Predisposing Factors for 30-Day Complications Following Leg Amputation

BACKGROUND

Although amputation rates, morbidity, and mortality have been established for select populations, the impact of general demographic factors on postoperative surgical complications remains little studied.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program database was searched for leg amputations from 2012 to 2017 using CPT codes 27881, 27882, 27884, and 27886, identifying 4162 patients. A total of 29 demographic variables with 4 complications (surgical infection, additional service, and deep-vein thrombosis [DVT], and sepsis) were analyzed.

RESULTS

Preoperative open, contaminated, or dirty/infected wounds; longer intraoperative times; development of sepsis prior to surgery; and admission of patients from home or another hospital influenced postoperative infection rates. Preoperative open, infected, or dirty/infected wounds; height; weight; total length of hospital stay; and ethnicity affected postoperative additional service incidence. Preoperative congestive heart failure, large decreases in body weight, and total length of hospital stay influenced postoperative DVT rates. Preoperative functional heath status, total length of hospital stay, amputations conducted as emergency cases, preoperative acute renal failure, open or infected wounds, sepsis, and contaminated or dirty/infected wounds affected postoperative sepsis rates.

BACKGROUND

Conclusion. Understanding these risk factors may allow providers to anticipate and address higher rates of complications in certain patient populations.

LEVEL OF EVIDENCE

Level III: Prognostic.

Thromboprophylaxis and Bleeding Complications in Orthopedic and Trauma Patients: A Systematic Review

This systematic review was conducted to investigate the effects of currently used chemoprophylactic modalities to assess concerns regarding their usage. Preventive benefits of thromboprophylaxis were weighed against potential complications in orthopedic and trauma patients. The Ovid MEDLINE® database was used to identify relevant studies. The authors independently screened the initial study articles by title and abstract, eliminating articles not dealing with venous thromboembolism (VTE) chemoprophylaxis in orthopedic or trauma populations. The remaining articles were assessed for eligibility through full-text analysis. The analyzed studies within this review suggested that Factor X_a inhibitors and direct oral anticoagulants hold promise as safe and potentially more effective thromboprophylactic entities when compared to low molecular weight heparin in trauma and orthopedic patients. Thromboprophylaxis had little to no effect on major bleeding incidence, although we could not definitively conclude there was no effect on overall bleeding. Early thromboprophylaxis, especially when identifiable risk factors are present, can improve VTE prevention without changing major bleeding rates. Additionally, we could not conclude whether extended prophylaxis affects VTE incidence, although it seemed to have no effect on major bleeding. Finally, we determined that thromboprophylaxis in the lower extremity trauma population is questionable without the presence of underlying risk factors.

Predisposing Factors for 30-Day Complications Following Achilles Tendon Repair

Certain risk factors for Achilles tendon repair complications, including tobacco use, diabetes mellitus, steroid use, and obesity, have been well-reviewed. This study analyzes the impact of a range of demographic factors on unique surgical complications within the 30-day postoperative period. We extracted data from the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2017 and searched for Achilles tendon repairs using CPT codes 27650, 27652, and 27654, identifying 4,040 patients. Twenty-two demographic variables and their association with each of 4 complications were analyzed using t tests or chi-squared tests. A logistic regression was conducted to determine independent risk factors for each outcome, based on results from the bivariate analyses. Variables having p <.2 on bivariate analysis were included in the multivariate analysis of the corresponding surgical complication. Patients with open or infected wounds preoperatively were more likely to return with a postoperative surgical infection (p< .001). Likewise, each additional year of the patient's age increased their likelihood of developing a surgical infection (p= .03). Patients with "clean/contaminated" wound sites prior to repair were more likely to return for an additional service (p= .02). Furthermore, each additional inch of the patient's height (p= .03) and every additional minute of operative time increased a patient's risk of developing a new-onset deep vein thrombosis (p= .01). This study offers providers a more complete picture of which preoperative characteristics affect Achilles tendon repair patients, directing management to reduce postoperative complication rates.

Tumefactive multiple sclerosis (TMS): A case series of this challenging variant of MS

BACKGROUND

Tumefactive MS is a rare variant of multiple sclerosis that poses a diagnostic and a therapeutic challenge due to its close resemblance to central nervous neoplasms on MRI. TMS is defined as acute large >2 cm, tumour like demyelinating lesion in the CNS that may occur with surrounding edema, mass effect and ring enhancement. Some of the known mimickers are CNS lymphoma, metastasis, primary brain tumour such as glioblastoma, brain abscesses. The prevalence of TMS is estimated to be 1-3/1000 cases. There are also reported cases of drug induced TMS cases especially with fingolimod and natalizumab therapy. We report the occurrence of tumefactive MS at our institution.

METHODS

We retrospectively reviewed the chart of the patients with multiple sclerosis including initial visits, hospitalizations, clinic follow up notes and collected data on demographic, ethnicity, presenting signs and symptoms, imaging modalities, cerebrospinal fluid analysis results, disease progression. After reviewing the charts, we isolated the patients with tumefactive multiple sclerosis from the group and summarized the cases. Four of these patients were managed with Glatiramer acetate, 2 on dimethyl fumarate and 1 on beta interferon with 0-2 clinical flare ups on subsequent years.

RESULTS

Out of 323 patients reviewed with multiple sclerosis or possible multiple sclerosis, 7 carried a diagnosis of tumefactive MS. The age range of these patients were 19 to 62 years old with 4 females and 3 males. Five patients were Caucasian and 2 were Hispanic. Out of seven patients, 6 were newly diagnosed MS following biopsy of the lesion. The histological findings in 3 patients who underwent biopsy demonstrated include reactive gliosis and inflammatory cells predominantly macrophages and lymphocytes while 1 patient showed hypercellular brain tissue with perineuronal satellosis.

CONCLUSION

Tumefactive MS remains a challenging disease to diagnosis and often times requires a biopsy for definitive diagnosis or to exclude neoplasms, other inflammatory conditions such as neurosarcoidosis. The demographic of the patients in this case series is no different than patients with relapsing remitting multiple sclerosis (RRMS). However, based on our experience, the patients with TMS do respond to disease modifying agents such as Glatiramer acetate and Dimethyl fumarate with similar progression as of RRMS.