RESUMEN
BACKGROUND: Fragility fractures of the hip are known to be followed frequently by subsequent fragility fractures, including second hip fractures. Data on subsequent fractures are available for aggregated index femoral neck and intertrochanteric femoral fractures, grouped generically as hip fractures, but not specifically for femoral neck fractures. There is increasing recognition that a subsequent fracture often occurs early after a hip fracture in the elderly, creating an emphasis on the concept of "imminent fracture risk." Since 2000, there have been many reports on the care gap in interventions after a fragility fracture, with concern regarding the slow uptake of appropriate systemic treatments designed to prevent a subsequent fracture in high-risk patients. METHODS: As planned a priori, we performed an analysis of subsequent fractures after an index femoral neck fracture in 2 prospective clinical trials involving 2,520 patients from 90 sites on 5 continents. We recorded the incidence and time of occurrence of all secondary fragility fractures as well as the reported use of bone-protective medication in all subjects. RESULTS: In the 24 months following the index femoral neck fracture, 226 (9.0%) of 2,520 patients sustained at least 1 subsequent fragility fracture, including 113 hip fractures (4.5%). The median interval from the index fracture to a subsequent fracture was approximately 9.0 months. Only 25.2% (634) of the 2,520 patients reported using bone-protective medications at any time during follow-up. Female patients, those with nondisplaced index fractures, and those treated with arthroplasty, were more likely to have received protective medication. CONCLUSIONS: Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in 2 large global cohorts. Interventions to prevent a subsequent fracture were instituted in only 1 of 4 patients, even though a focused directive was included in both study protocols. LEVEL OF EVIDENCE: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Fracturas del Cuello Femoral , Fracturas de Cadera , Humanos , Femenino , Anciano , Fracturas del Cuello Femoral/etiología , Fracturas del Cuello Femoral/cirugía , Fracturas del Cuello Femoral/epidemiología , Estudios Prospectivos , IncidenciaRESUMEN
Femoral neck areal bone mineral density (FN aBMD) is a key determinant of fracture risk in older adults; however, the majority of individuals who have a hip fracture are not considered osteoporotic according to their FN aBMD. This study uses novel tools to investigate the characteristics of bone microarchitecture that underpin bone fragility. Recent hip fracture patients (n = 108, 77% female) were compared with sex- and age-matched controls (n = 216) using high-resolution peripheral quantitative computed tomography (HR-pQCT) imaging of the distal radius and tibia. Standard morphological analysis of bone microarchitecture, micro-finite element analysis, and recently developed techniques to identify void spaces in bone microarchitecture were performed to evaluate differences between hip fracture patients and controls. In addition, a new approach for phenotyping bone microarchitecture was implemented to evaluate whether hip fractures in males and females occur more often in certain bone phenotypes. Overall, hip fracture patients had notable deterioration of bone microarchitecture and reduced bone mineral density compared with controls, especially at weight-bearing sites (tibia and femoral neck). Hip fracture patients were more likely to have void spaces present at either site and had void spaces that were two to four times larger on average when compared with non-fractured controls (p < 0.01). Finally, bone phenotyping revealed that hip fractures were significantly associated with the low density phenotype (p < 0.01), with the majority of patients classified in this phenotype (69%). However, female and male hip fracture populations were distributed differently across the bone phenotype continuum. These findings highlight how HR-pQCT can provide insight into the underlying mechanisms of bone fragility by using information about bone phenotypes and identification of microarchitectural defects (void spaces). The added information suggests that HR-pQCT can have a beneficial role in assessing the severity of structural deterioration in bone that is associated with osteoporotic hip fractures. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
Asunto(s)
Fracturas de Cadera , Fracturas Osteoporóticas , Masculino , Femenino , Humanos , Densidad Ósea , Fracturas Osteoporóticas/diagnóstico por imagen , Radio (Anatomía) , Cuello Femoral/diagnóstico por imagen , Tibia , Fracturas de Cadera/diagnóstico por imagen , Fenotipo , Absorciometría de Fotón/métodosRESUMEN
Four-dimensional computed tomography (4DCT), or dynamic CT, is an emerging modality with a wealth of orthopedic applications for both clinical practice and research. This technology creates CT volumes of a moving structure at multiple time points to depict real-time motion. Recent advances in acquisition technology and reduction in radiation dosage have allowed for increased adoption of the modality and have made imaging of joint motion feasible and safe. Musculoskeletal 4DCT has been used primarily to investigate wrist motion; however, the utility of 4DCT has been shown in other areas, including the shoulder, elbow, hip, knee and ankle. Imaging these joints through a full range of motion provides new insight into dynamic phenomena such as instability, impingement and joint kinematics. Although 4DCT has not yet been widely adopted in orthopedic practice and research, future use has the potential to enable a deeper understanding of musculoskeletal conditions and to improve patient care.
Asunto(s)
Tomografía Computarizada Cuatridimensional , Articulación de la Muñeca , Tomografía Computarizada Cuatridimensional/métodos , HumanosRESUMEN
INTRODUCTION: Maintaining reduction after syndesmotic injury is crucial to patient function; however, malreduction remains common. Flexible suture button fixation may allow more physiologic motion of the syndesmosis compared with rigid screw fixation. Conventional syndesmotic imaging fails to account for physiologic syndesmotic motion with ankle range of motion (ROM), providing misleading results. Four-dimensional computerized tomography (4DCT) can image joints through a dynamic ROM. Our purpose was to compare syndesmotic motion after rigid and flexible fixation using 4DCT. METHODS: We analyzed 13 patients with syndesmotic injury who were randomized to receive rigid (n = 7) or flexible (n = 6) fixation. Patients underwent bilateral ankle 4DCT while moving between ankle dorsiflexion and plantar flexion. Measures of syndesmotic position and rotation were extracted from 4DCT to determine syndesmotic motion as a function of ankle ROM. RESULTS: Uninjured ankles demonstrated significant decreases in syndesmotic width of 1.0 mm with ankle plantar flexion (SD = 0.6 mm, P < 0.01). Initial rigid fixation demonstrated reduced motion compared with uninjured ankles in 4 of 5 measures (P < 0.01) despite all patients in the rigid fixation group having removed, loose, or broken screws by the time of imaging. Rigid fixation led to less motion than flexible fixation in 3 measures (P = 0.02-0.04). There were no observed differences in syndesmotic position or motion between flexible fixation and uninjured ankles. CONCLUSION: Despite the loss of fixation in all subjects in the rigid fixation group, initial rigid fixation led to significantly reduced syndesmotic motion. Flexible fixation recreated more physiologic motion compared with rigid fixation and may be used to reduce rates of syndesmotic malreduction. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Traumatismos del Tobillo , Traumatismos del Tobillo/diagnóstico por imagen , Traumatismos del Tobillo/cirugía , Articulación del Tobillo/diagnóstico por imagen , Articulación del Tobillo/cirugía , Tornillos Óseos , Fijación Interna de Fracturas/métodos , Humanos , Tomografía Computarizada por Rayos XRESUMEN
Background: Dual-plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating with small-fragment clavicle plates for biomechanical noninferiority and to determine if an optimal plate configuration could be identified using a cadaveric model. Methods: Twenty-four cadaveric clavicles were randomized to 1 of 6 groups, stratified by computed tomography-based bone mineral content (BMC): precontoured superior or anterior fixation using a single 3.5-mm Locking Compression Plate (LCP), and 4 different dual-plating constructs utilizing 2.4-mm and 2.7-mm Adaptation plates or LCPs. An inferior butterfly fracture was created. Axial, torsional, and bending (anterior and superior surface loading) stiffnesses were determined through nondestructive cyclic testing, followed by a load-to-failure test in 3-point superior surface bending. Results: For axial stiffness, the 2 dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either Adaptation or LCP) were significantly stiffer than the other 4 constructs (p = 0.021 and p = 0.034). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared with the 3.5-mm superior plate (p = 0.043). No significant differences were found in torsional stiffness or load to failure between the different constructs. Conclusions: Dual plating using mini-fragment plates is biomechanically superior for the fixation of midshaft clavicle fractures when compared with a single, superior, 3.5-mm plate and has biomechanical properties similar to those of a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual-plating constructs were compared with each other. Clinical Relevance: This study validates the use of dual plating for midshaft clavicle fractures.
RESUMEN
BACKGROUND: Orthopaedic injuries may lead to an increased incidence of intimate partner violence (IPV) during recovery as people dependent on others' help are at a higher risk for abuse. Additionally, there is a lack of understanding of how IPV affects injury recovery. In women being treated for an orthopaedic injury, we aimed to determine the number of new IPV disclosures in the 12 months after an injury and to explore the impact of IPV on recovery. METHODS: We enrolled 250 female participants from 6 orthopaedic fracture clinics in Canada, the Netherlands, Spain, and Finland. IPV disclosure and clinical outcomes were assessed at the initial visit and during the 12-month follow-up period. RESULTS: Of 250 participants, 81 (32.4% [95% confidence interval (CI), 26.6% to 38.2%]) had a history of IPV in their lifetime and disclosed this at their initial orthopaedic clinic appointment. Twenty-one participants (12.4% [95% CI, 7.5% to 17.8%]) who did not disclose abuse at the initial visit disclosed IPV during the follow-up. In our a priori unadjusted analysis, disclosure of IPV at the initial appointment or a subsequent follow-up appointment was associated with a 32% lower likelihood of returning to a pre-injury level of function with no restrictions regarding responsibilities at home (hazard ratio, 0.68 [95% CI, 0.46 to 0.99]; p = 0.046). Participants disclosing IPV had lower health-related quality of life on the EuroQol-5 Dimensions (EQ-5D) at the 6-month-follow-up, with adjusted mean differences of -5.3 (95% CI, -10.2 to -0.4, p = 0.04) for the visual analog scale and -0.06 (95% CI, -0.11 to -0.01; p = 0.02) for the Function Index. They also had lower Function Index scores at the final 12-month follow-up visit, with an adjusted mean difference of -0.06 (95% CI, -0.10 to -0.02; p = 0.006). CONCLUSIONS: A surprisingly high percentage of women disclosed IPV within 12 months after the injury. Our exploratory results suggest that women who disclose IPV may have lower health-related quality of life. This study supports the need to optimize orthopaedic clinics to provide appropriate support for asking about and assisting individuals who experienced IPV. Additional research is warranted to further explore these findings. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Fracturas Óseas , Violencia de Pareja , Ortopedia , Femenino , Fracturas Óseas/epidemiología , Humanos , Masculino , Estudios Prospectivos , Calidad de VidaRESUMEN
Posttraumatic joint contracture is a debilitating complication following an acute fracture or intra-articular injury that can lead to loss of motion and an inability to complete activities of daily living. In prior studies using an established in vivo model, we found that ketotifen fumarate (KF), a mast cell stabilizer, was associated with a significant reduction in the severity of posttraumatic joint contracture. Our primary research question in the current study was to determine whether a dose-response relationship exists between KF and posttraumatic joint contracture reduction. METHODS: A standardized operative method to create posttraumatic joint contracture in a knee was performed on skeletally mature New Zealand White rabbits. The animals were randomly assigned to 1 of 5 groups (n = 10 per group): a nonoperative control group, an operative control group, or 1 of 3 experimental KF groups (0.01 mg/kg [the KF 0.01 group], 0.1 mg/kg [KF 0.1], or 5.0 mg/kg [KF 5.0]). Flexion contractures were measured following 8 weeks of knee immobilization using a hydraulic material-testing machine. The posterior knee joint capsules were then harvested for quantification of myofibroblast and mast cell numbers with immunohistochemistry analysis. RESULTS: Forty-five rabbits were used in the final analysis. Contracture severity was significantly reduced in the KF 0.1 group (p = 0.016) and the KF 5.0 group (p = 0.001) compared with the operative control group. When converted to a percent response, posttraumatic joint contracture reduction was 13%, 45%, and 63% for the KF 0.01, KF 0.1, and KF 5.0 groups, respectively. A half-maximal effective concentration (EC50) for KF of 0.22 mg/kg was established. There was also a decrease in myofibroblasts, mast cells, and substance P-containing nerve fiber counts with increasing doses of KF. CONCLUSIONS: Using a preclinical, rabbit in vivo model of posttraumatic joint contracture, increasing doses of KF were associated with decreasing biomechanical estimates of knee posttraumatic joint contracture as well as decreasing numbers of myofibroblasts, mast cells, and substance P-containing nerve fibers. CLINICAL RELEVANCE: KF has been used safely in humans for more than 40 years and, to our knowledge, is the first and only agent ready to be potentially translated into an effective treatment for posttraumatic joint contracture.
RESUMEN
BACKGROUND: Patients undergoing a major orthopedic surgery for metastatic bone disease (MBD) are at high risk of developing venous thromboembolic (VTE) complications. Despite concerns, there is no consensus on the most effective strategy to prevent VTE in these patients. The purpose of this systematic review was to determine the VTE rate following the surgical management of MBD. METHODS: The databases MEDLINE, EMBASE, and CENTRAL were searched using keywords related to VTE and MBD requiring surgical management. Included studies reported VTE rates in patients with surgically managed MBD. Descriptive statistics and weighted mean totals were calculated. RESULTS: In total, 2082 abstracts were screened, and 29 studies were included. The overall VTE rate was 4.7%. Patients receiving surgery for impending pathologic fracture had a higher rate of VTE (5.6%) compared to patients with acute pathologic fractures (4.2%). Low-molecular-weight heparin was the most used chemoprophylaxis. CONCLUSIONS: Relative to other cancer and orthopedic patients, the VTE rate is extremely high in patients with MBD. The discordant recommendations of thromboprophylaxis, and absence of research in this distinct and more granular surgical oncology subgroup, underpins the challenges associated with developing guidelines to lessen the VTE risks in the MBD patient population.
Asunto(s)
Neoplasias Óseas/complicaciones , Fijación de Fractura/efectos adversos , Fracturas Espontáneas/cirugía , Tromboembolia Venosa/etiología , Anticoagulantes/uso terapéutico , Neoplasias Óseas/secundario , Fracturas Espontáneas/etiología , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Complicaciones Posoperatorias , Tromboembolia Venosa/prevención & controlRESUMEN
BACKGROUND: The syndesmosis ligament complex stabilizes the distal tibiofibular joint while allowing for small amounts of physiologic motion. When injured, malreduction of the syndesmosis is the most important factor that contributes to inferior functional outcomes. Syndesmotic reduction is a dynamic measure, which is not adequately captured by conventional computed tomography (CT). Four-dimensional CT (4DCT) can image joints as they move through range of motion (ROM). The aim of this study was to employ 4DCT to determine in vivo syndesmotic motion with ankle ROM in uninjured ankles. METHODS: Uninjured ankles were analyzed in patients who had contralateral syndesmotic injuries, as well as a cohort of healthy volunteers with bilateral uninjured ankles. Bilateral ankle 4DCT scans were performed as participants moved their ankles between maximal dorsiflexion and plantarflexion. Multiple measures of syndesmotic width, as well as sagittal translation and fibular rotation, were automatically extracted from 4DCT using a custom program to determine the change in syndesmotic position with ankle ROM. RESULTS: Fifty-eight ankles were analyzed. Measures of syndesmotic width decreased by 0.7 to 1.1 mm as the ankle moved from dorsiflexion to plantarflexion (P < .001 for each measure). The fibula externally rotated by 1.2 degrees with ankle ROM (P < .001), but there was no significant motion in the sagittal plane (P = .43). No participants with bilateral uninjured ankles had a side-to-side difference in syndesmotic width of 2 mm or greater. CONCLUSION: 4DCT allows accurate, in vivo syndesmotic measurements, which change with ankle ROM, confirming prior work that was limited to biomechanical studies. Side-to-side syndesmotic measurements are consistent within subjects, validating the method of templating syndesmotic reduction off the contralateral ankle, in a consistent ankle position, to achieve anatomic reduction of syndesmotic injury. LEVEL OF EVIDENCE: Level II, prospective cohort study.
Asunto(s)
Traumatismos del Tobillo , Tomografía Computarizada Cuatridimensional , Traumatismos del Tobillo/diagnóstico por imagen , Articulación del Tobillo/diagnóstico por imagen , Peroné/diagnóstico por imagen , Humanos , Estudios Prospectivos , Rango del Movimiento ArticularRESUMEN
INTRODUCTION: Open reduction and internal fixation (ORIF) of displaced midshaft clavicle fractures is associated with higher union rates and earlier functional recovery. However, ORIF with plate fixation is associated with complications including implant irritation and implant failure. Dual plate fixation provides fixation in orthogonal planes, and uses a lower profile fixation technique in comparison to pre-contoured and surgeon-contoured small-fragment locking plates, which may be more prominent. The objective of this study was to conduct a systematic review to summarize outcomes and complications associated with surgical fixation of displaced acute midshaft clavicle fractures with dual plate fixation. METHODS: Using a predetermined study protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the databases MEDLINE, EMBASE, and CENTRAL were searched from inception to 2020 to identify studies reporting outcomes in acute midshaft clavicle fractures treated with dual plate fixation. All clinical studies which reported on outcomes of dual plating in patients with acute midshaft clavicle fractures were included. Baseline demographics, plate fixation constructs, fracture union rates, implant removal rates, maintenance of reduction, symptomatic implant rates, wound complications, and functional outcomes were extracted. All extracted data were recorded, and descriptive statistics were summarized. Meta-analysis was performed on fracture union rates and implant removal rates using random-effects modeling using Mantel-Haenszel weighting. RESULTS: Our literature search identified 2226 unique abstracts, of which eight studies met our study inclusion criteria following review. A total of 278 patients made up of 79.8% male with an average age of 36.0 years were included. The overall dual plate implant removal rate was 4.2% with excellent rates of union reported. Moreover, single plate fixation was associated with a 3.9-fold increased implant removal rate compared to dual plate fixation. CONCLUSION: Results from this systematic review demonstrate that ORIF of displaced midshaft clavicle fractures using a dual plate fixation technique is a viable option to reduce the incidence of implant removal, without negatively impacting the rate of fracture union. LEVEL OF EVIDENCE: Therapeutic Level III.
RESUMEN
BACKGROUND: Patients undergoing an orthopedic surgery for bone or soft tissue sarcoma are at increased venous thromboembolism (VTE) risk. Unfortunately, there is a lack of thromboprophylaxis guidelines in this population. The purpose of this systematic review was to determine the soft tissue and bone sarcoma VTE rate and to explore the thromboprophylaxis regimens used. METHODS: The databases MEDLINE, EMBASE, and CENTRAL were queried using keywords related to VTE and long bone malignancy requiring surgical intervention to 2020. Included studied reported VTE rate in patients with surgically managed extremity sarcoma. Descriptive statistics and weighted mean totals were calculated. RESULTS: A total of 2082 studies were screened and 23 studies were included. The overall VTE rate was 2.9%, with a rate of 3.7% and 1.4% in patients with bone and soft tissue sarcomas, respectively. Low-molecular-weight heparin was the most commonly used chemoprophylaxis. CONCLUSIONS: There is a high VTE rate following sarcoma surgery. The VTE rate is higher in bone sarcoma surgery, which may be attributed to differences in surgery and postoperative recovery. There was no consensus on the duration or type of thromboprophylaxis used. Future research is needed to determine the most effective thromboprophylaxis regimen in patients with sarcoma and whether individualized thromboprophylaxis is required.
Asunto(s)
Neoplasias Óseas/cirugía , Procedimientos Ortopédicos/estadística & datos numéricos , Osteosarcoma/cirugía , Sarcoma/cirugía , Neoplasias de los Tejidos Blandos/cirugía , Tromboembolia Venosa/epidemiología , Neoplasias Óseas/epidemiología , Neoplasias Óseas/patología , Estudios de Casos y Controles , Extremidades/patología , Extremidades/cirugía , Humanos , Estudios Observacionales como Asunto , Procedimientos Ortopédicos/efectos adversos , Osteosarcoma/epidemiología , Osteosarcoma/patología , Ensayos Clínicos Controlados Aleatorios como Asunto , Sarcoma/epidemiología , Neoplasias de los Tejidos Blandos/epidemiología , Neoplasias de los Tejidos Blandos/patología , Tromboembolia Venosa/etiologíaRESUMEN
Bone strength determined from finite element (FE) modelling provides an estimate of fracture healing progression following a distal radius fracture (DRF), but how these measures relate to patient-reported outcomes and functional outcomes remains unknown. We hypothesized that changes in bone stiffness and bone mineral density measured using high-resolution peripheral quantitative computed tomography (HR-pQCT) are associated with clinically available measures of functional and patient-reported outcomes. We also aimed to identify which clinical outcome measures best predict fracture stiffness and could therefore be used to inform cast removal. Participants (n = 30) with stable distal radius fractures were followed for two week intervals from the time of fracture until two months post-fracture, then at three months and six months post-fracture. At each follow-up, participants underwent clinical, radiographic, and functional assessments, as well as had their fractured wrist scanned using HR-pQCT. Recovery of bone stiffness during fracture healing was determined from micro-FE (µFE) models generated from HR-pQCT image data. During the DRF healing process, significant longitudinal changes were found in µFE-estimated stiffness, patient-reported outcomes, grip strength, range of motion (ROM), tenderness, number of cortices healed based on radiographs, and fracture line visibility (p < 0.05); however, no significant change was detected in HR-pQCT based total bone mineral density. Patient-reported outcomes, such as the Patient-Rated Wrist Evaluation (PRWE) and the Quick Disability of the Arm, Shoulder and Hand (QuickDASH) questionnaire, correlated strongly with µFE-estimated stiffness (0.61 ≥ rm ≥ 0.66). Based on µFE-estimated stiffness, PRWE and QuickDASH are the best predictors of stiffness recovery (p < 0.05) and may be used to guide duration of cast immobilization in the clinical setting.
RESUMEN
AIMS: Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 14 October 2019 to identify studies directly comparing outcomes among hip fracture patients receiving direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) prior to hospital admission to hip fracture patients not on OACs. Random effects meta-analyses were used to pool all outcomes (TTS, in-hospital mortality, and 30-day mortality). RESULTS: A total of 34 studies (involving 39,446 patients) were included in our systematic review. TTS was 13.7 hours longer (95% confidence interval (CI) 9.8 to 17.5; p < 0.001) among hip fracture patients on OACs compared to those not on OACs. This translated to a three-fold higher odds of having surgery beyond the recommended 48 hours from admission (odds ratio (OR) 3.0 (95% CI 2.1 to 4.3); p = 0.001). In-hospital mortality was higher (OR 1.4 (95% CI 1.0 to 1.8); p < 0.03) among anticoagulated patients. Among studies comparing anticoagulants, there was no statistically significant difference in time-to-surgery between patients taking a DOAC compared to a VKA. CONCLUSION: Patients presenting with a hip fracture who were taking OACs prior to injury experience a delay in time-to-surgery and higher mortality than non-anticoagulated patients. Patients on DOACs may be at risk of further delays. Evaluating expedited surgical protocols in hip fracture patients on OACs is an urgent priority, with the potential to decrease morbidity and mortality in this group of high-risk patients. Cite this article: Bone Joint J 2021;103-B(2):222-233.
Asunto(s)
Anticoagulantes/uso terapéutico , Fijación de Fractura , Fracturas de Cadera/cirugía , Tromboembolia/tratamiento farmacológico , Tromboembolia/prevención & control , Tiempo de Tratamiento , Administración Oral , Fracturas de Cadera/complicaciones , Fracturas de Cadera/mortalidad , Humanos , Tromboembolia/complicaciones , Resultado del TratamientoRESUMEN
BACKGROUND: The primary objective of this study was to determine the incidence of symptomatic venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), in the hip fracture population. Secondary objectives included determining timing of VTE diagnosis, VTE thromboprophylaxis given, and identifying any factors associated with VTE. METHODS: Using data from the FAITH and HEALTH trials, the incidence of VTE, including DVT and PE, and the timing of VTE were determined. A multivariable Cox regression analysis was used to determine which factors were associated with increased risk of VTE, including age, treatment for comorbidity, thromboprophylaxis, time to surgery, and method of fracture management. RESULTS: 2520 hip fracture patients were included in the analysis. Sixty-four patients (2.5%) had a VTE [DVT: 36 (1.4%), PE: 28 (1.1%)]. Thirty-five (54.7%) were diagnosed less than 6 weeks postfracture and 29 (45.3%) more than 6 weeks postfracture. One thousand nine hundred ninety-three (79%) patients received thromboprophylaxis preoperatively and 2502 (99%) received thromboprophylaxis postoperatively. The most common method of preoperative (46%) and postoperative (73%) thromboprophylaxis was low molecular weight heparin. Treatment with arthroplasty compared to internal fixation was the only variable associated with increased risk of VTE (hazard ratio 2.67, P = 0.02). CONCLUSIONS: The incidence of symptomatic VTE in hip fracture patients recruited to the 2 trials was 2.5%. Although over half of the cases were diagnosed within 6 weeks of fracture, VTE is still prevalent after this period. The majority of patients received thromboprophylaxis. Treatment with arthroplasty rather than fixation was associated with increased incidence of VTE. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Fracturas de Cadera , Embolia Pulmonar , Tromboembolia Venosa , Anticoagulantes , Heparina de Bajo-Peso-Molecular , Fracturas de Cadera/cirugía , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Embolia Pulmonar/epidemiología , Embolia Pulmonar/prevención & control , Factores de Riesgo , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiología , Tromboembolia Venosa/etiologíaRESUMEN
OBJECTIVE: To assess the use of ketotifen fumarate (KF) to reduce posttraumatic contractures after elbow fractures and/or dislocations. DESIGN: Randomized clinical trial. SETTING: Three hospitals in Calgary, Canada, including one Level 1 trauma center. PARTICIPANTS: Adults (n = 151) sustaining operative or nonoperatively managed isolated distal humerus or proximal radius ± ulna fractures or elbow dislocations within 7 days of injury. INTERVENTIONS: KF 5 mg (n = 74) or lactose placebo (PL, n = 77) orally twice daily for 6 weeks. MAIN OUTCOMES: Primary outcome elbow flexion-extension arc range of motion (ROM) at 12 weeks postrandomization. Safety measures including serious adverse events and radiographic fracture line disappearance from 2 to 52 weeks postrandomization. RESULTS: The elbow ROM (mean, confidence interval) was not significantly different between KF (122 degrees, 118-127 degrees) and PL (124 degrees, 119-130 degrees) groups (P = 0.56). There was a significant difference in elbow ROM at 12 weeks postrandomization comparing operative (117 degrees, 112-122 degrees) versus nonoperative groups (128 degrees, 124-133 degrees) irrespective of intervention (P = 0.0011). There were 11 serious adverse events (KF = 6, PL = 5) that were those expected in an elbow fracture population potentially taking KF. There was no statistically significant difference in the rates of these events between the groups. The disappearance of fracture lines over the course of time was similar between groups. There was one nonunion in each group. CONCLUSIONS: In a population of operative and nonoperatively managed elbow fractures and/or dislocations KF did not reduce posttraumatic contractures. The administration of KF in this population was not found to result in a significantly higher number of major adverse events when compared with placebo. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Contractura , Articulación del Codo , Adulto , Canadá , Contractura/etiología , Contractura/prevención & control , Articulación del Codo/diagnóstico por imagen , Humanos , Cetotifen , Rango del Movimiento Articular , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Musculoskeletal (MSK) trauma is a major cause of disability and pain worldwide. Despite surgical advances following MSK injuries, poor functional outcomes following surgery remain a major public health concern. Traditional methods of rehabilitation involving bed rest and immobilization led to muscle weakness, joint stiffness, and an inability to return to previous levels of activity. Recent research has provided evidence that early rehabilitation with a multidisciplinary team can prevent these negative outcomes and improve functional outcomes following MSK trauma. In order to continue to optimize recovery, standardized rehabilitation protocols and technological advances are required.
Asunto(s)
Fracturas Óseas/rehabilitación , Dolor Musculoesquelético/rehabilitación , Sistema Musculoesquelético/lesiones , Humanos , Manejo del Dolor , Grupo de Atención al Paciente/organización & administración , Calidad de Vida , Recuperación de la Función , Resultado del TratamientoRESUMEN
CASE: We present a case of acute disseminated intravascular coagulation (DIC) after prophylactic femoral intramedullary stabilization in a patient with metastatic prostate cancer. Preoperative international normalized ratio of 1.4 was attributed to malnutrition, and the patient was not medically optimized. DIC developed 1 hour postoperatively and was managed with blood product resuscitation. At the 4-month follow-up, the patient presented with bilateral pulmonary emboli and was transitioned to palliative care. CONCLUSIONS: DIC after intramedullary stabilization in patients with metastatic bone disease is a rare condition with high mortality rate. Early recognition, blood product resuscitation, and involvement of appropriate subspecialty services are imperative in DIC management.
Asunto(s)
Neoplasias Óseas/cirugía , Coagulación Intravascular Diseminada/etiología , Fémur/cirugía , Fijación Intramedular de Fracturas/efectos adversos , Complicaciones Posoperatorias/etiología , Neoplasias de la Próstata/complicaciones , Anciano de 80 o más Años , Neoplasias Óseas/complicaciones , Neoplasias Óseas/secundario , Fémur/patología , Humanos , Masculino , Neoplasias de la Próstata/patologíaRESUMEN
BACKGROUND: Injuries and resulting stiffness around joints, especially the elbow, have huge psychological effects by reducing quality of life through interference with normal daily activities such as feeding, dressing, grooming, and reaching for objects. Over the last several years and through numerous research results, the myofibroblast-mast cell-neuropeptide axis of fibrosis had been implicated in post-traumatic joint contractures. Pre-clinical models and a pilot randomized clinical trial (RCT) demonstrated the feasibility and safety of using Ketotifen Fumarate (KF), a mast cell stabilizer to prevent elbow joint contractures. This study aims to evaluate the efficacy of KF in reducing joint contracture severity in adult participants with operately treated elbow fractures and/or dislocations. METHODS/DESIGN: A Phase III randomized, controlled, double-blinded multicentre trial with 3 parallel groups (KF 2 mg or 5 mg or lactose placebo twice daily orally for 6 weeks). The study population consist of adults who are at least 18 years old and within 7 days of injury. The types of injuries are distal humerus (AO/OTA type 13) and/or proximal ulna and/or proximal radius fractures (AO/OTA type 2 U1 and/or 2R1) and/or elbow dislocations (open fractures with or without nerve injury may be included). A stratified randomization scheme by hospital site will be used to assign eligible participants to the groups in a 1:1:1 ratio. The primary outcome is change in elbow flexion-extension range of motion (ROM) arc from baseline to 12 weeks post-randomization. The secondary outcomes are changes in ROM from baseline to 6, 24 & 52 weeks, PROMs at 2, 6, 12, 24 & 52 weeks and impact of KF on safety including serious adverse events and fracture healing. Descriptive analysis for all outcomes will be reported and ANCOVA be used to evaluate the efficacy KF over lactose placebo with respect to the improvement in ROM. DISCUSSION: The results of this study will provide evidence for the use of KF in reducing post-traumatic joint contractures and improving quality of life after joint injuries. TRIAL REGISTRATION: This study was prospectively registered (July 10, 2018) with ClinicalTrials.gov reference: NCT03582176.