Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention

OBJECTIVES

To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Three academic Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC.

OUTCOME MEASURES AND COMPARISONS

Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality.

RESULTS

Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons).

CONCLUSIONS

Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines.

LEVEL OF EVIDENCE

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

Skin Antisepsis before Surgical Fixation of Extremity Fractures

BACKGROUND

Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture).

METHODS

In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications.

RESULTS

A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups.

CONCLUSIONS

Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Epidemiology of pelvic and acetabular fractures in the USA from 2007 to 2014

Incidence of pelvic and acetabular fracture is increasing in Europe. From 2007 to 2014 in the USA, this study found an age-adjusted incidence of 198 and 40 fractures/100,000/year, respectively, much higher than what has been described before. Incidence remained steady over that period and only a small increase in incidence of pelvic fracture in men was identified.

PURPOSE

To determine the incidence of pelvic ring and acetabular fractures in the USA over the period 2007-2014 and to examine trends over time.

METHODS

Retrospective population-based observational study using data from the Nationwide Emergency Department Sample (NEDS), a 20% stratified all-payer sample of US hospital-based emergency departments (EDs). All patients seen in the ED and diagnosed with pelvic/acetabular fracture from 2007 to 2014 were included. The primary outcome was age-adjusted incidence of pelvic and acetabular fractures per 100,000 persons/years. Secondary outcomes included incidence stratified by age and sex, patient- and hospital-related characteristics, and ED procedures. Tests for linear trends were used to determine if there were statistically significant differences by sex and age groups over time.

RESULTS

The age-adjusted incidence of pelvic fracture was 198 fractures/100,000/year, 323 in women and 114 in men. The age-adjusted incidence of acetabular fracture was 40 fractures/100,000/year, 36 in women and 51 in men. A small increase in the age-adjusted incidence of pelvic fracture in men was the only significant trend observed during the study time (p = 0.03). Over that period, the mean age of patients at presentation increased, as well as their number of comorbidities and associated fragility fractures, and they were more often sent home or to nursing facilities.

CONCLUSIONS

When considering all patients coming to the ED, not only those admitted to the hospital, adjusted incidence of pelvic and acetabular fracture is much higher than what has been described before. Contrarily to the global increase seen in other countries, incidence of pelvic and acetabular fractures dropped in the USA from 2007 to 2014 and only a small increase in age-adjusted incidence of pelvic fracture in men was identified.

Outcomes of associated both-column acetabular fractures with and without a posterior wall fracture- A retrospective observational cohort study

Aims & objectives

Our study sought to determine if posterior wall (PW) involvement in associated both-column acetabular fractures (ABCAFs) is associated with different clinical outcomes, primarily rate of conversion to total hip arthroplasty (THA), in comparison to ABCAFs with no PW involvement.

Materials & methods

This retrospective observational cohort study was performed at two academic Level 1 trauma centers. Two study groups were identified. The first study group consisted of 18 patients who sustained an ABCAF with PW involvement (+PW). The second study group consisted of 26 patients who sustained an ABCAF with no PW involvement (-PW). All patients achieved a minimum 12-months of follow-up and/or received a THA conversion procedure at a time remote to their index open reduction internal fixation (ORIF) procedure. The primary outcome of this study was subsequent conversion to THA on the injured hip. The secondary outcome was the presence of post-operative pain at ≥6 months and/or complications.

Results

No difference in rate of conversion to THA between + PW (n = 4, 22.2%) and -PW (n = 3, 11.5%) groups was demonstrated (p = 0.419). Similarly, no differences were seen between groups regarding complication rate (p = 0.814) and post-operative pain (p = 0.142).

Conclusion

Involvement of the PW does not appear to create worse clinical outcomes in comparison to no involvement in ABCAFs particularly as it relates to ipsilateral joint replacement.

The direct posterior gluteal muscle splitting approach for posterior access to acetabular fractures: Surgical technique and case series

We present a minimally invasive direct posterior, gluteal muscle splitting approach (PMS) as an alternative to the traditional Kocher-Langenbeck (KL) approach for posterior access to acetabular fractures. We believe it offers significant advantages and provides improved access while maximizing the range of fracture patterns that can be addressed through a posterior approach. One hundred and eighty-four consecutive patients treated with this approach by the senior author (RMS) between 2001 and 2018 were reviewed. The most common individual fracture pattern addressed was a posterior wall (66/36%) but more complex combination fracture types were the dominant group (106/58%), and included transverse with posterior wall, posterior wall / posterior column, and T types. A radiographically congruent reduction was consistently obtained at surgery, without any operative sciatic nerve palsies and a comparable heterotopic bone formation rate to previous reports. We have reviewed all 120 patients who were followed beyond 6 months and noted the hip replacement conversion rates to be different with each fracture type. The rate was highest with Transverse/ posterior wall injuries (36%), 16% of the posterior wall injuries were converted, a history of dislocation was not specifically associated with conversion. We believe this approach improves the posterior access to the acetabulum, but this study also confirms the poor prognosis of specific groups of higher energy multi-fragmentary, posterior acetabular injuries and suggests the need for a classification system that better predicts the prognosis for the hip joint. LEVEL OF EVIDENCE: 4.

Risk Factors for Aseptic Revision of Operatively Treated Ankle Fractures

BACKGROUND

Early revision rates within 12 months after ankle fracture open reduction internal fixation (AF-ORIF) are fairly low; however, they remain relevant given the volume of ankle fractures occurring annually. Understanding these rates is complex because reoperation due to technical or mechanical complications is typically reported alongside soft tissue-related problems such as symptomatic hardware, wound dehiscence, or infection. There are limited data identifying risk factors specifically for revision of ankle fracture fixation in the absence of soft tissue complications. Understanding variables that predispose to aseptic technical and mechanical failure without this confounder may provide insight and improve patient care.

METHODS

A retrospective cohort study was performed at 2 large academic medical centers. Research Patient Data Registry (RPDR) data available from 2002 to 2019 were used to identify patients who underwent aseptic revision of AF-ORIF within 12 months (n = 33). A control group (n = 100) was selected by identifying sequential patients who underwent AF-ORIF not requiring revision within 12 months. Multiple factors were recorded for all patients in both cohorts. Each fracture was also evaluated according to the Ankle Reduction Classification System (ARCS) of Chien et al,⁸ which categorizes biplanar talar displacement in relation to a central tibial plumb line into 1 of 3 grades: A (0-2 mm), B (3-10 mm), and C (>10 mm). Adapted from its original purpose of grading reduction quality, we applied ARCS to pre-reduction radiographs to assess initial fracture displacement. All variables collected were compared in univariate analysis. Variables that achieved significance in univariate comparisons were included as candidates for multivariable analysis.

RESULTS

Final multivariable logistic regression modeling demonstrated the following factors to independently predict the need for aseptic revision surgery: documented falls in the early postoperative period (aOR, 298; 95% CI, 15.4, 5759; P < .001), movement-altering disorders (aOR, 81.7; 95% CI, 4.12, 1620; P = .004), a nonanatomic mortise (medial clear space [MCS] > superior clear space [SCS]) on immediate postoperative imaging (aOR, 38.4; 95% CI, 5.53, 267; P < .001), initial coronal plane tibiotalar displacement >10 mm and sagittal plane tibiotalar dislocation (ARCS-C) (aOR vs ARCS-A, 25.8; 95% CI, 2.81, 237; P = .004), substance abuse (aOR, 15.7; 95% CI, 2.66, 92.8; P = .002), and polytrauma (aOR, 12.3; 95% CI, 2.02, 74.8; P = .006).

CONCLUSION

In this investigation we found a notable increase in risk for revision surgery after AF-ORIF for patients who had one of the following: (1) falls in the early postoperative period, (2) movement-altering disorders, (3) a nonanatomic mortise (MCS > SCS) on immediate postoperative imaging, (4) more severe initial fracture displacement, (5) substance abuse, or (6) polytrauma. Identifying these factors may allow surgeons to better understand risk and counsel patients, and may serve as future targets for intervention aimed at improving patient safety and outcomes after ankle fracture ORIF.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

End-stage renal disease increases risk of postoperative complications after lower extremity fracture

INTRODUCTION

End-stage renal disease (ESRD) leads to multiple systemic effects and patients suffer from multiple comorbidities including fractures. While previous studies have examined complications following hip fracture surgery in ESRD patients, there are no studies evaluating other lower extremity fractures. This study aimed to identify postoperative complication risk in patients with ESRD who had lower extremity fractures.

METHODS

Using our database from 2000 to 2015 at two level-one trauma centres, we collected data on patients over age 40, who had lower extremity fractures and surgical fixation. Diagnosis of ESRD was made before the injury. Each ESRD patient was matched by two non-ESRD patients regarding age, gender, American Society of Anaesthesiologists (ASA) score, and AO/OTA fracture classification. Postoperative outcomes were non-union, mechanical failure, and infection. The number of outcome events was compared between the ESRD and non-ESRD cohorts.

RESULTS

A total of 195 patients (65 ESRD patients matched to 130 non-ESRD patients) were identified. Median follow-up was 31 months (12-141 months). Patients with ESRD were 3.6 time more likely to have at least one postoperative complication (mechanical failure, non-union, or infection) compared to non-ESRD patients (9/65 vs. 5/130, p = 0.02). In particular, mechanical failure was eight times higher among ESRD patients compared to non-ESRD patients (8/65 vs. 2/130, p < 0.01).

CONCLUSIONS

ESRD was associated with higher rates of complications, especially mechanical failure, after lower extremity fracture surgeries.

Impact of Age on Consent in a Geriatric Orthopaedic Trauma Patient Population

Introduction:

Persistent misconceptions of frailty and dementia in geriatric patients impact physician-patient communication and leave patients vulnerable to disempowerment. Physicians may inappropriately focus the discussion of treatment options to health care proxies instead of patients. Our study explores the consenting process in a decision-making capable orthogeriatric trauma patient population to determine if there is a relationship between increased patient age and surgical consent by health care proxy.

Methods:

Patients aged 65 and older who underwent operative orthopaedic fracture fixation between 1 of 2 Level 1 Trauma Centers were retrospectively reviewed. Decision-making capable status was defined as an absence of patient history of cognitive impairment and a negative patient pre-surgical Confusion Assessment Method (CAM) and Mini-Cog Assessment screen. Provider of surgical consent was the main outcome and was determined by signature on the consent form.

Results:

510 patients were included, and 276 (54.1%) patients were deemed capable of consent. In 27 (9.8%) of 276 decision-capable patients, physicians obtained consent from health care proxies. 20 of these 27 patients (74.1%) were 80 years of age or older. However, in patients aged 70 to 79, only 7 health care proxies provided consent. (p = 0.07). For every unit increase in age, the log odds of proxy consent increased by .0008 (p < 0.001). Age (p < 0.001), income level (p = 0.03), and physical presence of proxy at consult (p < 0.001) were factors associated with significantly increased utilization of health care proxy provided consent. Language other than English was a significant predictor of proxy-provided consent (p = 0.035). 48 (22%) decision-making incapable patients provided their own surgical consent.

Discussion:

The positive linear association between age and health care proxy provided consent in cognitively intact geriatric orthopaedic patients indicates that increased patient age impacts the consenting process. Increased physician vigilance and adoption of institutional consenting guidelines can reinforce appropriate respect of geriatric patients’ consenting capacity.

The effectiveness of germicidal wipes and ultraviolet irradiation in reducing bacterial loads on electronic tablet devices used to obtain patient information in orthopaedic clinics: evaluation of tablet cleaning methods

BACKGROUND

Electronic tablet devices are commonly used in outpatient clinics to obtain patient information for both clinical and research purposes. These devices are often colonized with bacteria; there are many cleaning methods to reduce this bacterial load.

AIM

The primary purpose of this study was to evaluate whether regular cleaning with either germicidal wipes or ultraviolet (UV) irradiation leads to lower bacterial levels compared with irregular cleaning.

METHODS

A randomized blinded trial was conducted of tablet cleaning strategies between each patient encounter in orthopaedic clinics. The cleaning method was randomized to either germicidal wipes, UV irradiation, or cleaning only when the tablet was visibly soiled. Research assistants (blinded to the treatment) obtained bacterial cultures from the tablets at the beginning and end of each clinic day.

FINDINGS

Using germicidal wipes between each patient encounter vs no routine cleaning resulted in a marked decrease in the amount of bacterial contamination (risk ratio (RR) = 0.17 (0.04-0.67)). Similarly, using UV irradiation between each patient encounter led to significantly lower bacterial contamination rates (RR = 0.29 (95% confidence interval (CI) = 0.09-0.95)) compared with no routine cleaning. The majority of bacteria identified were normal skin flora. No meticillin-resistant Staphylococcus aureus was identified and only sparse colonies of meticillin-sensitive S. aureus.

CONCLUSION

Electronic tablets used in orthopaedic trauma clinics are colonized with bacteria if no routine cleaning is performed. Routine use of either UV irradiation or germicidal wipes significantly decreases this bacterial burden. Providers should implement routine cleaning of tablets between each patient encounter to minimize exposure to potential pathogens.

Long-term outcomes after open reduction and internal fixation of bicondylar tibial plateau fractures

INTRODUCTION

To establish normative data, long-term patient-reported functional outcome and health-related quality of life (HrQoL) after operative treatment of bicondylar tibial plateau fractures. Secondly, to identify risk factors associated with functional outcome and HrQoL.

PATIENTS AND METHODS

We performed a retrospective cohort study at two Level I trauma centers. All adult patients with AO/OTA 41-C or Schatzker V/ VI tibial plateau fractures treated between 2001 and 2016 (n = 450) by open reduction internal fixation (ORIF). The survey was completed by 214 patients (48%). Primary outcome was patient-reported functional outcome assessed with the PROMIS Physical Function (PROMIS PF). Secondary outcomes were HrQoL measured with the EuroQol 5-Dimensions 3-Levels (EQ-5D-3 L), infection rate, and total knee arthroplasty (TKA) rate.

RESULTS

Infection occurred in 26 cases (12%) and TKA was performed in 6 patients (3%). The median PROMIS PF scores was 49.8 (IQR;42-54). The median EQ-5D-3 L was 0.83 (IQR;0.78-1.0).%). The multivariable regression model revealed female gender, diabetes, and worse HrQoL were correlated with worse functional outcome. The multivariable regression model revealed smoking, diabetes, and the subsequent need for TKA to be correlated with worse HrQoL.

CONCLUSION

The PROMIS PF and EQ-5D-3L did not reach a minimum clinically important difference. The PROMIS PF items revealed patients had no difficulty in walking more than a mile or climbing a flight of stairs. However, patients were limited in doing vigorous activities and patients should be counseled about the expected long-term outcomes. This study emphasizes the correlation between injury specific functional outcome measures and general health measures.

LEVEL OF EVIDENCE

Therapeutic Level III.

Long-term outcomes after operative treatment for tibial pilon fractures

OBJECTIVES

Aims of the present study were to establish generalizable outcome data on long-term functional outcomes and health-related quality of life (HRQoL) after operative treatment of pilon fractures on a large scale. Second, it was aimed to examine factors associated with these outcomes.

DESIGN

Retrospective cohort study with follow-up by questionnaire.

SETTING

Two level 1 trauma centers.

PATIENTS

Two hundred twenty-five of 480 eligible patients completed the survey (response rate 47%).

INTERVENTION

Open reduction internal fixation for tibial pilon fracture.

MAIN OUTCOME MEASUREMENTS

Ankle function measured using the Foot and Ankle Ability Measure, physical function using the Patient-Reported Outcomes Measurement System Physical Function (PROMIS PF, Short Form 10a) questionnaire and HRQoL using the EuroQol 5-Dimensions 3-Level (EQ-5D-3L) questionnaire.

RESULTS

At a medium follow-up of 82 months (82 (interquartile range (IQR), 45-120), median Foot and Ankle Ability Measure was 74 (IQR, 57-82), median PROMIS PF 49 (IQR, 44-57), median EQ-5D-3L 0.81 (IQR, 0.71-0.84). HRQoL was significantly lower compared to a reference population (P < .001). In multivariable regression analyses, smoking was associated with poorer HRQoL. Higher body mass index, deep infection, and lower HRQoL were associated with worse ankle function.

CONCLUSIONS

Long-term patient-reported outcomes after operative treatment of pilon fractures reveal impaired functionality and lower HRQoL compared to an uninjured reference population. As pilon fractures can have significant effects on a patient's life, patients should be counseled about the expected long-term outcomes to set realistic expectations. This study emphasizes the importance of obtaining both general and region-specific measures when evaluating outcomes after injury, in order to evaluate the injury of interest in the accurate context.

LEVEL OF EVIDENCE

Prognostic level III.

Is the proximity of external fixator pins to eventual definitive fixation implants related to the risk of deep infection in the staged management of tibial pilon fractures?

INTRODUCTION

In the staged management of tibial pilon fractures, overlap between definitive internal fixation and external fixation pin sites has been investigated as a risk factor for infection with equivocal conclusions. Our aim was to determine if overlap or proximity of definitive internal fixation to external fixation pin sites influences the risk of deep infection.

PATIENTS AND METHODS

We reviewed 280 AO/OTA 43B or 43C type distal tibia fractures in 277 patients at two level-one trauma centers. Patients underwent staged management using early temporizing external fixation followed by definitive open reduction and plate fixation. Primary outcome was the association between pin site overlap and the development of deep infection. Secondary outcome was the relationship between development of deep infection and the distance from pin site to definitive fixation.

RESULTS

The average duration between external fixation and definitive internal fixation was 14 days. 24% of fractures developed deep infection requiring surgical intervention. There was no association between pin site overlap and the development of deep infection (p = 0.18). There was no relationship between infection and the distance between proximal plate extent and pin site (p = 0.13).

DISCUSSION

We identified no association between pin site overlap and the development of deep infection. We suggest that temporizing external fixation pins should be placed so as to obtain optimal stability of the construct with lesser emphasis on aiming to be absolutely outside the zone of future fixation.

LEVEL OF EVIDENCE

Level III Therapeutic Retrospective Comparative study.

Impact of daily noise exposure monitoring on occupational noise exposures in manufacturing workers

OBJECTIVE

Despite the use of hearing protection devices (HPDs), noise induced hearing loss (NIHL) remains one of the most prevalent occupational conditions. A new technology allows for daily monitoring of noise exposures under HPDs. We report on an intervention employing the voluntary use of this technology in a worksite setting.

DESIGN

Volunteers were fitted with a device allowing them to monitor noise exposure under their hearing protection on a daily basis. The trends in noise exposures for individuals who completed at least six months of the intervention were analysed.

STUDY SAMPLE

Recruitment occurred at three manufacturing facilities, with 127 workers enrolling and 66 workers actively using the device during their work shifts.

RESULTS

Among volunteers downloading regularly, the percentage of daily exposures in excess of the OSHA action level (85 dBA) decreased from 14% to 8%, while the percentage of daily exposures in excess of 90 dBA decreased from 4% to less than 2%.

CONCLUSION

Initial results from this longitudinal study indicate that volunteers find daily noise exposure monitoring to be feasible, and that workers who monitor daily are able to reduce exposures. The results of subject adherence shed light on the challenges and possibilities of worksite interventions for health and safety.

Tracking occupational hearing loss across global industries: a comparative analysis of metrics

Occupational hearing loss is one of the most prevalent occupational conditions; yet, there is no acknowledged international metric to allow comparisons of risk between different industries and regions. In order to make recommendations for an international standard of occupational hearing loss, members of an international industry group (the International Aluminium Association) submitted details of different hearing loss metrics currently in use by members. We compared the performance of these metrics using an audiometric data set for over 6000 individuals working in 10 locations of one member company. We calculated rates for each metric at each location from 2002 to 2006. For comparison, we calculated the difference of observed-expected (for age) binaural high-frequency hearing loss (in dB/year) for each location over the same time period. We performed linear regression to determine the correlation between each metric and the observed-expected rate of hearing loss. The different metrics produced discrepant results, with annual rates ranging from 0.0% for a less-sensitive metric to more than 10% for a highly sensitive metric. At least two metrics, a 10dB age-corrected threshold shift from baseline and a 15dB nonage-corrected shift metric, correlated well with the difference of observed-expected high-frequency hearing loss. This study suggests that it is feasible to develop an international standard for tracking occupational hearing loss in industrial working populations.