Aspirin: are patients actually taking it?-A quality assessment study.

BACKGROUND: The purpose of the study was to assess patient adherence to an aspirin-based prophylactic deep venous thromboembolism (DVT) care management plan after total lower extremity arthroplasty. METHODS: Using a cross-sectional study design, patients who underwent total hip or knee replacement surgery by a single senior surgeon were surveyed at their routine 6-week follow-up appointment regarding adherence to aspirin DVT prophylaxis. Postoperatively, patients were advised to take 325 mg of aspirin twice daily for 6 weeks to prevent DVT. RESULTS: Of the 101 patients surveyed, 45 underwent total hip arthroplasty while 56 underwent total knee arthroplasty. There were 48 (48%) patients who were still taking aspirin at their routine 6-week postoperative follow-up appointment and 53 (52%) patients who were not taking aspirin (nonadherent group). Of the latter, 3 (6%) never took aspirin postoperatively, 14 (26%) discontinued within 2 weeks postoperatively, and 23 (43%) did not take it any longer for half the time prescribed. In the nonadherent group, 8 patients reported that they felt they did not need the aspirin prophylaxis, 5 experienced side effects, and 10 were unsure of how long they needed to take it. There was 1 patient with a calf DVT and no episodes of pulmonary embolism. CONCLUSIONS: Over half of our study, patients did not finish their aspirin regimen. We suggest a consistent outline of medication duration throughout the pre/postop course and communication regarding aspirin cessation.

Effect of Fixation Type and Bone Graft on Tarsometatarsal Fusion.

BACKGROUND:: End-stage tarsometatarsal (TMT) arthritis is commonly treated with arthrodesis of involved joints. Fixation hardware can consist of varying combinations of screws, plates, and staples with or without supplemental bone graft. There are limited data to demonstrate either superiority of a given fixation method or the impact of bone graft on fusion rates. The purpose of this study, therefore, was to determine whether nonunion rates after TMT arthrodesis were influenced by either the use of screw vs plate fixation or the addition of bone graft vs no bone graft. METHODS:: All patients older than 18 years undergoing arthrodesis for TMT arthritis between July 1991 and July 2016 were identified retrospectively. Exclusion criteria included less than 12 months follow-up, prior midfoot surgery, any added procedure beyond TMT arthrodesis using plates or screws, and acute foot trauma. All patients with radiographic or clinical nonunion, including those requiring revision surgery, were identified. Demographic data and associated risk factors were recorded via chart and radiographic image review. Eighty-eight patients (88 feet, mean follow-up: 75.1 ± 51.4; range, 12-179), with a total of 189 joints and who met enrollment criteria were treated by 9 different surgeons with arthrodesis. RESULTS:: The overall nonunion rate was 11.4%. Significant independent risk factors associated with nonunion were (1) arthrodesis using plate fixation with all screws through the plate (odds ratio [OR], 6.2; 95% confidence interval [CI], 1.8-21.3; P = .004), (2) smoking during the perioperative period (OR, 7.9; 95% CI, 2.1-30.2; P = .002), and (3) postoperative nonanatomic alignment (OR, 11.2; 95% CI, 2.1-60.8; P = .005). Bone graft utilization was found to significantly lower the rate of nonunion (OR, 0.2; 95% CI, 0.1-0.6; P = .006). CONCLUSION:: Isolated plate fixation, smoking, and postoperative nonanatomic alignment appear to significantly increase the rate of nonunion among patients undergoing TMT arthrodesis for midfoot arthritis. Concomitant use of autogenous bone graft significantly decreased this risk. LEVEL OF EVIDENCE:: Level III, retrospective comparative study.

Reoperation Rate Differences Between Open Reduction Internal Fixation and Primary Arthrodesis of Lisfranc Injuries.

BACKGROUND: Controversy persists as to whether Lisfranc injuries are best treated with open reduction internal fixation (ORIF) versus primary arthrodesis (PA). Reoperation rates certainly influence this debate, but prior studies are often confounded by inclusion of hardware removal as a complication rather than as a planned, staged procedure inherent to ORIF. The primary aim of this study was to evaluate whether reoperation rates, excluding planned hardware removal, differ between ORIF and PA. A secondary aim was to evaluate patient risk factors associated with reoperation after operative treatment of Lisfranc injuries. METHODS: Between July 1991 and July 2016, adult patients who sustained closed, isolated Lisfranc injuries with or without fractures and who underwent ORIF or PA with a minimum follow-up of 12 months were analyzed. Reoperation rates for reasons other than planned hardware removal were examined, as were patient risk factors predictive of reoperation. Two hundred seventeen patients met enrollment criteria (mean follow-up, 62.5 ± 43.1 months; range, 12-184), of which 163 (75.1%) underwent ORIF and 54 (24.9%) underwent PA. RESULTS: Overall and including planned procedures, patients treated with ORIF had a significantly higher rate of return to the operation room (75.5%) as compared to those in the PA group (31.5%, P < .001). When excluding planned hardware removal, however, there was no difference in reoperation rates between the 2 groups (29.5% in the ORIF group and 29.6% in the PA group, P = 1). Risk factors correlating with unplanned return to the operation room included deep infection ( P = .009-.001), delayed wound healing ( P = .008), and high-energy trauma ( P = .01). CONCLUSION: When excluding planned removal of hardware, patients with Lisfranc injuries treated with ORIF did not demonstrate a higher rate of reoperation compared with those undergoing PA. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Intracellular calcium signaling pathways during liver ischemia and reperfusion.

Calcium plays a major role in intracellular signaling mechanisms during ischemia reperfusion (I/R) injury of a liver cell. Under ischemic conditions, the absence of oxygen arrests oxidative phosphorylation, thereby eliminating the energy source by which hepatocellular mechanisms maintain homeostasis of calcium. This, in turn, leaves nonselective plasma membrane influx pores unopposed and results in a net increase in intracellular calcium concentrations. Subsequent reperfusion marks the onset and progression of apoptosis and necrosis, as it involves inflammatory responses as well as free-radical formation due to re-oxygenation of cells. These processes destroy the structural integrity of organelles, leading to disruptive redistribution of calcium between cellular and subcellular compartments. This initial elevation and later imbalance of intracellular calcium concentrations associated with I/R induce various molecular responses within each organelle. In the cytoplasm, a series of pro-apoptotic pathways involving various calcium sensitive enzymes are activated. The injury is further exacerbated in the endoplasmic reticulum (ER) due to the malfunction of mechanisms responsible for intracellular calcium sequestration. Both the mitochondria and the nucleus are also adversely affected, as their structural integrity and physiologic functions are disrupted. To date, however, the precise pathophysiology of these calcium-mediated signaling pathways is not fully understood due to its complex nature. This review aims to systematically examine the current literature about individual molecular signaling pathways in the cytoplasm, ER, mitochondria, and the nucleus prior to causing time-sensitive progression of permanent tissue injury.