subgroup receiving an ACB catheter demonstrated a significantly higher 90-day readmission rate (9%, p < 0.05). Patients utilizing chronic opioids preoperatively require more opioids in the immediate postoperative period after TKA compared with nonopioid users despite contemporary modalities. Nonetheless, the use of any type of ACB provides improved pain control in these patients.

Background: Orthopaedic surgeons routinely delay surgical management of femoral neck fractures in patients taking direct oral anticoagulants (DOACs) to decrease perioperative bleeding and associated complications. However, this practice contradicts the principles of hip fracture management, as early surgery is associated with morbidity and mortality benefits. The purpose of this study was to quantify the association of DOAC use and perioperative outcomes in patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fractures. We hypothesized that early surgical intervention on a patient taking a DOAC medication would not lead to worse perioperative outcomes. Methods: A retrospective cohort study was conducted on 2,833 patients who underwent primary THA or HA for femoral neck fractures between December 31, 2017, and January 29, 2024, across our hospital system. The patients taking a DOAC were divided into 3 groups based on the time since the last DOAC intake: 1 day, 2 days, and ≥3 days. Propensity matching was performed 1:1, accounting for age, sex, Elixhauser Comorbidity Index, preoperative chronic kidney disease stage, preoperative hemoglobin, body mass index, and hospital type. Subanalyses utilizing linear and conditional logistic regression models were performed to assess differences in outcomes between the groups that had a DOAC withheld and the control groups. Results: The mean age of all patients was 81 ± 10 years, 1,805 patients (64%) were women, and 207 patients (7%) were taking a DOAC prior to surgery. Despite comparable preoperative and postoperative hemoglobin levels between the groups that had a DOAC withheld and the control groups (all p > 0.05), the patients who had a DOAC withheld for 1 day were more likely to receive a postoperative blood transfusion (23.1% compared with 0%; p = 0.002). This difference in transfusion rate was not observed in other cohorts. There were no differences in medical complications, reoperation, discharge disposition, or mortality between the groups that had a DOAC withheld and the matched controls at any time point. Conclusions: Delaying surgical management due to DOAC medications may be unnecessary in patients undergoing arthroplasty for femoral neck fractures. Consideration should be given to adjusting transfusion triggers to reduce unwarranted blood transfusions in patients taking a DOAC. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Case: We present a 55-year-old woman with a very short transfemoral amputation who underwent osseointegration. We compared gait analyses before and following osseointegration, demonstrating improvements in kinematics. At follow-up, the patient wore the prosthetic for 16 hours and averaged 10,000 steps daily. She achieved her goal of walking the beach with her prosthetic limb and often traveled without an assistive device. Conclusion: This case study of a patient with a very short transfemoral amputation demonstrated continued improvements in gait and significantly increased prosthetic use over time.

Introduction Surgical site infections (SSI) continue to be a risk associated with surgery. The Centers for Disease Control (CDC) uses surgical wound class (SWC) to predict SSI postoperatively. Prior studies have shown that the current wound class definitions are unreliable for surgical subspecialties. Therefore, an alternative surgical wound classification (ASWC) was created to more accurately reflect risk of SSI following orthopedic procedures. The purpose of this study was to compare the two systems. Methods Seventy patients who developed 90-day SSI following total joint arthroplasty (TJA) were matched 1:1 to patients without postoperative SSI. The SWC was recorded from operative reports. Wounds were then retrospectively reclassified according to the ASWC based on preoperative history from the medical record. The degree of agreement and degree of association with occurrence of SSI was compared between the two systems. Results The proportion of agreement between the systems was poor (41.4%). The current SWC was associated with risk of SSI in both unadjusted (p=0.045) and multivariable analysis (p=0.050). Comparatively, the ASWC demonstrated a stronger association with SSI in both unadjusted (p=0.001) and multivariable analysis (p=0.001). Conclusion The results of this study suggest that the ASWC is more predictive for SSI following TJA than the current SWC definitions for total joint arthroplasty.

Abstract Background Radiation‐associated soft tissue sarcomas (RA‐STS) are rare complications of patients receiving radiation therapy (RT) and are generally associated with a poor prognosis. Most of the literature surrounding RA‐STS of the chest is centered on angiosarcoma. Therefore, we aim to document the management and outcome of patients with non‐angiosarcoma RA‐STS of the chest. Methods We reviewed 17 patients (all female, median age 65 years) diagnosed with RA‐STS. The most common primary malignancy was breast carcinoma ( n = 15), with a median RT dose of 57.9 Gy. All patients underwent surgical resection; five patients (29%) received radiotherapy; and five patients (29%) received peri‐operative chemotherapy. Results The 5‐year local recurrence and metastatic‐free survival were 61% and 60%, while the 5‐year disease‐specific survival was 53%. Local recurrence was associated with death due to disease (HR 9.06, p = 0.01). Complications occurred in nine of patients, most commonly due to a wound complication ( n = 7). At the most recent follow‐up, the median Musculoskeletal Tumor Society Score was 63%. Conclusion RA‐STS involving the chest wall are aggressive tumors with a high risk of local relapse and death due to disease. Local recurrence was associated with death due to disease; as such, we recommend aggressive surgical management with evaluation for adjuvant therapies.

AimsPrior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient’s quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients.MethodsLifetime Markov models were developed evaluating active healthy middle-aged male amputees. Costs of the prostheses, associated complications, use/non-use, and annual costs of arthroplasty parts and service for both a socket and osseointegrated (OPRA) prosthesis were included. Effectiveness was evaluated using the questionnaire for persons with a transfemoral amputation (Q-TFA) until death. All costs and Q-TFA were discounted at 3% annually. Sensitivity analyses on those cost variables which affected a change in treatment (OPRA to socket, or socket to OPRA) were evaluated to determine threshold values. Incremental cost-effectiveness ratios (ICERs) were calculated.ResultsFor treatment-naïve patients, the lifetime ICER for OPRA was $279/quality-adjusted life-year (QALY). For treatment-refractory patients the ICER was $273/QALY. In sensitivity analysis, the variable thresholds that would affect a change in the course of treatment based on cost (from socket to OPRA), included the following for the treatment-naïve group: yearly replacement components for socket > $8,511; cost yearly replacement parts OPRA < $1,758; and for treatment-refractory group: yearly replacement component for socket of > $12,467.ConclusionThe use of the OPRA prosthesis in physically active transfemoral amputees should be considered as a cost-effective alternative in both treatment-naïve and treatment-refractory socket prosthesis patients. Disease-specific quality of life assessments such as Q-TFA are more sensitive when evaluating cost-effectiveness.Cite this article: Bone Jt Open 2024;5(3):218–226.

AbstractIntroductionTranexamic acid (TXA) is an antifibrinolytic drug that has been shown to reduce blood loss following surgery. The use of TXA during orthopedic procedures has gained widespread acceptance, with multiple clinical studies demonstrating no increase in thrombotic complications. While TXA has been shown to be safe and effective for several orthopedic procedures, its use in orthopedic sarcoma surgery is not well established. Cancer‐associated thrombosis remains a significant cause of morbidity and mortality in patients with sarcoma. It is unknown if intraoperative TXA use will increase the risk of developing a postoperative thrombotic complication in this population. This study aimed to compare the risk of postoperative thrombotic complications in patients who received TXA during sarcoma resection to patients who did not receive TXA.MethodsA retrospective review was performed of 1099 patients who underwent resection of a soft tissue or bone sarcoma at our institution between 2010 and 2021. Baseline demographics and postoperative outcomes were compared between patients who did and did not receive intraoperative TXA. We evaluated 90‐day complication rates, including: deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), cerebrovascular accident (CVA), and mortality.ResultsTXA was used more commonly for bone tumors (p < 0.001), tumors located in the pelvis (p = 0.004), and larger tumors (p < 0.001). Patients who received intraoperative TXA were associated with a significant increase in developing a postoperative DVT (odds ratio [OR]: 2.22, p = 0.036) and PE (OR: 4.62, p < 0.001), but had no increase in CVA, MI, or mortality (all p > 0.05) within 90 days of surgery, following univariate analysis. Multivariable analysis confirmed that TXA was independently associated with developing a postoperative PE (OR: 10.64, 95% confidence interval: 2.23–50.86, p = 0.003). We found no association with DVT, MI, CVA, or mortality within 90 days postoperatively, following intraoperative TXA use.ConclusionOur results demonstrate a higher associated risk of PE following TXA use in sarcoma surgery and caution is warranted with TXA use in this patient population.

Background: While there has been much interest in the increased dislocation rate in total hip arthroplasty (THA) patients with a lumbar spine fusion (LSF), there is minimal literature comparing the risk based on surgical approach. The purpose of this study was to determine if a direct anterior (DA) approach was protective against dislocation when compared to the anterolateral and posterior approaches in this high-risk patient population. Methods: A retrospective review was performed of 6554 THAs performed at our institution from January 2011 to May 2021. 294 (4.5%) patients had a prior LSF and were included in the analysis. The surgical approach, timing of LSF in relation to THA, vertebral levels fused, timing of THA dislocation, and the need for revision surgery were recorded for statistical analysis. Results: In total, 39.7.3% of patients underwent a DA approach (n = 117), 25.9% underwent an anterolateral approach ( n = 76), and 34.3% underwent a posterior approach ( n = 101). There was no difference in number of vertebral levels fused between groups (mean 2.5, all p > 0.05). There was a total of 13 (4.4%) THA dislocation events, with an average time from surgery to dislocation of 5.6 months (0.3–30.5 months). There were fewer dislocations in the DA cohort (0.9%) in comparison to both the anterolateral (6.6%, p = 0.036) and posterior groups (6.9%, p = 0.026). Conclusions: The DA approach demonstrated a significantly lower THA dislocation rate compared to both the anterolateral and posterior approaches in patients with a concomitant LSF.

Surgical treatment of pelvic sarcoma involving the bone is the standard of care but is associated with several sequelae and reduced functional quality of life (QOL). Treatment with photon and proton radiotherapy is associated with relapse. Carbon ion radiotherapy (CIRT) may reduce both relapse rates and treatment sequelae. The PROSPER study is a tricontinental, nonrandomized, prospective, three-arm, pragmatic trial evaluating treatments of pelvic sarcoma involving the bone. Patients aged at least 15 years are eligible for inclusion. Participants must have an Eastern Cooperative Oncology Group Performance Status score of two or less, newly diagnosed disease, and histopathologic confirmation of pelvic chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma with bone involvement, rhabdomyosarcoma (RMS) with bone involvement, or non-RMS soft tissue sarcoma with bone involvement. Treatment arms include (1) CIRT (n = 30) delivered in Europe and Asia, (2) surgical treatment with or without adjuvant radiotherapy (n = 30), and (3) proton therapy (n = 30). Arms two and three will be conducted at Mayo Clinic campuses in Arizona, Florida, and Minnesota. The primary end point is to compare the 1-year change in functional QOL between CIRT and surgical treatment. Additional comparisons among the three arms will be made between treatment sequelae, local control, and other QOL measures.

Background: The deep peroneal nerve (DPN) plays a role in afferent nociceptive dorsal midfoot joint pain perception. DPN neurectomy for treatment of symptomatic dorsal midfoot osteoarthritis allows early mobilization and weightbearing. The purpose of our study was to evaluate the patient satisfaction and pain relief after DPN neurectomy for treatment of chronic dorsal midfoot pain due to osteoarthritis. Methods: In this retrospective, IRB-approved, questionnaire-based study, we evaluated 48 patients (55 feet) with an average follow-up of 35.1 (range, 16-51) months who underwent DPN neurectomy at our institution between September 2017 and February 2021. There were 38 women and 10 men, 41 unilateral (22 right, 19 left) and 7 bilateral procedures, with an average age of 67.8 (range, 35-88) years at the time of surgery. A questionnaire that included questions regarding postsurgical dorsal midfoot pain relief, surgical result satisfaction, and current functional limitations was administered via telephone. Demographic information, patient responses, and complications were recorded. Results: Of the 48 patients, 80.8% were satisfied with the result of the surgery in relieving their dorsal midfoot pain, 84.6% would repeat the surgery under the same circumstances, 83.8% would recommend the surgery to a friend, 10.4% reported they wish they had undergone arthrodesis, 91.7% reported pain relief in the first 6 months, and 55.6% reported current activity limitations. Six feet (10.9%) underwent a second procedure with an average postoperative time of 20.5 (range, 1-36) months. Complications included 1 hematoma and deep wound infection, 1 DPN neuroma and superficial peroneal nerve entrapment, and 4 patients with inadequate pain relief. Conclusion: In this cohort, DPN neurectomy appeared to be a reasonable surgical alternative to arthrodesis for the management of chronic dorsal midfoot pain due to midfoot osteoarthritis after failed nonoperative management. Level of Evidence: Level IV, retrospective case series.