Preoperative incidence and risk factors of deep venous thrombosis in patients with isolated femoral shaft fracture

Predictors of 30-day mortality, unplanned related readmission and reoperation among isolated closed femoral shaft fractures

Background

Isolated, closed, femoral shaft fractures are dangerous injuries that commonly occur in the setting of high energy trauma or among older patients with significant comorbidities. Despite their prevalence, relatively little data exists connecting patient independent risk factors to the time to 30-day mortality, unplanned reoperations and unplanned readmissions in these fractures.

Methods

Using National Surgical Quality Improvement Program (NSQIP) database, isolated close femoral shaft fractures were identified using ICD-10 codes. Patient demographics, perioperative course and adverse events were identified. Categorical and binary variables were analyzed among procedure cohorts using Chi2 analysis. Univariate and multivariate analysis were conducted to identify independent risk factors associated with primary outcomes.

Results

Between 2010 and 2019, 1346 closed isolated femoral shaft fracture patients with a mean age of 66.7 were identified, of whom 30.6% and 69.4% were male and female, respectively. Surgical procedures included: 915 (68.0%) intramedullary nail (IMN); 428 (31.8%) open reduction internal fixation (ORIF); and 3 (0.2%) external fixator (Ex-fix). Patients who underwent ORIF reported 3.19 (OR: 3.19; CI: 1.45-7.03; p = 0.004) and 2.12 (OR: 2.12; CI: 1.10-4.09; p = 0.024) increased odds of mortality and unplanned related readmission compared to patients who received IMN. Transfusion, DVT, and PE rates were 34.2%, 1.4%, and 1.1%, respectively. Furthermore, 50% of mortality cases occurred within 6 days of surgery. Patients requiring reintubation reported 61.8 (OR: 61.8; CI: 15.7-242.40; p < 0.001) increased odds of mortality compared to patients not requiring reintubation.

Conclusion

Patients with femoral shaft fractures who require reintubation have increased odds of mortality than those successfully extubated. In addition to precautions prior to extubation, patients with femoral shaft fractures should also be carefully monitored for the development of DVT or PE, and they should be definitively fixed with IMN whenever possible.

Prevalence and risk factors for proximal deep vein thrombosis at admission in patients with traumatic fractures: a multicenter retrospective study

Objective

This study aimed to determine the associated risk factors for proximal deep vein thrombosis (DVT) in patients with lower extremity and pelvic-acetabular fractures.

Methods

The medical records of 4,056 patients with lower extremity and pelvic-acetabular fractures were retrospectively reviewed. The patients were classified into proximal or non-proximal DVT groups. Logistic regression models were used to determine the independent risk variables for proximal DVT. The predictive value of the related risk factors was further analyzed using receiver operating characteristic curves.

Results

The prevalence of proximal DVT was 3.16%. Sex, body mass index (BMI), fracture site, injury mechanism, diabetes, coronary heart disease (CHD), injury-to-admission interval, hematocrit, platelet counts, and D-dimer levels differed significantly between the two groups. BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT. CHD decreased the risk of proximal DVT. The platelet and D-dimer had high negative predictive value for predicting proximal DVT formation, with cut-off values of 174 × 109/L and 2.18 mg/L, respectively.

Conclusion

BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT in patients with lower extremity and pelvic-acetabular fractures. Platelet count and D-dimer level were effective indicators for excluding proximal DVT occurrence. CHD decreased the risk of proximal DVT.

Segmental femoral fracture malunion: evidence and prognostic analysis of medical intervention in the third century BC

We examined the remains of an individual who was unearthed from the Tuchengzi site and was believed to be from the Warring States period in China. The remains exhibited segmental femoral fracture. We aimed to deduce the cause of fracture, medical interventions, healing process, and motion behavior after fracture healing using several techniques, including macroscopic observation, computed tomography (CT), and finite element analysis. Based on the morphology of the long bones, it appeared that the individual was male. The fractures resulted in an adduction angle of 5.47° and an anterior flexion angle of 21.34° in the proximal femur, while the femoral neck anteversion angle had been replaced by a retroversion angle of 10.74°. Additionally, the distal femur formed an abnormal anterior convex angle of 144.60°. CT revealed mature callus formation and visible trabecular bundles. The finite element analysis indicated that the maximum von Mises stress in the femur was 17.44 MPa during standing and 96.46 MPa during walking. We suggest that medical practitioners in the Warring States period possessed a good knowledge of thigh anatomy, enabling them to perform fracture reduction and fixation. Reasonable medical intervention facilitated fracture healing and load recovery. Satisfactory fracture healing ensured that the individual could engage in normal standing and walking activities after rehabilitation.

Exploring the potential mechanism and molecular targets of Taohong Siwu Decoction against deep vein thrombosis based on network pharmacology and analysis docking

This study aims to investigate the mechanism of Taohong Siwu Decoction (THSWD) against deep vein thrombosis (DVT) using network pharmacology and molecular docking technology. We used the Traditional Chinese Medicine Systems Pharmacology database and reviewed literature to identify the main chemical components of THSWD. To find targets for DVT, we consulted GeneCards, Therapeutic Target Database, and PharmGKB databases. We used Cytoscape 3.8.2 software to construct herb-disease-gene-target networks. Additionally, we integrated drug targets and disease targets on the STRING platform to create a protein-protein interaction network. Then, we conducted Kyoto Encyclopedia of Genes and Genomes and gene ontology analysis. Finally, We employed the molecular docking method to validate our findings. We identified 56 potential targets associated with DVT and found 61 effective components. beta-sitosterol, quercetin, and kaempferol were the most prominent among these components. Our analysis of the protein-protein interaction network revealed that IL6, L1B, and AKT1 had the highest degree of association. Gene ontology analysis showed that THSWD treatment for DVT may involve response to inorganic substances, negative regulation of cell differentiation, plasma membrane protein complex, positive regulation of phosphorylation, and signaling receptor regulator activity. Kyoto Encyclopedia of Genes and Genomes analysis indicated that lipid and atherosclerosis, pathways in cancer, as well as the PI3K-Akt pathway are the main signal pathways involved. Molecular docking results demonstrated strong binding affinity between beta-sitosterol, quercetin, kaempferol, and AKT1 proteins as well as IL1B and IL6 proteins. The main targets for THSWD treatment of DVT may include AKT1, IL1B, and IL6. Beta-sitosterol, quercetin, and kaempferol may be the active ingredients responsible for producing this effect. These compounds may slow down the progression of DVT by regulating the inflammatory response through the PI3K/Akt pathway.

Neutrophil extracellular traps mediate deep vein thrombosis: from mechanism to therapy

Deep venous thrombosis (DVT) is a part of venous thromboembolism (VTE) that clinically manifests as swelling and pain in the lower limbs. The most serious clinical complication of DVT is pulmonary embolism (PE), which has a high mortality rate. To date, its underlying mechanisms are not fully understood, and patients usually present with clinical symptoms only after the formation of the thrombus. Thus, it is essential to understand the underlying mechanisms of deep vein thrombosis for an early diagnosis and treatment of DVT. In recent years, many studies have concluded that Neutrophil Extracellular Traps (NETs) are closely associated with DVT. These are released by neutrophils and, in addition to trapping pathogens, can mediate the formation of deep vein thrombi, thereby blocking blood vessels and leading to the development of disease. Therefore, this paper describes the occurrence and development of NETs and discusses the mechanism of action of NETs on deep vein thrombosis. It aims to provide a direction for improved diagnosis and treatment of deep vein thrombosis in the near future.

Deep vein thrombosis and validation of the Caprini risk assessment model in Chinese orthopaedic trauma patients: a multi-center retrospective cohort study enrolling 34,893 patients

BACKGROUND

The risk of venous thromboembolism among orthopaedic trauma patients is high, but prevalence of deep vein thrombosis (DVT) remains unknown. In addition, the Caprini risk assessment model (RAM) score in orthopaedic trauma patients is undetermined in previous research. This study is aimed to determine the incidence of DVT and then validate the Caprini RAM in orthopaedic trauma patients.

METHODS

This is a retrospective cohort study enrolling orthopaedic trauma inpatients from seven tertiary and secondary hospitals during a 3-year period (from April 1, 2018 through April 30, 2021). Caprini RAM scores were assessed by experienced nurses on admission. The patients with suspected DVT were verified through duplex ultrasonography by qualified radiologists, and then prospectively followed once a year after discharge.

RESULTS

In total, 34,893 patients were enrolled in our study. The Caprini RAM identified 45.7% of patients at low risk (Caprini score 0-2), 25.9% at medium risk (3-4), and 28.3% at high risk (5-6), highest risk (7-8), and superhigh risk (> 8). Patients with Caprini score > 5 were likely to be older, female, and with longer length of hospital stay. Moreover, 8695 patients had received ultrasonography to detect DVT. The prevalence of DVT was determined to be 19.0% [95% confidence interval (CI) 18.2-19.9%], which significantly increased with Caprini score. The area under curve of the Caprini RAM for DVT was 0.77 (95% CI 0.76-0.78) with a threshold of 4.5. Furthermore, 6108 patients who had received ultrasonography completed the follow-up. DVT patients had a hazard ratio of 1.75 (95% CI 1.11-2.76; P = 0.005) in the mortality, compared to non-DVT ones. Caprini scores were significantly associated with increase in the mortality [odds ratio (OR) 1.14; 95% CI 1.07-1.21; P < 0.001]; DVT remained an independent effect (OR 1.5; 95% CI 1.02-2.26; P = 0.042).

CONCLUSIONS

The Caprini RAM may be valid in Chinese orthopaedic trauma patients. Prevalence of DVT and higher Caprini score were significantly associated with increased all-cause mortality among orthopaedic trauma patients after discharge. Further study is warranted to explore the causes of higher mortality in patients with DVT.

Successful cardiopulmonary resuscitation of cardiac arrest induced by massive pulmonary embolism under general anesthesia: a case report

Background

While pulmonary embolism (PE) is a common occurrence, a large life-threatening PE is not. Herein, we discuss the case of a patient with a life-threatening PE that occurred under general anesthesia.

Case presentation

We present the case of a 59-year-old male patient who was at bed rest for several days due to trauma, which resulted in femoral and rib fractures and a lung contusion. The patient was scheduled for femoral fracture reduction and internal fixation under general anesthesia. After disinfection and surgical towel laying, there was a sudden occurrence of severe PE and cardiac arrest; the patient was successfully resuscitated. Computed tomography pulmonary angiography (CTPA) was performed to confirm the diagnosis, and the patient's condition improved after thrombolytic therapy. Unfortunately, the patient's family eventually discontinued treatment.

Discussion

Massive PE frequently occurs suddenly, may endanger a patient's life at any point in time, and cannot be diagnosed quickly on the basis of clinical manifestations. Although the vital signs fluctuate greatly and there is insufficient time to conduct more tests, some factors such as special disease history, electrocardiography, end-tidal carbon dioxide, and blood gas analysis may help us determine the preliminary diagnosis; however, the final diagnosis is made using CTPA. Current treatment options include thrombectomy, thrombolysis, and early anticoagulation, of which thrombolysis and early anticoagulation are the most feasible.

Conclusion

Massive PE is a life-threatening disease that requires early diagnosis and timely treatment to save patients' lives.

Treatment of Venous Thromboembolism in Trauma Patients: Features and Possibilities

The aim. Treatment of venous thromboembolism continues to be one of the most controversial problems of modern angiology. This issue is especially relevant in the treatment of patients with traumatological pathology. Methods. Treatment of 1915 patients with fractures of lower extremities from 2017 to 2022 at the Vinnytsia Regional Pyrohov Clinical Hospital was analyzed. During the study period, 727 (38%) deep vein thromboses were diagnosed. Results. During the study period, 4 (0.2%) pulmonary embolisms were diagnosed, among which 3 (0.15%) were fatal. In 99.5% of patients with venous thrombosis and injuries, it was possible to achieve clinical improvement and regression of the thrombotic process. Conclusions. Treatment tactics for trauma patients with venous thromboembolism should be individualized and take into account the severity and localization of the injury, the need and urgency of trauma surgery, the risk of pulmonary embolism.

Dynamic Changes and Relevant Factors of Perioperative Deep Vein Thrombosis in Patients with Thoracolumbar Fractures Caused by High-Energy Injuries

OBJECTIVE

To investigate the dynamic changes and relevant factors of deep vein thrombosis (DVT) in patients with thoracolumbar fractures caused by high-energy injuries.

METHODS

From January 2016 to June 2021, a total of 655 patients with thoracolumbar fractures who underwent surgical treatment in our hospital were retrospectively analyzed. The patients were examined by preoperative and postoperative ultrasonography, and divided into thrombus growth group, thrombus invariant group, and thrombus regression group according to the preoperative and postoperative ultrasonographic results. Medical record data, including demographic data, surgical data, and laboratory results, were collected and the differences in various factors among the groups were compared.

RESULTS

DVT was found in 99 patients (15.1%, 99/655) before surgery, including 79 cases of distal thrombus, 7 cases of proximal thrombus, and 13 cases of mixed thrombus. The incidence of postoperative DVT increased to 20.6% (134/655), including 96 cases of distal thrombus, 15 cases of proximal thrombus, and 23 cases of mixed thrombus. Among them, 39.7% had thrombus growth, 49.3% had thrombus basically unchanged and 11.0% had thrombolysis. There were significant differences in age, lower extremity muscle strength, time from trauma to surgery, operation time, blood loss, blood transfusion, and post 3-D-dimer among the three groups.

CONCLUSIONS

In patients with thoracolumbar fractures caused by high-energy injuries, the majority of patients with DVT do not change or grow after surgery, and only a few of them have thrombolysis. Younger age, lower extremity motor, and fewer blood transfusion contribute to thrombolysis. Delayed surgical intervention, longer operation time, and higher blood loss can lead to thrombosis growth. Post 3-D-dimer is closely related to the dynamic changes of thrombus.