Compliance to perioperative anticoagulation protocols in elderly patients undergoing elective orthopedic procedures: a retrospective observational cohort study on 548 patients.

BACKGROUND: Compliance with perioperative anticoagulation guidelines is essential to minimize bleeding and thromboembolic risks in patients undergoing surgery. Compared to vitamin-K antagonists (VKAs), perioperative management of direct oral anticoagulants (DOACs) contains fewer steps. Therefore, we hypothesized that noncompliance with guidelines in VKA users is higher than in DOAC users. The primary aim of our study was to investigate the difference in noncompliance to perioperative anticoagulant management guidelines between elderly patients using VKAs versus those using DOACs. The secondary aim was to determine the difference in occurrence of conflicting information communicated to the patients and the difference in incidence of coagulation-related adverse events. METHODS: This retrospective non-controlled observational cohort study examined elderly patients undergoing elective orthopedic surgery in a teaching hospital in the Netherlands. All patients undergoing elective orthopedic surgery between 1 May 2016 and 1 January 2020, aged 70 years and over, using VKAs or DOACs were selected. Nonelective surgeries were excluded. The primary outcome was the noncompliance to perioperative anticoagulant management guidelines. Secondary outcomes were missing or conflicting information on anticoagulation management communicated to the patient and coagulation-related adverse events. For continuous data, the unpaired T-test was used and for categorical data, the chi-square test. RESULTS: In patients using VKAs, noncompliance to one of the steps of perioperative anticoagulation management was 81%, compared to 55% in patients using DOACs (p < 0.001). In most cases, VKAs or DOACs were interrupted for longer than recommended. In 13% of patients using a VKA with perioperative bridging, bridging was not conducted as recommended in the guidelines. In 13% of patients using a DOAC, a low-molecular-weight heparin (LMWH) was prescribed while a DOAC had already been restarted postoperatively. VKA users received conflicting information about perioperative anticoagulation management more often than DOAC users (33% versus 20%; p < 0.001). No difference was seen in postoperative coagulation-related complications. CONCLUSION: Guidelines compliance in DOAC users is higher than in VKA users. Clinical decision support to help in selecting the right interruption interval in DOAC users, simplified standardized perioperative management, good coordination of instructions given to patients, and familiarity with updated guidelines are important in reducing noncompliance.

A simple surgical technique for correcting malunion after midshaft clavicle fracture.

Clavicle malunion occurs in two-thirds of all clavicle fractures treated conservatively. It can lead to pain, shoulder dysfunction and cosmetic complaints. Surgical treatment of all midshaft fractures will lead to overtreatment, as not all malunions are symptomatic. In the past, several treatment modalities for correcting malunion of the clavicle have been described, and all have been successful but none have shown superiority. This article describes a new surgical technique with excising a wedge to realign the clavicle malunion.

Fast track rehabilitation after reversed total shoulder arthroplasty: a protocol for an international multicentre prospective cohort study.

INTRODUCTION: The use of reversed total shoulder arthroplasty (rTSA) has increased because of an increasing number of indications for this procedure and by ageing of the population. Usual postoperative care consists of immobilisation of the shoulder for a period of 2-6 weeks to allow healing of the subscapularis tendon and protection of the joint. However, new literature proved that reattachment of the subscapularis tendon is unnecessary. Therefore we hypothesised that immobilisation of the shoulder is not necessary and patients can start safely with mobilisation on the first postoperative day. We expect this fast track protocol to be safe and result in better short-term and long-term functional outcomes. METHODS AND ANALYSIS: In our prospective cohort, we will include at least 75 patients aged 50 years and older indicated for rTSA, with acute fracture treatment as an exclusion criterion. Patients will be selected and operated in three hospitals: two in the Netherlands and one in Curacao.Patients will visit the outpatient clinic preoperative, at 6 weeks, 3 months and 1 year postoperative. The data that will be collected includes baseline characteristics, reason for surgery, complications and adverse events, patient reported outcomes (Oxford Shoulder Score, EuroQol-5D and Numeric Rating Scale for pain) and range of motion of the shoulder.All patients will be instructed to use a sling only for 1 day and to follow a progressive physiotherapy schedule for 12 weeks. The primary outcome is the occurrence of complications and adverse events. ETHICS AND DISSEMINATION: The Medical Ethics Committee from the VUmc and Curacao reviewed this study protocol and granted exemption from ethical approval (METC VUmc 2019.111, METC Curacao 2019-02). Study results will be presented at (inter)national conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL7656).

Long-term follow-up of conservatively treated midshaft clavicular fractures on functional outcome.

BACKGROUND: The aim of this study was to examine the long-term effect of shortening after a midshaft clavicular fracture on strength deficiency in the shoulder. METHOD: This study included 18 participants (14 males, 4 females) with a conservatively treated midshaft clavicular fracture. Mean age was 52.2 ±â€¯13.8 years, range 32-76 years). The mean follow-up time was 13.5 ±â€¯0.4 years. Participants filled in a QUICKDASH questionnaire and both clavicle lengths were measured using a caliper. The isometric strengths in internal rotation, external rotation and abduction of both arms were measured with a handheld dynamometer. RESULTS: Average shortening of the clavicle in this group was 1.09 cm (SD 0.53). Nearly all strength measurements showed no significant difference between the shortened and the unaffected side. Multiple regression revealed a small (3N per mm length difference) but statistically significant relationship on external rotation between the relative extent of shortening of the clavicle, dominant side of the fracture and the isometric force difference between the unaffected and affected arm, F(2,15) = 5.746, p < .05, adj. R2 = .358. Over 14 years there was a reduction in mean DASH-score of 4.4 (8.8 ±â€¯12.3; current DASH = 4.4 ±â€¯7.7)In this group, long term effects of clavicular shortening were small. Based on these results we conclude that on the long term clavicular shortening will not result in significant strength loss.

Humeral retroversion and shoulder muscle changes in infants with internal rotation contractures following brachial plexus birth palsy.

AIM: To examine humeral retroversion in infants who sustained brachial plexus birth palsy (BPBI) and suffered from an internal rotation contracture. Additionally, the role of the infraspinatus (IS) and subscapularis (SSc) muscles in the genesis of this bony deformation is explored. METHODS: Bilateral magnetic resonance imaging (MRI) scans of 35 infants (age range: 2-7 mo old) with BPBI were retrospectively analyzed. Retroversion was measured according to two proximal axes and one distal axis (transepicondylar axis). The proximal axes were: (1) the perpendicular line to the borders of the articular surface (humeral centerline); and (2) the longest diameter through the humeral head. Muscle cross-sectional areas of the IS and SSc muscles were measured on the MRI-slides representing the largest muscle belly. The difference in retroversion was correlated with the ratio of muscle-sizes and passive external rotation measurements. RESULTS: Retroversion on the involved side was significantly decreased, 1.0° vs 27.6° (1) and 8.5° vs 27.2° (2), (P < 0.01), as compared to the uninvolved side. The size of the SSc and IS muscles on the involved side was significantly decreased, 2.26 cm² vs 2.79 cm² and 1.53 cm² vs 2.19 cm², respectively (P < 0.05). Furthermore, the muscle ratio (SSc/IS) at the involved side was significantly smaller compared to the uninvolved side (P = 0.007). CONCLUSION: Even in our youngest patient population, humeral retroversion has a high likelihood of being decreased. Altered humeral retroversion warrants attention as a structural change in any child being evaluated for the treatment of an internal rotation contracture.