Perioperative Outcomes of Patients with Bleeding Disorders Undergoing Major Surgery at an Academic Hemophilia Treatment Center

Reevaluating the Routine Use of Mastoid Pressure Dressings in Otologic Surgery: A Randomized Controlled Trial

OBJECTIVE

The use of mastoid pressure dressings (MPDs) after otologic surgery has been a standard practice for decades, believed to minimize complications such as hematoma and wound infection. However, the efficacy of MPDs in improving patient outcomes has been questioned. This study aimed to evaluate the necessity and impact of MPDs on postoperative pain, complications, and overall patient comfort.

METHOD

In this prospective, randomized, controlled trial, 200 patients undergoing major ear surgeries were randomly assigned to receive either a MPD group or a non-MPD (NMPD) group. Postoperative pain was assessed using the Visual Analog Scale at the 3rd, 6th, and 24th hour. Complications, including hematoma, wound infection, and skin erythema, were systematically recorded.

RESULTS

Patients in the MPD group reported significantly-higher pain levels at all measured intervals than in the NMPD group (P < .05). Complications such as skin erythema and auricular bruising were more prevalent in the MPD group. Importantly, there was no significant difference between the two groups in the incidence of hematomas or wound infections.

CONCLUSION

The findings suggest that MPDs may contribute to increased postoperative pain and discomfort without offering significant benefits in preventing complications. Given the lack of significant benefit and the increased patient discomfort observed with MPDs, their routine use in otologic surgery may warrant reconsideration. Future research should further explore optimal postoperative care strategies to enhance patient comfort and outcomes.

Bleeding Complications, Transfusion, and Acute Care Costs After Major Arthroplasty in Patients With Hereditary Bleeding Disorders: A National Healthcare Database Analysis

BACKGROUND

Advances in blood conservation have reduced the need for allogeneic transfusions in total knee and hip arthroplasty (TKA/THA). This study aimed to assess whether perioperative bleeding complications, including hemorrhage/hematoma, allogeneic transfusions, and postoperative anemia, occurred at similar rates between patients with hereditary bleeding disorders (BDs) and controls. Using a national health care database, we assessed the use of clotting factor concentrates (CFCs), perioperative outcomes, and resource utilization.

METHODS

A retrospective cohort study was conducted using the Premier Health Database (2017-2021) to analyze differences in outcomes and costs between 1528 patients with hereditary BDs and 20,509 non-BD controls undergoing elective TKA and THA. Summary statistics, bivariate analyses, and odds ratios (ORs) were used to evaluate perioperative outcomes and resource use.

RESULTS

Patients with hereditary BDs were slightly younger, predominantly female, and more often treated at larger, urban hospitals compared to controls. Bleeding complications, including hemorrhage and hematoma, were infrequent but higher in the BD group (1.1% vs 0.2%; P < .0001). Transfusion rates were higher in THA than TKA, with significantly increased odds for patients with hereditary BD: for THA, OR 2.7 (95% confidence interval [CI], 2.0-3.7; P < .0001); and for TKA, OR 2.6 (95% CI, 1.9-3.8; P < .0001). CFC exposures occurred in 16.4% of patients with hereditary BD compared to 0.03% in controls. Of 270 reported CFC exposures, factor VIII (FVIII) and von Willebrand factor (VWF) were most commonly used (49.6% and 23.0%, respectively), followed by FIX concentrate (12.6%) and bypassing agents, including FVIIa (8.5%) and anti-inhibitor coagulant complex (AICC; 3.7%). Antifibrinolytic therapy was administered in most cases. Pharmacy costs for patients with hereditary BD were significantly higher, with a mean of $23,792 (95% CI, $8722-$39,312), being over 30 times the mean cost in controls ($750; 95% CI, $739-$762). Other outcomes were not different, except for a higher incidence of venous thromboembolism in the BD group (OR 3.9, 95% CI, 2.4-6.1; P < .0001).

CONCLUSIONS

THA and TKA in patients with hereditary BDs are relatively safe, with most outcomes comparable to controls. However, higher rates of bleeding, transfusion, and VTE underscore the need for optimizing anemia management and targeted use of CFCs along with antifibrinolytic therapy.

Risk Factors and Incidence of 30-Day Readmission Following Outpatient Total Knee Arthroplasty

BACKGROUND

Reflecting advancements in surgical techniques and postoperative care, total knee arthroplasty (TKA) is being performed increasingly as an outpatient procedure. This study aimed to report the frequency and timing of unplanned readmission after outpatient TKA with updated data, identify risk factors for readmission after outpatient TKA, and identify common causes for readmission after outpatient TKA with a much larger cohort compared to previous studies.

METHODS

This study retrospectively analyzed data from 31,347 patients who underwent outpatient TKAs between 2012 and 2021. Adverse events and unplanned readmissions were identified. Timing and reason for readmission were recorded. Statistical analysis involved multivariate logistic regression to identify patient risk factors for readmission.

RESULTS

Following surgery, 1.86% of cases reported an unplanned readmission within 30 days. Multivariate analysis demonstrated that age (odds ratio (OR): 1.042; P < 0.001), body mass index (OR: 1.023; P = 0.002), operative time (OR: 1.003; P = 0.017), congestive heart failure (OR: 3.079; P < 0.001), chronic obstructive pulmonary disease (OR: 2.577; P < 0.001), bleeding disorders (OR: 1.706; P = 0.025), hypertension (1.436; P < 0.001), and partially dependent functional status (OR: 2.486; P = 0.036) significantly increased the risk of 30-day readmission. Reasons unrelated to the surgical site contributed the most to readmission at 68.3%, while reasons related to the surgical site made up 27.3%, followed by knee-related complaints (4.4%). The most common days on which readmissions occurred were postoperative days two, four, and one.

CONCLUSIONS

Our analysis revealed a low readmission risk (1.86%) after outpatient TKA. Readmission rates were found to decrease over the observed time, despite a dramatic increase in outpatient cases. The most common reason for 30-day readmission was an organ or space surgical site infection. Identified risk factors for readmission highlight areas for targeted mitigation to enhance patient outcomes and healthcare efficiency.

Gynecomastia Surgery in 4996 Male Patients Over 14 Years: A Retrospective Analysis of Surgical Trends, Predictive Risk Factors, and Short-Term Outcomes

BACKGROUND

The high prevalence of benign male breast tissue enlargement (gynecomastia) has resulted in a marked increase of gynecomastia cases. While about one third of male adults experience some form of gynecomastia, gynecomastia surgery (GS) outcome research is limited to small study populations and single-center/-surgeon databases. In this study, we aimed to access the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify preoperative risk factors for complications and investigate postoperative outcomes of GS.

METHODS

In this retrospective study, we queried the ACS-NSQIP database from 2008 to 2021 to identify male adult patients who underwent GS. Postoperative outcomes involved the occurrence of any, surgical and medical complications, as well as reoperation, readmission, and mortality within a 30-day postoperative time period. Univariable and multivariable assessment were performed to identify risk factors for complications while adjusting for possible confounders.

RESULTS

The study included 4,996 GS patients with a mean age of 33.7 ± 15 years and BMI of 28.2 ± 5.1 kg/m2. White patients constituted 54% (n = 2713) of the cohort, and 27% (n = 1346) were obese. Except for 2020, there was a steady increase in GS cases over the study period. Outpatient surgeries were most common at 95% (n = 4730), while general surgeons performed the majority of GS (n = 3580; 72%). Postoperatively, 91% (n = 4538) of patients were discharged home; 4.4% (n = 222) experienced any complications. Multivariable analysis identified inpatient setting (p < 0.001), BMI (p = 0.023), prior sepsis (p = 0.018), and bleeding disorders (p = 0.047) as independent risk factors for complications.

CONCLUSION

In this study, we analyzed 4996 male adult GS patients from the ACS-NSQIP database, revealing an increased caseload and significant general surgeon involvement. Risk factors like bleeding disorders, inpatient status, and prior sepsis were linked to postoperative complications, while BMI was crucial for predicting adverse events. Overall, our findings may aid in enhancing patient care through advanced preoperative screening and closer perioperative management.

LEVEL OF EVIDENCE III

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[Update on point-of-care-based coagulation treatment : Systems, reagents, device-specific treatment algorithms]

Viscoelastic test (VET) procedures suitable for point-of-care (POC) testing are in widespread clinical use. Due to the expanded range of available devices and in particular due to the development of new test approaches and methods, the authors believe that an update of the current treatment algorithms is necessary. The aim of this article is to provide an overview of the currently available VET devices and the associated reagents. In addition, two treatment algorithms for the VET devices most commonly used in German-speaking countries are presented.

Successful transfemoral prosthesis in a patient with haemophilia A and factor VIII inhibitors: A case report

Haemophilia A patients who develop factor VIII inhibitors pose a challenge with respect to bleeding and orthopaedic management. This is particularly relevant in cases requiring amputation. We present here a case of a patient with severe haemophilia A and inhibitors who had a history of multiple surgeries due to periprosthetic joint infection and a non-healing wound which led to above-knee amputation. Following the implementation of appropriate and suitable transfemoral prosthesis and emicizumab therapy, the patient experienced a significant improvement in mobility and quality of life without any adverse events or bleeding episodes. Additional studies are required to more fully understand treatment options for lower limb amputations in the haemophilia population.

Investigation of the effects of intranasal desmopressin on the bleeding of the patients during open septorhinoplasty: A randomized double-blind clinical trial

OBJECTIVES

Rhinoplasty is one of the most common cosmetic surgeries in the world. Lack of adequate local homeostasis may lead to excessive bleeding during the operation, which increases the time of operation and recovery period, and the prevalence of complications. This study investigated the effects of nasal desmopressin on the quality of the surgical field and the volume of bleeding during rhinoplasty.

MATERIALS AND METHODS

This double-blind randomized clinical trial was performed on 120 patients aged 18-40 years who were candidates for rhinoplasty. Patients were randomly divided into three groups: low-dose desmopressin group and high-dose desmopressin group and placebo group. Hemodynamic changes and surgical field based on BOEZAART criteria, and the volume of bleeding were calculated.

RESULTS

In this study 115 women (95.8%) and 5 men (4.2%) participated. The mean age of patients was (27 ± 6.8). Bleeding volume in high dose desmopressin group was (21.7 cc ± 12.3), (27.7 cc ± 12.3) in low dose group, and (38.3 cc ± 12.3) in the placebo group, The difference in blood volume among the three groups was statistically significant with p < 0.005. Clean surgical field according to BOEZAART classification was marginally significant in both desmopressin groups. The differences in blood pressure, heart rate, blood and urine sodium, and hemoglobin before and after surgery between groups there not statistically significant.

CONCLUSION

Based on the results of the present study topical nasal spray desmopressin can reduce surgical field bleeding during rhinoplasty. To generalize the results to other surgeries in the ENT field it is recommended to conduct studies.

In the era of primary prophylaxis in hemophilia, what types of orthopedic surgical interventions have been published in the 2020-2023 period and in which countries?

INTRODUCTION

Primary prophylaxis has significantly reduced the number of orthopedic surgical procedures performed on patients with hemophilia (PWH) worldwide. However, studies on orthopedic surgery in PWH are still being published in the medical literature.

AREAS COVERED

The aim of this article is to determine the types of orthopedic surgical interventions in PWH published between 2020 and 2023 and the countries in which they are published.

EXPERT OPINION

The following orthopedic surgical procedures are still performed on PWH: total knee, ankle, elbow and hip arthroplasty, ankle fusion, ankle distraction, and the surgical removal of hemophilic pseudotumors. The countries in which articles on orthopedic surgery in hemophilia have been published in the period 2000-2023 include China (14 articles); Republic of Korea and U.S.A. (3 articles each); Germany, Italy, Japan, Poland and Turkey (2 articles each); and 1 article each in the following countries: Austria, Belgium, Chile, France, Ireland, New Zealand, Russia, and The Netherlands. These data suggest that primary prophylaxis should be improved and extended to all patients globally.