Risk factors of perioperative blood transfusion in elderly patients with femoral intertrochanteric fracture

Proximal femoral nail anti-rotation vs dynamic hip screws decrease the incidence of surgical site infections in patients with intertrochanteric fractures: A meta-analysis

In this study, a meta-analysis was conducted to comprehensively analyse the effectiveness of using proximal femoral nail anti-rotation (PFNA) and dynamic hip screws (DHS) to treat intertrochanteric fractures on postoperative surgical site infections (SSI). PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang databases were searched from their inception until December 2022 to identify studies that compared PFNA and DHS in the treatment of intertrochanteric fractures. Two investigators independently screened the retrieved studies to assess their quality and verify their eligibility for inclusion. Meta-analyses were performed with RevMan 5.4 software. Thirty studies, including 3158 patients, met the inclusion criteria. These studies included 1574 patients treated with PFNA, and 1584 were treated with DHS. The findings of the meta-analysis revealed a significant reduction in the incidence of SSI in patients treated with PFNA compared with those treated with DHS (2.64% vs 6.76%, odds ratio [OR]: 0.40, 95% confidence intervals [CIs]: 0.28-0.57, P < .001), superficial SSI (2.58% vs 5.01%, OR: 0.53, 95% CIs: 0.33-0.85, P = .008) and deep SSI (1.26% vs 3.43%, OR: 0.41, 95% CIs: 0.19-0.92, P = .03). PFNA was more effective than DHS in reducing the incidence of SSI. Even so, significant variations in sample sizes among the included studies meant that the methodology for some studies had qualitative deficiencies. Therefore, additional studies with large sample sizes are needed to validate these results.

Blood-Transfusion Risk Factors after Intramedullary Nailing for Extracapsular Femoral Neck Fracture in Elderly Patients

BACKGROUND

Extracapsular femoral neck fractures (eFNF) are the third most common type of fracture in traumatology. Intramedullary nailing (IMN) is one of the most frequently used ortho-pedic treatments for eFNF. Blood loss is one of the main complications of this treatment. This study aimed to identify and evaluate the perioperative risk factors that lead to blood transfusion in frail patients with eFNF who undergo IMN.

METHODS

From July 2020 to December 2020, 170 eFNF-affected patients who were treated with IMN were enrolled and divided into two groups according to blood transfusion: NBT (71 patients who did not need a blood transfusion), and BT (72 patients who needed blood transfusion). Gender, age, BMI, pre-operative hemoglobin levels, in-ternational normalized ratio (INR) level, number of blood units transfused, length of hospital stay, surgery duration, type of anesthesia, pre-operative ASA score, Charlson Comorbidity Index, and mortality rate were assessed.

RESULTS

Cohorts differed only for pre-operatively Hb and surgery time (p < 0.05).

CONCLUSION

Patients who have a lower preoperative Hb level and longer surgery time have a high blood-transfusion risk and should be closely followed peri-operatively.

Association between fracture type and the risk of bleeding in intertrochanteric femur fractures

Introduction

The current study aimed to determine the association between fracture type and pre-operative hemoglobin level decrease in intertrochanteric fractures. Further, the erythrocyte unit required in replacement therapy until discharge according to fracture type was evaluated.

Patients and methods

We retrospectively analyzed 194 patients diagnosed with intertrochanteric femur fracture who received proximal femoral nail implantation. Among them, 122 met the inclusion criteria, and they were divided into group 1 (stable fracture) and group 2 (unstable fracture) according to the Arbeitsgemeinschaft für Osteosynthesefragen classification. Data on age, sex, fracture side, surgical waiting time, pre- and post-operative hemoglobin levels, and total erythrocyte units required were assessed. Then, statistical analysis was performed.

Results

The stable and unstable groups were similar in terms of age, sex, fracture side, and surgical waiting time (p > 0.05). The average erythrocyte units required in replacement therapy were 1.62 (total: 96) in group 2 and 0.91 (total: 57) in group 1. Moreover, group 2 was more likely to require eythrocyte replacement than group 1 (p = 0.001). The average hemoglobin level decreases were 1.70 g/dL in group 1 and 1.95 g/dL in group 2. The pre-operative hemoglobin level decrease had a similar distribution in both groups (p = 0.239).

Conclusions

The pre-operative blood loss volume was similar between unstable and stable intertrochanteric fractures. Moreover, at unstable group, the need for erythrocyte replacement therapy was high in the whole period until discharge.

The role of routine laboratory tests after unilateral total knee arthroplasty

Background

Recent studies suggest that routine laboratory tests are not required within 1 day after partial knee arthroplasty. In this study, we evaluated the utility of routine postoperative laboratory tests after initial unilateral total knee arthroplasty (TKA) in an Asian population. In addition, we explored risk factors associated with abnormal test results.

Methods

Clinical data of patients who underwent original unilateral TKA between 2015 and 2020 were retrospectively analyzed. Patient characteristics and laboratory test results were recorded. Multivariate binary logistic regression analysis was performed to identify risk factors associated with 3 abnormal laboratory results.

Results

A total of 713 patients, who underwent relevant laboratory tests within 3 days of TKA surgery, were enrolled. Among them, 8.1%, 9.9%, and 3.4% patients with anemia, hypoalbuminemia, and abnormal serum potassium levels required clinical intervention after surgery. Binary logistic regression analysis revealed that preoperative hemoglobin levels, estimated blood loss, and age were independent risk factors of postoperative blood transfusion in TKA patients. On the other hand, preoperative albumin levels, intraoperative blood loss, and operation time were risk factors associated with postoperative albumin supplementation. In addition, lower body mass index (BMI) and preoperative hypokalemia were potential risk factors of postoperative potassium supplementation.

Conclusion

Considering that more than 90% of abnormal postoperative laboratory tests do not require clinical intervention, we believe that routine laboratory tests after surgery have little significance in patients with primary unilateral TKA. However, postoperative laboratory testing is necessary for patients with established risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05509-0.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review

OBJECTIVES

To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma.

DATA SOURCES

A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010.

STUDY SELECTION

English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I.

DATA SYNTHESIS

The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible.

CONCLUSIONS

Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

Postoperative haemoglobin estimation in elderly hip fractures

OBJECTIVE

The purpose of our study was to analyze the effect of postoperative hemoglobin check on the day of surgery and 1 day postoperatively in elderly hip fracture patients with an aim to determine an optimum timing of postoperative hemoglobin check.

MATERIAL AND METHODS

A retrospective study of 253 patients. Age, Charlson morbidity index, fracture type, time from admission to surgery, type of surgery, preoperative hemoglobin, postoperative hemoglobin, hemoglobin drop, day of postoperative hemoglobin measurement, blood transfusion, length of hospital stay, and 30-day mortality were recorded.

RESULTS

One hundred and sixty-three patients (Group I) had postoperative hemoglobin check on the first postoperative day and 90 patients (Group II) on the day of surgery. Mean age in Group I was 82 years and 80 years in Group II. Mean Charlson morbidity index for Group I was 5.9 and Group II was 5.7. There was a significantly higher hemoglobin drop in Group I (P < 0.05) but no difference in blood transfusion requirement, length of stay, or 30-day mortality in the two groups (P > 0.05).

CONCLUSION

Our results suggest that postoperative hemoglobin measurement on the day of surgery is not a true reflection of hemoglobin drop and recommend estimation of hemoglobin on the first postoperative day.

Allogeneic Red Blood Cell Transfusion Rate and Risk Factors After Hemiarthroplasty in Elderly Patients With Femoral Neck Fracture

Objective

This study aimed to determine the rate and risk factors of allogeneic red blood cell transfusions (ABT) after hemiarthroplasty (HA) in elderly patients with femoral neck fracture (FNF).

Methods

The subjects of the study were elderly patients (≥65 years old) who were admitted to the geriatric trauma orthopedics ward of Beijing Jishuitan Hospital between March 2018 and June 2019 for HA treatment due to an FNF. The perioperative data were collected retrospectively, and univariate and multivariate stepwise logistic regression analyses were performed to determine the post-operative ABT rate and its risk factors.

Results

There were 445 patients in the study, of whom 177 (39.8%) received ABT after surgery. Multivariate stepwise logistic regression analysis showed that preoperative low hemoglobin (Hb), high intraoperative blood loss (IBL), advanced age, and a low body mass index (BMI) are independent risk factors of ABT after HA in elderly FNF patients.

Conclusion

ABT after HA is a common phenomenon in elderly patients with FNF. Their post-operative ABT needs are related to preoperative low Hb, high IBL, advanced age, and low BMI. Therefore, ABT can be reduced by taking these factors into account. When the same patient had three risk factors (preoperative low hemoglobin, advanced age, and low BMI), the risk of ABT was very high (78.3%). Also, when patients have two risk factors of preoperative low hemoglobin and low BMI, the risk of ABT was also high (80.0%).

Preoperative risk factors for postoperative blood transfusion after hip fracture surgery: establishment of a nomogram

Background

This study aimed to explore the preoperative risk factors related to blood transfusion after hip fracture operations and to establish a nomogram prediction model. The application of this model will likely reduce unnecessary transfusions and avoid wasting blood products.

Methods

This was a retrospective analysis of all patients undergoing hip fracture surgery from January 2013 to January 2020. Univariate and multivariate logistic regression analyses were used to evaluate the association between preoperative risk factors and blood transfusion after hip fracture operations. Finally, the risk factors obtained from the multivariate regression analysis were used to establish the nomogram model. The validation of the nomogram was assessed by the concordance index (C-index), the receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and calibration curves.

Results

A total of 820 patients were included in the present study for evaluation. Multivariate logistic regression analysis demonstrated that low preoperative hemoglobin (Hb), general anesthesia (GA), non-use of tranexamic acid (TXA), and older age were independent risk factors for blood transfusion after hip fracture operation. The C-index of this model was 0.86 (95% CI, 0.83–0.89). Internal validation proved the nomogram model’s adequacy and accuracy, and the results showed that the predicted value agreed well with the actual values.

Conclusions

A nomogram model was developed based on independent risk factors for blood transfusion after hip fracture surgery. Preoperative intervention can effectively reduce the incidence of blood transfusion after hip fracture operations.

Influence of integrated orthogeriatric care on morbidity and mortality and length of hospital stay for hip fracture

BACKGROUND AND OBJECTIVES

Compare the morbidity and mortality, the length of hospital stay and the economic cost of the fragility fracture of the hip, in two nonconsecutive years thanks to the integrated orthogeriatric care.

MATERIAL AND METHOD

Retrospective observational cohort study with 633 patients with hip fragility fracture with a mean age of 85.5 years, treated in the same Trauma and Orthopaedic Surgery service in two different years (2012 and 2017). Mean stay, surgical delay, perioperative mortality, one month and one year, and perioperative complications such as acute urine retention, pressure ulcers, and need for transfusion were measured.

RESULTS

Mortality during admission decreased from 10% in 2012 to 3.6% in 2017 (P=.004 *), while mortality at thirty days (10.5% vs 7%) (P=.123) and one year (28.9% versus 24.9%) (P=.277). Hospital stay times, surgical delay, and postoperative admission time also decreased. The estimated total annual economic savings thanks to integrated orthogeriatric care amounted to €1,017,084.94.

CONCLUSIONS

Integrated orthogeriatric care of the patient with fragility fracture of the hip, results in a more effective and efficient care model. Both the care and the clinical situation of patients are improved in the perioperative period, both hospital stay and mortality during admission are significantly reduced, and all this with significant associated economic savings.

The factors that affect blood loss in intertrochanteric fractures treated with proximal femoral nail in the elderly

PURPOSE

Intertrochanteric femur fractures (IFF) is one of the biggest health problems in elderly population and mostly treated by proximal femoral nails. Although it is done in less invasive technique this method can cause higher blood loss than expected and subsequent allogenic blood transfusions. In this study, we aimed to investigate the factors that were related to the blood loss in proximal femoral nail fixation of IFF including patients' ongoing anticoagulant treatments.

METHODS

231 consecutive patients with IFF who treated with proximal femoral nail anti-rotation between January 2017 and December 2019 were included the study. The factors that can affect the blood loss determined as patients demographics, time from injury to operation, duration of operation, the American Society of Anesthesiologists (ASA) scores, preoperative anticoagulant medications. Hematocrit and hemoglobin were obtained on admission day, postoperative day one and postoperative day 3. Total blood loss and allogenic blood transfusions assessed.

RESULTS

Higher BMI is found related to higher blood loss. The patients who were operated in the first two days after admission had lower blood loss levels independent from anticoagulant use (p = 0.027). Preoperative Hct was higher in patients who did not need RBCs in the perioperative period (p = 0.039). According to the AO classification, A2.1 fractures had lower blood loss levels.

CONCLUSION

This study demonstrated that ongoing anticoagulant treatments of intertrochanteric fracture patients did not increase the perioperative blood loss. The factors affecting blood loss in the proximal femoral nail fixation were BMI, the time to surgery, and fracture type in the elderly.

The Analysis for Anemia Increasing Fracture Risk

Background

Fractures are a major public health problem for elderly people throughout the world. Anemia is also a common, important health problem among elderly populations. The aim of this article was to estimate the association between anemia and fracture incidence via a systematic review and meta-analysis.

Material/Methods

The participant, intervention, observation, and study design (PICOS) reporting guidelines were followed, and databases were searched from their inception to May 2020 to identify relevant studies. When heterogeneity was significant, and a random-effects model was used. Subgroup analysis was conducted to explore the source of heterogeneity based on sex, study design, and region.

Result

We found that anemia significantly increased fracture risk [relative risk (RR)=1.26, 95% confidence interval (CI)=1.14–1.39, P<0.001], specifically, hip fracture (RR=1.44, 95% CI=1.29–1.61), spine fracture (RR=1.15, 95% CI=1.08–1.23), and nonspine fracture (RR=1.42, 95% CI=1.33–1.52). Males with anemia had a 1.51-fold higher fracture risk, females had a 1.09-fold higher fracture risk. And the association was stronger in Asian (RR=1.22, 95% CI=1.07–1.40), but not in American and European study populations.

Conclusions

In conclusion, a significantly increased fracture risk was observed, and anemia can be a predictor of fracture risk.