Do Prophylactic Inferior Vena Cava Filters Affect the Rates of Venous Thromboembolism and Pulmonary Embolism in Patients Undergoing Major Spine Surgery?

STUDY DESIGN: Retrospective Analysis. BACKGROUND: Venous thromboembolism (VTE) represents a significant cause of morbidity and mortality in major spine surgery. Placement of prophylactic inferior vena cava filters (IVCF) in patients undergoing major spine surgery was previously adopted at our institution. This study reports our experience and compares VTE rates between patients with and without preoperative IVCF placement. METHODS: A Retrospective comparative study was conducted on adult patients who underwent IVCF placement and those who did not prior to their spinal fusion procedure, between 2013 and 2016. Thoracolumbar fusions (anterior and/or posterior) of 7 or more levels, spinal osteotomies, and a minimum of a 3-month follow-up were included. Traumatic, oncologic, and cervical pathology were excluded. Primary outcomes measured included the incidence of overall VTE (DVT/PE), death, IVCF related complications, and IVCF retrieval. RESULTS: 386 patients who underwent major spine surgery, 258 met the eligibility criteria. Of those patients, 105 patients (40.7%) had prophylactic IVCF placement. All patients had postoperative SCDs and chemoprophylaxis. The presence of an IVCF was associated with an increased rate of overall VTE (14.3% vs 6.5%, P ≤ .05) and DVT episodes (8.6% vs 2.6%, P = .04). The rate of PE for the IVCF group and non-IVCF group was 8.6% and 4.6%, respectively, which was not statistically significant (P = .32). The all-cause mortality rate overall of 2.3% was statistically similar between both groups (P = 1.0). The IVCF group had higher rates of hematoma/seroma vs the non-IVCF group (12.4% vs 3.9%, P ≤ .05). 99 IVCFs were retrievable designs, and 85% were successfully retrieved. Overall IVCF-related complication rate was 11%. CONCLUSIONS: No statistical difference in PE or mortality rates existed between the IVCF and the control group. Patients with IVCF placement experienced approximately twice the rate of VTE and three times the rate of DVT compared to those without IVCF. The IVCF-related complication rate was 11%. Based on the results of this study, the authors recommend against the routine use of prophylactic IVCFs in adults undergoing major spine surgery. LEVEL OF EVIDENCE: III.

Stable fixation of short-stem femoral implants in patients 70 years and older.

BACKGROUND: Limitations of conventional uncemented femoral stems persist, including proximal-distal mismatch, nonideal load transfer, loss of bone, and difficulties with minimally invasive surgery. Metaphyseal-engaging short-stem implants have been designed to address these issues in THA. While these devices have been studied in younger patients, it is unclear whether they offer advantages in older patients. QUESTIONS/PURPOSES: We asked whether the stability and bony ingrowth of an off-the-shelf short stem in patients 70 years and older were similar to those achieved in patients younger than 70 years at 2-year followup. Furthermore, we asked whether pain and function scores were affected by age, bone quality, or varus alignment. PATIENTS AND METHODS: We retrospectively reviewed 60 patients (65 hips) 70 years and older (mean, 75 years; range, 70-86 years) treated with an uncemented short stem (range, 90-105 mm). We compared radiographic alignment, stability, and bony ingrowth, as well as Harris hip scores and WOMAC pain scores, to a cohort of 89 patients (91 hips) younger than 70 years. Minimum followup was 24 months (mean, 35 months; range, 24-60 months). RESULTS: Radiographs showed proximal bony ingrowth and stable fixation of all implants. Average Harris hip score at last followup was 88 (range, 70-100) for the 70 years and older cohort and 93 (range, 70-100) for younger than 70 years cohort; no patients reported thigh pain. Postoperative WOMAC scores averaged 6 (range, 0-43) and 5 (range, 0-25), respectively. CONCLUSIONS: Short-stem implants provide solid, dependable fixation in osteoporotic bone at minimum 2-year followup, while meeting some of the limitations in conventional primary THA. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Efficacy of preoperative home use of 2% chlorhexidine gluconate cloth before shoulder surgery.

HYPOTHESIS: Deep infection after shoulder surgery is a rare but devastating problem. This study tested the hypothesis that the home application of a 2% chlorhexidine gluconate cloth before shoulder surgery would be more efficacious than a standard shower of soap and water at decreasing the preoperative cutaneous levels of pathogenic bacteria on the shoulder. MATERIALS AND METHODS: This randomized, prospective study evaluated 100 consecutive patients undergoing shoulder surgery. Patients were randomly assigned to use 2% chlorhexidine gluconate-impregnated cloths (treatment group) or to shower with soap and water before surgery (control group). Cutaneous cultures were taken from the patients'shoulders in the preoperative holding area. Patients were monitored for 2 months postoperatively for clinical signs of infection. RESULTS: In the treatment group vs the control group, the overall positive culture rate was 66% vs 94% (P = .0008), and the positive culture rate for coagulase-negative Staphylococcus was 30% vs 70% (P = .0001). The positive culture rate for Propionibacterium acnes was 46% in the treatment group vs 58% in the control group (P = .32). No infections occurred in any patients at a minimum of 2-months after surgery. DISCUSSION: The use of the 2% chlorhexidine cloth was effective at decreasing overall bacterial culture rates before shoulder surgery and was particularly effective at decreasing the quantity of coagulase-negative Staphylococcus, a known causative agent of postoperative shoulder infections. CONCLUSION: Use of chlorhexidine impregnated cloths prior to shoulder surgery may be a useful adjunct to presently used infection prevention strategies.

Amide enolate additions to acylsilanes: in situ generation of unusual and stereoselective homoenolate equivalents.

The synthesis of beta-hydroxy carbonyl compounds is an important goal due to their prevalence in bioactive molecules. A novel approach to construct these structural motifs involves the multicomponent reaction of acylsilanes, amides, and electrophiles. The addition of amide enolates to acylsilanes generates beta-silyloxy homoenolate reactivity by undergoing a 1,2-Brook rearrangement. These unique nucleophiles formed in situ can then undergo addition to alkyl halides, aldehydes, ketones, and imines. The gamma-amino-beta-hydroxy amide products derived from the addition of these homoenolates to N-diphenylphosphinyl imines are generated with excellent diastereoselectivity (> or = 20:1) and can be efficiently converted to highly valuable gamma-lactams. Finally, the use of optically active amide enolates delivers beta-hydroxy amide products with high levels of diastereoselectivity (> or = 10:1).