Delayed Surgery Does Not Reduce Transfusion Rates in Low-Energy Hip Fractures on Direct Oral Anticoagulants

OBJECTIVES

To compare transfusion rates in patients on direct oral anticoagulants (DOACs) with nonanticoagulated patients undergoing hip fracture surgery and, secondarily, to determine whether time to surgery or complications differ between these groups.

DESIGN

Multicenter retrospective cohort.

SETTING

Three tertiary care, academic, Level I trauma centers.

PATIENTS

Acute, operatively treated, low-energy hip fracture patients 55 years of age and older were included. Anticoagulated patients were matched in a 1:2 ratio to "control" nonanticoagulated hip fracture patients using propensity score matching.

MAIN OUTCOME MEASUREMENTS

The primary outcome was incidence of perioperative transfusion. The secondary outcomes included time to surgery, length of stay, and 90-day complications, readmissions, reoperations, and mortality.

RESULTS

One hundred thirty-two patients with hip fracture admitted on DOACs were identified (107 factor Xa inhibitors, 25 dabigatran) and were matched to 262 "control" nonanticoagulated patients. There was no difference in overall transfusion rates between anticoagulation and control groups (43.2%; n = 57 DOAC vs. 39.7%; n = 104 control; P = 0.517). The median time from admission to surgery was 41.7 hours in the DOAC group and 26.0 hours in the control group (P < 0.001). There were no differences in 90-day complication, readmission, reoperation, or mortality rates between DOAC and control groups. Comparing DOAC patients undergoing surgery within 24 hours and after 24 hours, there were no differences in transfusion rates (P = 0.558) or overall complication rates (P = 0.179).

CONCLUSIONS

This study supports growing evidence that DOAC use should not be a determining factor in delaying surgery for patients with hip fracture who are otherwise medically optimized.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Healing the Index Tibial Nonunion: Risk Factors for Development of a Recalcitrant Nonunion in 222 Patients

OBJECTIVES

To compare and stratify the healing rates after our index nonunion surgery using contemporary methods of fixation, report the prevalence of recalcitrant non-union, and identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion.

DESIGN

Retrospective analysis of a prospectively collected database.

SETTING

Academic Level 1 Trauma Center.

PATIENTS/PARTICIPANTS

Two hundred twenty-two tibial nonunions treated with internal fixation by a single surgeon.

INTERVENTION

Bivariate and multivariate regression analysis were performed to compare healing rates by the type of fixation and graft augmentation and to identify specific demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion.

RESULTS

Of the 222 patients, 162 (73%) healed as intended and 51 (23%) required 1 or more subsequent interventions to achieve union (96%). Nine fractures (4%) failed to unite. The 60 fractures (27%) that required a subsequent intervention(s) or failed to consolidate were defined as recalcitrant nonunions. There were no statistically significant differences in the recalcitrant rate when we compared plates versus nails or types of bone graft. Risk factors for developing a recalcitrant nonunion were multifactorial and included grade III open fractures, compartment syndrome, deep infection, and 2 or more prior surgical procedures.

CONCLUSIONS

Internal fixation remains a successful method of treatment for most tibial nonunions. However, 27% of patients required a subsequent intervention because of failure to heal our index nonunion procedure. Factors that are associated with recalcitrant nonunions were a grade III open fracture, compartment syndrome, deep infection, and 2 or more or more prior surgical procedures.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial

Objectives

Therapeutic virtual reality (VR) has emerged as an effective, drug-free tool for pain management, but there is a lack of randomized, controlled data evaluating its effectiveness in hospitalized patients. We sought to measure the impact of on-demand VR versus “health and wellness” television programming for pain in hospitalized patients.

Methods

We performed a prospective, randomized, comparative effectiveness trial in hospitalized patients with an average pain score of ≥3 out of 10 points. Patients in the experimental group received a library of 21 VR experiences administered using the Samsung Gear Oculus headset; control patients viewed specialized television programming to promote health and wellness. Clinical staff followed usual care; study interventions were not protocolized. The primary outcome was patient-reported pain using a numeric rating scale, as recorded by nursing staff during usual care. Pre- and post-intervention pain scores were compared immediately after initial treatment and after 48- and 72-hours.

Results

There were 120 subjects (61 VR; 59 control). The mean within-subject difference in immediate pre- and post-intervention pain scores was larger in the VR group (-1.72 points; SD 3.56) than in the control group (-0.46 points; SD 3.01); this difference was significant in favor of VR (P < .04). When limited to the subgroup of patients with severe baseline pain (≥7 points), the effect of VR was more pronounced vs. control (-3.04, SD 3.75 vs. -0.93, SD 2.16 points; P = .02). In regression analyses adjusting for pre-intervention pain, time, age, gender, and type of pain, VR yielded a .59 (P = .03) and .56 (P = .04) point incremental reduction in pain versus control during the 48- and 72-hour post-intervention periods, respectively.

Conclusions

VR significantly reduces pain versus an active control condition in hospitalized patients. VR is most effective for severe pain. Future trials should evaluate standardized order sets that interpose VR as an early non-drug option for analgesia.

Yoga-Induced Myositis Ossificans Traumatica of the Scapholunate Ligament

Background  Myositis ossificans traumatica (MOT) involves the heterotopic development of lamellar bone after a traumatic injury. Despite being termed "myositis," MOT is not limited to muscle but rather can involve tendons, fat, and fascia. "Traumatica" reflects that lesions are usually associated with a history of significant trauma, that is, fractures or surgery; however, many reports suggest they can also be linked to repetitive low-energy insults. In both cases, the inflammatory response secondary to tissue injury generates a proliferative osteoblastic cascade. Case Description  We present a case of persistent wrist pain in a 43-year-old woman associated with yoga activities. Her radiographic studies demonstrated partial scapholunate (SL) ligament tear and an associated mass lesion. Surgical pathology revealed MOT involving the SL ligament. Literature Review  MOT lesions in the upper extremity are usually localized around the elbow, and cases in the hand are relatively rare. There are no prior reports of occurrences within the wrist joint or in association with the SL ligament. However, biomechanical studies have quantified significant mechanical strains across the SL interval during various yoga poses. This pattern of microtrauma is capable of generating MOT. Clinical Relevance  Upper extremity weight-bearing positions are common in yoga and subject the wrist, especially the SL interval, to high mechanical strains. This pattern of microtrauma should lead the clinician to suspect MOT when encountering a mass in the wrist, but malignancy and infection must be ruled out.

Postoperative complications with cryotherapy in bone tumors

The technique of cryosurgery has been used to control local recurrence in a variety of benign and malignant bone tumors. Early studies revealed significant complication rates (25%) that included fracture, infection, and soft tissue injury. Our method of cryosurgery has yielded excellent tumor control with improved complication rates. The objective of this study is to determine the characteristics of postoperative complications after pouring liquid nitrogen into curettaged bone defects, and to review our current indications and surgical technique in bone tumor management.

We reviewed charts in over 200 patients who received cryoablation for bone tumors from 1994 to 2015. Imaging studies were evaluated in all patients diagnosed with a complication. All patients receiving cryotherapy had soft tissue management intraoperatively that included warm saline directed to the structures. Liquid nitrogen was poured into the bone defect and in some cases, additional spraying with a cryogun into the defect was performed.

The majority of cryotherapy was used in cases of active or aggressive benign tumors. Our low complication rate of 2.34% included 1 post-operative fracture, 3 infection, and 1 paraesthesia. Bone graft or cementation was used in the majority of patients, all of which fully incorporated.

Cryoablation is an excellent from of adjuvant therapy for active and aggressive benign tumors and may be used in malignant tumors as well. Soft tissue protection is critical to avoid skin necrosis and wound breakdown. We recommend the use of cryotherapy in active and aggressive bone tumors as an adjuvant treatment prior to bone grafting or cementation.

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Cryoablation as an adjuvant treatment is recommended in active and aggressive benign tumors.

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A combination of a slow freeze and quick thaw, repeated for two cycles giving optimal penetration and stability across structures.

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Soft tissue management with warm saline is critical in preventing intraoperative injury.

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Controlled cryotherapy techniques can limit complication rates and local recurrence rates.

Recent advances in the chemistry of spinosyns

The spinosyns are a new class of fermentation-derived insect control agents that are effective against a variety of chewing insect pests. The successful introduction of spinosad into the agricultural marketplace represents an important milestone in the use of natural products for commercial pest control. The development of a natural product presents additional limitations relative to a synthetic material. While the latter affords some degree of control in building appropriate physical attributes such as photostability, a natural product, designed to function in a different environment, is often less suited for traditional spray applications. Despite its intrinsic photolability, spinosad is stable enough to perform under field conditions. In an effort to generate analogs with improved physical characteristics, we have developed a variety of conditions for selectively modifying different portions of the molecule, and we have discovered analogs with greater activity against a broader spectrum of pests. The inability to translate improved greenhouse activity to actual field conditions resulted in a detailed study of the effects of formulations and crystallinity on biological activity. Through this effort, measurably improved field performance of synthetic spinosyn analogs relative to the natural product have now been observed.

Determination of lesion to normal bone uptake ratios of skeletal radiopharmaceuticals by QARG (quantitative autoradiography)

An animal model was developed to determine the ratio of uptake of different bone seeking radiotracers in skeletal lesions relative to normal bone in rats by dual tracer quantitative autoradiography (QARG). The lesion to normal bone uptake ratios (L/NB ratios) of 99mTc-MDP, 99mTc-HDP and 99mTc-DMAD were compared using 153Sm-EDTMP as an internal standard. The results from these studies demonstrated that the L/NB ratio of 99mTc-DMAD was an average of 54 and 71% higher than 99mTc-MDP and 99mTc-HDP, respectively and 79% higher than measured for 153Sm-EDTMP.

Physiological profile of caged layers during one production year, molt, and postmolt: egg production, egg shell quality, liver, femur, and blood parameters

A longitudinal study of a flock of Single Comb White Leghorn pullets was initiated at 19 weeks of age (preproduction) and continued through a production year, a forced molt, and for 4 months of postmolt production. A representative sample of hens was obtained at 12-week intervals during the first year and at subsequent selected times. Liver lipid, femur weight, femur volume, femur density, egg weight, shell weight, percent shell, milligrams shell/square centimeter of shell surface area, serum calcium, serum phosphorus, and serum alkaline phosphatase were determined. Percent hen-day production peaked at 90% and then declined by .6 to .7% each week during the first production year. After molting, percent hen-day egg production peaked at 80% and declined .9% per week over the subsequent 20 weeks. Egg weight increased continually during the first production year. Shell weight was greatest immediately postmolt; thereafter it declined. Shell thickness was greatest at 31 weeks of age and declined throughout the first year. After molting, the shell thickness of 83-week-old hens was similar to values of hens about 37 weeks of age. Serum calcium and phosphorus of laying hens were influenced by age, feed intake and environmental temperature. The lowest values occurred during hot weather. Liver lipid was lowest in nonlaying hens (17 to 20%) and was approximately 42% of dry weight in laying hens. Femur density was greater in laying than nonlaying hens.