Admission Inflammation Markers Influence Long-term Mortality in Elderly Patients Undergoing Hip Fracture Surgery: A Retrospective Cohort Study.

OBJECTIVES: Hip fractures in elderly patients are associated with a high mortality rate. Most deaths associated with hip fracture result from complications after surgery. Recent studies suggest that some inflammation biomarkers may be useful to estimate excess mortality. This study aimed to investigate the prognostic value of admission inflammation biomarkers in elderly patients with hip fracture. METHODS: We reports on a retrospective study of elderly hip fracture patients admitted to a hospital in China between January 2015 and December 2019. A total of 1085 patients were included in the study, and their demographic and pre-operative characteristics were analyzed. The inflammation biomarkers included monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), and C-reactive protein (CRP) to albumin ratio (CAR). The predictive performance of NLR, MLR and CAR was assessed by receiver operating characteristics (ROC) curve analysis and the association between admission inflammation markers and mortality was evaluated by Cox proportional regression. RESULTS: The 30-day, 1-year, 2-year, and 4-year mortality were 1.6%, 11.5%, 21.4% and 48.9%, respectively. The optimal cut-off values of admission NLR, MLR and CAR for 1-year mortality were 7.28, 0.76, and 1.36. After adjusting the covariates, preoperative NLR ≥ 7.28 (HR = 1.419, 95% CI: 1.080-1.864, p = 0.012) were found to be only independent risk factors with 4-year all-cause mortality, the preoperative CAR ≥ 1.36 was independently associated with 1-year (HR = 1.700, 95% CI: 1.173-2.465, p = 0.005), 2 year (HR = 1.464, 95% CI: 1.107-1.936, p = 0.008), and 4-year (HR = 1.341, 95% CI: 1.057-1.700, p = 0.016) all-cause mortality, While age, CCI score, and low hemoglobin at admission were also risk factors for postoperative all-cause mortality. CONCLUSION: Admission CAR and NLR may be useful indicators for predicting the long-term mortality of elderly patients undergoing hip fracture surgery, and that more research is needed to validate these findings.

Improved Calculation Method of TAD for Intertrochanteric Fractures.

Purpose: To investigate the relative position of femur fixed screws using intramedullary systems for intertrochanteric fractures and to improve the accurate measurement method of the tip-to-apex distance (TAD) while providing a theoretical basis for the clinical treatment of such fractures. Methods: In the anteroposterior (AP) radiographs of the hip joint, the femoral neck axis through the femoral head geometry point was designated as the X-axis, while the line perpendicular to the X-axis passing through the femoral head geometry point was designated as the Y-axis. In the lateral radiographs of the hip joint, the line perpendicular to the X-axis passing through the femoral head geometry point was identified as the Z-axis. The head of the nail tip's location projected on the three axes was described as A AP, B in the AP radiographs; and A LAT, C in the lateral radiograph. The TAD was described as X AP and X LAT. The radius of the femoral head was D. All distance units were expressed in mm. Results: When the lateral projection angle was standardized, the A AP was equal to the A LAT, while the X AP 2=B 2+(D - A AP)2 and X LAT 2=C 2+(D - A LAT)2. When the lateral projection angle was not standardized, the value of C had no significant change; however, the (D - A LAT) value changed. Conclusions: The measurement value did not match the actual values of TAD when the lateral projection angle was not standardized, possibly leading to a misinterpretation during clinical work. The X LAT should be amended using the formula X LAT 2=C 2+(D - A AP)2.

Finite element analysis of new headless compression supporting screw for the treatment of unstable femoral neck fracture.

BACKGROUND: Femoral neck fracture is an unsolved challenge in orthopedics. The complication rate in particular is high. There remains a lack of consensus on the optimal choice of internal fixation for unstable femoral neck fracture. OBJECTIVE: The study aimed to develop a new headless compression supporting screw (HCSS) for the treatment of unstable foemoral neck fracture. METHODS: We designed a new HCSS and used a femoral neck fracture (Pauwels III fracture) model (left, fourth-generation composite, Sawbones) and three-dimensional finite element analysis to compare the biomechanical performance of HCSSs with that of cannulated compression screws (CCSs) for treatment of unstable femoral neck fracture. RESULTS: Maximum displacement, peak von Mises stress, peak strain, and rotation for the HCSS were smaller than those for the CCS. The stress was more widely distributed for the HCSS, whereas the stress was concentrated for the CCS. CONCLUSIONS: The HCSS resulted in better biomechanical stability than that from the CCS. For Pauwels III fractures the HCSS exhibits better resistance to shear forces and better support, providing a new clinical treatment.

The impact of perioperative glucose variability on outcomes after hip fracture.

ABSTRACT: Diabetes is considered an independent risk factor for hip fracture. In the present study, we evaluated whether perioperative glucose variability (GV) was a significant predictor of the outcomes of patients with diabetes after hip fracture.We analyzed the characteristics and outcomes of all patients with hip fractures admitted to our hospital between September 2008 and December 2012. Patients with diabetes were grouped into tertiles for GV, and multivariate survival analysis included age, sex, fracture type, mean fasting plasma glucose, and GV.Among the 1099 patients included in this study, 239 (21.7%) had diabetes. Patients with diabetes were more likely to develop infectious complications (5.4% vs 2.8%, P = .045), and experience mortality postoperatively (1 month: 5.5% vs 2.7%, P = .052; 12 months: 15.1% vs 8.7%, P = .006). The postoperative mortality rate was increased across the GV tertiles, and GV was an independent predictor of 1- and 12-month mortality after surgery.Patients with diabetes had poor prognoses after hip fracture. Perioperative GV is an independent predictor of mortality in patients with diabetes. Therefore, GV might be considered a valid additional parameter to consider in the management of these patients.

Multidirectional percutaneous drilling and autologous bone marrow injection for the treatment of femoral diaphyseal nonunions: a prospective interventional study.

BACKGROUND: To examine the outcomes of multidirectional percutaneous drilling and autologous concentrated bone marrow (BM) transplantation for atrophic femoral diaphyseal nonunion characterized by intact hardware and mechanical stability at the nonunion site. METHODS: Fourteen patients (22-63 years of age) were admitted to our hospital with atrophic femoral diaphyseal nonunion. All patients were treated with a combination of multidirectional percutaneous drilling and autologous concentrated BM transplantation. Radiographic evaluation was conducted every month after transplantation until bone healing was achieved. RESULTS: Bony union was achieved in 13 of the 14 patients (92.9%) after an average of 3.9 months (range: 2.5-6 months). The average radiographic union scale in tibial (RUST) scale score improved significantly from the preoperative period (6.15±1.21) to follow-up (11.23±0.73; P<0.05). The mean follow-up after transplantation was 31.4±9.5 months (range: 18-50 months). At the final follow-up, the quality of function had improved significantly, allowing a return to normal activities. CONCLUSION: Combined multidirectional percutaneous drilling and autologous concentrated BM transplantation is an easy, safe, inexpensive, and efficacious method to treat atrophic femoral diaphyseal nonunion characterized by intact hardware and mechanical stability at the nonunion site.Trial registration number: ISRCTN29808592.

Effect of cervus and cucumis polypeptide combined with zoledronic acid on bone metabolic biochemical markers in glucocorticoids - Induced osteoporosis patients.

OBJECTIVE: To investigate the effect of cervus and cucumis polypeptide combined with zoledronic acid on bone metabolic biochemical markers in glucocorticoids - induced osteoporosis patients. METHODS: A total of 100 patients with glucocorticoids - induced osteoporosis admitted to our hospital from January 2015 to June 2017 were enrolled in this study. Patients were divided into observation group and control group by random number table method, 50 cases in each group. Patients in the observation group were treated with deer melon polypeptide in combination with zoledronic acid, and patients in the control group were treated with zoledronic acid alone. The patients in both groups were treated for 2 months. The changes of bone mineral density (BMD) and biochemical markers of bone metabolism in lumbar vertebrae L1-4, left femoral neck and large trochanter were analyzed before and after treatment. RESULTS: The pre- BMD at lumbar spine L1-4, left femoral neck and great trochanter had no statistic difference (P > 0.05), the BMD at each sites improved after treatment, and the difference were statistical before and after treatment (P < 0.05). BMD at above sites of two groups after treatment had statistical difference (P < 0.05), and the BMD at lumbar spine L1-4, left femoral neck and great trochanter in the observation group was higher than that of the control group. There were no significant differences in PTH, 25-(OH)D3, TRACP, ß-CTX and BGP levels between the two groups before treatment (P > 0.05). The levels of 25-(OH)D3, TRACP, ß-CTX and BGP in the two groups were significantly improved after treatment (P < 0.05), and the levels of PTH, TRACP and ß-CTX in the observation group were significantly lower than those in the control group. The levels of 25-(OH) D3 and BGP were significantly higher than those of the control group (P < 0.05). CONCLUSION: The cervus and cucumis polypeptide combined with zoledronic acid can improve the BMD at lumbar spine L1-4, left femoral neck and great trochanter, and ameliorate the bone metabolic biochemical markers for patients with glucocorticoids - induced osteoporosis.

A sequential delivery system employing the synergism of EPO and NGF promotes sciatic nerve repair.

The different mechanisms of nerve growth factor (NGF) and erythropoietin (EPO) in promoting repair of peripheral nerve injuries suggest a potential therapeutic application through the synergism of the two. Yet NGF has also been reported to induce early nerve apoptosis after injury. To utilize the potential synergism of NGF and EPO while minimize the possible defect, in this study, we first confirmed the time dependency of NGF caused nerve apoptosis, and then established a sequential and sustained delivery system for NGF and EPO with poly(lactide-co-glycolide) (PLGA), which has been approved by the US FDA for human use because of its injectable, biocompatible, and biodegradable properties. EPO was encapsulated in PLGA-microspheres (MS) for sustained releasing, while NGF was encapsulated in BSA-incorporated PLGA (B-PLGA) MS to postpone its release. In rat model of sciatic nerve injury, co-delivery of EPO/PLGA-MS and NGF/B-PLGA-MS resulted in significant nerve recovery. Hopefully, this sequential delivery system could provide a new therapeutic strategy for peripheral never injury.

Analysis of the independent risk factors of neurologic deficit after thoracolumbar burst fracture.

BACKGROUND: The objective of this study is to identify the independent risk factors of neurologic deficit after thoracolumbar burst fracture. Traumatic fractures of the thoracolumbar spine are the most common type of spinal column fractures. Many studies have attempted to determine whether neurologic deficit in such fractures is related to spinal canal stenosis or other parameters observed on axial computed tomography. However, this relationship remains controversial. METHODS: A review of the clinical data and axial computed tomography (CT) for 105 patients was performed. Neurologic deficit was classified according to the American Spinal Injury Association (ASIA) classification. Various preoperative CT parameters, including vertebral body compression, canal stenosis, sagittal alignment, and fragment reverse, were analyzed using ordinal logistic regression analysis. RESULTS: Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, canal volume, transverse canal diameter, median sagittal diameter, Cobb angle, compression ratio of the sagittal diameter, compression ratio of the cross-sectional area, and compression ratios of the anterior vertebral height (AVH), middle vertebral height (MVH), and posterior vertebral height (PVH) were significantly associated with severity of nerve injury (P < 0.05). However, flip angle and rotation angle of bony fragments were unrelated to severity of nerve damage. Multivariate logistic regression identified AO classification, compression ratio of median sagittal diameter, anterior vertebral compression ratio, and distance from the posterior margin to the vertebral body above to be independent variables associated with neurologic deficit. CONCLUSIONS: The four CT parameters most strongly associated with neurologic deficit in thoracolumbar burst fractures are AO classification, compression ratio of median sagittal diameter, anterior vertebral compression ratio, and distance from the posterior margin to the vertebral body above.

The compliance of thromboprophylaxis affects the risk of venous thromboembolism in patients undergoing hip fracture surgery.

OBJECTIVE: Venous thromboembolism (VTE) is major problem after hip fracture surgery with substantial morbidity and mortality. This study aimed to assess the postoperative compliance of thromboprophylaxis in elderly patients undergoing hip fracture surgery and to confirm the correlation between compliance and VTE risk. METHODS: This retrospective cohort study included consecutive elderly hip fracture patients who undergoing surgery. According to the thromboprophylaxis regimens, patients were divided into non-compliant group (<14days), poor compliant group (14-27days) and good compliant group (≥28days). The primary outcome was the incidence of symptomatic DVT, PE within 6weeks postoperatively. RESULTS: Between 2008 and 2012, 1214 eligible patients were included in this study. 761 (64.7%) patients were non-compliant, 224 (19.0%) patients were poor compliant, and 192 (16.3%) patients were good compliant. The overall VTE rate was 7.9% (73/1177), PE rate was 0.3% (4/1177). The VTE rate in good compliant group was lowest among three groups (4.2 vs. 5.4 vs. 9.6%, P=0.013), but the PE rates showed no significant differences (0 vs. 0.9 vs. 0.3%, P=0.241). The multivariate analysis showed that non-compliance was an independent risk factor of suffering VTE undergoing hip fracture surgery. CONCLUSIONS: In this study we found fewer than 1 in 5 patients maintained compliant with thromboprophylaxis guidelines after discharge following hip surgery. This is particularly concerning because those who were non-compliant had a higher risk of VTE postoperatively compared with those who were good compliant.

Anemia on Admission Is an Independent Predictor of Long-Term Mortality in Hip Fracture Population: A Prospective Study With 2-Year Follow-Up.

Anemia is a disputable factor for long-term mortality in hip fracture population in previous studies. Previous studies indicated that the level of hemoglobin (Hb) might fluctuate due to various factors, such as comorbidities and in-hospital interventions, and the changing level of Hb, may lead to discordance diagnosis of anemia and thus to the conflicting conclusions on prognostic value of anemia. So in this study, we aim to compare factors affecting the diagnosis of anemia at different time-points, admission, postoperation, and discharge, and to determine which the time point is most suitable for mortality prediction.This prospective cohort study included 1330 hip fracture patients from 1 January 2000 to 18 November 2012. Hb levels at 3 different time points, such as admission, postoperation, and discharge, were collected and used to stratify the cohort into anemia and nonanemia groups. Candidate factors including commodities, perioperative factors, blood transfusion, and other in-hospital interventions were collected before discharge. Logistic regression analyses were performed to detect risk factors for anemia for the 3 time points separately. Kaplan-Meier and multivariate Cox regression analyses were used to evaluate the association between anemia and 2-year mortality.Factors affecting the diagnosis of anemia were different for the 3 time points. Age, female sex, American Society of Anesthesiologists score (ASA), and intertrochanteric fracture were associated with admission anemia, while surgical procedure, surgical duration, blood transfusion, blood loss during the operation, and drainage volume were major risk factors for postoperation anemia. Cox proportional-hazards regression analysis suggested that the risk of all-cause mortality was higher in the anemia group on admission (1.680, 95%CI: 1.201-2.350, P < 0.01), but not postoperation or on discharge, after adjustment for confounding factors.Our study showed that risk factors for anemia varied at different time points, and therapy interventions would greatly affect the status of postoperation and discharge anemia in hip fracture patients. The take-home message is when anemia is used for mortality prediction in these patients, a specific time point should be chosen. We suggest that only admission anemia should be used for mortality prediction, but not postoperation nor discharge anemia.

Red Cell Distribution Width as an Independent Predictor of Long-Term Mortality in Hip Fracture Patients: A Prospective Cohort Study.

Red blood cell distribution width (RDW) has been found to be a significant prognostic factor of mortality in many cardiovascular diseases. However, a link between RDW at admission with long-term mortality in the hip fracture population has not been well established. Therefore, we sought to evaluate the long-term prognostic value of RDW in a well-defined hip fracture cohort, and to compare the effect of RDW in patients with and without anemia. A prospective cohort study was performed on 1479 hip fracture patients admitted at the General Hospital of Chinese PLA between January 2000 and October 2011 with a follow-up study over a 2-year period. A total of 1479 patients were used for the evaluation of 2-year all-cause mortality, while 804 patients with more than 4 years of follow-up were extracted for further evaluation of 4-year all-cause mortality. Cox proportional regression was used to evaluate the association between admission RDW and long-term mortality, adjusting for potential confounding variables. Higher RDW values were strongly associated with increased all-cause mortality. After adjusting for age, mean corpuscular volume, admission hemoglobin, comorbidities, and complications, RDW had a significant independent association with both 2-year mortality with a hazard ratio (HR) of 1.183 (95% confidence interval [CI], 1.017 to 1.376) and 4-year mortality with an HR of 1.244 (95% CI, 1.052 to 1.471). In stratified analysis, the effect of RDW was even more pronounced, with 2-year mortality HR of 1.341 (95% CI, 1.095 to 1.643) and 4-year mortality HR of 1.345 (95% CI, 1.071 to 1.688) in non-anemic patients. In non-anemic patients, elevated RDW values are significantly associated with increased odds of all-cause mortality, implying that RDW may be a possible laboratory biomarker for risk stratification in non-anemic hip fracture patients. Further studies are needed to confirm the current finding in different and larger hip fracture cohorts.

Three-Dimensional Analysis of the Curvature of the Femoral Canal in 426 Chinese Femurs.

PURPOSE: The human femur has long been considered to have an anatomical anterior curvature in the sagittal plane. We established a new method to evaluate the femoral curvature in three-dimensional (3D) space and reveal its influencing factors in Chinese population. METHODS: 3D models of 426 femurs and the medullary canal were constructed using Mimics software. We standardized the positions of all femurs using 3ds Max software. After measuring the anatomical parameters, including the radius of femoral curvature (RFC) and banking angle, of the femurs using the established femur-specific coordinate system, we analyzed and determined the relationships between the anatomical parameters of the femur and the general characteristics of the population. RESULTS: Pearson's correlation analyses showed that there were positive correlations between the RFC and height (r = 0.339, p < 0.001) and the femoral length and RFC (r = 0.369, p < 0.001) and a negative correlation between the femoral length and banking angle (r = -0.223, p < 0.001). Stepwise linear regression analyses showed that the most relevant factors for the RFC and banking angle were the femoral length and gender, respectively. CONCLUSIONS: This study concluded that the banking angle of the femur was significantly larger in female than in male.

[Treatment of clavicular fractures using intramedullary nailing or K-wire versus plating fixation: a meta-analysis].

OBJECTIVE: TFo compare the efficacy and complications rate of intramedullary (IM) nailing or K-wire versus plating fixation for clavicular fractures. METHODS: Pubmed, Embase, Cochrane Library databases, CNKI, VIP and Wangfang databases were searched to find all randomized or quasi-randomized controlled trials of clavicle fractures using plating versus IM nailing or K-wire. The methodologic quality of the studies was assessed. After independent study selection by 2 authors ,data were collected and extracted independently. Outcomes of postoperative shoulder functional measurement, the efficacy and information of the operation and complications rate were meta-analyzed using RevMan 5 software. RESULTS: Nine hundreds and seventy-six patients in 10 randomized controlled trials (RCTs) and 3 quasi-RCTs were involved in the meta-analysis,of which 5 studies compared the K-wire and the plating fixations and 8 studies compared the IM nailing and the plating fixations. The overall odds ratio(OR) (with 95% CI) of the operation efficacy for K-wire versus the plating was 3.79 (1.93, 7.46). The overall weighted mean difference (with 95% CI) of Constant Shoulder score for plating versus IM fixation was -1.39 (-3.43, 0.65) in 6 studies. The overall OR of the plating versus IM nailing was 9.34(2.70, 32.32) for the overall major complications in 5 studies and 5.04 (1.52,16.77) for the revision rate in 5 studies. CONCLUSION: The current limited evidences suggested that the IM fixation could reduce the incidences of the overall major complications and the revision surgery, while the post-operative efficacy of the plating was superior to the K-wire. More high quality RCTs are still needed in the future.

Selective oxidative degradation of toluene for the recovery of surfactant by an electro/Fe²âº/persulfate process.

An electro/Fe(2+)/persulfate process has been conducted for toluene removal from surfactant (SDS) flushing solution, and the pseudo-second-order reaction rate constant (k2 value) of toluene removal has been optimized by a response surface methodology (RSM). The results indicated that in this process, the reaction between persulfate and externally added Fe(2+) generates sulfate-free radicals, and at the same time, Fe(2+) is electro-regenerated at the cathode by the reduction of Fe(3+). RSM based on Box-Behnken design (BBD) has been applied to analyze the experimental variables, of which the concentrations of persulfate and Fe(2+) showed a positive effect on the rate constant of toluene removal, whereas the concentration of SDS showed a negative effect. The interactions between pairs of variables proved to be significant, such as between SDS, persulfate, and Fe(2+) concentrations. ANOVA results confirmed that the proposed models were accurate and reliable for analysis of the variables of the electro/Fe(2+)/persulfate process. The shapes of the 3D response surfaces and contour plots showed that the SDS, persulfate, and Fe(2+) concentrations substantially affected the k2 value of toluene removal. The results indicated that increasing persulfate or Fe(2+) concentration increased the k2 value, whereas increasing SDS concentration decreased the k2 value. The reaction intermediates have been identified by GC-MS, and a plausible degradation pathway for toluene degradation is proposed.

Localized and sustained delivery of erythropoietin from PLGA microspheres promotes functional recovery and nerve regeneration in peripheral nerve injury.

Erythropoietin (EPO) has been demonstrated to exert neuroprotective effects on peripheral nerve injury recovery. Though daily intraperitoneal injection of EPO during a long period of time was effective, it was a tedious procedure. In addition, only limited amount of EPO could reach the injury sites by general administration, and free EPO is easily degraded in vivo. In this study, we encapsulated EPO in poly(lactide-co-glycolide) (PLGA) microspheres. Both in vitro and in vivo release assays showed that the EPO-PLGA microspheres allowed sustained release of EPO within a period of two weeks. After administration of such EPO-PLGA microspheres, the peripheral nerve injured rats had significantly better recovery compared with those which received daily intraperitoneal injection of EPO, empty PLGA microspheres, or saline treatments. This was supported by the functional, electrophysiological, and histological evaluations of the recovery done at week 8 postoperatively. We conclude that sustained delivery of EPO could be achieved by using EPO-PLGA microspheres, and such delivery method could further enhance the recovery function of EPO in nerve injury recovery.

Systematic reviews on reports of hip fractures in Web of Science: a bibliometric analysis of publication activity.

BACKGROUND: The objective of this study was to analyze the trend in the publication of systematic reviews on hip fractures through a bibliometric approach. METHODS: Literature including systematic reviews or meta-analyses on hip fractures was searched from the ISI Web of Science citation database. The search results were analyzed in terms of geographical authorship and frequency of citation by country, institution, author, and periodical distribution. RESULTS: A total of 654 published systematic reviews from 1995 to 2013 in 48 countries or regions were retrieved. The United States (171) was the predominant country in terms of the number of total publications, followed by the United Kingdom (149), Canada (120), Australia (76), and China (54). The number of systematic reviews significantly increased during the last 6 years, especially in China. The production ranking changed in 2012, at which time the United States and China were the leaders in the yearly production of systematic reviews on hip fractures. The amount of literature (27 publications) from China contributed almost one-quarter of the total literature (109 publications) in 2012. However, the average number of citations of each article from China was still low (6.70), while the highest number of citations of each article was from Sweden (193.36). The references were published in 239 different journals, with 15 journals contributing to 41.3% of the systematic reviews on hip fractures. The two journals that contributed the most were Osteoporosis International (10.6%) and the Cochrane Database of Systematic Reviews (7.6%). The predominant institution in terms of the number of publications was McMaster University (36) in Canada. CONCLUSIONS: The best evidence in the field of hip fractures has attracted increasing attention. Systematic reviews on hip fractures from China have been increasingly more frequent during the past 6 years, particularly in 2012.

[Risk factors of hidden blood loss in internal fixation of intertrochanteric fracture].

OBJECTIVE: To analyze the associated risk factors of hidden blood loss in the internal fixation of intertrochanteric fracture. METHODS: A retrospective analysis was made on the clinical data of 317 cases of intertrochanteric fractures which were treated by internal fixation between January 1993 and December 2008. There were 154 males and 163 females with an average disease duration of 4.58 days (range, 7 hours to 33 days); the age was (69.86 +/- 15.42) years; the average height was 1.64 m (range, 1.50-1.84 m); and the average weight was 62.26 kg (range, 39-85 kg). Of them, intramedullary fixation was used in 203 patients and extramedullary fixation in 114 patients. The operation time was (61.99 +/- 18.25) minutes. The red blood cell transfusion was given to 84 patients, and the transfusion amount was 200-1 000 mL. The drainage volume was 0-750 mL (mean, 61.85 mL). Hidden blood loss was calculated through change of hematocrit level before and after operation. The multiple linear regression was performed to analyse the risk factors of hidden blood loss. RESULTS: The total blood loss was (918.60 +/- 204.44) mL, the hidden blood loss was (797.77 +/- 192.58) mL, and intraoperative visible blood loss was (257.32 +/- 271.24) mL. Single factor analysis showed hidden blood loss was significantly higher in variables as follows: gender, age, injury cause, fracture type, American anesthesiologists grading, anesthesia mode, hypertension, diabetes, disease duration, operation time, intraoperative transfusion of red blood cells, and fixation type. Multiple linear regression showed age, fracture type, anesthesia mode, and fixation type were significant risk factors. CONCLUSION: The risk factors of hidden blood loss are advanced age (> 60 years), unstable fracture, general anesthesia, and imtramedullary fixation. Especially in elder patients with unstable fracture treated by intramedullary fixation under general anesthesia, hidden blood loss is more significant.

Efficacy and safety of rivaroxaban versus low-molecular-weight heparin therapy in patients with lower limb fractures.

Thromboprophylaxis with rivaroxaban has proved effective and safe in patients undergoing hip and knee replacement surgery. As it is unclear whether it is also effective and safe in fracture patients, the aim of the present study was to evaluate the efficacy and safety of rivaroxaban in patients with lower limb fractures. We performed a retrospective cohort study of 2,050 consecutive patients treated for lower limb fractures at our trauma center, comparing rates of venous thromboembolism (VTE), bleeding and surgical complications, and the length of hospital stay for 608 patients who received rivaroxaban and 717 who received a low-molecular-weight heparin (LMWH). Rates of symptomatic VTE were 4.9 and 8.6% in the rivaroxaban and LMWH groups, respectively (p = 0.008), and distal VTE rates were 1.8 and 5.7%, respectively (p = 0.036). The incidence of major bleeding events in the rivaroxaban group was also lower than in the LMWH group (0.2 vs 0.6%), but the difference between the groups was not statistically significant. The mean length of hospital stay was significantly shorter in the rivaroxaban group (12.2 vs 13.1 days, respectively; p = 0.016). This retrospective cohort study is the first report documenting the efficacy and safety of rivaroxaban in patients with lower extremity fractures. In comparison with LMWH, rivaroxaban reduced the incidence of VTE by 45% without increasing the risk of bleeding. However, prospective, randomized controlled trials comparing rivaroxaban and LMWH are needed to confirm our findings.

[IMPACT OF PERIOPERATIVE AVERAGE BLOOD-GLUCOSE LEVEL ON PROGNOSIS OF PATIENTS WITH HIP FRACTURE AND DIABETES MELLITUS].

OBJECTIVE: To explore the impact of perioperative average blood-glucose level on the prognosis of patients with hip fracture and diabetes mellitus. METHODS: A retrospective analysis was made on the clinical data of 244 patients with hip fracture and diabetes mellitus who accorded with the inclusion criteria between September 2009 and September 2012. Of 244 patients, 125 patients with poorly controlled fasting blood-glucose (average fasting blood-glucose level > 7.8 mmol/L) were assigned in group A, and 119 patients with well controlled fasting blood-glucose (average fasting blood-glucose level ≤ 7.8 mmol/L) were assigned in group B according to "China guideline for type 2 diabetes" criteria. There was no significant difference in gender, age, disease duration of diabetes mellitus, serum albumin, fracture type and disease duration, surgical procedure, anaesthesia, and complications between 2 groups (P > 0.05). Group A had a higher hemoglobin level and fewer patients who can do some outdoor activities than group B (t = -2.353, P = 0.020; χ2 = 4.333, P = 0.037). The hospitalization time, days to await surgery, stitch removal time, the postoperative complication rate, the mortality at 1 month and 1 year after operation, and ambulatory ability at 1 year after operation were compared between the 2 groups. RESULTS: A total of 223 patients (114 in group A and 109 in group B) were followed up 12-15 months (mean, 13.5 months). The days to await surgery of group A were significantly more than those of group B (t = -2.743, P=0.007), but no significant difference was found in hospitalization time and stitch removal time between 2 groups (P > 0.05). The postoperative complication rate of group A (19.2%, 24/125) was significantly higher than that of group B (8.4%, 10/119) (χ2 =5.926, P = 0.015). Group A had a higher mortality at 1 month after operation than group B (6.1% vs. 0) (χ2 = 5.038, P = 0.025), but no significant difference was shown at 1 year after operation between groups A and B (8.8% vs. 4.6%) (χ2 = 1.555, P = 0.212). At 1 year after operation in patients who can do some outdoor activities, the proportions of patients who turned to do some indoor activities was 19.2% (15/78) in the group A and 13.5% (12/89) in group B, showing no significant difference (χ2 = l.013, P = 0.314). CONCLUSION: Poorly controlled perioperative fasting blood-glucose may lead undesirable influence on the prognosis of patients with hip fracture and diabetes mellitus. In order to reduce the complication rate and other accidents, the fasting blood-glucose level should be controlled to 7.8 mmol/L or less.