Setting Of Orthopedic Surgery Research Articles

Clinical Application of Unidirectional Porous Hydroxyapatite to Bone Tumor Surgery and Other Orthopedic Surgery.

Unidirectional porous hydroxyapatite (UDPHAp) was developed as a remarkable scaffold characterized by a distinct structure with unidirectional pores oriented in the horizontal direction and connected through interposes. We evaluated the radiographic changes, clinical outcomes, and complications following UDPHAp implantation for the treatment of bone tumors. Excellent bone formation within and around the implant was observed in all patients treated with intralesional resection and UDPHAp implantation for benign bone tumors. The absorption of UDPHAp and remodeling of the bone marrow space was observed in 45% of the patients at a mean of 17 months postoperatively and was significantly more common in younger patients. Preoperative cortical thinning was completely regenerated in 84% of patients at a mean of 10 months postoperatively. No complications related to the implanted UDPHAp were observed. In a pediatric patient with bone sarcoma, when the defect after fibular resection was filled with UDPHAp implants, radiography showed complete resorption of the implant and clear formation of cortex and marrow in the resected part of the fibula. The patient could walk well without crutches and participate in sports activities. UDPHAp is a useful bone graft substitute for the treatment of benign bone tumors, and the use of this material has a low complication rate. We also review and discuss the potential of UDPHAp as a bone graft substitute in the clinical setting of orthopedic surgery.

Is Limited English Proficiency Associated With Differences in Care Processes and Treatment Outcomes in Patients Undergoing Orthopaedic Surgery? A Systematic Review

Background Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations. Questions/purposes In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries? Methods On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed. Results There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores. Conclusion Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses. Level of Evidence Level III, therapeutic study

Annals Consult Guys - Standardizing Venous Thromboembolism Prophylaxis in the Setting of Orthopedic Surgery.

Annals Consult Guys - Standardizing Venous Thromboembolism Prophylaxis in the Setting of Orthopedic Surgery.

The MeNT-OS Score for Orthopaedic Surgery: An Objective Scoring System for Prioritisation of Orthopaedic Elective Surgeries During a Pandemic.

IntroductionThe reintroduction of elective Orthopaedic surgery during the COVID-19 pandemic is likely to occur in phases, dictated by resource limitations and loco-regional pandemic status. Guidelines providing a general framework for the prioritisation of surgery have largely been based on surgical urgency, while scoring systems such as the MeNTS score may have limited applicability in the setting of Orthopaedic Surgery. We, therefore, propose an Orthopaedic-specific algorithm (‘MeNT-OS’), based on a modification of the MeNTS scoring system, that may be used to objectively triage and prioritise Orthopaedic cases during the COVID-19 pandemic.MethodsWe developed a scoring algorithm modified from the Medically Necessary Time-Sensitive Procedure (MeNTS) score with 13 unique variables, reflecting human and physical resource utilisation, surgical complexity, functional status of patients, as well as COVID-19 transmission risk. This score was then trialled in a sample of 118 cases, comprising 69 completed and 49 postponed cases. A higher overall score was intended to correlate with lower surgical prioritisation.ResultsThe use of our scoring system resulted in higher average scores for postponed cases compared to completed cases, as well as higher median, 25th and 75th percentile scores. These results were statistically significant and showed concordance with the ad hoc decisions made before the scoring system was used, with the lower scores for completed cases suggesting a more favourable risk–benefit ratio for being performed as compared to the postponed cases.ConclusionThe utility of the proposed ‘MeNT-OS’ scoring system has been assessed using data from our institution and offers an objective and systematic approach that is geared towards Orthopaedic procedures. We believe this scoring tool can provide Orthopaedic surgeons a safe and equitable approach to making difficult decisions on prioritisation of surgery during the COVID-19 period, and possibly other resource-limited settings in the future.

A beat-by-beat cardiovascular index, CARDEAN, to titrate opioid administration in the setting of orthopaedic surgery: a prospective randomized trial.

To determine whether a beat-by-beat cardiovascular index (CARDEAN: cardiovascular depth of analgesia, Alpha-2 Ltd, Lyon, France) reduces the incidence of tachycardia in ASA I-III patients undergoing orthopaedic surgery. A total of 76 patients were prospectively randomized into (1) a control group or (2) the CARDEAN group, in which the nurse anaesthetist was blinded to CARDEAN application. In addition to conventional signs, an external observer instructed the nurse anaesthetist to administer sufentanil 0.1µgkg-1 when the CARDEAN crossed a threshold (≥60). The primary outcome was the incidence of tachycardia (>120% of reference heart rate, HR). Non-invasive blood pressure (BP), electrocardiogram (ECG), O2 saturation-photoplethysmography and the bispectral index (40<BIS<60) were monitored. HR and an estimation of beat-by-beat BP changes acquired from photoplethysmography and ECG were combined in an algorithm that detected hypertension followed by tachycardia (index scaled 0-100). Sufentanil 0.1µgkg-1 was administered when tachycardia, hypertension or movement ("conventional signs") was observed. Data for 66 patients (27 with known hypertension) were analysed. In the CARDEAN group, (a) the dose of sufentanil was higher (control: 0.46µgkg-1100min-1, CARDEAN: 0.57µgkg-1100min-1, p=0.016), (b) the incidence rates of tachycardia and untoward events were lower (respectively: -44%; control: 2.52 events100min-1 [1.98-3.22]; CARDEAN: 1.42 [1.03-1.96], p=0.005, hazard ratio: 0.56; movement, muscular contraction, or coughing: control: 0.74 events100min-1 [0.47-1.16]; CARDEAN: 0.31 [0.15-0.62], p=0.038), and (c) extubation occurred more often in the operating room (control: 76.5%, CARDEAN: 97%, p=0.016). CARDEAN-titrated opioid administration was associated with a higher dose of sufentanil, a reduction in tachycardia and earlier emergence in ASA I-III patients undergoing major orthopaedic surgery.

Skin closure with surgical staples in ankle fractures: a safe and reliable method.

The purpose of this study is to examine the rates of surgical site complications of staple closure versus suture closure following open reduction and internal fixation of closed unstable ankle fractures. Between 2014 and 2016, a total of 545 patients with closed ankle fractures were treated at our level-1 trauma centre by means of open reduction and internal fixation. A total of 360 patients matched the inclusion criteria and were included in the final analysis of this study. This included 119 patients undergoing wound closure using sutures and 241 patients using surgical staples. The demographics, clinical data, and injury characteristics were recorded. The primary outcome measure was the adverse event of any type of surgical site complication. The overall rate of patients with a surgical site complication was 15.6%. There was a trend towards a higher risk of surgical site complication in patients undergoing wound closure with sutures as compared with staples (20.2% versus 13.3%); however, this difference was not statistically significant (P = 0.0897). The rate of superficial surgical site infection also trended higher in patients undergoing wound closure with sutures versus staples without demonstrating statistical significance (10.1% versus 5%, P = 0.0678). The rate of deep surgical site infection was similar in both groups. The use of metal staples remains controversial in the setting of orthopedic surgery, particularly involving the foot and ankle. The current study supports that metal staples are a safe and reliable option in the closure of traumatic ankle fractures.

Crisis change management during COVID-19 in the elective orthopaedic hospital: Easing the trauma burden of acute hospitals

IntroductionWith the emergence of the 2019 novel coronavirus and its resulting pandemic status in March 2020 all routine elective orthopaedic surgery was cancelled in our institution. The developing picture in Italy, of acute hospitals becoming overwhelmed with treating patients suffering with severe and life-threatening symptoms from the disease, prompted the orthopaedic surgeons to formulate a plan to transfer trauma patients requiring surgery to the elective hospital to unburden the acute hospital system. MethodsUnder the threat of this pandemic; protocols and algorithms were established for referral, acceptance and care of trauma patients from acute hospitals in the region. Each day, as new guidance on COVID-19 emerged, our process and algorithms were adjusted to reflect pertinent change. ResultsThe screening of all patients referred, worked well in keeping our hospital “COVID-free” with respect to patients undergoing operations. An upward trend in cases referred reflected the decreased capacity in the acute hospitals due to rising cases of COVID-19 within the hospital network. During the first 7 weeks of the pandemic 308 operations were performed, (31.1% upper limb, 33.4% lower limb, 4.1% spine, 14.1% urgent elective, 17.4% plastic surgery cases). Regular review and audit of the activity in the hospital as well as communication with the referring teams enabled appropriate planning to accommodate the increase in case-mix as the need arose. DiscussionThis paper details the steps that were taken in planning for such a change in management specific to the orthopaedic surgery setting and the lessons learnt during this process. The success of the development of this pathway was facilitated by clear communication channels, flexibility to adapt to changing process and feedback from all stakeholders. The implementation of this pathway allowed the unburdening of acute hospitals dealing with the pandemic that was steadily reducing access to operating theatres and anaesthetic resources.

Stress Hyperglycemia and Complications Following Traumatic Injuries in Individuals With/Without Diabetes: The Case of Orthopedic Surgery.

PurposeHyperglycemia in trauma patients may stem from metabolic response to stress, both in the presence and the absence of underlying diabetes. We aimed to test the association of stress hyperglycemia with risks of adverse events subjects undergoing orthopedic surgery.Patients and MethodsIn a prospective observational study, we enrolled 202 consecutive patients with hyperglycemia at hospital admission for trauma injuries requiring orthopedic surgery. Based on history, diabetes was present in 183, and 13 more were defined as unknown diabetes on the basis of HbA1c ≥48mmol/mol. Stress hyperglycemia was defined in subjects with/without diabetes by a stress hyperglycemia ratio (SHR) >1.14, calculated as admission glucose/average glucose, estimated from glycosylated hemoglobin. Logistic regression analysis was used to calculate the risk of post-surgery adverse events associated with different states of hyperglycemia, after correction for demographic and clinical confounders.ResultsStress hyperglycemia was diagnosed, either as superimposed to diabetes (54/196 cases, 27.6%) as well as in the 6 cases without diabetes. At least one complication was recorded in 68 cases (33.7%), the most common being systemic infection (22.8% of cases). In the total cohort, stress hyperglycemia, irrespective of the presence of diabetes, increased the risk of adverse events (any events, odds ratio [OR], 4.43; 95% confidence interval [CI], 2.11–9.30), cardiovascular events (OR, 7.09; 95% CI, 2.47–19.91), systemic infections (OR, 4.21; 95% CI, 1.97–9.03) and other adverse events (OR, 6.30; 95% CI, 1.41–28.03), after adjustment for confounders; hospital stay was much longer. The same was true when the analysis was limited to the diabetes cohort or by comparing pure stress hyperglycemia vs diabetes without stress hyperglycemia.ConclusionThe study highlights the importance of stress hyperglycemia for adverse events in the setting of orthopedic surgery following trauma injuries. This condition requires stricter management, considering the much longer length of hospital stay and higher costs.

Orthopaedic Physician Attire Influences Patient Perceptions in an Urban Inpatient Setting.

Prior research suggests that physician attire has an important effect on patient perceptions, and can influence the patient-physician relationship. Previous studies have established the effect of specialty, location, and setting on patient preferences for physician attire, and the importance of these preferences and perceptions on both the physician-patient relationship and first impressions. To date, no studies have examined the influence of attire in the inpatient orthopaedic surgery setting on these perceptions. (1) Do differences in orthopaedic physician attire influence patient confidence in their surgeon, perception of trustworthiness, safety, how caring their physician is, how smart their surgeon is, how well the surgery would go, and how willing they are to discuss personal information with the surgeon? (2) Do patients perceive physicians who are men and women differently with respect to those endpoints? Ninety-three of 110 patients undergoing orthopaedic surgery at an urban academic medical center participated in a three-part survey. In the first part, each patient was randomly presented 10 images of both men and women surgeons, each dressed in five different outfits: business attire (BA), a white coat over business attire (WB), scrubs alone (SA), a white coat over scrubs (WS), and casual attire (CA). Respondents rated each image on a five-point Likert scale regarding how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and the patient's willingness to discuss personal information with the surgeon. In the second part, the respondent ranked all images, by gender, from the most to least confident based on attire. Pair-wise comparisons for women surgeons demonstrated no difference in patient preference between white coat over business attire compared with white coat over scrubs or scrubs alone, though each was preferable to business attire and casual attire (WS versus WB: mean difference [MD], 0.1 ± 0.6; 95% CI, 0.0-0.2; p = 1.0; WS versus SA: MD, 0.2 ± 0.7; 95% CI, 0-0.3; p = 0.7; WB versus SA: 0.1 ± 0.9; 95% CI, -0.1 to 0.2; p = 1.0). The same results were found when rating the surgeon's perceived intelligence, skill, trust, confidentiality, caring, and safety. In the pair-wise comparisons for male surgeons, white coat over scrubs was not preferred to white coat over business attire, scrubs alone, or business attire (WS versus WB: MD, -0.1 ± 0.6; 95% CI, 0-0.1; p = 1.0; WS versus SA: MD, 0 ± 0.4; 95% CI, -0.2 to 0; p = 1.0; WS versus BA: MD, 0.2 ± 0.8; 95% CI, 0-0.4; p = 0.6). WB and SA were not different (MD, 0.0 ± 0.6; 95% CI, -0.1 to 0.2; p = 1.0), though both were preferred to BA and CA (WB versus BA: MD, 0.3 ± 0.8; 95% CI, 0.1-0.5; p = 0.02; WB versus CA: 1.0 ± 1.0; 95% CI, 0.8-1.2; p < 0.01). We found no difference between SA and BA (MD, 0.3 ± 0.7; 95% CI, 0.1-0.4; p = 0.06). We found that each was preferred to CA (SA versus CA: 0.9 ± 1.0; 95% CI, 0.7-1.2; p < 0.01; BA versus CA: 0.7 ± 1.0; 95% CI, 0.5-0.9; p < 0.01), with similar results in all other categories. When asked to rank all types of attire, patients preferred WS or WB for both men and women surgeons, followed by SA, BA, and CA. Similar to findings in the outpatient orthopaedic setting, in the inpatient setting, we found patients had a moderate overall preference for physicians wearing a white coat, either over scrubs or business attire, and, to some extent, scrubs alone. Respondents did not show any difference in preference based on the gender of the pictured surgeon. For men and women orthopaedic surgeons in the urban inpatient setting, stereotypical physician's attire such as a white coat over either scrubs or business attire, or even scrubs alone may improve numerous components of the patient-physician relationship and should therefore be strongly considered to enhance overall patient care. Level II, therapeutic study.

Current Concepts in Orthopaedic Care Disparities.

Healthcare delivery is profoundly affected by race/ethnicity, sex, and socioeconomic status. The effect of these factors on patient health and the quality of care received is being studied in more detail. Orthopaedic surgery over the past several years has paid increasing attention to these disparities as well. Not only do these disparities exist with regard to accessing care but also with regard to the quality of care received and postoperative outcomes. Total joint arthroplasty, hip fractures, and spine surgery represent areas where the effect of these factors has been reported. Not only is it essential for the clinician to understand the extent of care disparities but also the manner in which these disparities affect patient health and outcomes within the orthopaedic surgery setting. Strategies should be devised to minimize the effect of these factors on clinical care and patient health.

Cerebral near-infrared spectroscopy (NIRS) for perioperative monitoring of brain oxygenation in children and adults.

Cerebral near-infrared spectroscopy (NIRS) for perioperative monitoring of brain oxygenation in children and adults.

Physicians' Attire Influences Patients' Perceptions in the Urban Outpatient Orthopaedic Surgery Setting.

Previous work has established that physician attire influences patients' perceptions of their physicians. However, research from different specialties has disagreed regarding what kinds of physician attire might result in increased trust and confidence on the part of patients. The purpose of this study was to investigate how surgeon attire affects patients' perceptions of trust and confidence in an urban orthopaedic outpatient setting. Eighty-five of 100 patients solicited completed a three-part questionnaire in the outpatient orthopaedic clinic at an urban teaching hospital. In the first section, participants viewed eight images, four of a male surgeon and four of a female surgeon wearing a white coat over formal attire, scrubs, business attire, and casual attire, and rated each image on a five-level Likert scale. Participants were asked how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and how willing they would be to discuss personal information with the pictured surgeon. The participant ranked all images from most to least confident in the second part and the last section obtained demographic information from the patients. Surveys were scored using a five-level Likert scale and a Friedman test was used to detect statistical significance when comparing all attires. For multiple pairwise comparisons, a Bonferroni correction was applied. The white coat on the male surgeon elicited modestly higher ratings in confidence (mean difference [MD], 0.367±0.737; 95% CI, 0.202-0.532; p < 0.001), intelligence (MD, 0.216 ± 0.603; 95% CI, 0.077-0.356; p = 0.027), surgical skill (MD, 0.325 ± 0.658; 95% CI, 0.175-0.474; p < 0.001), trust (MD, 0.312 ± 0.613; 95% CI, 0.173-0.451; p < 0.001), ability to discuss confidential information (MD, 0.253 ± 0.742; 95% CI, 0.087-0.419; p = 0.023), caring (MD, 0.279 ± 0.655; 95% CI, 0.124-0.432; p = 0.006), and safety (MD, 0.260 ± 0.594; 95% CI, 0.125-0.395; p = 0.002) compared with business attire. Similarly, the white coat was preferred to casual attire in all categories (confidence: MD, 0.810 ± 0.921; smart: MD, 0.493 ± 0.801; surgical skill: MD, 0.640 ± 0.880; ability to discuss: MD, 0.564 ± 0.988; trust: MD, 0.545 ± 0.836; safety: MD, 0.581 ± 0.860; caring: MD, 0.479 ± 0.852; p < 0.001 for all comparisons). For the female surgeon, white coat and scrubs were not different, however the white coat was preferred to business attire in four of seven categories. Casual clothing was widely disliked in all categories for surgeons (men and women). When attire was compared for confidence on a scale, the white coat ranked higher than business (MD, 0.439 ± 1.491; p = 0.006) and casual attire (MD, 1.043 ± 2.054; p < 0.001), but not scrubs (MD, 0.169 ± 1.230; p = 1.000). In this urban outpatient orthopaedic practice, patients' preferences varied based on the sex of the pictured surgeon in the survey. Overall, however, modest preferences were observed for the white coat in terms of confidence, intelligence, trust, and safety. Furthermore patients are more willing to discuss personal information and believe that their surgery will go better if the surgeon wears a white coat or scrubs. These results are consistent with those of several studies in other settings and therefore may be generalizable in other locations and specialties. Given the increasing awareness and concern for physician-spread hospital infection, this study lends support to scrub attire over business or casual attire if physicians do not wear a white coat. Level II, therapeutic study.

Risk of postoperative acute kidney injury in patients undergoing orthopaedic surgery—development and validation of a risk score and effect of acute kidney injury on survival: observational cohort study

Study question What is the predicted risk of acute kidney injury after orthopaedic surgery and does it affect short term and long term survival? Methods The cohort comprised adults resident...

CORR Insights(®): Preoperative Opioid Misuse is Associated With Increased Morbidity and Mortality After Elective Orthopaedic Surgery.

N arcotics are a necessity for patients in the setting of orthopaedic surgery. Many elective orthopaedic procedures require rehabilitation and therapy to maximize outcomes and assist with the return of function. Narcotics during rehabilitation allow a level of intensity and progress that would not be attainable otherwise. At the same time, the side effects of narcotics and the potential for abuse are well known and are a cause of concern for all orthopaedic surgeons. Management of narcotic use in the postoperative period requires constant vigilance in order to decrease dosing appropriately as recovery progresses. Additionally, well-intentioned primary care physicians, trying to help with musculoskeletal pain, manage some patients preoperatively with narcotics; some of these patients develop narcotic dependence. Managing postoperative pain in these patients is much more difficult, and intuitively, most orthopaedic surgeons understand this. Unfortunately, the number of narcotic prescriptions has increased dramatically during the last several years, and this represents a growing global problem [1, 2]. The article by Menendez et al. details the rise in narcotic dependence and describes the effect of preoperative narcotic use on postoperative outcomes. Using a healthcare utilization database they demonstrate higher complications and worse outcomes for patients undergoing elective orthopaedic surgery in the inpatient setting including prolonged length of stay, increased need for mechanical ventilation, and death. They also demonstrate an increase of 152% in the incidence of narcotic dependence in patients presenting for elective orthopaedic procedures from 2002 to 2011. Even at their highest measured level, the study authors found 0.24% (1 in 425) of patients had opioid dependence. It is fair to say that this, likely, grossly underestimates the true incidence.

The discovery of dabigatran etexilate.

Thromboembolic disease is a major cause of mortality and morbidity in the developed world and is caused by an excessive stimulation of coagulation. Thrombin is a key serine protease in the coagulation cascade and numerous efforts have been made to develop safe and effective orally active direct thrombin inhibitors (DTIs). Current anticoagulant therapy includes the use of indirect thrombin inhibitors (e.g., heparins, low-molecular-weight-heparins) and vitamin K antagonists such as warfarin. However there are several caveats in the clinical use of these agents including narrow therapeutic window, parenteral delivery, and food- and drug–drug interactions. Dabigatran is a synthetic, reversible DTI with high affinity and specificity for its target binding both free and clot-bound thrombin, and offers a favorable pharmacokinetic profile. Large randomized clinical trials have demonstrated that dabigatran provides comparable or superior thromboprophylaxis in multiple thromboembolic disease indications compared to standard of care. This minireview will highlight the discovery and development of dabigatran, the first in a class of new oral anticoagulant agents to be licensed worldwide for the prevention of thromboembolism in the setting of orthopedic surgery and stroke prevent in atrial fibrillation.

Abstract 324: Cancer, Arterial Thrombosis and Major Bleeding Following Orthopedic Surgery

Background: Although cancer is a well-recognized risk factor for venous thromboembolic events, the relationship between cancer and perioperative arterial thrombotic and bleeding complications is uncertain. We therefore sought to investigate the incidence of thrombotic and bleeding events in subjects with and without a history of cancer undergoing orthopedic surgery. Methods: We performed a retrospective cohort analysis of 3,082 subjects &gt; 21 years of age undergoing orthopedic surgery of the hip, knee, or spine between November 1, 2008 and December 31, 2009 at a tertiary care medical center. The presence of cancer was determined by ICD-9 diagnostic coding. In-hospital outcomes included perioperative myocardial necrosis (troponin &gt; 99 th percentile), major bleeding (as per the International Society on Thrombosis and Haemostasis [ISTH] perioperative bleeding definition), and coded myocardial infarction (MI) and post-operative hemorrhage using the hospital administrative dataset using ICD-9 procedure codes. Results: Of the 3,082 subjects, 69 (2.2%) were identified as having a history of cancer. Subjects with cancer were older (65.5±14.7 vs 60.6±13.2, P=0.003) and less likely female (32/69 [46%] vs 1790/3013 [59%], P=0.03). Subjects with cancer had a greater incidence of myocardial necrosis (15/69 [21.7%] vs 164/3013 [5.4%], P&lt;0.001), MI (3/69 [4.3%] vs 17/3013 [0.6%], P&lt;0.001), perioperative major bleeding (21/69 [30.4%] vs 144/3013 [4.8%], P&lt;0.001), and post-operative hemorrhage (6/69 [8.7%] vs 20/3013 [0.7%], P&lt;0.001) than subjects without cancer. Following multivariable logistic regression, cancer was associated with myocardial necrosis (OR 2.64, 95% CI 1.30-5.35, P=0.007), MI (OR 2.65, 95% CI 0.63-11.09, P=0.18), major bleeding, (OR 6.45, 95% CI 3.42-12.17, P&lt;0.001), and post-operative hemorrhage (OR 7.64, 95% CI 2.44-23.93, P&lt;0.001). Conclusions: There is an increased risk of both thrombotic and bleeding complications in subjects with cancer in the setting of orthopedic surgery. This perioperative risk deserves careful attention in preoperative clearance and future studies aimed at attenuating this increased risk are warranted.

From Creatine Kinase-MB to Troponin

From Creatine Kinase-MB to Troponin

Brave new world: The current and future use of novel anticoagulants

Advances in antithrombotic therapy began when traditional anticoagulant agents such as heparin and the vitamin K antagonists like Coumadin became commercially available in the 1940s and 1950s. Inherent limitations of these compounds, including the need for monitoring and multiple food and drug interactions (with coumadin), spurred the development of newer parenteral compounds like low molecular weight heparin, the pentasaccharide fondaparinux, and direct thrombin inhibitors such as hirudin, argatroban and bivalirudin with advantages over traditional compounds. Despite the failure of the first oral anticoagulant in 50 years--the direct thrombin inhibitor ximelagatran--due to issues with liver toxicity, new oral agents such as the Factor Xa inhibitors rivaroxaban, apixaban, YM-150, and DU-176b and oral direct thrombin inhibitors such as dabigatran are in advanced stages of development, with dabigatran and rivaroxaban now approved for use outside of the United States for thromboprophylaxis in the setting of orthopedic surgery. These and other novel agents have the potential to greatly expand our armamentarium to treat thromboembolic disease, with more targeted approaches to specific procoagulant complexes, a predictable anticoagulant response that does not require monitoring, and use in both acute and long-term treatment settings.

Prevention of venous thromboembolism in the orthopedic surgery patient.

Patients undergoing major orthopedic surgery--hip or knee arthroplasty, or hip fracture repair--are in the highest risk category for venous thromboembolism (VTE) solely on the basis of the orthopedic procedure itself. Despite this, nearly half of patients undergoing these procedures do not receive appropriate prophylaxis against VTE, often due to a disproportionate fear of bleeding complications in this population. Guidelines from the American College of Chest Physicians (ACCP) provide evidence-based recommendations for many aspects of VTE risk reduction in the setting of orthopedic surgery, as detailed in this review. The ACCP recommends the use of either low-molecular-weight heparin (LMWH), fondaparinux, or adjusted-dose warfarin as preferred VTE prophylaxis in patients undergoing either hip or knee arthroplasty. Fondaparinux is the preferred recommendation for patients undergoing hip fracture repair, followed by LMWH, unfractionated heparin, and adjusted-dose warfarin as alternative options. Extended-duration prophylaxis (for 4 to 5 weeks) is now recommended for patients undergoing hip arthroplasty or hip fracture repair. Patients undergoing knee arthroscopy do not require routine pharmacologic VTE prophylaxis.

Evidence for extended prophylaxis in the setting of orthopedic surgery.

Patients undergoing orthopedic surgery represent one of the highest risk groups for the development of venous thromboembolism (VTE). Evidence shows that this risk extends beyond the period in which the patient is hospitalized, especially for patients undergoing hip surgery. Clinical trials have shown that extended prophylaxis with the low-molecular-weight heparins is effective in reducing the rate of total VTE, and a meta-analysis demonstrated a reduction in symptomatic VTE with extended prophylaxis after total hip replacement surgery. Based on these results, the American College of Chest Physicians gives a grade 2A recommendation for the use of extended prophylaxis after orthopedic surgery. Until recently, data evaluating the role of prophylaxis in patients undergoing hip fracture surgery were limited. Subsequently, a novel anticoagulant, fondaparinux, demonstrated significant benefit in these patients and has become the first and only agent approved by the United States Food and Drug Administration (FDA) for use in patients undergoing hip fracture surgery Despite the limitations of the older trials, their findings supported the need to evaluate extended prophylaxis in patients undergoing hip fracture surgery. In the first well-conducted trial of extended prophylaxis for hip fracture surgery, fondaparinux provided impressive results in reducing total and symptomatic VTE. The results of this trial have once again led to fondaparinux being the first and only agent to be granted FDA approval for the indication of extended prophylaxis in patients undergoing hip fracture surgery.