Quantification and influencing factors of perioperative hidden blood loss during intramedullary fixation for intertrochanteric fractures in the elderly.

INTRODUCTION: We aimed to quantify perioperative hidden blood loss (HBL) and investigate its influencing factors in elderly patients with intertrochanteric fractures (IFs) undergoing intramedullary fixation surgery. MATERIALS AND METHODS: We prospectively collected the clinical data of 200 elderly patients with IFs treated with intramedullary fixation surgery in our hospital between December 1, 2014 and August 31, 2018. The intraoperative visible blood loss, blood transfusion rate, and pre- and postoperative hemoglobin (Hb) levels as well as the general characteristics of the enrolled patients were recorded. A multiple linear regression analysis model (stepwise) was used to identify independent factors affecting perioperative HBL. RESULTS: The mean perioperative HBL was 614.72 ± 368.14 mL, which accounted for 84.05% of the mean total perioperative blood loss (731.37 ± 391.50 mL). The mean preoperative HBL was 368.33 ± 325.57 mL, which accounted for 50.36% of the mean total perioperative blood loss. Patients with fracture types AO/OTA 31-A2.2 to A3.3 had more severe preoperative HBL (median 580.10 mL), and most of them developed mild-to-moderate anemia before the operation, and 27.63% of them received preoperative blood transfusion. Compared with patients operated within 5 days after injury, patients operated over 5 days had lower Hb value at admission (101.56 ± 19.49 vs. 107.28 ± 16.53; P = 0.026) and higher preoperative transfusion rate (25.84% vs. 9.01%; P = 0.001). Multiple linear regression analysis revealed that fracture types AO/OTA 31-A2.2 to A3.3, male sex, right-sided injury, and operation time > 60 min were independently associated with increased perioperative HBL. Tranexamic acid treatment was negatively correlated with perioperative HBL. CONCLUSION: IFs in elderly patients undergoing intramedullary fixation surgery were associated with significant perioperative HBL and anemia. Persistent HBL occurred before the operation and on the first few postoperative days. Surgeons should pay more attention to preoperative HBL in patients with fracture types AO/OTA 31-A2.2 to A3.3 and regularly measure Hb levels preoperatively to avoid anemia. Shortening preoperative time may helps to reduce preoperative blood loss.

Operative Versus Nonoperative Treatment for Displaced Intra-Articular Calcaneal Fractures: A Meta-Analysis of Randomized Controlled Trials.

The purpose of the present study was to perform an updated meta-analysis of the operative versus nonoperative treatment of displaced intra-articular calcaneal fractures in adults. We searched the Cochrane Library, MEDLINE, EMBASE, and Google Scholar for eligible studies. All published randomized controlled trials comparing operative with nonoperative treatment for displaced intra-articular calcaneal fractures were eligible. The meta-analysis was performed using RevMan, version 5.0, software. Seven studies assessing 824 patients were eligible for the meta-analysis. The pooled results indicated no significant differences between the 2 groups with regard to the functional results. The incidence of complications was 25.0% (80 of 319) in the operative group and 16.6% (55 of 330) in the nonoperative group (relative risk 1.53, 95% confidence interval 1.13 to 2.08; p = .006) with a significant difference. The rate of subtalar arthrodesis was significantly lower in the operative group than in the nonoperative group. The current evidence is still insufficient to ascertain whether operative treatment is superior to nonoperative treatment for displaced intra-articular calcaneal fractures. Operative treatment can reduce the risk of late subtalar arthrodesis but is associated with a greater risk of complications. The small sample size and the great heterogeneity of the included studies made it difficult to draw conclusions regarding some of the combined results. Furthermore, more high-quality, randomized controlled trials with long-term follow-up data on this issue are required to provide evidence for surgeons to make an informed decision.

Systematic review of cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures in older patients.

The purpose of this review was to assess the effectiveness and safety of cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures in older patients. We searched the Cochrane Library, MEDLINE and EMBASE for published randomized clinical trials comparing cemented with uncemented hemiarthroplasty for femoral neck fractures. Eight trials assessing 1,175 hips were eligible for meta-analysis. The pooled results showed that there was no significant difference between cemented and uncemented group with regard to the mortality, reoperation rates and postoperational complications. The overall incidence of residual pain at 1 year after operation was 23.6% in the cemented prosthesis and 34.4% in the uncemented, with significant difference (relative risk 0.69, 95% CI 0.53-0.90; P = 0.007; fixed-effect models).The available evidence suggested that compared with uncemented hemiarthroplasty, cemented hemiarthroplasty in treating the elderly with displaced femoral neck fractures was not associated with a higher risk of mortality, reoperation and complications but can reduce the risk of residual pain and provide better functional results.

Systematic review of patellar resurfacing in total knee arthroplasty.

Controversies existing over resurfacing the patella in total knee arthroplasty remain in the literature. The purpose of this review was to evaluate the effectiveness of resurfacing versus nonresurfacing the patella in total knee arthroplasty. We searched the Cochrane Library, MEDLINE and EMBASE for published randomised clinical trials relevant to patellar resurfacing. The relative risk of reoperation was significantly lower for the patellar resurfacing group than for the nonresurfacing group (relative risk 0.57, 95% confidence interval 0.38-0.84, P =0.004). The overall incidence of postoperative anterior knee pain of the 1,421 knees included was 12.9% in the patellar resurfacing group and 24.1% in the nonresurfacing group. The existing evidence indicates that patellar resurfacing can reduce the risk of reoperation with no improvement in postoperative knee function or patient satisfaction over total knee arthroplasty without patellar resurfacing. Whether it can decrease the incidence of anterior knee pain remains uncertain.

Efficacy and Safety of Tranexamic Acid for Controlling Bleeding During Surgical Treatment of Intertrochanteric Fragility Fracture with Proximal Femoral Nail Anti-rotation: A Randomized Controlled Trial.

BACKGROUND: Intertrochanteric fragility fracture (IFF) treated with proximal femoral nail anti-rotation (PFNA) is associated with significant hidden blood loss and high blood transfusion rate. The purpose of the present study was to evaluate the efficacy and safety of tranexamic acid (TXA) in reducing blood loss in these patients. MATERIALS AND METHODS: Consecutive eligible patients were recruited and randomly assigned to a TXA group or a control group. The TXA group received 15 mg/kg body weight of TXA intravenously 15 min before incision and the same dose 3 h later. The control group received 100 mL of saline intravenously 15 min before incision. The efficacy outcomes included the total perioperative blood loss, postoperative transfusion rate, postoperative hemoglobin level, and length of the hospital stay. The safety outcomes were the incidence of thrombotic events and the mortality rate within 6 weeks after surgery. RESULTS: We had 44 patients in the TXA group and 46 patients in the control group for the final analysis. The TXA group had significantly lower total perioperative blood loss than the control group (384.5 ± 366.3 mL vs. 566.2 ± 361.5 mL; P < 0.020). Postoperative transfusion rate was 15.9% in the TXA group versus 36.9% in the control group (P = 0.024). Each group had one patient with postoperative deep venous thrombosis. In the control group, three patients had cerebral infarction, and one patient died within 6 weeks after the operation. CONCLUSION: Intravenous TXA is effective in reducing total perioperative blood loss and transfusion rate in IFF treated with PFNA. No increased risk of thrombotic events was observed with the use of TXA; however, this study was underpowered for detecting this outcome. Further research is necessary before TXA can be recommended for high-risk patients.

[Case-control studies on locking plates and dynamic hip screw in treatment of intertrochanteric hip fractures].

OBJECTIVE: To explore the clinical effects of locking plates in the treatment of intertrochanteric hip fractures. METHODS: From February 2006 to December 2008,108 patients with intertrochanteric hip fractures treated with locking plate and DHS were retrospective analyzed. Fifty-one patients were treated with locking plates, including 23 males and 28 females, aged 45 to 86 years old (averaged 66.0 years old); and fifty-seven patients were treated with DHS, including 26 males and 31 females,aged 43 to 81 years old (averaged 64.1 years old). The outcome measures collected for statistical analysis on the following aspects: operative time, blood loss, drainage, healing time, complications and Harris scores. RESULTS: One hundred and eight patients were followed up ranging from 8 to 24 months (averaged 12.5 months). In locking plate group, the operative time was (87 +/- 14) minutes; blood loss was (367 +/- 213) ml; drainage was (63 +/- 14) ml; healing time was (11.9 +/- 3.4) weeks; 7 patients had complications; and the Harriss score was (85 +/- 6). While in DHS group, the operative time was (115 +/- 23) minutes; blood loss was (582 +/- 243) ml; drainage was (98 +/- 16) ml; healing time was (12.4 +/- 2.5) weeks; 9 patients had complications; and the Harriss score was (84 +/- 8). There were no significant differences in the healing time, complications and Harris scores between two groups (P > 0.05),but there were significant differences in the operative time,blood loss, drainage between two groups (P < 0.05). Comparing with DHS group, the locking plate group was of shorter operative time, fewer blood loss and drainage. CONCLUSION: Proximal femoral locking plate is simple, minimally invasive,stable fixation with fewer complications, and is an effective method for intertrochanteric hip fractures.