Incidence and Risk Factors of Deep Vein Thrombosis in Patients With Pelvic and Acetabular Fractures

Comparison of patient demographics and patient-specific risk factors for readmissions following open reduction and internal fixation for acetabular fractures

PURPOSE

Acetabular fractures are highly complex injuries often resulting from high-energy trauma. The gold standard treatment for these injuries has become open reduction internal fixation (ORIF). The purpose of this study is to further this understanding and investigate how (1) patient demographics and (2) patient-specific risk factors affect 90-day readmission rates.

METHODS

A retrospective, nationwide query of private insurance database from January 1st, 2010 to October 31st, 2020 was performed using ICD-9, ICD-10, and CPT codes. Patients who underwent acetabular ORIF and were readmitted within 90 days following index procedure were included, patients who were not readmitted served as controls. Patients were divided by demographics and specific risk factors associated with readmission.

RESULTS

The query yielded a total of 3942 patients. Age and sex were found to be non-significant contributing risk factors to 90-day readmissions. Data also showed that statistically significant comorbidities included arrhythmia, cerebrovascular disease, coagulopathy, fluid and electrolyte abnormalities, and pathologic weight loss.

CONCLUSION

This study illustrated how several patient-specific risk factors may contribute to increased 90-day readmission risk following acetabular ORIF. A heightened awareness of these comorbidities in patients requiring acetabular ORIF is required to improve patient outcomes and minimize rates of readmission. Further investigation is needed to improve patient outcomes, and increase awareness of potential post-operative complications in these higher-risk patient populations.

Impact of preoperative anemia on patients undergoing total joint replacement of lower extremity: a systematic review and meta-analysis

PURPOSE

Preoperative anemia increases postoperative morbidity, mortality, and the risk of allogeneic transfusion. However, the incidence of preoperative anemia in patients undergoing total hip arthroplasty and total knee arthroplasty (TKA) and its relationship to postoperative outcomes has not been previously reported.

METHODS

We conducted a comprehensive literature search through PubMed, Cochrane Library, Web of Sincien, and Embase from inception to July 2023 to investigate the prevalence of preoperative anemia in patients undergoing Total Joint Arthroplasty, comorbidities between anemic and non-anemicpatients before surgery, and postoperative outcomes. postoperative outcomes were analyzed. Overall prevalence was calculated using a random-effects model, and heterogeneity between studies was examined by Cochran's Q test and quantified by the I2 statistic. Subgroup analyses and meta-regression analyses were performed to identify sources of heterogeneity. Publication bias was assessed by funnel plots and validated by Egger's test.

RESULTS

A total of 21 studies with 369,101 samples were included, all of which were retrospective cohort studies. 3 studies were of high quality and 18 studies were of moderate quality. The results showed that the prevalence of preoperative anemia was 22% in patients awaiting arthroplasty; subgroup analyses revealed that the prevalence of preoperative anemia was highest in patients awaiting revision of total knee arthroplasty; the highest prevalence of preoperative anemia was found in the Americas; preoperative anemia was more prevalent in the female than in the male population; and preoperative anemia with a history of preoperative anemia was more common in the female than in the male population. patients with a history of preoperative anemia; patients with joint replacement who had a history of preoperative anemia had an increased risk of infection, postoperative blood transfusion rate, postoperative blood transfusion, Deep vein thrombosis of the lower limbs, days in hospital, readmission within three months, and mortality compared with patients who did not have preoperative anemia.

CONCLUSION

The prevalence of preoperative anemia in patients awaiting total joint arthroplasty is 22%, and is higher in TKA and female patients undergoing revision, while preoperative anemia is detrimental to the patient's postoperative recovery and will increase the risk of postoperative complications, transfusion rates, days in the hospital, readmission rates, and mortality.

Pure Posterior Native Hip Dislocation Following Low-Energy Injury - a Rare Case Report

Hip dislocations are traumatic injuries that commonly derive from high energy trauma such as traffic accidents or falls from great heights. In addition, these injuries present an increased incidence after partial or total hip arthroplasty in elderly patients. Associate literature dictates that in case of a native hip dislocation, early reduction is crucial for avoidance of further complications such as avascular necrosis of the femoral head and post traumatic arthritis. In this article, we present a rare case of a native pure posterior hip dislocation after low-energy trauma. We also demonstrate the treatment and follow-up algorithm concerning this kind of injury.

Interaction of preoperative chemoprophylaxis and tranexamic acid use does not affect transfusion in acetabular fracture surgery

PURPOSE

While the effects of tranexamic acid (TXA) use on transfusion rates after acetabular fracture surgery are unclear, previous evidence suggests that holding deep vein thrombosis (DVT) chemoprophylaxis may improve TXA efficacy. This study examines whether holding DVT chemoprophylaxis in patients receiving TXA affects intraoperative and postoperative transfusion rates in acetabular fracture surgery.

METHODS

We reviewed electronic medical records (EMR) of 305 patients who underwent open reduction and internal fixation of acetabular fractures (AO/OTA 62) and stratified patients per the following perioperative treatment: (1) no intraoperative TXA (noTXA), (2) intraoperative TXA and no preoperative DVT prophylaxis (opTXA/noDVTP), or (3) intraoperative TXA and preoperative DVT prophylaxis (opTXA/opDVTP). The primary outcomes were need for intraoperative or postoperative transfusion. Risk factors for each primary outcome were assessed using multivariable regression.

RESULTS

Intraoperative or postoperative transfusion rates did not significantly differ between opTXA/opDVTP and opTXA/noDVTP groups (46.2% vs. 36%, p = 0.463; 15.4% vs. 28%, p = 0.181). Median units transfused did not differ between groups (2 ± 1 vs. 2 ± 1, p = 0.515; 2 ± 1 vs. 2 ± 0, p = 0.099). There was no association between preoperative DVT chemoprophylaxis and TXA with intraoperative or postoperative transfusions. EBL, preoperative hematocrit, and IV fluids were associated with intraoperative transfusions; age and Charlson Comorbidity Index (CCI) were associated with postoperative transfusions.

CONCLUSION

Our findings suggest holding DVT prophylaxis did not alter the effect of TXA on blood loss or need for transfusion.

Generation of a Predictive Clinical Model for Isolated Distal Deep Vein Thrombosis (ICMVT) Detection

BACKGROUND Isolated distal deep vein thrombosis (ICMVT) increases the risk of pulmonary embolism. Although predictive models are available, their utility in predicting the risk is unknown. To develop a clinical prediction model for isolated distal calf muscle venous thrombosis, data from 462 patients were used to assess the independent risk variables for ICMVT. MATERIAL AND METHODS The area under curve (AUC) for Model A and Model B were calculated and other risk factors were based on age, pitting edema in the symptomatic leg, calf swelling with least 3 cm larger than the asymptomatic leg, recent bed rest for 3 days or more in the past 4 weeks, requiring general or major surgery with regional anesthesia, sex, and local tenderness distributed along the deep venous system as independent predictors of calf muscle venous thrombosis. Model A includes the risk variables for C-reactive protein and D-dimer. RESULTS The area under ROC curve for Model A training set was 0.924 (95% CI: 0.895-0.952), the area under ROC curve for Model B training set was 0.887 (95% CI: 0.852-0.922), and the AUC difference between the 2 models was statistically significant (P<0.001); the area under ROC curve for Model A obtained in the validation set was 0.902 (95% CI: 0.844-0.961), the area under ROC curve for Model B was 0.842 (95% CI: 0. 0.773-0.910), and the difference between the 2 models was statistically significant (P=0.012). CONCLUSIONS Predictive Model A better predicts isolated calf muscle venous thrombosis and is able to help clinicians rapidly and early diagnose ICMVT, displaying higher utility for missed diagnosis prevention and disease therapy.

Development and validation of a nomogram for predicting deep venous thrombosis in patients with pelvic and acetabular fractures: a retrospective cohort study : Predictive model for pelvic/acetabular fractures

PURPOSE

To construct a novel nomogram model that can predict DVT and avoid unnecessary examination.

METHODS

Patients admitted to the hospital with pelvis/acetabular fractures were included between July 2014 and July 2018. The potential predictors associated with DVT were analyzed using Univariate and multivariable logistic regression analysis. The predictive nomogram was constructed and internally validated.

RESULTS

230 patients were finally enrolled. There were 149 individuals in the non-DVT group and 81 in the DVT group. Following analysis, we obtained the final nomogram model. The risk factors included age (OR, 1.037; 95% CI, 1.013-1.062; P = 0.002), body mass index (BMI) (OR, 1.253; 95% CI, 1.120-1.403; P < 0.001); instant application of anticoagulant after admission (IAA) (OR, 2.734; 95% CI, 0.847-8.829; P = 0.093), hemoglobin (HGB) (OR, 0.970; 95% CI, 0.954-0.986; P < 0.001), D-Dimer(OR, 1.154; 95% CI, 1.016-1.310; P = 0.027) and fibrinogen (FIB) (OR, 1.286; 95% CI, 1.024-1.616; P = 0.002). The apparent C-statistic was 0.811, and the adjusted C-statistic was 0.777 after internal validations, demonstrating good discrimination. Hosmer and Lemeshow's goodness of fit (GOF) test of the predictive model showed a good calibration for the probability of prediction and observation (χ2 = 3.285, P = 0.915; P > 0.05). The decision curve analysis (DCA) and Clinical impact plot (CIC) demonstrated superior clinical use of the nomogram.

CONCLUSIONS

An easy-to-calculate nomogram model for predicting DVT in patients with pelvic-acetabular fractures were developed. It could help clinicians to reduce DVT and avoid unnecessary examinations.

Incidence of deep vein thrombosis and symptomatic pulmonary embolism in Taiwanese patients with pelvic and/or acetabular fractures: a retrospective study

Venous thromboembolism (VTE) is common in patients with trauma, and thromboprophylaxis has been advocated. However, conflicting results regarding VTE rates in the Asian population following orthopaedic procedures have been presented. We aimed to investigate the VTE incidence in Taiwanese patients with pelvic and/or acetabular fractures and identify the associated risk factors. We included 402 patients who underwent surgery for pelvic and/or acetabular fractures. All patients received mechanical thromboprophylaxis with graduated compression stockings. Duplex scanning was performed postoperatively or during follow-up when signs or symptoms of deep vein thrombosis (DVT) developed. Variables with a significance level of ≤ 0.1 in the univariate analyses were introduced into the multivariate logistic regression analysis to identify DVT risk factors. The overall DVT and symptomatic pulmonary embolism (PE) rate was 3.48% (14/402 patients). Among patients with DVT, 46.1% were asymptomatic. Patients with VTE were significantly older than those without. Multivariate logistic regression analysis revealed that age was a VTE risk factor. The incidence of DVT and symptomatic PE in our cohort was low. Advanced age was a risk factor for VTE. These findings could help clinicians develop appropriate prevention and treatment strategies for VTE in Taiwanese patients with pelvic and/or acetabular fractures.

Mechanical thromboprophylaxis for hip fractures in elderly patients: a prospective randomized controlled study

BACKGROUND

Hip fractures, most common in the geriatric age group, can develop proximal deep vein thrombosis (DVT). There is no consensus regarding the ideal method or duration of prophylaxis, particularly in a trauma patient. This study bridges this lacuna in data by making a random comparison between mechanical prophylaxis alone vis-a-vis combined with mechanical and Enoxaparin-based chemoprophylaxis.

MATERIALS AND METHODS

75 Elderly hip trauma patients from January 2019 to October 2020 at a single tertiary care center were randomly allocated into two groups using the sequentially numbered opaque sealed envelope method (SNOSE): one (n=44) receiving Enoxaparin and Mechanical prophylaxis and another (n=31) receiving Mechanical prophylaxis alone. All patients underwent CT (computed tomography) venography to screen for proximal DVT between days 5 to 10 of injury. The primary outcomes were the incidence of proximal DVT and pulmonary embolism (PE), and safety outcomes (wound complications and adverse systemic events) were recorded during the treatment.

RESULTS

No symptomatic or asymptomatic proximal DVT and death incidence was reported in either group. One case of pulmonary embolism was seen in the combined prophylaxis group. There was no significant difference between the groups regarding the above-mentioned parameters mentioned.

CONCLUSIONS

There is no significant difference in the incidence of proximal DVT between mechanical alone and combined chemical-mechanical prophylaxis in elderly patients sustaining hip trauma. The incidence of proximal DVT can be reduced by mechanical prophylaxis alone. It was efficacious and safer than combined mechanical and enoxaparin prophylaxis in preventing venous thromboembolism in elderly hip trauma patients.

Timing of venous thromboemboli in patients with acetabular and pelvic ring fractures

PURPOSE

To determine the timing of symptomatic venous thromboemboli (VTE) in patients sustaining a pelvic and/or acetabular fracture. Secondly, to evaluate for any factors that may influence this timing.

METHODS

A retrospective cohort of 47 patients with acetabular and/or pelvic ring injuries who developed VTEs at a single academic level I trauma center were identified from 2012 to 2018. The chronology of VTE diagnosis in relation to date of injury, initial surgery, final surgery, and date of discharge was evaluated. Patients who developed VTEs were then evaluated based on known risk factors for VTE to determine if any of these affected timing.

RESULTS

Symptomatic VTEs were diagnosed in 3.8% of patients with pelvic and/or acetabular fractures. In patients who developed a thromboembolism, diagnosis occurred on average 21.5 (± 19.2), 20.7 (± 19.9), 9.8 (± 23.4), and 4.3 (± 27.6) days after injury, index procedure, final procedure, and date of discharge. 25% of patients developed VTE more than 4 weeks after their initial injury. No known risk factors effected the timing of VTE.

CONCLUSION

The 2015 OTA expert panel recommends 4 weeks of anticoagulation for orthopedic trauma patients at high risk of VTE, which may be too short a duration. In our cohort, 25% of VTEs occurred greater than 4 weeks after injury. Additional research is needed to clarify the exact duration of anticoagulation after pelvic and acetabular fractures; however, surgeons may want to consider anticoagulating patients for greater than 4 weeks.

LEVEL OF EVIDENCE

Level III-retrospective cohort.

A nomogram to predict postoperative deep vein thrombosis in patients with femoral fracture: a retrospective study

OBJECTIVE

The implementation of more active anticoagulant prevention and treatment measures has indeed led to a significant reduction in the incidence of perioperative deep vein thrombosis (DVT) among patients with bone trauma. However, it is important to note that despite these efforts, the incidence of DVT still remains relatively high. According to the Caprini score, all patients undergoing major orthopedic surgery were defined as the high-risk group for DVT. Stratifying the risk further within high-risk groups for DVT continues to present challenges. As a result, the commonly used Caprini score during the perioperative period is not applicable to orthopedic patients. We attempt to establish a specialized model to predict postoperative DVT risk in patients with femoral fracture.

METHODS

We collected the clinical data of 513 patients undergoing femoral fracture surgery in our hospital from May 2018 to December 2019. According to the independent risk factors of DVT obtained by univariate and multivariate logistic regression analysis, the corresponding nomogram model was established and verified internally. The discriminative capacity of nomogram was evaluated by receiver operating characteristic (ROC) curve and area under the curve (AUC). The calibration curve used to verify model consistency was the fitted line between predicted and actual incidences. The clinical validity of the nomogram model was assessed using decision curve analysis (DCA) which could quantify the net benefit of different risk threshold probabilities. Bootstrap method was applied to the internal validation of the nomogram model. Furthermore, a comparison was made between the Caprini score and the developed nomogram model.

RESULTS

The Caprini scores of subjects ranged from 5 to 17 points. The incidence of DVT was not positively correlated with the Caprini score. The predictors of the nomogram model included 10 risk factors such as age, hypoalbuminemia, multiple trauma, perioperative red blood cell infusion, etc. Compared with the Caprini scale (AUC = 0.571, 95% CI 0.479-0.623), the calibration accuracy and identification ability of nomogram were higher (AUC = 0.865,95% CI 0.780-0.935). The decision curve analysis (DCA) indicated the clinical effectiveness of nomogram was higher than the Caprini score.

CONCLUSIONS

The nomogram was established to effectively predict postoperative DVT in patients with femoral fracture. To further reduce the incidence, more specialized risk assessment models for DVT should take into account the unique risk factors and characteristics associated with specific patient populations.

Analysis of risk factors of lower extremity deep venous thrombosis in patients undergoing hepatobiliary surgery

This study analyzed records of 200 patients who underwent hepatobiliary surgery to identify factors that contribute to lower extremity venous thromboembolism (VTE). 19 patients (9.50%) developed lower extremity deep vein thrombosis. Univariate analysis revealed significant differences between the study group and the control group in terms of age, body mass index, previous thromboembolic history, hypertension, type 2 diabetes, hyperlipidemia, smoking history, times of lower extremity venipuncture, operation time, postoperative bedrest time, postoperative platelet count, postoperative D-dimer level, and postoperative C-reactive protein level (P<0.05). Multivariable logistic regression analysis identified age ≥60 years, body mass index ≥24 kg/m2, previous history of thromboembolism, hypertension, type 2 diabetes mellitus, hyperlipidemia, smoking history, number of lower extremity venipunctures ≥5, operation time ≥2 hours, postoperative bedrest time ≥48 hours, postoperative blood platelet count ≥300×109/L, postoperative D-dimer level ≥200 g/L, and postoperative C-reactive protein ≥8.0 mg/L as significant predisposing factors for lower extremity VTE. The study concludes that patients undergoing hepatobiliary surgery are at an increased risk of developing lower extremity VTE, and prevention strategies must be tailored to each patient's unique set of risk factors. This includes careful management of postoperative bed rest, monitoring of platelet count, D-dimer and C-reactive protein levels, controlling hypertension, type 2 diabetes mellitus, hyperlipidemia, and cessation of smoking. This study highlights the importance of early identification of patients at high risk of lower extremity VTE following hepatobiliary surgery and comprehensive prevention measures.

OUTCOMES OF SURGICAL TREATMENT FOR DISPLACED BOTH-COLUMN ACETABULAR FRACTURES

Complex both-column acetabulum fractures are severe injuries, often with associated injuries and complications with uncertain clinical and functional outcome. Modern traumatological protocols point to early surgical treatment, with anatomical reduction and stable internal fixation of fragments as a prerequisite for achieving a good treatment outcome. This retrospective-prospective multicenter cohort study was conducted during the 2014-2020 period and included 24 cases that met the input parameters, using the Letournel and Judet classification, and application of a combined surgical approach, a modified Stoppa and Kocher-Langenbeck approach. The results of treatment with complications, associated injuries and functional outcome are described. Fractures were caused by high kinetic energy trauma, and the cause was traffic accident in 17/24 (70.84%), fall from a height in 5/24 (20.83%) and crash injuries in 2/24 (8.33%) cases. The sample included 18 (75.00%) male and 6 (25.00%) female, with 10/24 (41.67%) right sided and 14/24 (58.33%) left sided fractures. Their mean age was 45.06 (range, 24-62) years. The mean follow-up time was 2.8 (range, 1-5) years. Postoperative complications were detected in 14/24 (58.33%) cases, including wound infection in 4/24 (16.67%), deep vein thrombosis in 2/24 (8.33%), heterotopic ossification in 2/24 (8.33%), hip osteoarthrosis in 3/24 (12.50%), avascular necrosis of femoral head in 2/24 (8.33%), total hip arthroplasty procedures in 3/24 (12.50%), abdominal complications in 2/24 (8.33%), urologic complications in 2/24 (8.33%), iatrogenic nerve lesion in 3/24 (12.50%), and fatal pulmonary embolism in 2/24 (8.33%) cases; there was no loss of reduction or non-union acetabular fracture. Associated injuries that we recorded as major trauma were presented in 13/24 (54.17%) study patients. The final functional results according to the Harris Hip Score (HHS) were excellent in 7/22 (31.82%), good in 10/22 (45.45%), moderate in 4/22 (18.18%) patients, and poor in 1/22 (4.55%) patient. The mean HHS was 84 (range 34-98). Complications and results have led us to a conclusion that primary injuries significantly affect the clinical and functional results. A good diagnostic procedure, assessment of the general condition and application of the trauma scoring system, surgical treatment that includes early hip reduction, open reduction internal fixation and physical rehabilitation are necessary.

Risk factors for venous thromboembolism following surgical treatment of fractures: A systematic review and meta-analysis

This study aimed to determine the risk factors for postoperative venous thromboembolism (VTE) in patients treated surgically for fractures using a meta-analytic approach. Electronic searches were performed in PubMed, Embase, and the Cochrane library from inception until February 2022. The odds ratio (OR) and 95% confidence interval (CI) were applied to calculate the pooled effect estimate using the random-effects model. Sensitivity, subgroup, and publication bias tests were also performed. Forty-four studies involving 3 239 291 patients and reporting 11 768 VTE cases were selected for the meta-analysis. We found that elderly (OR: 1.72; 95% CI: 1.38-2.15; P < .001), American Society of Anesthesiologists (ASA) ≥ 3 (OR: 1.82; 95% CI: 1.46-2.29; P < .001), blood transfusion (OR: 1.82; 95% CI: 1.14-2.92; P = .013), cardiovascular disease (CVD) (OR: 1.40; 95% CI: 1.22-1.61; P < .001), elevated D-dimer (OR: 4.55; 95% CI: 2.08-9.98; P < .001), diabetes mellitus (DM) (OR: 1.36; 95% CI: 1.19-1.54; P < .001), hypertension (OR: 1.31; 95% CI: 1.09-1.56; P = .003), immobility (OR: 3.45; 95% CI: 2.23-5.32; P < .001), lung disease (LD) (OR: 2.40; 95% CI: 1.29-4.47; P = .006), obesity (OR: 1.52; 95% CI: 1.27-1.82; P < .001), peripheral artery disease (PAD) (OR: 2.13; 95% CI: 1.21-3.73; P = .008), prior thromboembolic event (PTE) (OR: 5.17; 95% CI: 3.14-8.50; P < .001), and steroid use (OR: 2.37; 95% CI: 1.73-3.24; P < .001) were associated with an increased risk of VTE. Additionally, regional anaesthesia (OR: 0.66; 95% CI: 0.45-0.96; P = .029) was associated with a reduced risk of VTE following surgical treatment of fractures. However, alcohol intake, cancer, current smoking, deep surgical site infection, fusion surgery, heart failure, hypercholesterolemia, liver and kidney disease, sex, open fracture, operative time, preoperative anticoagulant use, rheumatoid arthritis, and stroke were not associated with the risk of VTE. Post-surgical risk factors for VTE include elderly, ASA ≥ 3, blood transfusion, CVD, elevated D-dimer, DM, hypertension, immobility, LD, obesity, PAD, PTE, and steroid use.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Ogilvie Syndrome in Patients With Traumatic Pelvic and/or Acetabular Fractures: A Retrospective Cohort Study

OBJECTIVES

To assess the incidence, risk factors, and clinical outcomes of Ogilvie syndrome (OS) in patients with pelvic and/or acetabular fractures.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS

One thousand sixty patients with pelvic and/or acetabular fractures treated at Rigshospitalet, Copenhagen, between 2009 and 2020.

INTERVENTION

Interventions comprised the treatment of pelvic and/or acetabular fractures with emergency external and/or internal fixation.

MAIN OUTCOME MEASUREMENTS

Outcomes included diagnosis of OS, perioperative complications, ICU stay and length, length of admission, and mortality.

RESULTS

We identified 1060 patients with pelvic and/or acetabular fractures. Of these, 25 patients were diagnosed with OS perioperatively, corresponding to incidences of 1.6%, 2.7%, and 2.6% for acetabular, pelvic, and combined fractures, respectively. Risk factors included congestive heart failure, diabetes, concomitant traumatic lesions, head trauma, fractures of the cranial vault and/or basal skull, retroperitoneal hematomas and spinal cord injuries, and emergency internal fixation and extraperitoneal packing. Six (24%) patients underwent laparotomy, and all patients had ischemia or perforation of the cecum for which right hemicolectomy was performed. Ogilvie syndrome was associated with a significant increase in nosocomial infections, sepsis, pulmonary embolism, ICU stay, and prolonged hospital admission.

CONCLUSION

Ogilvie syndrome in patients with pelvic and/or acetabular fractures is associated with increased risk of perioperative complications and prolonged hospital and ICU stays, resulting in an increased risk of morbidity and mortality.

LEVEL OF EVIDENCE

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

High fibrinogen and mixed proximal and distal thrombosis are associated with the risk of residual venous thrombosis in patients with posttraumatic deep vein thrombosis

Background

The risk factors for residual venous thrombosis (RVT) in patients with post-trauma deep vein thrombosis (DVT) are unknown.

Methods

We evaluated 127 patients with DVT after trauma, all of whom were treated with conventional anticoagulation and assessed for the presence of RVT with venous compression ultrasound (CUS), using an internal diameter of the venous lumen ≥ 4 mm after compression as the criterion.

Results

RVT was present in 59 (46%) patients, and complete thrombus dissolution was present in 68 (54%) patients. Among them, mixed proximal and distal thrombosis (OR, 4.292; 95% CI, 1.253-14.707), diabetes (OR, 6.345; 95% CI, 1.125-35.786), fibrinogen > 4.145 g/L (OR, 2.858; 95% CI, 1.034-7.897), the time between detection of thrombus and initiation of antithrombotic therapy > 2.5 days (OR, 3.470; 95% CI, 1.085-11.094) was an independent risk factor for RVT in patients with posttraumatic DVT.

Conclusion

A mixed proximal and distal thrombosis, diabetes mellitus, late initiation of antithrombotic therapy, and high fibrinogen levels increase the risk of RVT in patients with posttraumatic DVT. Therefore, treatment regimens for patients with posttraumatic DVT can be adjusted according to the site of thrombosis, the presence of diabetes mellitus, and the level of fibrinogen, and antithrombotic therapy can be started as early as possible after the detection of thrombosis to prevent the development of RVT and its serious complications.

A nomogram for prediction of deep venous thrombosis risk in elderly femoral intertrochanteric fracture patients: A dual-center retrospective study

Objective

Deep venous thrombosis (DVT) of the lower extremity is a common perioperative complication of femoral intertrochanteric fracture. This study aimed to identify the risk factors of lower extremity deep vein thrombosis (DVT) in elderly femoral intertrochanteric fracture patients and establish a nomogram model.

Methods

From August 2014 to June 2021, a total of 1,652 femoral intertrochanteric fracture patients over the age of 65 were enrolled in our study. We distinguished independent risk factors by univariate and multivariate Cox analyses. A nomogram model was then built, and the discriminative and calibration of the model was evaluated through receiver operating characteristics (ROC) and calibration plots.

Results

A total of 378 patients developed DVT (292 in the training group, 86 in the validation group) while the remaining patients did not. According to the univariate and multivariate Cox analyses results, age (OR = 1.07, 95% CI: 1.04-1.10), fibrinogen (OR = 2.09, 95% CI: 1.68-2.60), D-dimer (OR = 1.33, 95% CI: 1.27-1.40), time from injury to admission (OR = 1.78, 95% CI: 1.55-2.05), functional status (OR = 4.21, 95% CI: 2.86-6.20), and diabetes (OR = 1.65, 95% CI: 1.10-2.48) were identified as independent risk factors of DVT. The ROC values for DVT of the training and validation group were 0.862 and 0.912, and the P-value of the Hosmer-Lemeshow calibration test was 0.767.

Conclusion

This nomogram model can be used to predict the probability of preoperative DVT in elderly patients with femoral intertrochanteric fracture and guide physician in perioperative thrombosis management.

Risk Factors of Deep Vein Thrombosis in Adults with Acute Compartment Syndrome Following Lower Extremity Fractures

This study aimed to identify the risk factors of deep vein thrombosis (DVT) in adults with acute compartment syndrome (ACS) following lower extremity fractures. We collected data on adults with ACS following lower extremity fractures in our hospital from November 2013 to January 2021. Patients were divided into the DVT group and the non-DVT group according to whether they had DVT or not. The demographics, comorbidities, and admission laboratory examinations were computed by univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analysis. In our study, the rate of DVT (26 of 110) was 23.6%. Univariate analysis showed that numerous factors were associated with the formation of DVT. Logistic regression analysis showed that patients with multiple fractures (P = .015, OR = 5.688), patients with a history of hypertension (P = .011, OR = 16.673), and patients with a higher BMI (P = .008, OR = 1.950) and FDP (P = .013, OR = 1.031) were relevant predictors of DVT. ROC curve analysis indicated 24.73 kg/m² and 28.33 μg/mL were the cutoff values of BMI and FDP to predict the DVT, respectively. Furthermore, the combination of BMI and FDP had the highest diagnostic accuracy. Our findings identified multiple fractures, BMI, and FDP as independent risk factors for DVT in patients with ACS following lower extremity fractures and determined the cutoff values of BMI and FDP, helping us individualize the assessment of the risk of DVT to manage early targeted interventions.

Outcome of surgically treated acetabular fractures: risk factors for postoperative complications and for early conversion to total hip arthroplasty

INTRODUCTION

The gold standard of Acetabular fractures treatment is open reduction and internal fixation (ORIF). Our purpose is to assess the short- to medium-term outcomes and complications of surgically treated acetabular fractures. We analysed factors influencing clinical outcomes, incidence of complications and predictors of conversion in total hip arthroplasty (THA).

MATERIALS AND METHODS

We retrospectively analysed 102 patients with acetabular fracture surgically treated between December 2017 and September 2020. We evaluated the quality of reduction with x-ray measuring residual displacement, classified into 3 groups (Matta Radiological Score). At the final follow-up, radiographs were graded according to Matta's Radiological Outcome Grading, and the clinical outcomes were graded using Oxford Hip Score (OHS).

RESULTS

62 patients were enrolled. OHS was influenced by quality of reduction (p = 0.031), injury severity score (ISS) (p = 0.003) and BMI > 30 (p < 0.0001). The late sequelae were heterotopic ossification (HO) in 13 patients, osteoarthritis (OA) in 22 and avascular necrosis (AVN) in 4. HO was significantly affected by posterior approach and ISS > 15. The analysis showed a correlation between AVN and posterior hip dislocation. OA had a correlation with postoperative quality of reduction (p = 0.014). Eight patients required THA with a significant correlation between THA and posterior dislocation, isolated posterior wall fracture and ISS > 15.

CONCLUSION

A high rate of patients with acetabular fractures still develop complications and require THA. Identification of predictors for poor outcome may help to inform surgical decision-making regarding options of plate osteosynthesis or 'Fix and Replace', to avoid poor outcomes and early revision surgery.

Sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma

INTRODUCTION

Patients with pelvic trauma are at high risk of thromboembolic complications, but effective methods of prophylaxis are still to be accepted widely. The incidence of venous thromboembolism (VTE) has been reported to be as high as 61%, which represents the commonest cause of morbidity and mortality in this cohort. New oral anticoagulants are now available and may be used instead of LMWH injections for extended prophylaxis. Rivaroxaban has not been comprehensively considered in the previous pelvic and acetabular trauma literature, but its known benefits include increased patient compliance, especially in the minority of patients who are unable to self-administer injections, and that it does not require monitoring.

MATERIALS AND METHODS

All patients referred to our pelvic trauma service between 2015 and 2020 were considered for this study, exclusion criteria involved those patients who had contraindications to rivaroxaban, those who were referred to our service but were never managed at our centre and those managed by other teams (e.g. neurosurgery). Operative patients were initially managed with LMWH until 24 h post-operatively when they started rivaroxaban. Conservatively managed patients started Rivaroxaban straight away. Data were collected on demographics, injury mechanism, fracture classification and clinically relevant VTE and bleeding events up until 3 months post discharge.

RESULTS

The overall incidence of VTE was 2%. These represented 3 DVTs and 3 PEs, and occurred in patients who were managed operatively. No major bleeding events were observed. There were two minor bleeding events, both occurring in patients who were managed conservatively with rivaroxaban alone, and they did not require further intervention. 90% of patients surveyed expressed preference for oral prophylaxis. Reported compliance with rivaroxaban was 100%.

CONCLUSION

Our data show that this VTE regimen protocol is safe and effective in this group of injured patients and is at least non-inferior to the standard prophylaxis of LMWH alone.

Determination of Deep Vein Thrombosis Risk in Patients Staying in an Orthopedics and Traumatology Clinic

Background: Deep vein thrombosis (DVT) is an important life-threatening complication in patients having orthopedic surgery and its risk factors are still debatable. Aim: This study aimed to determine preoperative and postoperative DVT risk, its risk factors and their effects on preoperative and postoperative DVT risk scores in patients having orthopedic surgery and staying in an orthopedics and traumatology clinic. Method: This descriptive, cross-sectional study was performed with 244 patients. Data were gathered with a sociodemographic, health status and prophylaxis for DVT form and the Autar Deep Vein Thrombosis Risk Assessment Scale (Autar DVTRAS). Results: There was a strong significant difference between the preoperative and postoperative mean scores for the Autar DVTRAS (p

Preoperative anemia and deep vein thrombosis in patients with perioperative bone trauma: a cohort study

Background

In current active prevention (including physical and drug prevention), the incidence of perioperative deep vein thrombosis (DVT) of the lower extremities remains high in patients with bone trauma. Risk factors need to be further optimized, and high-risk patients must be identified early. Preoperative comorbidities, especially preoperative anemia, and DVT in patients with perioperative bone trauma are not clear. The purpose of this study was to explore the causal relationship between preoperative anemia and DVT in patients with perioperative bone trauma, and further reduce the incidence of DVT in patients with bone trauma.

Objectives

To analyze the relationship between preoperative anemia and perioperative DVT in patients with femoral and pelvic fractures and provide a reference for the optimization of risk factors for DVT.

Methods

The clinical data of 1049 patients with femoral and pelvic fractures who received surgical treatment from May 2018 to June 2021 were retrospectively analyzed. Propensity score matching (PSM) was performed for the covariates of DVT. Modified Poisson regression was used to analyze the relationship between preoperative anemia and DVT.

Results

After matching 1:1 propensity scores in 1049 patients included in this study, there were 258 patients in the anemic and non-anemic groups. Preoperative anemia was statistically significant for the formation of DVT in patients with perioperative bone trauma (P = 0.000, RR = 1.567 [95% CI 1.217–2.017]). This conclusion remained true after PSM (P = 0.009, RR = 1.500 [95% CI 1.105–2.036]). Preoperative anemia has some predictive value for perioperative DVT, with DVT-associated preoperative anemia thresholds of 125 g/L and area under the receiver operating characteristic curve of 0.5877 (95% CI 0.5345 to 0.6408). On this basis, sensitivity and specificity were 89.2 and 30.3%, respectively, with a Youden index of 0.195. In addition, we conducted an E-value determination of the propensity score; the E-value analysis showed robustness to unmeasured confounding.

Conclusions

Preoperative anemia is highly correlated with perioperative DVT in patients with bone trauma, which is the cause of perioperative DVT in these patients.

COVID-19 and the potential of Janus family kinase (JAK) pathway inhibition: A novel treatment strategy

Recent evidence proposed that the severity of the coronavirus disease 2019 (COVID-19) in patients is a consequence of cytokine storm, characterized by increased IL-1β, IL-6, IL-18, TNF-α, and IFN-γ. Hence, managing the cytokine storm by drugs has been suggested for the treatment of patients with severe COVID-19. Several of the proinflammatory cytokines involved in the pathogenesis of COVID-19 infection recruit a distinct intracellular signaling pathway mediated by JAKs. Consequently, JAK inhibitors, including baricitinib, pacritinib, ruxolitinib, and tofacitinib, may represent an effective therapeutic strategy for controlling the JAK to treat COVID-19. This study indicates the mechanism of cytokine storm and JAK/STAT pathway in COVID-19 as well as the medications used for JAK/STAT inhibitors.

Does Aspirin Provide Adequate Chemoprophylaxis for Venous Thromboembolic Events in Operative Pelvic and Acetabular Fractures?

BACKGROUND

Several strategies exist to prevent venous thromboembolism (VTE) in operative pelvic and acetabular fractures, however literature lacks consensus on the optimal thromboprophylaxis. Even more debated, and perhaps controversial, is whether aspirin provides adequate thromboprophylaxis in the setting of these injuries. The primary objective was to evaluate the efficacy of aspirin in the prevention of venous thromboembolism (VTE) events, including deep vein thrombosis (DVT) and pulmonary embolism (PE) in operative pelvic and acetabular fractures compared to other anticoagulants.

METHODS

A retrospective chart review of pelvic and acetabular fractures that underwent operative fixation was completed. The incidence of VTE and hematoma formation was evaluated and compared between patients who received aspirin versus enoxaparin or heparin. Multivariate analysis was performed to control for confounding demographic, comorbidity, and injury-related variables. The outcome measurements included development of DVT and/or PE and hematoma formation.

RESULTS

Of patients with operative pelvic and acetabular fractures, 4.2% developed a DVT and 3.5% developed a PE, with 1.4% developing both. Of these patients 37.5% were treated with aspirin versus the 62.5% treated with heparin or enoxaparin. There was no significant difference in the incidence of DVT or PE between cohorts (p=0.498 and p=0.262). Aspirin trended toward significance as protective against post-operative hematoma (p=0.085).

CONCLUSION

This study suggests that aspirin is an acceptable method of VTE thromboprophylaxis with no inferior results to other common anticoagulants used in operative pelvis and acetabular fractures. As a chemoprophylactic agent, aspirin is an efficacious option in these complex injuries that shows no increase in the incidence in symptomatic VTE events. Level of Evidence: III.

Thromboembolic events in pelvic and acetabulum fractures: a systematic review of the current literature on incidence, screening, and thromboprophylaxis

PURPOSE

Rates of venous thromboembolic events (VTEs) as high as 41% deep vein thrombosis (DVT) were reported in association with pelvic and acetabular fractures (PAFs). There is no clear consensus on VTE prophylaxis for PAFs. Extracting evidence-based guidelines is key to overcome this challenging complication. The aims of this review are (A) to highlight the incidence of VTEs in PAFs, (B) to examine the screening and prophylaxis methods available in the current literature, and (C) direct future creation of a best practice protocol to reduce the risk of VTE in PAFs.

METHODS

We performed a systematic search of Medline, EMBASE databases, and the Cochrane library. MESH terms were used to identify studies pertinent to VTE in PAFs, including incidence, prophylaxis, and screening.

RESULTS

In total, 28 studies were identified and grouped into four categories including incidence, screening, prophylaxis, and the use of inferior vena cava filters (IVCFs). Incidence of VTE ranged from 0.21 to 41% for DVT and 0 to 21.7% for PE. Nine studies screened 1360 patients using different imaging modalities. Ten articles, 2836 patients, examined different thromboprophylaxis protocols. Two out of three studies investigating the use of IVCF showed significant reduction of the rates of PE.

CONCLUSION

Incidence of VTE in PAF varies significantly with different protocols. The current literature shows that screening is still controversial. The combination of chemical and mechanical prophylaxis starting at 24 hours from the injury would provide the best protection. Guidelines were extracted; however, higher level multicenter studies are still required to guide future protocols.

Analysis of high-risk factors for preoperative DVT in elderly patients with simple hip fractures and construction of a nomogram prediction model

BACKGROUND

Hip fractures are anatomically classified in relation to femoral neck, intertrochanteric or subtrochanteric fractures. Simple hip fractures discussed in this study are femoral neck fractures or intertrochanteric fractures, which are the most common types of hip fractures. Controversy remains regarding the value of biochemical indices of thrombosis in elderly patients with fractures. A retrospective study was conducted to investigate the index admission data in blood draws of elderly patients with hip fractures and their high-risk factors for deep venous thrombosis (DVT). A nomogram prediction model for DVT was established to facilitate a rapid, accurate, and effective prediction based on the results.

METHODS

The data were based on 562 elderly patients undergoing hip fracture surgery, from whom 274 patients were selected for enrollment. The 274 patients were divided into two groups using preoperative vascular color Doppler ultrasonography. Chi-square tests, t-tests, and U tests were conducted, and logistic regression analysis was conducted showing different factors between the two groups. Independent risk factors with statistical significance (P < 0.05) were obtained, and the logistic regression equation and the new variable prediction probability_1 (PRE_1) were constructed. The receiver operating characteristic (ROC) curve of risk factors and PRE_1 was drawn to obtain the area under the curve (AUC) and truncation value of each risk factor. Finally, a nomogram prediction model was constructed using the R programming language to calculate the concordance index (C-index).

RESULTS

Time from injury to hospitalization, platelet (PLT) count, D-dimer level, fibrinogen (FIB) level, and systemic immune-inflammatory index (SII) score were independent risk factors for preoperative DVT in elderly patients with hip fractures. The logistic regression equation and PRE_1 were constructed by combining the above factors. ROC analysis showed that the area under the curve for PRE_1 (AUC = 0.808) was greater than that of the other factors. The sensitivity of PRE_1 (sensitivity = 0.756) was also higher than that of the other factors, and the specificity of PRE_1 (specificity = 0.756) was higher than that of two other factors. Moreover, a predictive nomogram was established, and the results showed a high consistency between the actual probability and the predicted probability (C-index = 0.808), indicating a high predictive value in fractures accompanied by DVT.

CONCLUSIONS

This study confirmed that SII score could be used as a risk factor in the prediction of DVT occurrence. A nomogram prediction model was constructed by combining 5 independent risk factors: time from injury to admission, PLT count, D-dimer level, FIB level, and SII score, which had high predictive values for fractures accompanied by DVT. This model use is limited to simple hip fracture.

High Altitude as a Risk Factor for Venous Thromboembolism in Tibial Plateau Fractures

Background: Tibial plateau fractures are often significant injuries that can require complex surgical interventions with prolonged perioperative immobilization, thereby increasing the risk of developing venous thromboembolic (VTE) events, specifically, deep vein thrombosis (DVT) and pulmonary embolism (PE). Risk stratification is paramount for guiding VTE prophylaxis. Although high altitude has been suggested to create a prothrombotic state, virtually no studies have explored its clinical effects in lower extremity trauma. The purpose of this study was to compare surgical fixation of tibial plateau fractures at high and low altitudes and its effects on post-operative VTE development.

Methods: The Truven MarketScan claims database was used to retrospectively identify patients who underwent surgical fixation of isolated and closed tibial plateau fractures using Current Procedural Terminology (CPT) codes over a 10-year period. Extraneous injuries were excluded using the International Classification of Diseases, 10^th edition (ICD-10), and CPT codes. Patient demographics, comorbidities, and DVT chemoprophylaxis prescriptions were obtained. Patients were partitioned into high altitude (>4000 feet) or low altitude (<100 feet) cohorts based on the zip codes of their surgery locations. One-to-one matching and univariate analysis were used to assess and control any baseline discrepancies between cohorts; multivariate regression was then performed between cohorts to determine the odds ratios (OR) for developing VTEs post-operatively.

Results: There were 7,832 patients included for analysis. There was no statistical difference between high and low altitude cohorts in developing VTEs within 30 days post-operatively. Higher altitudes were associated with increased odds of developing DVT (OR 1.21, p = 0.043) and PE (OR 1.27, p = 0.037) within 90 days post-operatively.

Conclusions: Surgical fixation of tibial plateau fractures is associated with an increased risk of developing VTEs at high altitudes within 90 days post-operatively. Understanding such risk factors in specific orthopaedic patient populations is essential for optimizing DVT prophylaxis protocols. Further studies should investigate this relationship and the role of DVT prophylaxis regimens in this population. 

Incidence and Risk Factors of Venous Thromboembolism in Patients After Transurethral Resection of the Prostate (TURP)

Objective

Venous thromboembolism (VTE) in patients following transurethral resection of the prostate (TURP) has been overlooked for many years. This research was aimed to investigate the incidence and risk factors of VTE in patients after TURP.

Methods

A total of 451 patients who underwent TURP between January 2017 and December 2020 were retrospectively analyzed. Clinical data of the patients were collected, such as basic demographic data, prostate volume, creatinine values, hemoglobin values, surgery duration, Caprini score, international prostate symptom score (IPSS), quality of life (QOL) score, plasma D-dimer levels, and so on. Univariate analysis and multivariate logistic regression were performed to identify the potential risk factors of VTE. Venous ultrasonography of lower extremities was performed routinely to detect VTE for patients after TURP.

Results

In total, 36 (8%) out of the 451 patients suffered from VTE. A total of 12 (2.7%) patients were confirmed with deep venous thrombosis (DVT). Two patients (0.4%) were identified with pulmonary embolism (PE). Twenty-two (4.9%) patients were suffered from superficial venous thrombosis. Furthermore, according to the results of multivariate stepwise logistic regression analysis, having a history of VTE (adjusted odds ratio [aOR] = 10.980, 95% CI = 2.265–53.223), complicated with postoperative bladder hematoma (aOR = 6.302, 95% CI = 2.265–17.532), D-dimer >1.25 mg/L (aOR = 4.402, 95% CI = 1.798–10.774), and age >65 (aOR = 3.106, 95% CI = 1.084–8.893) were independent risk factors of VTE after TURP. In addition, the nomogram prediction model is a useful auxiliary prevention tool of VTE.

Conclusion

The incidence of VTE is severely underestimated in patients following TURP. A lot of asymptomatic VTEs have been overlooked. Early detection and diagnosis of VTE are essential. Nevertheless, further verifications based on the results of large-scaled studies are still needed.

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.

Assessment of deep vein thrombosis using routine pre- and postoperative duplex Doppler ultrasound in patients with pelvic trauma : a prospective study

AIMS

The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture.

METHODS

All patients treated surgically for a pelvic and/or acetabular fracture between October 2016 and January 2020 were enrolled into this prospective single-centre study. The demographic, medical, and surgical details of the patients were recorded. DVT screening of the lower limbs was routinely performed using DUS before and at six to ten days after surgery. CT angiography was used in patients who were suspected of having PE. Age-adjusted univariate and stepwise multiple logistic regression analysis were used to determine the association between explanatory variables and postoperative DVT.

RESULTS

A total of 191 patients were included. A DVT was found preoperatively in 12 patients (6.3%), of which six were proximal. A postoperative DVT was found in 42 patients (22%), of which 27 were proximal. Eight patients (4.2%) had a PE, which was secondary to a DVT in three. None of the 12 patients in whom a vena cava filter was implanted prophylactically had a PE. Multivariate logistic regression analysis indicated that the association with the need for spinal surgery (odds ratio (OR) 19.78 (95% confidence interval (CI) 1.12 to 348.08); p = 0.041), intramedullary nailing of a long bone fracture (OR 4.44 (95% CI 1.05 to 18.86); p = 0.043), an operating time > two hours (OR 3.28 (95% CI 1.09 to 9.88); p = 0.035), and additional trauma surgery (OR 3.1 (95% CI 1.03 to 9.45); p = 0.045) were statistically the most relevant independent predictors of a postoperative DVT.

CONCLUSION

The acknowledgement of the risk factors for the development of a DVT and their weight is crucial to set a threshold for the index of suspicion for this diagnosis by medical staff. We suggest the routine use of the DUS screening for DVT in patients with a pelvic and/or acetabular fracture before and six to ten days after surgery. Cite this article: Bone Joint J 2022;104-B(2):283-289.

Is Plating Fixation Through the Kocher–Langenbeck Approach for Associated Posterior Wall Fragment Indispensable in Both‐Column Acetabular Fractures?

Objective

Methods

Results

Conclusions

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.

Higher altitude leads to increased risk of venous thromboembolism after acetabular and pelvic ring injury

INTRODUCTION

There is a high post-operative incidence of venous thromboembolisms (VTEs), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE), in pelvic ring and acetabular fractures, and identification of risk factors for VTEs is crucial to decrease this highly morbid complication. High altitudes have a known physiological effect on the body that may predispose patients to developing VTEs in the postoperative period. The purpose of this study was to investigate the relationship between pelvic ring and acetabular fractures occurring at high altitudes and the development of postoperative VTEs.

METHODS

In this retrospective study, the Truven MarketScan claims database was used to identify patients who underwent surgical fixation of a pelvic ring and/or acetabular fracture from January 2009 to December 2018 using Current Procedural Terminology (CPT) codes. Patient characteristics, including medical comorbidities, were collected. The zip codes of where the surgeries took place were used to determine recovery altitude and patients were separated into either the high altitude (>4000 feet) or low altitude (<100 feet) cohorts. Chi-squared and multivariate analyses were performed to investigate the association between altitude and the development of VTE postoperatively.

RESULTS

In total, 68,923 patients were included for analysis. At 30-days postoperatively, a higher altitude was associated with increased odds of developing a PE (OR 1.47, p = 0.019). At 90-days postoperatively, a higher altitude was associated with increased odds of DVT (OR 1.24, p = 0.029) and PE (OR 1.63, p < 0.001).

CONCLUSION

Surgical fixation of pelvic ring and acetabular fractures performed at a higher altitude (>4,000feet) are associated with increased odds of developing a PE in the first 30 days as well as developing a DVT or PE at 90 days postoperatively. Future prospective studies are needed to further elucidate the causality of altitude on the development of postoperative VTEs.

The Incidence and Location of Deep Vein Thrombosis in Lower Extremity Fracture Patients Receiving Sequential Chemical Prophylaxis

To investigate the incidence and location of deep vein thrombosis (DVT) in patients with lower extremity fractures receiving pharmacological thromboprophylaxis with LMWH followed by rivaroxaban. All patients aged ≥18 years with lower extremity fractures were included in the study. Duplex ultrasonography (DUS) was performed in the lower extremities before and after surgery for DVT evaluation. According to the location, the DVT was divided into proximal, distal, and mixed thromboses. According to fracture location, patients were classified as having fractures proximal, around, and distal to the knee. All patients received sequential chemical prophylaxis. A total of 404 patients with a mean age of 44.2 ± 13.8 years were included. The incidence of DVT postoperatively was higher than that preoperatively and at 1 month postoperatively. Patients with fractures proximal and around the knee had higher DVT incidences detected on DUS postoperatively and at 1 month postoperatively. Most DVTs were located in the distal vein. DVT incidence and severity were the highest immediately after surgery. DVT incidence in fractures around and proximal to the knee increased after surgery and at 1 month postoperatively. Although with chemical thromboprophylaxis, distal DVT was the most variable during the early stage.

Analysis of perioperative risk factors for deep vein thrombosis in patients with femoral and pelvic fractures

Objective

Clinical characteristics, anticoagulant protocols, and risk factors of deep vein thrombosis (DVT) in patients with femoral and pelvic fractures were analyzed throughout the perioperative period to provide references for early identification and optimization of risk factors.

Methods

This was a retrospective study. A total of 569 patients undergoing surgery of femoral and pelvic fractures from May 2018 to December 2019 were included.

The clinical data including general conditions, trauma, surgery, anticoagulant protocols, and laboratory indexes were collected. According to the results of deep vein Doppler ultrasonography of the lower extremities, the patients were divided into non-DVT group and DVT group. Univariate analysis and multivariate logistic regression analysis were used to identify the independent risk factors of preoperative and postoperative DVT.

Results

The incidence of DVT was 40.25% and preoperative DVT was 26.71%, which was higher than the incidence of postoperative DVT of 17.22%. Most of them were thrombus on the affected side (60.26%) and distal thrombus (81.66%). The average time of DVT formation was 6.55 ± 0.47 days after trauma and 6.67 ± 0.48 days after surgery. Chronic obstructive pulmonary disease (COPD), anemia, hypoproteinemia, non-anticoagulation before surgery, delayed anticoagulation after trauma and admission, high-energy trauma, multiple injuries, drinking history, and advanced age were independent risk factors for perioperative DVT. The increased level of fibrinogen degradation products was an independent risk factor for preoperative DVT. These risk factors were identified to be independently associated with postoperative DVT, including intraoperative blood transfusion, postoperative blood transfusion, pulmonary infection, preoperative non-anticoagulation, postoperative delayed anticoagulation, preoperative waiting time > 7 days, operative time > 2 h, c-reactive protein, fibrinogen level, platelet count 1 day after surgery, c-reactive protein, fibrinogen, and hemoglobin levels 3 days after surgery, comminuted fracture.

Conclusions

At present, anticoagulation and other DVT prevention and treatment programs have not changed the current situation that the incidence of DVT is still high. Through the analysis of the risk factors of DVT throughout the perioperative period, optimizing the perioperative blood transfusion, preoperative lung disease, hypoproteinemia, anemia, inflammation, etc., and surgery as soon as possible after trauma may further reduce its incidence.

Guidelines for the prevention of venous thromboembolism in hospitalized patients with pelvi-acetabular trauma

BACKGROUND

Venous thromboembolism is a dreaded complication leading to increased morbidity and mortality in patients having pelvi-acetabular fractures.

OBJECTIVES

These evidence based guidelines aim to provide the decision making ability in the prevention of venous thromboembolism in patients with pelvi-acetabular trauma planned for operative or non operative treatment.

METHODS

The patients were subclassified into 5 categories. The PICO framework was used to devise research questions in each category. The systematic reviews were performed for each research question. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess outcomes of critical interest. The guideline panel consisting of expert members of different subspecialties, analyzed the evidence and made recommendations.

RESULTS

The guideline panel proposed 21 recommendations. There are five recommendations in category 1 to 3, two recommendations in category 4 and four recommendations in category 5.

CONCLUSION

In pelvi-acetabular fractures there is strong evidence to suggest that thromboprophylaxis should be given. It should be initiated as early as possible after control of hemorrhage. The chemical prophylaxis is the preferred mode and LMWH is the preferred agent of choice. The mechanical methods can be used as an adjunct. The routine prophylactic use of IVC filters is not recommended. However, the use of retrievable IVC filters in high risk patients with established VTE in preoperative period can be considered. The use of newer directly acting oral anticoagulants is gaining importance.

Incidence of DVT and PE after surgical reconstruction for pelvic and acetabular fractures: Does routine duplex scanning affect management?

BACKGROUND

Prevention and detection of thromboembolism with pelvic and acetabular fractures remains controversial. The aim of this study was to evaluate a protocol using LMWH prophylaxis and duplex screening both pre-operatively (if there is a delay > 72 h to surgery) and post-operatively at day 5-7. We assessed the incidence of thromboembolism and associated risk factors.

METHODS

A total of 255 consecutive patients who underwent pelvic and/or acetabular reconstruction in a major trauma and tertiary referral centre between January 2013 and December 2015 were studied. Forty-three patients were excluded due to non-adherence to protocol leaving 212 patients included in the study.

RESULTS

Patients were of mean age 49 years (15-94) and mean ISS 24.5 (4-66). Pre-operative screening detected two patients with asymptomatic above-knee DVT who then underwent pre-operative IVC filter insertion. Post-operative screening detected seven patients (3%) with lower limb DVTs (3 proximal and 4 below knee). The three patients with proximal DVTs were fully anticoagulated and did not develop symptomatic PE. Six patients (2.8%) developed post-operative PE, four of which were symptomatic and confirmed by CT angiography. Seven patients (3%) died in the post-operative period due to non-VTE-related causes. The overall rate of VTE was 6%, including DVT 4% and PE 2.8%. PE was associated with administration of tranexamic acid in ED (p > 0.03) and total amount of blood transfused during admission (p > 0.001). VTE was not associated with age, injury type, ISS, delay to surgery or associated injuries.

CONCLUSION

A protocol-based approach to VTE prophylaxis and screening in trauma patients with pelvic and/or acetabular reconstruction resulted in no VTE-related mortality. Pre- and post-operative screening for DVT changed the management in five patients, with none developing PE. Patients requiring more aggressive resuscitation had a higher rate of PE. The VTE rate was lower than previously reported.

An overview of the key principles and guidelines in the management of pelvic fractures

Pelvic fractures are complex injuries with a range of different presentations depending on the mechanism of trauma. Due to the morbidity and mortality of pelvic fractures, patients require thorough investigation and timely management with multidisciplinary input. Various surgical and non-surgical techniques can be used to treat pelvic fractures, as well as any associated visceral injuries. Following repair, it is important to remain vigilant for postoperative complications such as infection, sexual and urinary dysfunction, chronic pain and adverse psychological health. This article summarises the relevant UK guidance and literature and presents them in a format that follows the patient’s journey. In doing so, it highlights the key perioperative factors that need to be considered in cases of pelvic fracture.

Comparison of posterior ring fixation with combined anterior and posterior ring fixation for the treatment of lateral compression type 2 pelvic fractures

PURPOSE

The aim of surgical treatment for lateral compression type 2 (LC-2) pelvic fractures is to enable early mobilization and provide pain relief. Anterior and posterior ring fixation is usually performed simultaneously, with the goal of providing good biomechanical stability. However, it is unclear whether anterior ring fixation is necessary. This study therefore aimed to determine the feasibility of isolated posterior ring fixation for LC-2 pelvic fractures.

METHODS

Records of patients with LC-2 pelvic fractures were extracted from a medical database. Patients who underwent posterior pelvic ring fixation alone (PR fixation group) or anterior and posterior ring fixation (APR fixation group) were included. Patients' operative characteristics, time to clinical healing, length of hospital stay, time to weight bearing, and complications were recorded at follow-up. Radiography was used to assess healing and fracture displacement. Functional outcomes were evaluated using the Majeed grading system.

RESULTS

The PR fixation group included 44 patients, and the APR fixation group included 49 patients. Operative time, intra-operative blood loss, units of blood transfused, intra-operative fluid administered, and post-operative drainage were lower in the PR fixation group than in the APR fixation group. Length of hospital stay was also shorter in the PR fixation group than in the APR fixation group. Although the frequency (8/44) of fracture displacement in the superior ramus prior to union was high in the PR fixation group, no significant differences in time to weight bearing, time to clinical healing, or Majeed scores were found between the groups at follow-up.

CONCLUSIONS

Isolated posterior ring fixation for LC-2 pelvic fractures is feasible; patients who underwent treatment with this technique had functional outcomes similar to that of those who underwent anterior and posterior ring fixation.

Impact of a goal-directed factor-based coagulation management on thromboembolic events following major trauma

BACKGROUND

A factor-based coagulation management following major trauma is recommended as standard of care by the European Trauma Treatment Guidelines. However, concerns about the thromboembolic risk of this approach are still prevalent. Our study therefore aims to assess if such a haemostatic management is associated with an increased risk for thromboembolic events.

METHODS

In this retrospective observational study carried out at the University Hospital Zurich we compared two three-year periods before (period 1: 2005-2007) and after (period 2: 2012-2014) implementation of a factor-based coagulation algorithm. We included all adult patients following major trauma primarily admitted to the University Hospital Zurich. Thromboembolic events were defined as a new in-hospital appearance of any peripheral thrombosis, arterial embolism, pulmonary embolism, stroke or myocardial infarction. A logistic regression was performed to investigate the association of thromboembolic events with possible confounders such as age, sex, specific Abbreviated Injury Scale (AIS) subgroups, allogeneic blood products, and the coagulation management.

RESULTS

Out of 1138 patients, 772 met the inclusion criteria: 344 patients in period 1 and 428 patients in period 2. Thromboembolic events were present in 25 patients (7.3%) of period 1 and in 42 patients (9.8%) of period 2 (raw OR 1.39, 95% CI 0.83 to 2.33, p = 0.21). Only AIS extremities (adjusted OR 1.26, 95% CI 1.05 to 1.52, p = 0.015) and exposure to allogeneic blood products (adjusted OR 2.39, 95% CI 1.33 to 4.30, p = 0.004) were independently associated with thromboembolic events in the logistic regression, but the factor-based coagulation management was not (adjusted OR 1.60, 95% CI 0.90-2.86, p = 0.11).

CONCLUSION

There is no evidence that a goal-directed, factor-based coagulation management is associated with an increased risk for thromboembolic events following major trauma.

[Rate of thrombosis and bleeding after urological surgery under standardized anticoagulation]

BACKGROUND

According to the current definition of the German guideline for prevention of venous thromboembolism, urological surgery includes a high number of high-risk patients. All patients undergoing urological surgery between 2012 and 2016 were analyzed with regard to complications (bleeding or thrombosis).

MATERIALS AND METHODS

This study is a retrospective and monocentric cohort study. Included were all patients who underwent surgery between 2012 and 2016 at the Urological Department at the University Hospital of Luebeck. Information was collected relating to anticoagulation, patient-specific and surgery-specific risk factors, and complications.

RESULTS

In all, 3609 surgeries were analyzed: 77.8% of patients received no medical prophylaxis, 10.2% received an aggregation inhibitor, and 8.5% synthetic, unfractionated or low molecular weight heparin. Heparin was administered to 80.4% of patients after surgery. During an average hospital stay of 4.5 days, 93.3% of the patients received no change in anticoagulation. Merely 0.8% of all patients suffered from clinical thomboembolic events within 28 days. In contrast the number of bleedings was higher with 20.3% (minor: 4.8%, major: 15.5%).

CONCLUSION

We found a slight risk for postoperative thromboembolism (0.8%). The risk for postoperative bleeding in contrast was 20.3%, including 15.5% major bleedings. The results are discussed in relation to the current guidelines.