Girdlestone resection arthroplasty of the hip (GRA): a case series-outdated procedure or acceptable outcome?

Despite considerable legacy issues, Girdlestone's resection arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical co-morbidities which preclude staged or significant surgical interventions, and/or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes.

Current advances in 2022: A critical review of selected topics by the Association for the Advancement of Blood and Biotherapies (AABB) Clinical Transfusion Medicine Committee.

BACKGROUND: The Association for the Advancement of Blood and Biotherapies Clinical Transfusion Medicine Committee (CTMC) composes a summary of new and important advances in transfusion medicine (TM) on an annual basis. Since 2018, this has been assembled into a manuscript and published in Transfusion. STUDY DESIGN AND METHODS: CTMC members selected original manuscripts relevant to TM that were published electronically and/or in print during calendar year 2022. Papers were selected based on perceived importance and/or originality. References for selected papers were made available to CTMC members to provide feedback. Members were also encouraged to identify papers that may have been omitted initially. They then worked in groups of two to three to write a summary for each new publication within their broader topic. Each topic summary was then reviewed and edited by two separate committee members. The final manuscript was assembled by the first and senior authors. While this review is extensive, it is not a systematic review and some publications considered important by readers may have been excluded. RESULTS: For calendar year 2022, summaries of key publications were assembled for the following broader topics within TM: blood component therapy; infectious diseases, blood donor testing, and collections; patient blood management; immunohematology and genomics; hemostasis; hemoglobinopathies; apheresis and cell therapy; pediatrics; and health care disparities, diversity, equity, and inclusion. DISCUSSION: This Committee Report reviews and summarizes important publications and advances in TM published during calendar year 2022, and maybe a useful educational tool.

Can a Blade-Stopping Mechanism on Circular Table Saws Reduce the Severity of Hand Injuries in Contact Scenarios? A Cadaveric Study.

PURPOSE: Table saws are commonly used woodworking tools that carry a substantial risk of injury. Blade-stopping technology has been developed and has the potential to reduce the frequency and severity of injury. This study aimed to evaluate this technology on human tissue and characterize the resulting injuries. METHODS: Twenty-seven fresh, frozen cadaveric specimen hands were used. Three scenarios were tested, with the specimen (1) moving forward ("forward"); (2) moving backward, such as in a kickback scenario ("reverse"); and (3) dropped from above the saw blade ("top"). Each scenario was tested at both slow (0.001 m/sec) and fast (forward: 0.6 m/sec; reverse: 0.5 m/sec; top: 2.4 m/sec) approach speeds. The severity of the injuries was characterized by anatomic evaluation and confirmed with radiographic evaluation. Injuries were classified as no laceration, superficial soft tissue injury, deep soft tissue injury, and bony injury. RESULTS: For the slow approach speed, the brake cartridge engaged in 100% of the trials for all 3 scenarios, and 100% of the specimens sustained no injuries. Forward testing at a fast approach speed revealed the brake cartridge engaged in 89% of the trials (injuries: 4 superficial, 2 deep, 3 bony). Reverse testing at a fast approach speed revealed the brake cartridge engaged in 11% of trials (injuries: 1 superficial, 8 bony). Top testing at a fast approach speed revealed the brake cartridge engaged in 89% of the trials (injuries: 9 bony). CONCLUSIONS: Modern blade-stopping technology did not prevent all traumatic hand injuries in fast approach speed scenarios, but it reduced the incidence and severity of injuries. The technology was more effective at low approach speed scenarios. CLINICAL RELEVANCE: The findings of this study provide information to help understand the factors that can prevent or reduce the severity of contact injuries (hand, finger, or thumb) for operators of table saws.

Red Blood Cell Transfusion: 2023 AABB International Guidelines.

Importance: Red blood cell transfusion is a common medical intervention with benefits and harms. Objective: To provide recommendations for use of red blood cell transfusion in adults and children. Evidence Review: Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed. Findings: For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence). Conclusions and Relevance: It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.

Biomechanical Comparison of Knotless Suture Anchor Versus Percutaneous End-to-End Technique for Mid-Substance Achilles Tendon Rupture Repair.

Percutaneous Achilles tendon repairs can be performed with 2 distal fixation techniques: knotless suture anchor repair (KL) or percutaneous end-to-end repair (ETE). There is a paucity of literature comparing the biomechanical strength of these 2 distal fixation techniques. The aim of this study was to compare the strength of KL and ETE repairs using flat-braided suture for mid-substance Achilles tendon rupture during simulated progressive rehabilitation. Nine matched pairs of fresh-frozen below-knee cadaveric extremities were randomly assigned into these 2 repair groups. Each specimen was tested in 2 parts sequentially; Part I simulating passive ankle range of motion (cyclic: 20N-100N), and Part II simulating ambulation in a walking boot (cyclic: 20N-190N). The number of cycles, gap displacement, and the mode of failure were recorded for each repair. Achilles tendon repairs using the percutaneous methods of ETE and KL techniques showed no significant difference in the number of cycles to clinical failure, mean gap displacement, or overall failure rate. During Part I, the survival rate in terms of clinical failure for KL and ETE groups was 8 of 9 repairs and 7 of 9 repairs, respectively. During Part II, all repairs experienced clinical failure in both groups. Five repairs in the KL group experienced suture anchor pull out from the calcaneus, and 3 repairs failed at suture-tendon interface. Four repairs in the ETE group failed due to knot slippage and 5 repairs failed at suture-tendon interface. Both techniques are viable options in treating acute mid-substance Achilles tendon ruptures.

Better than 'normal': Describing the distribution of and outliers in RBC usage.

BACKGROUND/CASE STUDIES: Optimizing a hospital blood inventory requires understanding the distribution of blood usage at the institution. Standard methods for describing red blood cell (RBC) usage like mean and standard deviation assume a normal distribution. Other distributions may fit the distribution of daily RBC usage better and provide more accurate insights into blood usage and in6ventory management. STUDY DESIGN/METHODS: RBC usage data from 2014 through 2020 were queried from the laboratory information system. Theoretical distributions were fit against this empirical distribution of daily RBC usage. Goodness-of-fit was assessed visually using Pearson/Cullen and Frey plots as well as quantitatively using Kolomogorov-Smirnov (K-S) distance and the Akaike Information Criterion (AIC). RESULTS/FINDINGS: 241,957 units of RBCs were transfused over 2557 days in the study period. The log-normal and gamma distributions had superior K-S distances and AICs for daily RBC usage. The top percentile of days for RBC usage was significantly more likely to have at least one ultramassively transfused patient (p < .001, Fisher's Exact Test). CONCLUSIONS: The log-normal and gamma distributions better describe the right-skewed and entirely positive empirical distribution of daily RBC usage as compared to the normal distribution. This should broadly inform inventory management efforts and future descriptions of RBC usage at the institutional level.

Current advances in transfusion medicine 2021: A critical review of selected topics by the AABB Clinical Transfusion Medicine Committee.

BACKGROUND: Each year the AABB Clinical Transfusion Medicine Committee (CTMC) procures a synopsis highlighting new, important, and clinically relevant studies in the field of transfusion medicine (TM). This has been made available as a publication in Transfusion since 2018. METHODS: CTMC members reviewed and identified original manuscripts covering TM-related topics published electronically (ahead-of-print) or in print from December 2020 to December 2021. Selection of publications was discussed at committee meetings and chosen based on perceived relevance and originality. Next, committee members worked in pairs to create a synopsis of each topic, which was then reviewed by additional committee members. The first and senior authors assembled the final manuscript. Although this synopsis is extensive, it is not exhaustive, and some articles may have been excluded or missed. RESULTS: The following topics are included: blood products; convalescent plasma; donor collections and testing; hemoglobinopathies; immunohematology and genomics; hemostasis; patient blood management; pediatrics; therapeutic apheresis; and cell therapy. CONCLUSIONS: This synopsis highlights and summarizes recent key developments in TM and may be useful for educational purposes.

Hospital red blood cell and platelet supply and utilization from March to December of the first year of the COVID-19 pandemic: The BEST collaborative study.

BACKGROUND: At the start of the coronavirus disease 2019 (COVID-19) pandemic, widespread blood shortages were anticipated. We sought to determine how hospital blood supply and blood utilization were affected by the first wave of COVID-19. STUDY DESIGN AND METHODS: Weekly red blood cell (RBC) and platelet (PLT) inventory, transfusion, and outdate data were collected from 13 institutions in the United States, Brazil, Canada, and Denmark from March 1st to December 31st of 2020 and 2019. Data from the sites were aligned based on each site's local first peak of COVID-19 cases, and data from 2020 (pandemic year) were compared with data from the corresponding period in 2019 (pre-pandemic baseline). RESULTS: RBC inventories were 3% lower in 2020 than in 2019 (680 vs. 704, p < .001) and 5% fewer RBCs were transfused per week compared to 2019 (477 vs. 501, p < .001). However, during the first COVID-19 peak, RBC and PLT inventories were higher than normal, as reflected by deviation from par, days on hand, and percent outdated. At this time, 16% fewer inpatient beds were occupied, and 43% fewer surgeries were performed compared to 2019 (p < .001). In contrast to 2019 when there was no correlation, there was, in 2020, significant negative correlations between RBC and PLT days on hand and both percentage occupancy of inpatient beds and percentage of surgeries performed. CONCLUSION: During the COVID-19 pandemic in 2020, RBC and PLT inventories remained adequate. During the first wave of cases, significant decreases in patient care activities were associated with excess RBC and PLT supplies and increased product outdating.

A randomized study of a best practice alert for platelet transfusions.

BACKGROUND AND OBJECTIVES: Inappropriate platelet transfusions represent an opportunity for improvements in patient care. Use of a best practice alert (BPA) as clinical decision support (CDS) for red cell transfusions has successfully reduced unnecessary red blood cell (RBC) transfusions in prior studies. We studied the impact of a platelet transfusion BPA with visibility randomized by patient chart. MATERIALS AND METHODS: A BPA was built to introduce CDS at the time of platelet ordering in the electronic health record. Alert visibility was randomized at the patient encounter level. BPA eligible platelet transfusions for patients with both visible and non-visible alerts were recorded along with reasons given for override of the BPA. Focused interviews were performed with providers who interacted with the BPA to assess its impact on their decision making. RESULTS: Over a 9-month study period, 446 patient charts were randomized. The visible alert group used 25.3% fewer BPA eligible platelets. Mean monthly usage of platelets eligible for BPA display was 65.7 for the control group and 49.1 for the visible alert group (p = 0.07). BPA-eligible platelets used per inpatient day at risk per month were not significantly different between groups (2.4 vs. 2.1, p = 0.53). CONCLUSION: It is feasible to study CDS via chart-based randomization. A platelet BPA reduced total platelets used over the study period and may have resulted in $151,069 in yearly savings, although there were no differences when adjusted for inpatient days at risk. During interviews, providers offered additional workflow insights allowing further improvement of CDS for platelet transfusions.

Plasmonic Temperature-Programmed Desorption.

Temperature-programmed desorption (TPD) allows for the determination of the bonding strength and coverage of molecular mono- or multilayers on a surface and is widely used in surface science. In its traditional form using a mass spectrometric readout, this information is derived indirectly by analysis of resulting desorption peaks. This is problematic because the mass spectrometer signal not only originates from the sample surface but also potentially from other surfaces in the measurement chamber. As a complementary alternative, we introduce plasmonic TPD, which directly measures the surface coverage of molecular species adsorbed on metal nanoparticles at ultrahigh vacuum conditions. Using the examples of methanol and benzene on Au nanoparticle surfaces, the method can resolve all relevant features in the submonolayer and multilayer regimes. Furthermore, it enables the study of two types of nanoparticles simultaneously, which is challenging in a traditional TPD experiment, as we demonstrate specifically for Au and Ag.

Blood usage at a large academic center in Maryland in relation to the COVID-19 pandemic in 2020.

BACKGROUND: Blood usage and collections were impacted throughout 2020 both by the severity of the COVID-19 pandemic as well as public health decisions affecting hospital operations. We sought to understand the longer-term effects of the pandemic on blood usage via changes in case volume and clinical intensity as well as whether the blood needs of COVID-19-positive patients differed from other transfused patients. STUDY DESIGN AND METHODS: A single-center retrospective study of blood use in 2020 as compared to 2014-2019 was conducted at a tertiary care center. Statistical analysis was performed in an R-based workflow. p values are reported using two-sided t-tests for total hospital blood usage and using Mann-Whitney U tests for comparisons of patient blood usage. RESULTS: Mean monthly red cell usage in 2020 decreased by 11.2% (p = .003), plasma usage decreased by 23.8%, (p < .001) platelet usage decreased by 11.4% (p < .001), and monthly cryoprecipitate use increased by 18% (p = .03). A linear regression model predicted significant associations between total blood usage and the year, number of Medicare eligible discharges, and Case Mix Index. COVID-19-positive patients requiring at least one blood product did not use significantly different amounts of red cells, plasma, or platelets from all other transfused patients. CONCLUSIONS: Year 2020 began with decreased blood usage that was normalized by late spring. Reassuringly, transfused COVID-19-positive patients in general and those requiring ICU level care do not use significantly increased amounts of blood as compared to similar transfused hospital patients.

Current advances in transfusion medicine 2020: A critical review of selected topics by the AABB Clinical Transfusion Medicine Committee.

BACKGROUND: The AABB Clinical Transfusion Medicine Committee (CTMC) compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine (TM), which has been made available as a manuscript published in Transfusion since 2018. METHODS: CTMC committee members reviewed original manuscripts including TM-related topics published electronically (ahead) or in print from December 2019 to December 2020. The selection of topics and manuscripts was discussed at committee meetings and chosen based on relevance and originality. Next, committee members worked in pairs to create a synopsis of each topic, which was then reviewed by two additional committee members. The first and senior authors of this manuscript assembled the final manuscript. Although this synopsis is extensive, it is not exhaustive, and some papers may have been excluded or missed. RESULTS: The following topics are included: COVID-19 effects on the blood supply and regulatory landscape, COVID convalescent plasma, adult transfusion practices, whole blood, molecular immunohematology, pediatric TM, cellular therapy, and apheresis medicine. CONCLUSIONS: This synopsis provides easy access to relevant topics and may be useful as an educational tool.

Perioperative Mortality After Cemented or Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures-A Systematic Review and Meta-analysis.

BACKGROUND: Debate surrounds the use of cemented or uncemented prostheses for the treatment of displaced femoral neck fractures (FNF). Many guidelines recommend the use of the cemented hemiarthroplasty (CHA). Proponents of CHA point out the increased re-operation rate while proponents of uncemented hemiarthroplasty (HA) highlight the increased mortality rate in the perioperative period. The aim of this study was to systematically review the literature to evaluate perioperative mortality after HA for displaced FNFs. METHODS: A systematic review and meta-analysis was performed of MEDLINE, Cochrane Library, and Embase databases evaluating perioperative mortality after HA for displaced FNFs. Randomized control trials and observational studies were included comparing current-generation stem designs. A meta-analysis was performed on studies that directly compared the different modes of fixation. RESULTS: Twenty-two studies were included (seven randomized control trials and 15 observational studies), with a total of 183,167 HAs for treatment of a displaced FNF. Fourteen studies were included in the meta-analysis. There was a higher cumulative odds of death within the first 48 hours in those with CHA compared with uncemented HA (OR: 1.64; 95% CI: 1.35, 2.00; P ≤ .01). No difference was found in mortality at 7 days, 30 days, and one year. CONCLUSION: CHA is associated with an increased mortality rate within the first two days of surgery with no difference at 7 days, 30 days, and one year. Surgeons should consider tailoring their stem choice based on the physiological status of the patient when planning HA for FNFs. Techniques to reduce the risk of bone cement implantation syndrome should be used.

Perioperative Mortality and Periprosthetic Fracture: A Single-Center Experience of 857 Uncemented Hemiarthroplasties for Displaced Femoral Neck Fractures.

BACKGROUND: Uncemented hemiarthroplasty (UHA) for displaced femoral neck fracture (FNF) is favored by some surgeons because of the reduced rate of perioperative mortality and operative time. However higher rates of intraoperative and postoperative periprosthetic fractures (PPFs) have been reported. The aim of the study was to review day-0, day-1, day-2, day-30, and one-year mortality as well as intraoperative and postoperative PPF after UHA for displaced FNF and compare this with cemented hemiarthroplasties (CHAs) performed. Secondary objectives were to assess whether femoral stem geometry and alignment were associated with PPF in UHA. METHODS: A retrospective observational study was conducted of patients treated with a hemiarthroplasty for a displaced FNF over an eleven-year period. Radiographic analysis was conducted of femoral geometry and stem alignment. RESULTS: Over the 11-year study period, 857 UHAs and 247 CHAs were performed. There were no on-table, day-0, day-1, or day-2 deaths in UHA. Intraoperative PPF occurred in 3.6% UHA and 2% CHA and postoperative PPF in 2.4% UHA and 4.8% CHA. Intraoperative PPF was not associated with increased mortality (P = .15), postoperative PPF, or all-cause revision in UHA. Valgus stem alignment was a risk factor for a postoperative PPF and additional surgery in UHA (P = .004). CONCLUSION: UHA was associated with no perioperative deaths and a 30-day mortality rate of 5% in this series. It can be considered in patients with multiple medical comorbidities. Careful surgical planning and technique is important to optimize stem alignment particularly in Dorr C type femurs.

Tools for rapid analysis of blood usage and inventory during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic caused downtrends in both blood collections and blood usage. Rapidly visualizing the impact of the pandemic and newly implemented hospital policies on usage could potentially inform blood ordering practices to help avoid wastage. STUDY DESIGN AND METHODS: Blood usage data were obtained from the laboratory information system. An R-based workflow was written in R Markdown for analysis and visualization. Reports were generated daily and shared with blood bank leadership. Selected reports were shared with institutional leadership, other departments, and collaborating blood suppliers. RESULTS: Mean daily transfusions dropped 42% from 3/9-13 to 3/16-20, with a significant decrease in usage of red cells, plasma, and cryoprecipitate. The greatest decline in use was seen in the general operating rooms, whereas outpatient transfusions remained steady. Weekly total blood usage decreased through the end of March into April and returned to normal levels in May. CONCLUSION: During two 5-weekday periods of changing hospital policies, overall blood usage decreased by almost half. Visualization of usage by hospital location showed a large decrease in general operating room usage after cancellation of elective procedures. This data visualization has informed decisions to modify standing product orders during an initial period of decreased usage as well as return to normal orders in later months.

Current state of whole blood transfusion for civilian trauma resuscitation.

BACKGROUND: Whole blood (WB) is rapidly emerging as the treatment modality of choice for the initial resuscitation of civilian trauma patients across the United States. The reemergence of WB has been rapid and driven in part by recognition of the importance of early plasma transfusion in the resuscitation process. STUDY DESIGN AND METHODS: The study was designed as a critical analysis of the available literature on WB transfusion in civilian trauma patients. Studies were included if they reported on transfusion of cold-stored WB used in a civilian setting and measured safety, feasibility, or a direct clinical outcome. RESULTS: Examination of the available literature supports the feasibility and safety of WB used in treatment of civilian trauma patients. The evidence regarding clinical outcomes, particularly with direct comparison to equivalent doses of component therapy, is more limited. The literature is predominantly descriptive and retrospective in nature and limited by the heterogeneity of clinical WB protocols being used. Based on this limited data set, there are limited conclusions that can be used to definitely support or refute the clinical superiority of WB to component therapy. CONCLUSION: Current literature supports the safety and feasibility of WB, but prospective randomized trials comparing WB to component therapy are needed to provide the definitive evidence on this topic.

Cemented Proximal Femoral Replacement for the Management of Non-Neoplastic Conditions: A Versatile Implant but Not Without Its Risks.

BACKGROUND: The demand for revision arthroplasty continues to grow. Proximal femoral bone loss poses a significant challenge to surgeons and proximal femoral replacements (PFRs) are one option to address this problem. The aim of our study is to assess the reoperation, complication, and mortality rates following PFR for treatment of non-neoplastic conditions. METHODS: A retrospective observational study was conducted of a consecutive group of patients treated with a PFR for non-neoplastic conditions between 2010 and 2018. Mortality was confirmed using the Irish national death events publication service. RESULTS: Over the 8-year study period, 79 PFRs in 78 patients were performed. Mean age of patients was 78.3 years (standard deviation 11.9), of which 37.2% were male. Periprosthetic fracture was the most common indication for PFR (63.3%). The 30-day mortality rate was 7.6% (6 patients), of which bone cement implantation syndrome occurred in 4 patients. One-year mortality was 12.7%. Complications occurred in 22.8%. CONCLUSION: A cemented PFR is a versatile prosthesis in the armamentarium of a revision arthroplasty surgeon that allows immediate full weight-bearing. However, it may appropriately be considered a last resort procedure that poses specific risks that must be explained to patients and family. We present the short-term outcomes on one of the largest series of PFR to date.

Impact of Type 2 Diabetes Mellitus on Human Bone Marrow Stromal Cell Number and Phenotypic Characteristics.

Human bone marrow-derived mesenchymal stromal cells (MSCs) have been investigated in numerous disease settings involving impaired regeneration because of the crucial role they play in tissue maintenance and repair. Considering the number of comorbidities associated with type 2 diabetes mellitus (T2DM), the hypothesis that MSCs mediate these comorbidities via a reduction in their native maintenance and repair activities is an intriguing line of inquiry. Here, it is demonstrated that the number of bone marrow-derived MSCs in people with T2DM was reduced compared to that of age-matched control (AMC) donors and that this was due to a specific decrease in the number of MSCs with osteogenic capacity. There were no differences in MSC cell surface phenotype or in MSC expansion, differentiation, or angiogenic or migratory capacity from donors living with T2DM as compared to AMCs. These findings elucidate the basic biology of MSCs and their potential as mediators of diabetic comorbidities, especially osteopathies, and provide insight into donor choice for MSC-based clinical trials. This study suggests that any role of bone marrow MSCs as a mediator of T2DM comorbidity is likely due to a reduction in the osteoprogenitor population size and not due to a permanent alteration to the MSCs' capacity to maintain tissue homeostasis through expansion and differentiation.

Transfusion-associated chest pain.

BACKGROUND: Chest pain is a common clinical dilemma and is rarely reported as part of suspected adverse events in transfusion recipients. The aim of this study is to describe and characterize the clinical presentation of transfusion-associated chest pain and how it relates to currently defined National Healthcare Safety Network hemovigilance entities. STUDY DESIGN AND METHODS: This is a retrospective chart review at a single large academic institution of patients who reported chest pain during or after a transfusion that resulted in a transfusion reaction investigation during the period January 2004 to December 2016. RESULTS: Of approximately 500,000 transfusions occurring during the study period and 3220 suspected transfusion reactions reported, 23 (0.7%) reactions involving chest pain were identified, of which 20 had medical records available for analysis. Ninety percent of cases presented with chest pain within 2.5 hours of the start of transfusion, with a mean time of onset of 92.2 minutes. Fourteen RBC units and 6 platelet units were implicated, and all transfusions were ABO identical. All posttransfusion workups were negative for hemolysis or agglutination on direct antiglobulin testing. Twenty percent of cases showed evidence of acute coronary ischemia that was first detected during transfusion with rising troponins or electrocardiographic abnormalities, all in association with RBC transfusion for anemia. For most reactions, the signs and symptoms did not fit any hemovigilance definitions for transfusion reactions. CONCLUSION: Chest pain is an infrequently reported chief complaint for transfusion reactions. Increased circulatory volume due to transfusion may be an important contributor to myocardial demand ischemia in at-risk patients. Additional studies are necessary to determine the clinical significance of chest pain during transfusion and to elucidate potential mechanisms.

Breaking Bad: A Comparative Descriptive Analysis of Periprosthetic Fractures Around Cemented and Uncemented Femoral Stems.

BACKGROUND: Periprosthetic fractures are most commonly classified according to the Vancouver classification system and more recently the Unified Classification System. The aim of this study is to provide a descriptive analysis of fracture patterns in femoral periprosthetic fractures (PPFs) by femoral stem fixation. METHODS: A retrospective observational study of all femoral PPFs over a 10-year period at our institution was conducted. Presenting radiographs were examined to assess the fracture pattern. RESULTS: Over the 10-year period, 138 femoral PPFs that underwent operative treatment were examined. Mean age of patients was 78 years with 45.7% male and median American Society of Anaesthesiologists grade 3. The femoral stem fixation was cemented in 83 patients and uncemented in 55 patients. Uncemented femoral stems most commonly caused a simple oblique fracture pattern (69.1%) with a more comminuted pattern seen in cemented fixation (59%). CONCLUSION: Fracture patterns differ according to femoral stem fixation. A simple "sickle-like" oblique fracture pattern was more commonly seen in uncemented stems while cemented tapered stems resulted in a comminuted "axe splitting" pattern.