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Lan R, Stiles ER, Ward SA, Lajam CM, Bosco JA. Patients With Moderate to Severe Liver Cirrhosis Have Significantly Higher Short-Term Complication Rates Following Total Knee Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2024; 39:1736-1740. [PMID: 38280615 DOI: 10.1016/j.arth.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/16/2024] [Accepted: 01/21/2024] [Indexed: 01/29/2024] Open
Abstract
BACKGROUND Liver cirrhosis is associated with increased perioperative morbidity. Our study used the Model for End-Stage Liver Disease (MELD) score to assess the impact of cirrhosis severity on postoperative outcomes following total knee arthroplasty (TKA). METHODS A retrospective review identified 59 patients with liver cirrhosis who underwent primary TKA at a large, urban, academic center from January 2013 to August 2022. Cirrhosis was categorized as mild (MELD < 10; n = 47) or moderate-severe (MELD ≥ 10; n = 12). Modified Clavien-Dindo classification was used to grade complications, where grade 2+ denoted significant intervention. Hospital length of stay, nonhome discharge, and mortality were collected. A 1:1 propensity matching was used to control for demographics and selected comorbidities. RESULTS Moderate-severe cirrhosis was associated with significantly higher rates of intrahospital overall (58.33 versus 16.67%, P = .036) complications, 30-day overall complications (75 versus 33.33%, P = .042), and 90-day overall complications (75 versus 33.33%, P = .042) when compared to matched mild cirrhosis patients. Compared to matched noncirrhotic controls, mild cirrhosis patients had no significant increase in complication rate or other outcomes (P > .05). CONCLUSIONS Patients with moderate-severe liver cirrhosis are at risk of short-term complications following primary TKA. Patients with mild cirrhosis have comparable outcomes to matched noncirrhotic patients. Surgeons can use MELD score prior to scheduling TKA to determine which patients require optimization or higher levels of perioperative care.
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Affiliation(s)
- Rae Lan
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Elizabeth R Stiles
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Spencer A Ward
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Kim MT, Tsouris N, Lung BE, Wang KE, Miskiewicz M, Komatsu DE, Wang ED. Predicting operative outcomes of total shoulder arthroplasty using the model for end-stage liver disease score. JSES Int 2024; 8:515-521. [PMID: 38707562 PMCID: PMC11064690 DOI: 10.1016/j.jseint.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background The aim of this study was to assess the efficacy of the Model for End-Stage Liver Disease (MELD) score in predicting postoperative complications following total shoulder arthroplasty (TSA). Methods The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2019. The study population was subsequently classified into two categories: those with a MELD score ≥ 10 and those with a MELD score < 10. A total of 5265 patients undergoing TSA between 2015 and 2019 were included in this study. Among these, 4690 (89.1%) patients had a MELD score ≥ 10, while 575 (10.9%) patients had a MELD score < 10. Postoperative complications within 30 days of the TSA were collected. Multivariate logistic regression analysis was conducted to explore the correlation between a MELD score ≥ 10 and postoperative complications. The anchor based optimal cutoff was calculated by receiver operating characteristic analysis to determine the MELD score cutoff that most accurately predicts a specific complication. Youden's index (J) determined the optimal cutoff point calculation for the maximum sensitivity and specificity; these were deemed to be "acceptable" if the area under curve (AUC) was greater than 0.7 and "excellent" if greater than 0.8. Results Multivariate regression analysis found a MELD score ≥ 10 to be independently associated with higher rates of reoperation (OR, 2.08; P = .013), cardiac complications (OR, 3.37; P = .030), renal complications (OR, 7.72; P = .020), bleeding transfusions (OR, 3.23; P < .001), and nonhome discharge (OR, 1.75; P < .001). The receiver operating characteristic analysis showed that AUC for a MELD score cutoff of 7.61 as a predictor of renal complications was 0.87 (excellent) with sensitivity of 100.0% and specificity of 70.0%. AUC for a MELD score cutoff of 7.76 as a predictor of mortality was 0.76 (acceptable) with sensitivity of 81.8% and specificity of 71.0%. Conclusion A MELD score ≥ 10 was correlated with high rates of reoperation, cardiac complications, renal complications, bleeding transfusions, and nonhome discharge following TSA. MELD score cutoffs of 7.61 and 7.76 were effective in predicting renal complications and mortality, respectively.
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Affiliation(s)
- Matthew T. Kim
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Nicholas Tsouris
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | | | - Katherine E. Wang
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Michael Miskiewicz
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - David E. Komatsu
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - Edward D. Wang
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
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Saeki C, Saito M, Tsubota A. Association of chronic liver disease with bone diseases and muscle weakness. J Bone Miner Metab 2024:10.1007/s00774-023-01488-x. [PMID: 38302761 DOI: 10.1007/s00774-023-01488-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/16/2023] [Indexed: 02/03/2024]
Abstract
The liver is a vital organ involved in nutrient metabolism, hormone regulation, immunity, cytokine production, and gut homeostasis. Impairment in liver function can result in malnutrition, chronic inflammation, decreased anabolic hormone levels, and dysbiosis. These conditions eventually cause an imbalance in osteoblast and osteoclast activities, resulting in bone loss. Osteoporosis is a frequent complication of chronic liver disease (CLD) that adversely affects quality of life and increases early mortality. Sarcopenia is another common complication of CLD characterized by progressive loss of skeletal muscle mass and function. Assessment criteria for sarcopenia specific to liver disease have been established, and sarcopenia has been reported to be associated with an increase in the risk of liver disease-related events and mortality in patients with CLD. Owing to their similar risk factors and underlying pathophysiological mechanisms, osteoporosis and sarcopenia often coexist (termed osteosarcopenia), progress in parallel, and further exacerbate the conditions mentioned above. Therefore, comprehensive management of these musculoskeletal disorders is imperative. This review summarizes the clinical implications and characteristics of osteoporosis, extending to sarcopenia and osteosarcopenia, in patients with CLD caused by different etiologies.
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Affiliation(s)
- Chisato Saeki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mitsuru Saito
- Department of Orthopedic Surgery, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Akihito Tsubota
- Project Research Units, Research Center for Medical Science, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Thomson M, Scott A, Trost S, Lake J, Lim N. Low screening rates and high prevalence of osteoporosis in cirrhosis: A real-world retrospective analysis. Aliment Pharmacol Ther 2024; 59:535-546. [PMID: 38059360 DOI: 10.1111/apt.17823] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/23/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Patients with cirrhosis are at increased risk for osteoporosis, and those who suffer a fracture are at high risk for mortality. Despite this, osteoporosis is often overlooked and undertreated. This study aimed to evaluate osteoporosis screening, management, and adverse osteoporosis medication events in patients with cirrhosis. METHODS We performed a retrospective chart review of adult outpatients with compensated and decompensated cirrhosis seen in single health system over a 6-year period. Patient demographics, liver and bone health comorbidities, DEXA scan results, and medications were abstracted. RESULTS In total, 5398 patients met criteria. The cohort was predominately white (79.1%) and older (age 59). 44.4% were female. 64.6% had decompensated cirrhosis. Median MELD-Na score was 12.8. 23.5% had a DEXA scan ordered, approximately 50% completed this test. Patients who were older, female, white, with more severe liver disease, and other osteoporosis risk factors were more likely to have a DEXA scan ordered. 48.5% of patients had osteopenia and 30.2% had osteoporosis on DEXA scan. Only 22.6% of patients with osteoporosis received treatment, most commonly oral bisphosphonates. Oral bisphosphonate prescription was not associated with variceal bleeding (8.4% without vs. 4.8% with, p = 0.487). CONCLUSION A minority of patients with cirrhosis were screened for osteoporosis. The majority screened had osteopenia or osteoporosis on DEXA scan. Less than a quarter of patients with osteoporosis were started on treatment. Real-world experience of oral bisphosphonate use did not reveal higher rates of gastrointestinal bleeding. There is room for improvement in all aspects of bone health care in cirrhosis.
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Affiliation(s)
- Mary Thomson
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adam Scott
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Suzanne Trost
- Division of Diabetes, Endocrinology and Metabolism, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jack Lake
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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Shi BY, Upfill-Brown A, Li A, Wu SY, Ahlquist S, Hart CM, Kremen TJ, Lee C, Stavrakis AI. MELD score predicts short-term outcomes after surgical management of proximal humerus fractures: a matched analysis. OTA Int 2023; 6:e289. [PMID: 37901451 PMCID: PMC10611337 DOI: 10.1097/oi9.0000000000000289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/21/2023] [Indexed: 10/31/2023]
Abstract
Objective We aimed to evaluate the difference in 30-day outcomes after surgical management of proximal humerus fractures (PHFs) between patients with and without chronic liver disease as defined by a MELD score greater than 10. Design This was a retrospective database review. Setting All centers participating in the American College of Surgeons National Surgical Quality Improvement Program database were included. Patients/Participants Patients with proximal humerus fractures who (1) underwent ORIF, HA, or SA and (2) had calculable MELD scores were included. Intervention Open reduction and internal fixation, hemiarthroplasty, or shoulder arthroplasty was used for treatment. Main outcome measurements Thirty-day complications, mortality, readmission, and reoperation rates were measured. Results Of the total 1732 PHF patients identified, 300 had a MELD score higher than 10. After propensity matching by significant covariates, MELD score higher than 10 was found to be significantly associated with higher rates of 30-day mortality, 30-day readmission, transfusion within 72 hours, and systemic complications. Among patients with a MELD score higher than 10, treatment with SA or HA instead of ORIF was associated with a higher rate of transfusion and longer operative time. There were no significant differences between treatment cohorts regarding mortality, reoperation, readmission, or complications. Conclusions A MELD score higher than 10 is associated with higher risk of surgical complications, transfusion, and death in patients undergoing surgery for proximal humerus fractures. Among patients with a MELD score higher than 10, ORIF was associated with a lower transfusion rate and shorter operative time than arthroplasty or hemiarthroplasty. Level of Evidence Prognostic Level III.
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Affiliation(s)
- Brendan Y. Shi
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Alexander Upfill-Brown
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Alan Li
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Shannon Y. Wu
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Seth Ahlquist
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Christopher M. Hart
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Thomas J. Kremen
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Alexandra I. Stavrakis
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
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Cheng T, Li G, Mao X, Hao L, Cheng X, Ning H. Impact of Hepatitis B virus infection on postoperative complications and length of stay in elderly patients with hip fracture: A retrospective cohort study. Injury 2023:S0020-1383(23)00453-9. [PMID: 37198044 DOI: 10.1016/j.injury.2023.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 03/28/2023] [Accepted: 05/10/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Osteoporosis and subsequent fractures are common in the chronic hepatitis B (CHB) population, especially in the elderly. This study investigated the effects of hepatitis B virus (HBV) infection on postoperative outcomes following hip fracture surgery. METHODS The study identified elderly patients who underwent hip fracture surgery at three academic tertiary care centres between January 2014 and December 2020. Propensity score matching was performed to compare the outcomes of 1,046 patients with HBV infection to 1,046 controls. RESULTS The seroprevalence of HBV among elderly patients undergoing hip surgery was 4.94%. The HBV cohort had significantly higher rates of medical complications (28.1 vs. 22.7%, p = 0.005), surgical complications (14.0 vs. 9.7%, p = 0.003), and unplanned readmissions (18.9 vs. 14.5%, p = 0.03) within 90 days of surgery. Patients with HBV infection were more likely to have increased length of stay (6.2 vs. 5.9 days, p = 0.009) and in-hospital charges (¥52,231 vs. ¥49,832, p < 0.00001). Multivariate logistic regression suggested that liver fibrosis and thrombocytopenia were independent risk factors for major complications and extended LOS. CONCLUSION Patients with HBV infection were at greater risk of adverse postoperative outcomes. We should pay more attention to the considerable burden of perioperative management of CHB patients. Due to the high proportion of undiagnosed patients in the Chinese elderly population, universal HBV screening should be considered preoperatively.
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Affiliation(s)
- Tao Cheng
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, The People's Republic of China.
| | - Guoyong Li
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, The People's Republic of China
| | - Xin Mao
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, The People's Republic of China
| | - Liang Hao
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, The People's Republic of China.
| | - Xigao Cheng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, The People's Republic of China
| | - Huiming Ning
- Department of Infectious Disease, Shanghai Eighth People's Hospital, Shanghai, The People's Republic of China
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Wier JR, Firoozabadi R, Patterson JT. Cirrhosis is independently associated with complications and mortality following operative treatment of acetabular fractures. Injury 2023; 54:S0020-1383(23)00171-7. [PMID: 36878732 DOI: 10.1016/j.injury.2023.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/19/2023] [Indexed: 03/08/2023]
Abstract
INTRODUCTION Patients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures. METHODS Adults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality. RESULTS After propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality. CONCLUSION Cirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- Julian R Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
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Fisher A, Srikusalanukul W, Fisher L, Smith PN. Comparison of Prognostic Value of 10 Biochemical Indices at Admission for Prediction Postoperative Myocardial Injury and Hospital Mortality in Patients with Osteoporotic Hip Fracture. J Clin Med 2022; 11:jcm11226784. [PMID: 36431261 PMCID: PMC9696473 DOI: 10.3390/jcm11226784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022] Open
Abstract
Aim: To evaluate the prognostic impact at admission of 10 biochemical indices for prediction postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In 1273 consecutive patients with HF (mean age 82.9 ± 8.7 years, 73.5% women), clinical and laboratory parameters were collected prospectively, and outcomes were recorded. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were preformed, the number needed to predict (NNP) outcome was calculated. Results: Age ≥ 80 years and IHD were the most prominent clinical factors associated with both PMI (with cardiac troponin I rise) and in-hospital death. PMI occurred in 555 (43.6%) patients and contributed to 80.3% (49/61) of all deaths (mortality rate 8.8% vs. 1.9% in non-PMI patients). The most accurate biochemical predictive markers were parathyroid hormone > 6.8 pmol/L, urea > 7.5 mmol/L, 25(OH)vitamin D < 25 nmol/L, albumin < 33 g/L, and ratios gamma-glutamyl transferase (GGT) to alanine aminotransferase > 2.5, urea/albumin ≥ 2.0 and GGT/albumin ≥ 7.0; the AUC for developing PMI ranged between 0.782 and 0.742 (NNP: 1.84−2.13), the AUC for fatal outcome ranged from 0.803 to 0.722, (NNP: 3.77−9.52). Conclusions: In HF patients, easily accessible biochemical indices at admission substantially improve prediction of hospital outcomes, especially in the aged >80 years with IHD.
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Affiliation(s)
- Alexander Fisher
- Departments of Geriatric Medicine, The Canberra Hospital, ACT Health, Canberra 2605, Australia
- Departments of Orthopaedic Surgery, The Canberra Hospital, ACT Health, Canberra 2605, Australia
- Medical School, Australian National University, Canberra 2605, Australia
- Correspondence:
| | - Wichat Srikusalanukul
- Departments of Geriatric Medicine, The Canberra Hospital, ACT Health, Canberra 2605, Australia
| | - Leon Fisher
- Department of Gastroenterology, Frankston Hospital, Peninsula Health, Melbourne 3199, Australia
| | - Paul N. Smith
- Departments of Orthopaedic Surgery, The Canberra Hospital, ACT Health, Canberra 2605, Australia
- Medical School, Australian National University, Canberra 2605, Australia
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Cannada LK. CORR Insights®: Hip Fractures in Patients With Liver Cirrhosis: Worsening Liver Function is Associated with Increased Mortality. Clin Orthop Relat Res 2022; 480:1089-1090. [PMID: 35134015 PMCID: PMC9263454 DOI: 10.1097/corr.0000000000002140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/25/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Lisa K Cannada
- Orthopaedic Trauma Surgeon, Novant Health Orthopaedics, Charlotte, NC, USA
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