Tranexamic acid with a pre-operative suspension of anticoagulation decreases operative time and blood transfusion in the treatment of pelvic and acetabulum fractures.

PURPOSE: The purpose was to evaluate the impact of intra-operative administration of tranexamic acid (TXA) and pre-operative discontinuation of prophylactic chemoprophylaxis in patients undergoing internal fixation of pelvic or acetabular fractures on the need for subsequent blood transfusion. Operative time and the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) were also assessed. METHODS: Data from a single level one trauma centre was retrospectively reviewed from January 2014 to December 2017 to identify pelvic ring or acetabular fractures managed operatively. Patients who did not receive their scheduled dose of chemoprophylaxis prior to surgery but who did receive intra-operative TXA were identified as the treatment group. Due to the interaction of VTE prophylaxis and TXA, the variables were analyzed using an interaction effect to account for administration of both individually and concomitantly. RESULTS: One hundred fifty-nine patients were included. The treatment group experienced a 20.7% reduction in blood product transfusion (regression coefficient (RC): - 0.207, p = 0.047, 95%CI: - 0.412 to - 0.003) and an average of 36 minutes (RC): - 36.90, p = 0.045, 95%CI: - 72.943 to - 0.841) reduction in surgical time as compared to controls. The treatment group did not experience differential rates of PE or DVT (RC: 1.302, p = 0.749, 95%CI: 0.259-6.546) or PE (RC: 1.024, p = 0.983, 95%CI: 0.114-9.208). CONCLUSIONS: In the study population, the combination of holding pre-operative chemoprophylaxis and administering intra-operative TXA is a safe and effective combination in reducing operative time and blood product transfusions.

A Higher Altitude Is an Independent Risk Factor for Venous Thromboembolisms After Total Hip Arthroplasty.

BACKGROUND: High altitudes lead to physiological changes that may predispose to venous thromboembolisms (VTEs) including deep vein thrombosis and pulmonary embolism (PE). No prior study has evaluated if there is also a higher risk of VTEs for total hip arthroplasties (THAs) performed at higher elevations. The purpose of this retrospective study was to identify if undergoing THA at a higher altitude center (>4000 feet above sea level) is an independent risk factor for a postoperative VTE. METHODS: A thorough evaluation of the Pearl Diver Database was performed for patients undergoing THAs from 2005 to 2014. Using International Classification of Diseases Ninth Edition facilitated in ascertaining patients who underwent THA. Using the ZIP codes of the hospitals where the procedure occurred, we separated our groups into high-altitude (>4000 ft) and low-altitude (<100 ft) groups. RESULTS: In the first 30 postoperative days, patients undergoing THA at a higher altitude experienced a significantly higher rate of PEs (odds ratio, 1.74; P = .003) when compared to similar patients at lower altitudes. This trend was also present for PE (odds ratio, 1.59; P < .001) at 90 days postoperatively. CONCLUSION: THAs performed at higher altitudes (>4000 feet) have a higher rate of acute postoperative PEs in the first 30 days and also 90 days postoperatively when compared to matched patients receiving the same surgery at a lower altitude (<100 feet). THA patients at high altitude should be counseled on these increased risks; however, owing to retrospective nature and confounders, prospective studies are necessary to explore this outcome in more detail.

A Case Report of a Vertical Zone III Sacral Fracture Due to Acute Lower Extremity Hyperabduction While Windsurfing.

Typically associated with motor vehicle accidents and falls, sacral fractures result from sudden compression of the iliac wings, placing bidirectional traction forces on the anterior and/or posterior aspects of the sacrum. Here we describe a vertical Zone III sacral fracture caused by sudden, forceful hyperabduction of the lower extremities. To the authors' knowledge this is the first report of a Zone III sacral fracture caused by this mechanism which occurred when the patient encountered a large wave while windsurfing. Imaging revealed a longitudinal fracture to the anterior sacrum, with a concomitant Zone II fracture and pubic symphysis diastasis. The patient was treated using anterior fixation plating and posterior percutaneous pinning. The purpose of this study is to increase provider awareness of an often underdiagnosed fracture, alert water sports enthusiasts of the risks associated with windsurfing, describe signs and symptoms of this often overlooked fracture, and discuss treatment modalities based on radiographic and clinical assessments of fracture stability.

High Altitude Is an Independent Risk Factor for Developing a Pulmonary Embolism, but Not a Deep Vein Thrombosis Following a 1- to 2-Level Lumbar Fusion.

STUDY DESIGN: Retrospective study. OBJECTIVE: To identify if a 1- to 2-level posterior lumbar fusion at higher altitude is an independent risk factor for postoperative deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS: A national Medicare database was queried for all patients undergoing 1- to 2-level lumbar fusions from 2005 to 2014. Those with a prior history of DVT, PE, coagulopathy, or peripheral vascular complications were excluded to better isolate altitude as the dependent variable. The groups were matched 1:1 based on age, gender, and comorbidities to limit potential cofounders. Using ZIP codes of the hospitals where the procedure occurred, we separated our patients into high (>4000 feet) and low (<100 feet) altitudes to investigate postoperative rates of DVTs and PEs at 90 days. RESULTS: Compared with lumbar fusions performed at low-altitude centers, patients undergoing the same procedure at high altitude had significantly higher PE rates (P = .010) at 90 days postoperatively, and similar rates of 90-day postoperative DVTs (P = .078). There were no significant differences in age or comorbidities between these cohorts due to our strict matching process (P = 1.00). CONCLUSION: Spinal fusions performed at altitudes >4000 feet incurred higher PE rates in the first 90 days compared with patients receiving the same surgery at <100 feet but did not incur higher rates of postoperative DVTs.

The Most Influential Publications in Odontoid Fracture Management.

OBJECTIVE: Management of odontoid fractures has improved and evolved due to advancing diagnostic guidelines and understanding of long-term outcomes. The aim of this study was to quantify the most frequently cited publications pertaining to odontoid fractures and determine their validity as a tool to practice evidence-based medicine. METHODS: A Clarivate Analytics Web of Science search was used to identify all articles related to odontoid fractures. The 50 most cited articles were reviewed. Criteria included the frequency of citation, year of publication, countries of origin, journal, levels of evidence (LOE), article types, and supporting authors and institutions. RESULTS: The top 3 most cited papers were "Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique" (Madawi 1997), "Atlantoaxial fixation using, plate and screw method: A report of 160 treated patients" (Goel 2002), and "The anatomical suitability of the C1-2 complex for transarticular screw fixation" (Paramore 1996). Spine (n = 13; 26%) was the most common journal, and the most frequent decade was 2000-2009 (n = 18; 36%). The United States was associated with the greatest number of publications, and the most common article type was clinical outcomes (n = 16; 32%). The most recurring LOE was IV (n = 20; 40%). CONCLUSIONS: This review provides a comprehensive understanding of the historical literature pertaining to odontoid fracture management. There is a paucity of high LOE publications regarding this topic, and clinicians should strive to provide more high-level studies. This article can help practitioners navigate the vast body of literature about this topic and identify high-impact publications.

A novel technique for stabilization of high-grade spondylolisthesis with transvertebral fusion without reduction.

Surgical treatment of high-grade spondylolisthesis and spondyloptosis is recommended in symptomatic patients, yet there exists much debate regarding the optimal surgical approach and the need for reduction. Similar to the Bohlman technique in that fixation is achieved across two vertebral endplates, we discuss a novel technique with the advantage of using bilateral threaded pedicle screws of large diameter and length instead of a single fibula allograft. Patients underwent posterior instrumented fusion without spondylolisthesis reduction using a novel technique placing pedicle screws with a transvertebral trajectory through the two end plates involved in the spondylolisthesis. Following screw placement, patients underwent decompression ±â€¯discectomy. Screws were connected to adjacent pedicle screws either in the upper adjacent vertebrae (i.e. L5) or the more rostral adjacent vertebrae (i.e. L4) if spinal alignment or instability necessitate including additional levels of fixation. Three patients were reviewed with ages of 67, 62, 58 years, operative times of 377-790 min, estimated blood loss 400-1050 cc, and follow-up times of 478-1082 days. There were no CSF leaks, intragenic neurologic deficits post-operatively, implant failures, revisions, or other systemic events. Two patients achieve radiographic fusion assessed by CT. At the time of final follow up, all patients were satisfied and essentially pain free. This one-stage technique offers the ability to manage local malalignment with a technique that inherently minimizes risk. The minimal complications and favorable outcomes make this technique an effective, efficient and safe procedure. Additional studies will focus on long term outcomes and should include larger patient samples.

An Elevated Metrorail as a Source of Orthopedic Injuries and Death at a Level-I Trauma Center.

Background: Elevated Metrorail systems differ from conventional trains by their slower speeds and collisions with pedestrians predominantly occurring at accessible stations or platforms. Here, the orthopedic implications of pedestrians struck by a Metrorail are evaluated, as were the correlations of substance abuse and psychiatric history on injury and death. Methods: Retrospective cohort study at a single Level-1 trauma center of patients requiring admission with orthopedic injuries following Metrorail impact from 1/2004-2/2017. Demographics, substance abuse, psychiatric history, intentionality, LOS, follow-up, fracture characteristics, and management were studied. Results: 33 patients sustained 104 total orthopedic injuries requiring admission; nine sustained 15 traumatic amputations. There were at least 37 open fractures, with some incomplete data in deceased (5) and amputation (9) patients. Suicide attempts were completed at 35.7% and were associated with a documented psychiatric illness and prior psychiatric evaluation. Spine injuries were associated with increased traumatic brain injuries, rib fractures, and open pelvic ring injuries, yet fewer humerus fractures. Open fractures were significantly predictive of death. 14 patients (42.4%) required ICU admission, and 26 (78.8%) patients required orthopaedic surgery (mean 1.3 ± 1.4 operations). Conclusions: Metrorail systems are unique sources of orthopaedic injuries requiring high rates of critical care and surgical intervention. Patients sustain multiple injuries, many with amputations. With this mechanism, there is a high rate of open fractures and suicide. Trauma centers should emphasize an extensive evaluation of orthopaedic injuries in this patient setting.Level of Evidence: II.

Is There a Correlation Between Preoperative or Postoperative Vitamin D Levels with Pseudarthrosis, Hardware Failure, and Revisions After Lumbar Spine Fusion?

BACKGROUND: Vitamin D deficiency is a well-known cause of postoperative complications in patients undergoing orthopedic surgery. Orthopedic complications seen in vitamin D deficiency include nonunion, pseudarthrosis, and hardware failure. We seek to investigate the relationship between vitamin D deficiency and outcomes after lumbar spinal fusions. METHODS: A retrospective patient chart review was conducted at a single center for all patients who underwent lumbar spinal fusions from January 2015 to September 2017 with preoperative or postoperative vitamin D laboratory values. We recorded demographics, social history, medications, pre-existing medical conditions, bone density (dual-energy x-ray absorptiometry) T-scores, procedural details, 1-year postoperative Visual Analog Score (VAS), documented pseudarthrosis, revisions, and hardware failure. A total of 150 patients were initially included in the cohort for analysis. RESULTS: Overall, preoperative and postoperative vitamin D levels were not significantly associated with a vast majority of the patient characteristics studied, including comorbidities, medications, or surgical diagnoses (P > 0.05). Age at surgery was significantly associated with vitamin D levels; older patients had higher serum levels of vitamin D both preoperatively (P = 0.03) and postoperatively (P = 0.01). Those with a higher average body mass index had lower vitamin D in both groups (P = 0.02). Vitamin D levels were not significantly associated with rates of postoperative pseudarthrosis, revision, or hardware complications (P > 0.05). VAS pain score at 1 year and smoking status preoperatively or postoperatively were not associated with vitamin D levels (P > 0.05). CONCLUSIONS: Both preoperative and postoperative vitamin D levels were not significantly associated with an increased or decreased risk of pseudarthrosis, revision surgery, hardware failure, or 1-year VAS pain score after lumbar spine fusion surgery.

Primary Intra-Medullary Nailing of Open Tibia Fractures Caused by Low-Velocity Gunshots: Does Operative Debridement Increase Infection Rates?

BACKGROUND: Although gunshot-induced extremity fractures are typically not considered open fractures, there is controversy regarding wound management in the setting of operative fixation to limit infection complications. Previous studies have evaluated the need for a formal irrigation and debridement (I&D) prior to intra-medullary nailing (IMN) of gunshot-induced femur fractures but none have specifically evaluated tibias. By comparing primary IMN for tibial shaft fractures caused by low-velocity firearms additionally treated with a formal operative I&D (group 1) with those without an I&D (group 2), we sought to identify whether there are: differences in treatment group infection rates; particular fracture patterns more prone to infection; and patient characteristics more prone to infections. PATIENTS AND METHODS: Retrospective cohort study at a single level I trauma center of gunshot-induced tibial shaft fractures managed primarily with IMN in 39 patients from October 1, 2008 to October 30, 2016. The following were studied: demographics, follow-up, fracture characteristics, injury management, and patient outcome. Fractures were categorized based on the Orthopaedic Trauma Association (OTA) classification system for diaphyseal tibia/fibula fractures. All patients had intravenous antibiotic agents at presentation and received three days of post-operative intravenous antibiotic agents per institutional protocol. RESULTS: In group 1, 6 of 23 patients (26.1%) developed superficial infections and 4 of 23 patients (17.4%) developed deep infections. In group 2, none of 16 patients (0%) developed superficial infections and 1 patient (6.25%) developed a deep infection, making the total cohort infection rate 28.2% (11/39). Superficial infections were associated with a formal I&D whereas deep infections were not. Tobacco smokers and type 42-A fractures had higher infection rates when treated with a formal I&D. CONCLUSION: A formal debridement, followed by primary IMN in tibia fractures caused by low-velocity firearms is associated with an increased risk of superficial infection that is well managed with antibiotic agents, but the incorporation of a debridement does not affect rate of deep infection. A formal I&D during IMN fixation should be avoided in patients that are smokers and have type 42-A tibia fractures as these are factors associated with increased infection rates.

Characterization of DNA degradation using direct current conductivity and dynamic dielectric relaxation techniques.

The purpose of this study was to evaluate DNA degradation upon thermal heating using dielectric relaxation and direct current (DC) conductivity methods. Herring sperm DNA, human growth hormone (HgH) plasmid DNA, and secreted alkaline phosphatase (SEAP) plasmid DNA were used as the examples. DNA was heated at 80 degrees C for 1 hour. The dielectric relaxation spectra as a function of the applied field frequency were measured for HgH DNA at 0.5 hours and at 1 hour. The frequency range covered was from 10 kHz to 100 kHz. The DC conductivity measurements were made for all 3 kinds of DNA at 4 time points: 0 hours, 0.5 hours, 0.75 hours, and 1 hour. At each time point the DC conductivity was measured for each sample as a function of concentration via water dilution. The results show that the dielectric relaxation method is less sensitive in characterizing heat-driven DNA degradation. Conversely, DC conductivity is very sensitive. The semiquantitative dependence of the conductivity upon heating suggests that DNA degradation involves more than plasmid DNA nicking. Double strand and single strand breaks may also occur. In addition, herring sperm DNA, HgH DNA, and SEAP DNA, though similar in their DC conductivity functional forms upon dilution, exhibit significant differences in their responses to sustained heating.