Postoperative Ambulatory Status Research Articles

Establishment and validation of an interactive artificial intelligence platform to predict postoperative ambulatory status for patients with metastatic spinal disease: a multicenter analysis.

Identification of patients with high-risk of experiencing inability to walk after surgery is important for surgeons to make therapeutic strategies for patients with metastatic spinal disease. However, there is a lack of clinical tool to assess postoperative ambulatory status for those patients. The emergence of artificial intelligence (AI) brings a promising opportunity to develop accurate prediction models. This study collected 455 patients with metastatic spinal disease who underwent posterior decompressive surgery at three tertiary medical institutions. Of these, 220 patients were collected from one medical institution to form the model derivation cohort, while 89 and 146 patients were collected from two other medical institutions to form the external validation cohorts 1 and 2, respectively. Patients in the model derivation cohort were used to develop and internally validate models. To establish the interactive AI platform, machine learning techniques were used to develop prediction models, including logistic regression (LR), decision tree (DT), random forest (RF), extreme gradient boosting machine (eXGBM), support vector machine (SVM), and neural network (NN). Furthermore, to enhance the resilience of the study's model, an ensemble machine learning approach was employed using a soft-voting method by combining the results of the above six algorithms. A scoring system incorporating 10 evaluation metrics was used to comprehensively assess the prediction performance of the developed models. The scoring system had a total score of 0 to 60, with higher scores denoting better prediction performance. An interactive AI platform was further deployed via Streamlit. The prediction performance was compared between medical experts and the AI platform in assessing the risk of experiencing postoperative inability to walk among patients with metastatic spinal disease. Among all developed models, the ensemble model outperformed the six other models with the highest score of 57, followed by the eXGBM model (54), SVM model (50), and NN model (50). The ensemble model had the best performance in accuracy and calibration slope, and the second-best performance in precise, recall, specificity, area under the curve (AUC), Brier score, and log loss. The scores of the LR model, RF model, and DT model were 39, 46, and 26, respectively. External validation demonstrated that the ensemble model had an AUC value of 0.873 (95% CI: 0.809-0.936) in the external validation cohort 1 and 0.924 (95% CI: 0.890-0.959) in the external validation cohort 2. In the new ensemble machine learning model excluding the feature of the number of comorbidities, the AUC value was still as high as 0.916 (95% CI: 0.863-0.969). In addition, the AUC values of the new model were 0.880 (95% CI: 0.819-0.940) in the external validation cohort 1 and 0.922 (95% CI: 0.887-0.958) in the external validation cohort 2, indicating favorable generalization of the model. The interactive AI platform was further deployed online based on the final machine learning model, and it was available at https://postoperativeambulatory-izpdr6gsxxwhitr8fubutd.streamlit.app/ . By using the AI platform, researchers were able to obtain the individual predicted risk of postoperative inability to walk, gain insights into the key factors influencing the outcome, and find the stratified therapeutic recommendations. The AUC value obtained from the AI platform was significantly higher than the average AUC value achieved by the medical experts ( P <0.001), denoting that the AI platform obviously outperformed the individual medical experts. The study successfully develops and validates an interactive AI platform for evaluating the risk of postoperative loss of ambulatory ability in patients with metastatic spinal disease. This AI platform has the potential to serve as a valuable model for guiding healthcare professionals in implementing surgical plans and ultimately enhancing patient outcomes.

Correlation between preoperative CT scan of the paraspinal, psoas, and gluteus muscles and postoperative ambulatory status in patients with femoral neck fractures

BackgroundThis study aimed to investigate the relationship between femoral neck fractures and sarcopenia.MethodsThis was a retrospective analysis of 92 patients with femoral neck fractures, from September 2017 to March 2020, who were classified into high ambulatory status (HG) and low ambulatory status (LG) groups. Ambulatory status was assessed before surgery, one week after surgery, at discharge, and during the final follow-up. To evaluate sarcopenia, muscle mass and fatty degeneration of the muscles were measured using preoperative CT. An axial slice of the superior end of the L5 vertebra was used to evaluate the paraspinal and psoas muscles, a slice of the superior end of the femoral head for the gluteus maximus muscle, and a slice of the inferior end of the sacroiliac joint for the gluteus medius muscle. The degeneration of the muscles was evaluated according to the Goutallier classification.ResultsThe cross-sectional area of the gluteus medius and paraspinal muscles was significantly correlated with ambulatory status before the injury, at discharge, and during the final follow-up.ConclusionsMeasurement of the gluteus medius and paraspinal muscles has the potential to evaluate sarcopenia and predict ambulatory status after femoral neck fractures.

Development of Machine-Learning Models to Predict Ambulation Outcomes Following Spinal Metastasis Surgery.

Retrospective cohort study. This study aimed to develop machine-learning algorithms to predict ambulation outcomes following surgery for spinal metastasis. Postoperative ambulation status following spinal metastasis surgery is currently difficult to predict. The improved ability to predict this important postoperative outcome would facilitate management decision-making and help in determining realistic treatment goals. This retrospective study included patients who underwent spinal metastasis at a university-based medical center in Thailand between January 2009 and November 2021. Collected data included preoperative parameters and ambulatory status 90 and 180 days following surgery. Thirteen machine-learning algorithms, namely, artificial neural network, logistic regression, CatBoost classifier, linear discriminant analysis, extreme gradient boosting, extra trees classifier, random forest classifier, gradient boosting classifier, light gradient boosting machine, naïve Bayes, K-neighbor classifier, Ada boost classifier, and decision tree classifier were developed to predict ambulatory status 90 and 180 days following surgery. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and F1-score. In total, 167 patients were enrolled. The number of patients classified as ambulatory 90 and 180 days following surgery was 140 (81.9%) and 137 (82.0%), respectively. The extreme gradient boosting algorithm was found to most accurately predict 180-day ambulatory outcome (AUC, 0.85; F1-score, 0.90), and the decision tree algorithm most accurately predicted 90-day ambulatory outcome (AUC, 0.94; F1-score, 0.88). Machine-learning algorithms were effective in predicting ambulatory status following surgery for spinal metastasis. Based on our data, the extreme gradient boosting and decision tree best predicted postoperative ambulatory status 180 and 90 days after spinal metastasis surgery, respectively.

Posterior Fixation Without Debridement for Vertebral Body Osteomyelitis and Discitis: A 10-Year Retrospective Review.

Surgical treatment of vertebral osteomyelitis, discitis, and epidural abscesses is indicated in the setting of failure of antibiotic therapy, neurological deficits, epidural abscess, or spinal instability/deformity. Historically, surgical treatment mandated aggressive debridement and spinal stabilization. However, there is growing evidence that direct debridement may not be necessary and may contribute to morbidity. The purpose of this study was to evaluate the efficacy of posterior instrumentation without debridement in treating spinal infections. A retrospective medical record review was performed to identify patients treated with posterior instrumentation for spontaneous spinal infections. Success of treatment was determined based on postoperative ambulatory status, surgical complications, and need for revision surgery. Twenty-seven patients treated with posterior-only long-segmented rigid fixation without formal debridement of infected material were included. The most common indications for surgical intervention included spinal instability (67%), neurologic compromise (67%), and failure of prolonged antibiotic treatment (63%). There were no recurrent deep infections in 21 of 22 patients who had long-term follow-up. Four patients required revision surgery, and 3 additional patients requested elective hardware removal. Postoperatively, 70% were ambulatory with no assistive devices postoperatively. Vertebral osteomyelitis/discitis are challenging medical problems. Single-stage long-segment fusion without formal debridement combined with antibiotics is effective in the management of spontaneous spinal infections. The present study suggests that acute instrumentation without anterior debridement is associated with a resolution of infection and improvements in neurologic deficits in patient with spontaneous spine infections.

Outcomes of Geriatric Hip Fractures in a Tertiary Referral Center in Malaysia During the COVID-19 Pandemic.

Introduction With the advancing age of the population, there are an increasing number of patients with geriatric hip fractures. Despite the advancement of surgical knowledge and improvement of implant designs to treat geriatric hip fractures, mortality and morbidity remainhigh among these frail patients. In conjunction with the COVID-19 pandemic, the collateral damage dealt to these patients remains unknown as scarce resources are funneled to deal with the pandemic. This study is geared to investigate the surgical outcomes of patients with geriatric hip fractures who were admitted during the initial phase of the COVID-19 pandemic. Methods This retrospective study was carried out at Hospital Kuala Lumpur, the largest public hospital in the capital of Malaysia, from March 1, 2020, to March 1, 2021. All patients of age 60 years and above were screened for suitability. Only patients who had undergone surgical intervention during the study period were included in this study. Patients' demographic data, mechanism of injury, waiting time for surgery, type of surgery, complications and ambulatory status were obtained from the medical records. Univariate analysis was performed to determine the factors associated with complications as well as the post-operative ambulatory status of the patients. Results A total of 52 patients were included in this study, with a median age of 72 years. The majority of the patients were Chinese (n=21, 40.4%). This was followed by Malay and Indian (n=14, 26.9% each) and other ethnicity (n=3, 5.8%). More than three-quarters of the patients had a trivial injury such as a fall due to a miss-step (n=16, 30.8%) and slip (n=16, 30.8%) and a fall due to dizziness (n=8, 15.4%). Only 12 patients (23.1%) sustained hip fractures due to trauma. The median time to surgery for these patients was 5 days (interquartile range: 4 days). Most of these patients underwent total hip replacement (n=30, 57.7%). This was followed by unipolar hemiarthroplasty (n=11, 21.2%), bipolar hemiarthroplasty (n=10, 19.2%) and internal fixation (n=1, 1.9%). Among these patients, six of them had documented complications. There were periprosthetic joint infection (n=2, 3.8%), dislocation (n=2, 3.8%), hematoma formation (n=1, 1.9%) and seroma (n=1, 1.9%). Six months after the surgery, most of the patients were able to ambulate, albeit some patients required walking aid such as walking stick and walking frame. Univariate analysis showed that all the factors were not associated with the complications and the post-operative ambulatory status of the patients. Conclusion The incidence of geriatric hip fractures remains high during the COVID-19 pandemic despite the movement control order (MCO) being enforced in Malaysia. With prompt surgical intervention, most of the patients can regain ambulatory status, albeit with a walking aid.

A Novel Strategy to Manage Below-Knee-Amputation (BKA) Stump Complications for Early Wound Healing and BKA Salvage.

The optimal management of major stump complications (operative infection or dehiscence) following below-knee-amputation (BKA) is unknown. We evaluated a novel operative strategy to aggressively treat major stump complications hypothesizing it would improve our rate of BKA salvage. Retrospective review of patients requiring operative intervention for BKA stump complications between 2015 and 2021. A novel strategy employing staged operative debridement for source control, negative pressure wound therapy, and reformalization was compared to standard care (less structured operative source control or above knee amputation). 32 patients were studied, 29 of which were male (90.6%) with an average age of 56.1 ± 9.6y. 30 (93.8%) had diabetes and 11 (34.4%) peripheral arterial disease (PAD). The novel strategy was used in 13 patients and 19 had standard care. Novel strategy patients had higher BKA salvage rates, 100% vs 73.7% (P = .064), and postoperative ambulatory status, 84.6% vs 57.9% (P = .141). Importantly, none of the patients undergoing the novel therapy had PAD, while all progressing to above-knee amputation (AKA) did. To better assess the efficacy of the novel technique, patients progressing to AKA were excluded. Patients undergoing novel therapy who had their BKA level salvaged (n = 13) were compared to usual care (n = 14). The novel therapy's time to prosthetic referral was 72.8 ± 53.7days vs 247 ± 121.6days (P < .001), but they did undergo more operations (4.3 ± 2.0 vs 1.9 ± 1.1, P < .001). Utilization of a novel operative strategy for BKA stump complications is effective in salvaging BKAs, particularly for patients without PAD.

Does a hip fracture mean we should we operate on a concomitant proximal humerus fracture?

Concomitant upper extremity and hip fractures present a challenge in postoperative mobilization in the geriatric population. Operative fixation of proximal humerus fractures allows for upper extremity weight bearing. This retrospective study compared outcomes between operative and non-operative proximal humerus fracture patients with concomitant hip fractures. A trauma database of 13,396 patients age > 55 years old was queried for concomitant hip and proximal humerus fracture patients between 2014-2021. Medical records were reviewed for demographics, hospital quality measures, Neer classification, morphine milligram equivalents (MME), and outcomes. All hip fractures were treated operatively. Patients were grouped based on operative vs. non-operative treatment of their proximal humerus fracture. Primary outcomes included comparing postoperative ambulatory status, pain, length of stay (LOS), intensive care unit (ICU) need, discharge disposition, and readmission rates. Forty-eight patients (0.4%) met inclusion criteria. Twelve patients (25%) underwent operative treatment for their proximal humerus fracture and 36 (75%) received non-operative treatment. Patients with operative fixations were younger (p < 0.01), had more complex Neer classifications (p = 0.031), more likely to be community ambulators (p < 0.01), and required more inpatient MMEs (p < 0.01). There were no differences in LOS (p = 0.415), need for ICU (p = 0.718), discharge location (p = 0.497), 30-day readmission (p = 0.228), or 90-day readmission (p = 0.135) between cohorts. At 6months postoperatively, among community or household ambulators, a higher percentage of operative patients returned to their baseline ambulatory functional status, however, this was not significant (70% vs. 52%, p = 0.342). There were three deaths in the non-operative cohort and no deaths in the operative cohort. Patients with hip fractures and concomitant proximal humerus fractures treated operatively required more inpatient MMEs and trended toward maintaining baseline ambulatory function. There were no differences in inpatient LOS, ICU need, discharge location, or readmissions. Future larger, multicenter studies are needed to further delineate if operative repair of concomitant proximal humerus fractures provides a benefit in the geriatric population.

Predictors of Postoperative Gain in Ambulatory Function After Decompressive Surgery for Metastatic Spinal Cord Compression.

Reports on the effects of timing of the surgery on the patient survival rate or the results of palliative laminectomy are limited. The aim of the study was to investigate the postoperative ambulatory status of neurologically impaired metastatic spinal cord compression (MSCC) patients who underwent laminectomy and evaluate predictors of postoperative ambulation recovery after laminectomy for MSCC. We included 175 patients who underwent decompressive surgery for MSCC. Changes in the Frankel grade (FG) were evaluated perioperatively. Among all patients, 113 were unable to walk preoperatively and were divided into two groups: 70 and 43 patients in the ambulation-regained and ambulation-not regained postoperatively groups, respectively. The percentage of patients eligible for postoperative chemotherapy and overall survival rate in each group were investigated. Furthermore, predictors of postoperative ambulation recovery after laminectomy for MSCC were examined. The most common primary tumor sites were the lung, prostate, and breast. FG improved with surgery in 80 cases, remained unchanged in 94 cases, and worsened in one case. In the ambulation-regained group, 70% were eligible for postoperative chemotherapy, while only 26% of the not-regained group were eligible for postoperative chemotherapy. The postoperative survival rate of the ambulation-regained group was significantly better than that of the not-regained group. Univariate predictors for not regaining the ability to walk were Karnofsky Performance Status ≤40 prior to surgery, FG B prior to surgery, and time to surgery since the inability to walk >48 h. Decompressive surgery benefits motor function postoperatively. Both good neurological status prior to surgery and prompt surgery for non-ambulatory MSCC are important predictors of improved functional outcome.

Comparison of Helical Blade Systems for Osteoporotic Intertrochanteric Fractures Using Biomechanical Analysis and Clinical Assessments.

Background and Objectives: This study aimed to compare the biomechanical properties and outcomes of osteoporotic intertrochanteric fractures treated with two different helical blade systems, the trochanteric fixation nail-advanced (TFNA) and proximal femoral nail antirotation II (PFNA), to evaluate the efficacy and safety of the newly introduced TFNA system. Materials and Methods: A biomechanical comparison of the two helical blades was performed using uniaxial compression tests on polyurethane foam blocks of different densities. The peak resistance (PR) and accumulated resistance (AR) were measured during the 20 mm advancement through the test block. For clinical comparison, 63 osteoporotic intertrochanteric fractures treated with TFNA were identified and compared with the same number of fractures treated with PFNA using propensity score matching. Ambulatory status, medial migration, lateral sliding, fixation failure, and patient-reported outcomes were compared between the two groups over a minimum of 1 year's follow up. Results: The uniaxial compression test showed that a slightly, but significantly lower resistance was required to advance the TFNA through the test block compared with the PFNA (20 PCF, p = 0.017 and p = 0.026; 30 PCF, p = 0.007 and p = 0.001 for PR and AR, respectively). Clinically, the two groups showed no significant differences in post-operative ambulatory status and patient-reported outcomes. However, in TFNA groups, significantly more medial migration (TFNA, 0.75 mm; PFNA, 0.40 mm; p = 0.0028) and also, lateral sliding was noted (TFNA, 3.99 mm; PFNA, 1.80 mm; p = 0.004). Surgical failure occurred in four and two fractures treated with the TFNA and PFNA, respectively. Conclusions: The results of our study suggest that the newly introduced TFNA provides clinical outcomes comparable with those of the PFNA. However, inferior resistance to medial migration in the TFNA raises concerns regarding potential fixation failures.

Lower Extremity Amputations Among Veterans: Have Ambulatory Outcomes and Survival Improved?

We hypothesize among patients undergoing lower extremity amputation, access to pre-, and post operative rehabilitation services; as well as improved medical care, have led to higher rates of postoperative ambulation, and improved survival. Retrospective single center review of all major lower extremity amputations performed at the Greater Los Angeles Veterans Affairs Healthcare System from 2000-2020 stratified into multiyear cohorts. We abstracted demographics, operative indication, comorbidities, preoperative medical management, perioperative complications, discharge location, and pre and postoperative ambulatory status. Odds of ambulation after amputation were analyzed using multivariate logistic regression. Survival was analyzed using multivariate logistic regression and Kaplan-Meier survival analysis. Multivariate logistic predictors were selected based on prior literature and clinical experience. We identified 654 operations in our study, noting fewer amputations performed in the latest 3 cohort years as compared to the initial cohort (2000-2004). Patients undergoing below-knee amputations (BKA) had 2.7 times (P<0.05) greater odds of postoperative ambulation and 86% (P<0.05) increased odds of survival compared to above-knee amputations (AKA). The odds of ambulation increased by 8.8% (P<0.05) for each consecutive study year. Ambulation post-amputation conferred 13.2 times (P<0.05) greater odds of survival. The odds of survival in "emergent" operations decreased by 48% (P<0.05) compared to an "elective" operation. For each additional comorbidity, the odds of survival decreased by 18% (P<0.05). Patients with any perioperative complication had a 48% (P<0.05) lower odds of survival. Kaplan-Meier survival estimates demonstrated significant survival difference between patients by amputation level and postoperative ambulatory status (P<0.05). Ambulatory status following distal amputation has improved over time and is significantly associated with increased survival post-amputation. Patients undergoing a BKA or discharged home were most likely to ambulate postoperatively. Amputation level, preoperative comorbidities, and perioperative complications remain strong predictors of survival.

Comparative Study of Circumferential Decompression and Posterior Decompression in Palliative Surgery for Metastatic Thoracic Spinal Tumors.

This was a case-control study. The present study aimed to evaluate the significance of circumferential tumor resection around the spinal cord in palliative decompression surgery for patients with metastatic spinal cord compression (MSCC) in the thoracic spine. Although the benefits of palliative surgery for MSCC are well known, the significance of circumferential tumor resection with cord compression has not yet been clarified. We retrospectively compared the outcomes of 45 and 34 patients with incomplete paralysis of modified Frankel grade B-D caused by MSCC with anterior cord compression (epidural spinal cord compression grade ≥2) treated at 2 different university hospitals (H1 and H2, respectively). All patients in H1 hospital underwent posterior decompression only, while all patients in H2 hospital underwent full circumferential decompression. We analyzed factors that affect the postoperative ambulatory status. evaluated by the modified Frankel classification. No significant differences were observed in the epidural spinal cord compression grade, spinal instability neoplastic score, new Katagiri score, revised Tokuhashi score, or postoperative survival between patients in H1 and H2 hospitals. A multivariable logistic regression analysis identified preoperative radiotherapy [odds ratio (OR): 0.23, 95% confidential interval (CI): 0.056-0.94] as a negative risk factor and postoperative chemotherapy (OR: 5.9, 95% CI: 1.3-27.0) as a positive risk factor for an improved ambulatory status. Five and 6 patients in H1 and H2 hospitals, respectively, showed deterioration in the ambulatory status. An older age (OR: 1.1, 95% CI: 1.0-1.2) and preoperative radiotherapy (OR: 10.3, 95% CI: 1.9-55.4) were extracted as significant independent risk factors for deterioration in the ambulatory status. Circumferential decompression did not improve the clinical results of patients regardless of the degree of paralysis. Preoperative radiotherapy interfered with the recovery of paralysis, and postoperative chemotherapy improved the ambulatory status. Clinical outcomes did not significantly differ between total circumferential decompression and posterior decompression, although further validation in a small number of cases is needed, such as patients with Frankel grade D.

Survivorship Analysis in Asymptomatic COVID-19+ Hip Fracture Patients: Is There an Increase in Mortality?

PurposeMortality rates following hip fracture surgery have been well-studied. This study was conducted to examine mortality rates in asymptomatic patients presenting for treatment of acute hip fractures with concurrent positive COVID-19(+) tests compared to those with negative COVID-19(–) tests.Materials and MethodsA total of 149 consecutive patients undergoing hip fracture surgery during the COVID-19 pandemic at two academic medical centers were reviewed retrospectively. Patients were divided into two groups for comparative analysis: one group included asymptomatic patients with COVID-19+ tests versus COVID-19– tests. The primary outcome was mortality at 30-days and 90-days.ResultsCOVID-19+ patients had a higher mortality rate than COVID-19– patients at 30-days (26.7% vs 6.0%, P=0.005) and 90-days (41.7% vs 17.2%, P=0.046) and trended towards an increased length of hospital stay (10.1±6.2 vs 6.8±3.8 days, P=0.06). COVID-19+ patients had more pre-existing respiratory disease (46.7% vs 11.2%, P=0.0002). Results of a Cox regression analysis showed an increased risk of mortality at 30-days and 90-days from COVID-19+ status alone without an increased risk of death in patients with pre-existing chronic respiratory disease.ConclusionFactors including time to surgery, age, preexisting comorbidities, and postoperative ambulatory status have been proven to affect mortality and complications in hip fracture patients; however, a positive COVID-19 test result adds another variable to this process. Implementation of protocols that will promote prompt orthogeriatric assessments, expedite patient transfer, limit operating room traffic, and optimize anesthesia time can preserve the standard of care in this unique patient population.

Development of Clinical Prediction Rules for One-Year Postoperative Functional Outcome in Patients with Intertrochanteric Fractures: The Intertrochanteric Fracture Ambulatory Prediction (IT-AP) Tool

Individualized prediction of postoperative ambulatory status for patients with intertrochanteric fractures is clinically relevant, during both preoperative and intraoperative periods. This study intended to develop clinical prediction rules (CPR) to predict one-year postoperative functional outcomes in patients with intertrochanteric fractures. CPR development was based on a secondary analysis of a retrospective cohort of patients with intertrochanteric fractures aged ≥50 years who underwent a surgical fixation. Good ambulatory status was defined as a New Mobility Score ≥ 5. Two CPR for preoperative and intraoperative predictions were derived using clinical profiles and surgical-related parameters using logistic regression with the multivariable fractional polynomial procedure. In this study, 221 patients with intertrochanteric fractures were included. Of these, 160 (72.4%) had good functional status at one year. The preoperative model showed an acceptable AuROC of 0.77 (95% CI 0.70 to 0.85). After surgical-related parameters were incorporated into the preoperative model, the model discriminative ability was significantly improved to an AuROC of 0.83 (95% CI 0.77 to 0.88) (p = 0.021). The newly-derived CPR enable physicians to provide patients with intertrochanteric fractures with their individualized predictions of functional outcome one year after surgery, which could be used for risk communication, surgical optimization and tailoring postoperative care that fits patients’ expectations.

Preoperative Vitamin D Deficiency is Associated with Postoperative Functional Recovery and Complications after Hip Fracture Surgery.

BackgroundLow concentrations of vitamin D are considered one of the risk factors for hip fracture and are associated with worse outcomes. The purpose of this retrospective study was to compare vitamin D deficient group and vitamin D sufficient group and assess the association preoperative vitamin D deficiency and postoperative walking ability after hip fracture surgery.MethodsBetween January 2014 and January 2020, 1,029 elderly patients with hip fracture (243 in men and 785 in women) were measured preoperative serum 25-hydroxy-vitamin D3 levels. Among 1,029 elderly patients, 702 patients were classified as Vitamin D deficient group (<20 ng/mL). Outcome parameters for functional recovery were the length of the hospital stay and KOVAL score, and those for complications were delirium, pneumonia, and thromboembolism.ResultsThe mean length of the hospital stay in the vitamin D deficient group was significantly longer than in the vitamin D sufficient group (27.7±17.8 vs. 2.9±11.8 days; odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02–1.05; P=0.001). The mean postoperative KOVAL score in the deficient group was significantly higher than in the sufficient group (4.0±2.1 vs. 3.1±1.9 days; OR, 1.21; 95% CI, 1.11–1.32; P=0.001). Vitamin D deficiency was significantly associated with a higher risk of delirium and pneumonia in deficiency group.ConclusionsPreoperative vitamin D deficiency in hip fractures patients was associated with prolonged duration of hospital stay and decrease of postoperative ambulatory status, and may increase the risk of delirium and pneumonia. Therefore, it is necessary to evaluate the preoperative vitamin D level and recommend vitamin D supplementation in elderly patients with a high probability of hip fracture.

Posterior Tibial Tendon Transfer for the Correction of Drop Foot.

Drop foot is a crippling condition that often requires surgical intervention to restore functional dorsiflexion. Although transfer of the posterior tibial (PT) tendon has been well described for the treatment of drop foot, there is no consensus on whether tendon transfers affecting the ankle joint sufficiently restore functional status for daily activities. In addition, most studies have focused on drop foot caused by peripheral nerve disorders. The purpose of this study was to evaluate the functional outcomes and patient satisfaction following PT tendon transfer for the correction of drop foot resulting from both peripheral and central neurologic causes. Patients with drop foot who underwent a PT tendon transfer were followed for a minimum of 1 year and investigated retrospectively. Outcome measures included the American Orthopaedic Foot & Ankle Society ankle and hindfoot scoring system, a patient satisfaction questionnaire, postoperative ankle range of motion, and postoperative ambulatory status. We evaluated 15 feet in 14 patients at a median follow-up of 50 months. The median postoperative American Orthopaedic Foot & Ankle Society ankle and hindfoot score was 85.0. Thirteen patients (92.9%) reported that they would undergo the procedure again. The median postoperative passive ankle dorsiflexion was 5.0°, and the median postoperative passive ankle plantarflexion was 30.0°. Thirteen patients (92.9%) were able to ambulate postoperatively. Ten (71.4%) ambulated without the use of an ankle-foot orthosis (AFO), and three (21.4%) ambulated with the use of an AFO. Overall, orthoses were able to be discontinued in 73.3% of the cases. Our results suggest that the PT tendon transfer is an effective procedure for the treatment of drop foot that can improve the patient's functional status and ability to ambulate. The majority of patients were able to discontinue the use of their AFO postoperatively.

Cervical Spine Reconstruction with Chest Tube Technique After Metastasis Resection: A Single-Center Experience

The silastic tube technique, in which a chest tube is placed into the vertebral body defect and impregnated with polymethyl methacrylate, showed good results in patients with lumbar and thoracic neoplastic diseases. There has been only 1 study about the effectiveness and safety of this technique in patients with cervical metastases. We aimed to report our experience in using this technique to reconstruct the spine after corpectomy for cervical metastasis. All patients with cervical spinal metastasis who underwent surgical treatment using a chest tube impregnated with polymethyl methacrylate in conjunction with anterior cervical plate stabilization were retrospectively recruited. Demographics, tumor histology, revised Tokuhashi score, preoperative and postoperative American Spinal Injury Association score, preoperative and postoperative ambulatory status, perioperative complications, and survival time were collected. This study included 16 patients. The most common primary tumor site was the lung (6 patients; 37.5%). The mean (SD) survival time was 408 (795) days (range, 1-2797 days), and the median survival time was 72 days (95% confidence interval 28-116 days). Four patients (25%) died within 30 postoperative days. There was no surgical site infection or instrument failure after the surgery. Five patients (31.2%) lived >180 days, and 3 patients (18.8%) lived >360 days. One patient (6.2%) was still alive at the end of the study. The silastic tube technique in conjunction with anterior cervical plate stabilization might be safe, effective, and cost-effective for patients with cervical spine metastasis.

Prognostic Factors of 1-Year Postoperative Functional Outcomes of Older Patients with Intertrochanteric Fractures in Thailand: A Retrospective Cohort Study.

Restoration of ambulatory status is considered a primary treatment goal for older patients with intertrochanteric fractures. Several surgical-related parameters were reported to be associated with mechanical failure without focusing on the functional outcomes. Our study examines the roles of both clinical and surgical parameters as prognostic factors on 1-year postoperative ambulatory outcomes, reaching a good functional outcome (the New Mobility Score: NMS ≥ 5) and returning to preinjury functional status at one year, of older patients with intertrochanteric fracture. Intertrochanteric fractures patients age ≥65 years who underwent surgical treatment at our institute between January 2017 and February 2020 were included. Of 209 patients included, 149 (71.3%) showed a good functional outcome at one year. The pre-injury ambulatory status (OR 52.72, 95%CI 5.19–535.77, p = 0.001), BMI <23 kg/m2 (OR 3.14, 95%CI 1.21–8.13, p = 0.018), Hb ≥10 g/dL (OR 3.26, 95%CI 1.11–9.57, p = 0.031), and NMS at discharge ≥2 (OR 8.50, 95%CI 3.33–21.70, p < 0.001) were identified as independent predictors for reaching a good postoperative functional outcome. Only aged ≤80 (OR 2.34, 95%CI 1.11–4.93, p = 0.025) and NMS at discharge ≥2 (OR 6.27, 95%CI 2.75–14.32, p < 0.001) were significantly associated with an ability to return to preinjury function. To improve postoperative ambulatory status, orthopedic surgeons should focus more on modifying factors, such as maintaining the preoperative hemoglobin ≥10 g/dL and providing adequate postoperative ambulation training to maximize the patients’ capability upon discharge. While surgical parameters were not identified as predictors, they can still be used as guidance to optimize the operation quality.

Sex, age, and other barriers for prosthetic referral following amputation and the impact on survival

BackgroundDespite advances in peripheral vascular disease treatment, lower extremity amputation continues to be necessary in a significant number of patients. Up to 80% of amputees are not referred for prosthetic fitting. The factors contributing to referral decisions have not been adequately investigated, nor has the impact of prosthetic referral on survival. We characterized differences between patients who were successfully referred to our in-house prosthetists and those who were not, and identified factors associated with prosthetic referral and predictive of survival. MethodsThis was a retrospective analysis of all patients who underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to June 30, 2017. Data regarding age, sex, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, end-stage renal disease, prior coronary artery bypass graft surgery, congestive heart failure, tobacco use, American Society of Anesthesiologists (ASA) score, previous arterial procedure, chronic obstructive pulmonary disease, statin use, postoperative ambulatory status, level of amputation, stump revision, and referral for prosthesis were collected. Survival was determined from a combination of sources, including the Social Security Death Master Index, multiple genealogic registries, and internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis referral. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality. ResultsThere were 293 patients included in this study. Mean age was 66 years, and mean BMI 27 kg/m2. The majority of patients were male (69%), white (53%), with diabetes (65.4%) and hypertension (77.5%), and underwent below-the-knee amputation (BKA) (73%). Prosthetic referral occurred in 123 (42.0%). Overall 5-year survival was 61.7% (95% confidence interval [CI], 55.9%-68.1%) (BKA 64.7% [95% CI, 57.9%-72.3%]; above-the-knee amputation 53.8% [95% CI, 43.4%-66.6%]). On multivariate analysis, age >70 years, female sex, diabetes, ASA score 4 or 5, and current tobacco use were associated with no referral for prosthetic fitting. Patients with BMI 25 to 30, a previous arterial procedure, BKA, and history of stump revision were more likely to be referred. Factors associated with decreased survival were increasing age, higher ASA class, black race, and BMI; prosthetic referral was seen to be protective. ConclusionsWe identified multiple patient factors associated with prosthetic referral, as well as several characteristics predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. Further research is needed to determine whether the factors identified as associated with nonreferral are markers for patient characteristics that make them clinically unsuitable for prosthetic fitting or if they are symptoms of unconscious bias or of the patient's access to care.

Simple and Reliable Magnetic Resonance Imaging Parameter to Predict Postoperative Ambulatory Function in Patients With Metastatic Epidural Spinal Cord Compression.

Retrospective case-control study. The aim of this study was to develop a simple and reliable imaging parameter to predict postoperative ambulatory status in patients with metastatic epidural spinal cord compression (MESCC). Sixty-three patients with MESCC underwent spine surgery because of neurologic deficits were included. On preoperative axial MRI, the cord compression ratio was analyzed for postoperative ambulatory status. The relationship between other imaging features, such as fracture of the affected vertebra and increased T2 signal intensity of the spinal cord at the compression level, and the postoperative ambulatory status were also analyzed. Cord compression ratio and increased T2 signal change of the spinal cord were significantly different between the postoperative ambulatory group and the non-ambulatory group. Receiver operating characteristic analysis showed that the optimal cut-off value was 0.84. In the multivariate regression analysis, only a cord compression ratio of more than 0.84 was significantly associated with postoperative ambulatory status (odds ratio = 10.80; 95% confidence interval = 2.79-41.86; P = .001). Interobserver/intraobserver agreements were strong for the cord compression ratio, however those agreements were weak for increased T2 signal intensity. On preoperative MRI, the cord compression ratio may predict postoperative ambulatory status in patients with MESCC. The measurement of this imaging parameter was simple and reliable. This imaging predictor may be helpful for both clinicians and patients.

High mortality rate following periprosthetic femoral fractures after total hip arthroplasty. A multicenter retrospective study

The main objective of this study was to evaluate the morbidity and mortality following periprosthetic femoral fractures (PFFs) after total hip arthroplasty. The secondary objectives were to explore risk factors for mortality and compare outcomes by method of treatment. A multicenter retrospective study was conducted (2016-2017) of all PFFs after total hip arthroplasty. We collected data on: ASA score, Charlson comorbidity index, type of fracture, method of treatment, timing of surgery, length of stay, systemic and local complications and mortality. Functional outcome was assessed in terms of preoperative and postoperative ambulatory status. Univariate and multivariate analysis were performed in the sample to identify risk factors for mortality. A total of 107 patients were evaluated and their mean age was 81 years old. The most common type of fracture according to the Vancouver classification was B1 (52.4% of patients), followed by B2 fractures (31.8%). The mortality rate during the first month was 9.3% and was associated with patients with ASA >3. Mortality rate in the first year was 22.3% and was associated with poorer walking ability before surgery and Charlson index ≥3. In the multivariable analysis, Charlson index ≥3 (odds ratio=6.85) and age ≥80 years old (odds ratio=7.446) were associated with 1-year mortality. Neither complications nor mortality rate were associated with either time to surgery or method of treatment. More than half of the patients (57.9%) did not regain their prefracture walking status. Major systemic complications developed in 23.4% of the patients and major local complications in 12.1%. Despite modern surgical techniques and multidisciplinary management, this study highlights the ambulatory status impairment and high rate of complications and mortality after PFF. Although the mortality rate during the first year was similar to that observed in other studies on PFFs, we found a higher mortality rate within the first month.