Incidence and risk factors of preoperative deep venous thrombosis in closed tibial shaft fracture: a prospective cohort study

Stability of One-Step Spray-on Splint for Lower Extremity Fractures During Splinting, MEDEVAC, and Impact

INTRODUCTION

Military transport can induce whole-body vibrations, and combat almost always involves high impact between lower extremities and the ground. Therefore, robust splinting technology is necessary for lower extremity fractures in these settings. Our team compared a novel one-step spray-on foam splint (FastCast) to the current military standard structured aluminum malleable (SAM) splint.

MATERIALS AND METHODS

Ten cadaveric specimens were subjected to complete tibia/fibula osteotomy. Specimens were fitted with custom accelerometer and gyroscope sensors superior and inferior to the fracture line. Each specimen underwent fracture and splinting from a standard of care SAM splint and an experimental FastCast spray foam splint in a randomized order. Each specimen was manually transported to an ambulance and then released from a 1 meter height to simulate impact. The custom sensors recorded accelerations and rotations throughout each event. Repeated-measures Friedman tests were used to assess differences between splint method within each event and between sensors within each splint method.

RESULTS

During splinting, overall summation of change and difference of change between sensors for accelerations and rotations were greater for SAM splints than FastCast across all axes (P ≤ 0.03). During transport, the range of acceleration along the linear superior/inferior axis was greater for SAM splint than FastCast (P = 0.02), as was the range of rotation along the transverse plane (P < 0.01). On impact, the summation of change observed was greater for SAM splint than FastCast with respect to acceleration and rotation on the posterior/anterior and superior/inferior axes (P ≤ 0.03), and the cumulative difference between superior and inferior sensors was greater for SAM than FastCast with respect to anterior-axis rotation (P < 0.05).

CONCLUSION

FastCast maintains stabilization of fractured lower extremities during transport and impacts to a significantly greater extent than SAM splints. Therefore, FastCast can potentially reduce the risk of fracture complications following physical stressors associated with combat and extraction.

Nomogram for predicting postoperative deep vein thrombosis in patients with spinal fractures caused by high-energy injuries

OBJECTIVE

Deep venous thrombosis (DVT) is a common complication in patients with spinal fractures caused by high-energy injuries. Early identification of patients at high risk of postoperative DVT is essential for the prevention of thrombosis. This study aimed to develop and validate a prediction model based on a nomogram to predict DVT in patients with spinal fractures caused by high-energy injuries.

METHODS

Clinical data were collected from 936 patients admitted to our hospital between January 2016 and December 2021 with spinal fractures caused by high-energy injuries. Multivariate logistic regression analysis was used to identify the risk factors for postoperative DVT and to develop a nomogram. The predictive performance of the nomogram was evaluated by the receiver operating characteristic (ROC) curve and calibration curve.

RESULTS

The incidence of preoperative DVT was 15.38% (144/936). The postoperative incidence of DVT was 20.5% (192/936). The multivariate analysis revealed that age, operation time, blood transfusion, duration of bed rest, American Spinal Injury Association (ASIA) score and D-dimer were risk factors for postoperative DVT. The area under the ROC curve of the nomogram was 0.835 and the calibration curve showed good calibration.

CONCLUSIONS

The nomogram showed a good ability to predict postoperative DVT in patients with spinal fractures caused by high-energy injuries, which may benefit pre- and postoperative DVT prophylaxis strategy development.

Prevalence of preoperative deep vein thrombosis in long bone fractures of lower limbs: a systematic review and meta-analysis

BACKGROUND

There is a paucity of data regarding the prevalence of preoperative deep vein thrombosis (DVT) in patients with long bone (including femur, tibia and fibula) fractures of the lower limbs. We performed a meta-analysis to address the issue.

METHODS

Electronic databases, including PubMed, EMBASE, the Web of Science, the Cochrane Library, the VIP database, CNKI, and the Wanfang database, were systematic searched for original articles that reported the prevalence of preoperative DVT in long bone fractures of the lower limbs from January 2016 to September 2021. The prevalence of preoperative DVT was pooled using random-effects models, and subgroups were established according to study type, detection method, sample size and fracture site.

RESULTS

Twenty-three articles reporting on 18,119 patients were eligible. The overall pooled preoperative DVT prevalence was 24.1% (95% CI 19.3-28.8%). In different subgroups, the preoperative DVT prevalences were 18.2-27.3%, 15.2-28.6%, 23.1-24.9%, 18.2-26.0% and 23.2-23.4% for different study designs, sample sizes, age groups, detection methods and fracture sites, respectively.

CONCLUSIONS

Despite the heterogeneity among studies, this systematic review suggests that the prevalence of preoperative DVT, which may seriously affect the prognosis of patients, is high. Therefore, greater efforts should be devoted to the improvement of screening and prevention strategies for preoperative DVT in lower-extremity long bone fractures.

LEVEL OF EVIDENCE

Level III. Trial Registration The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database with the registration number CRD42022324706.

A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology

Venous thromboembolism (VTE) is the third most common cause of death worldwide. The incidence of VTE varies according to different countries, ranging from 1-2 per 1000 person-years in Western Countries, while it is lower in Eastern Countries (<1 per 1000 person-years). Many risk factors have been identified in patients developing VTE, but the relative contribution of each risk factor to thrombotic risk, as well as pathogenetic mechanisms, have not been fully described. Herewith, we provide a comprehensive review of the most common risk factors for VTE, including male sex, diabetes, obesity, smoking, Factor V Leiden, Prothrombin G20210A Gene Mutation, Plasminogen Activator Inhibitor-1, oral contraceptives and hormonal replacement, long-haul flight, residual venous thrombosis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, trauma and fractures, pregnancy, immobilization, antiphospholipid syndrome, surgery and cancer. Regarding the latter, the incidence of VTE seems highest in pancreatic, liver and non-small cells lung cancer (>70 per 1000 person-years) and lowest in breast, melanoma and prostate cancer (<20 per 1000 person-years). In this comprehensive review, we summarized the prevalence of different risk factors for VTE and the potential molecular mechanisms/pathogenetic mediators leading to VTE.

Simultaneous Surgical Management of Acute Tibial Shaft Fracture and Post-traumatic Ankle Arthritis

The simultaneous management of tibial shaft fractures and post-traumatic ankle arthritis with ankle pain as the chief complaint can be challenging. Herein, we present a case managed with closed reduction, internal fixation, and tibiotalocalcaneal arthrodesis using a retrograde femoral nail. The patient was able to actively ambulate with full weight bearing and no pain approximately three months after the procedure. Patient consent for this case report was obtained.

Recommendations in the rehabilitation of patients undergoing hip abductor tendon repair: a systematic literature search and evidence based rehabilitation protocol

INTRODUCTION

Advanced hip imaging and surgical findings have demonstrated that a common cause of greater trochanteric pain syndrome (GTPS) is hip abductor tendon (HAT) tears. Traditionally, these patients have been managed non-operatively, often with temporary pain relief. More recently, there has been an increase in published work presenting the results of surgical intervention. A variety of open and endoscopic transtendinous, transosseous and/or bone anchored suture surgical techniques have been reported, with and without the use of tendon augmentation for repair reinforcement. While patient outcomes have demonstrated improvements in pain, symptoms and function, post-operative rehabilitation guidelines are often vague and underreported, providing no guidance to therapists.

MATERIALS AND METHODS

A systematic search of the literature was initially undertaken to identify published clinical studies on patients undergoing HAT repair, over a 3-year period up until May 2020. Following the application of strict inclusion and exclusion criteria, studies were identified and the detail relevant to rehabilitation was synthesized and presented. Published detail was combined with the authors clinical experience, with a detailed overview of rehabilitation proposed for this patient cohort.

RESULTS

A total of 17 studies were included, reporting varied detail on components of rehabilitation including post-operative weight bearing (WB) restrictions, the initiation of passive/active hip range of motion (ROM) and resistance exercises. A detailed rehabilitation guide is proposed.

CONCLUSION

In combining the current published literature on rehabilitation after HAT repair and our own clinical experience in the surgical management and post-operative rehabilitation of these patients, we present an evidence-based, structured rehabilitation protocol to better assist surgeons and therapists in treating these patients. This rehabilitation protocol has been implemented for several years through our institutions with encouraging published clinical outcomes.

Comparison of the Effects of Intramedullary Nailing and Plate Fixation on Lower-Extremity Deep Vein Thrombosis after Tibial Fractures

Lower-extremity deep vein thrombosis (DVT) is prone to occur after internal fixation of tibial fractures. This study analyzed the effect of intramedullary nailing (IMN) and plate fixation (PF) on lower-extremity DVT, providing reliable reference and guidance for future clinical treatment of tibial fractures. Sixty-eight patients with tibial fractures admitted to Honghui Hospital, Xi’an Jiaotong University, between February 2019 and October 2020 were selected as research participants, of which 32 cases treated with open reduction and locking-compression plate fixation were assigned to the FP group and 36 cases treated with closed reduction and interlocking IMN were included in the FN group. The two groups were compared regarding the following items: clinical efficacy, operation, rehabilitation, joint function, pain, inflammatory factors (IFs), incidence of adverse reactions (ARs), blood loss, prognosis, and quality of life (QoL). The related factors affecting the occurrence of DVT were analyzed. The results identified no evident difference in the overall response rate between the two groups ( $P>0.05$ ). The FN group showed longer operation time, higher incidence of ARs, and better rehabilitation, while there were lower incision length, VAS score, and IF levels ( $P<0.05$ ). The results revealed no significant difference in estnimated blood volume(EBV) and the incidence of DVT between the two groups( $P>0.05$ ); however, the total blood loss (TBL), hidden blood loss (HBL), and blood transfusion rates in FN group were higher while the visible blood loss (VBL) was lower compared to the FP group ( $P<0.05$ ). Logistic regression analysis identified that blood transfusion, VBL, HBL, TBL, and treatment methods were independent risk factors affecting the occurrence of lower-extremity DVT ( $P<0.05$ ). In addition, the prognostic QoL was better in the FN group ( $P<0.05$ ). Therefore, closed reduction and interlocking IMN are more effective than open reduction and locking-compression plate fixation in the treatment of tibial fractures, but patients are more likely to suffer from lower-extremity DVT. In the future, it is necessary to carefully choose the treatment method in the treatment of tibial fracture patients to ensure their rehabilitation.

Incidence and risk factors of preoperative deep venous thrombosis following pelvic and acetabular fractures: a retrospective case–control study

The objective of this study was to investigate the prevalence of preoperative deep venous thrombosis (DVT) in the pelvic cavity and lower extremities following pelvic and acetabular fractures and to identify the risk factors of the occurrence of DVT. Duplex ultrasound (DUS) screening and blood tests were conducted in patients admitted from June 2012 to December 2020 for surgical treatment of pelvic and acetabular fractures. Univariate analyses were performed on data of demographics, comorbidities, time from injury to surgery, injury mechanism, accompanied injury, and laboratory results. The optimal cutoff values of continuous variables with statistical significance were obtained by using the receiver operating characteristic (ROC) curve. A multivariate logistic regression analysis was then employed to examine the independent values in terms of predicting preoperative DVT. A total of 607 patients with pelvic and acetabular fractures were included, among whom 82 (13.5%) patients sustained preoperative DVTs. Specifically, 31.7% (26/82) were diagnosed with proximal DVTs. Fifty-two (63.4%) patients had DVT within 7 days after injury, and 67 (81.7%) patients within 10 days. The multivariate logistic regression analysis identified 6 factors independently associated with the presence of preoperative DVT, including age > 46 years (odds ratio [OR] = 2.94), BMI > 26.73 kg/m2 (OR = 3.91), time from injury to surgery > 9 days (OR = 5.39), associated injury (OR = 7.85), ALB < 32.8 g/L (OR = 2.71) and FIB > 3.095 g/L (OR = 3.34). Despite the modern prophylactic regimen, the preoperative DVT in patients with pelvic and acetabular fractures still draws the attention of orthopaedic surgeons. Better understanding these risk factors can help surgeons refine the risk stratification profile and perform early interdisciplinary management for patients at high risk of DVT.

Incidence and risk factors associated with preoperative deep venous thrombosis in the young and middle-aged patients after hip fracture

Objective

This study aims to investigate the incidence, occurrence timing and locations of preoperative DVT and identify the associated factors in this group.

Methods

A retrospective analysis of collected data in young and middle-aged (18–59 years) patients who presented with hip fracture between October 2015 and December 2018 was conducted. Before operation, patients were routinely examined for DVT by Duplex ultrasonography (DUS). Electronic medical records were retrieved to collect the data, involving demographics, comorbidities, injury and laboratory biomarkers after admission. Multivariate logistic regression analysis was performed to identify factors that were independently associated with DVT.

Results

Eight hundred and fifty-seven patients were included, and 51 (6.0%) were diagnosed with preoperative DVT, with 2.5% for proximal DVT. The average age of patients with DVT is 48.7 ± 9.4 year, while that of patients without DVT is 45.0 ± 10.9 year. The mean time from injury to diagnosis of DVT was 6.8 ± 5.5 days, 43.1% cases occurring at day 2–4 after injury. Among 51 patients with DVT, 97 thrombi were found. Most patients had thrombi at injured extremity (72.5%), 19.6% at uninjured and 7.8% at bilateral extremities. There are significantly difference between patients with DVT and patients without DVT in term of prevalence of total protein (41.2% vs 24.4%, P = 0.008), albumin (54.9% vs 25.6%, P = 0.001), low lactate dehydrogenase (51.0% vs 30.3%, P = 0.002), lower serum sodium concentration (60.8% vs 29.9%, P = 0.001), lower RBC count (68.6% vs 37.0%, P = 0.001), lower HGB (51.0% vs 35.1%, P = 0.022), higher HCT (86.3% vs 35.1%, P = 0.022) and higher platelet count (37.3% vs 11.3%, P = 0.001). The multivariate analyses showed increasing age in year (OR 1.04, 95% CI; P = 0.020), delay to DUS (OR, 1.26; P = 0.001), abnormal LDH (OR, 1.45; P = 0.026), lower serum sodium concentration (OR, 2.56; P = 0.007), and higher HCT level (OR, 4.11; P = 0.003) were independently associated with DVT.

Conclusion

These findings could be beneficial in informed preventive of DVT and optimized management of hip fracture in specific group of young and mid-aged patients.

Correlation Between the Fracture Line Plane and Perioperative Deep Vein Thrombosis in Patients with Tibial Fracture

Objective

To explore the correlation between the fracture line inferior plane and perioperative deep venous thrombosis (DVT) in patients with tibial fractures.

Methods

Data was collected from the medical records of 536 consecutive patients with tibial fractures at Xi’an Honghui Hospital. The patients were divided into distal, shaft, and proximal segment groups according to the fracture line inferior plane on radiographs. Multivariate logistic regression models were used to identify the role of the inferior plane of the fracture line in perioperative DVT.

Results

A total of 431 patients were included in the study and 226 patients had perioperative DVT in the lower extremities, including 11 proximal and 215 distal DVTs. Univariate regression analysis showed a significant correlation between the proximal segment and perioperative DVT; however, no correlation was found in the shaft segment group. Additionally, age, coronary heart disease, associated injuries, and time to operation ≥6 days were risk factors for perioperative DVT. However, fixation with intramedullary nails may be a protective factor for perioperative DVT compared with plates. After adjusting for potential confounding factors, the proximal segment group had an increased incidence of perioperative DVT compared to the distal segment group.

Conclusions

The proximal segment may be correlated with an increased incidence of perioperative DVT by 7.30-fold in patients with tibial fractures compared to that in the distal segment. In clinical practice, surgeons should be vigilant for DVT formation in these patients.

Relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation of displaced intra-articular calcaneal fracture

It is well established that the postoperative results were affected by the surgeon volume in a variety of elective and emergent orthopaedic surgeries; however, by far, no evidences have been available as for surgically treated displaced intra-articular calcaneal fractures (DIACFs). We aimed at investigating the relationship between surgeon volume and deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of DIACFs. This was a further analysis of prospectively collected data from a validated database. Patients with DIACFs stabilised by ORIF between 2016 and 2019 were identified. Surgeon volume was defined as the number of surgically treated calcaneal fractures within one calendar year and was dichotomised based on the optimal cut-off value. The outcome measure was DSSI within 1 year postoperatively. Multivariate logistics regression analyses were performed to examine the relationship, adjusting for confounders. Among 883 patients, 19 (2.2%) were found to have a DSSI. The DSSI incidence was 6.5% in surgeons with a low volume (<6/year), 5.5 times as that in those with a high volume (≥6/year) (incidence rate, 1.2%; P < 0.001). The multivariate analyses showed a low volume <6/year was associated with a 5.8-fold increased risk of DSSI (95% confidence interval, 2.2-16.5, P < 0.001). This value slightly increased after multiple sensitivity analyses, with statistical significances still unchanged (OR range, 6.6-6.9; P ≤ 0.001). The inverse relationship indicates a need for at least six cases/year for a surgeon to substantially reduce the DSSIs following the ORIF of DIACFs.

Surgeon volume and the risk of deep surgical site infection following open reduction and internal fixation of closed tibial plateau fracture

BACKGROUND

Emerging evidences supported that the surgeon case volume significantly affected post-operative complications or outcomes following a range of elective or non-elective orthopaedic surgery; no data has been available for surgically treated tibial plateau fractures. We aimed to investigate the relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of closed tibial plateau fracture.

METHODS

This was a further analysis of the prospectively collected data. Adult patients undergoing ORIF procedure for closed tibial plateau fracture between January 2016 and December 2019 were included. Surgeon volume was defined as the number of surgically treated tibial fractures in the preceding 12 months and dichotomized on the basis of the optimal cut-off value determined by the receiver operating characteristic (ROC) curve. The outcome was DSSI within one year post-operatively. Multiple multivariate logistic models were constructed for "drilling down" adjustment of confounders. Sensitivity and subgroup analyses were performed to assess the robustness of outcome and identify the "optimal" subgroups.

RESULTS

Among 742 patients, 20 (2.7%) had a DSSI and 17 experienced re-operations. The optimal cut-off value for case volume was nine, and the low-volume surgeon was independently associated with 2.9-fold (OR, 2.9; 95%CI, 1.1 to 7.5) increased risk of DSSI in the totally adjusted multivariate model. The sensitivity analyses restricted to patients with original BMI data or those operated within 14 days after injury did not alter the outcomes (OR, 2.937, and 95%CI, 1.133 to 7.615; OR, 2.658, and 95%CI, 1.018 to 7.959, respectively). The subgroup analyses showed a trend to higher risk of DSSI for type I-IV fractures (OR, 4.6; 95%CI, 0.9 to 27.8) classified as Schatzker classification and substantially higher risk in patients with concurrent fractures (OR, 6.1; 95%CI, 1.0 to 36.5).

CONCLUSION

The surgeon volume is independently associated with the rate of DSSI, and a number of ≥ nine cases/year are necessarily kept for reducing DSSIs; patients with concurrent fractures should be preferentially operated on by high-volume surgeons.

Perioperative red blood cell infusion and deep vein thrombosis in patients with femoral and pelvic fractures: a propensity score matching

BACKGROUND

The relationship between perioperative red blood cell (RBC) infusion and deep vein thrombosis (DVT) has not been determined.

OBJECTIVES

To analyze the time-event relationship between perioperative RBC infusion and DVT in patients with femoral and pelvic fractures after adjusting for confounding factors and to provide reference for optimizing DVT risk factors.

METHODS

The clinical data of 569 patients with femoral and pelvic fractures who received surgical treatment from May 2018 to December 2019 were retrospectively analyzed. Propensity score matching (PSM) was performed on 20 covariates of DVT. With the formation or progression of DVT after RBC infusion as the end point, the time-event relationship between perioperative RBC infusion and DVT in patients was analyzed by binary logistic regression.

RESULTS

After 1:1 PSM of 569 patients included in this study, 126 patients were in the transfusion group and the non-transfusion group, respectively. Before PSM (P = 0.023, OR = 1.496 [95% CI, 1.058-2.115]), perioperative RBC infusion was associated with DVT formation for femoral and pelvic fractures. This conclusion was still obtained after PSM (P = 0.038, OR = 1.728, 95% CI = (1.031, 2.896)). The risk of DVT in patients with RBC infusion of 2-4U and > 4U is 1.833 and 2.667 times that of ≤ 2U, respectively. After excluding patients who received preoperative RBC infusion and had DVT formation or progression prior to RBC infusion, perioperative RBC infusion was still associated with the formation of DVT in femoral and pelvic fractures (P = 0.037, OR = 2.231 [95% CI, 1.049-4.745]).

CONCLUSION

Perioperative RBC infusion is one of the causes of DVT in patients with femoral and pelvic fractures, and the risk of DVT is positively correlated with the amount of RBC infusion.

Postoperative computed tomography assessment of anteromedial cortex reduction is a predictor for reoperation after intramedullary nail fixation for pertrochanteric fractures

PURPOSE

Postoperative radiographs are routinely used to assess fracture reduction following intramedullary nail fixation for pertrochanteric fractures, even though computed tomography (CT) is a superior modality. We aimed to determine the association between reduction quality assessed by CT and rates of reoperation and to evaluate the association of reoperation and reduction quality according to the assessment modality (plain radiographs vs. CT).

METHODS

A retrospective analysis of 299 consecutive patients treated with intramedullary nail fixation for pertrochanteric fractures was conducted. Fracture reduction measured by postoperative radiographs and CT was categorized as anatomical type, extramedullary type, or intramedullary type. Postoperative data for analysis included reduction status, tip-apex distance (TAD), screw position in the femoral head, sliding distance, and conditions associated with reoperation.

RESULTS

Of the 299 patients included with a mean age of 83.1 ± 8.2 years, there were six patients who required reoperation (2.0%). According to the CT assessments, there were 42 intramedullary reductions (14.0%). Patients with a non-intramedullary reduction based on postoperative CT images were significantly more likely to have proper placement of the screw, a reduced TAD, a reduced sliding distance, and a lower reoperation rate than those with an intramedullary reduction (P < 0.05). The reduction quality assessed by postoperative CT was significantly associated with reoperation (95% CI, 1.45-29.31).

CONCLUSIONS

Intramedullary reduction assessed by CT was associated with reoperation. The reduction quality based on CT findings was more predictive for reoperation than that from plain radiographs.