Visual loss after orthopedic procedures.

Perioperative visual loss (PVL) is a very rare and unpredictable complication of surgery performed at distance from the visual pathways, mostly after spine or cardiac procedures. We report 6 consecutive patients with PVL after routine orthopedic procedures (osteosynthesis for complex fracture of the femur [2], total hip arthroplasty [2], hip prosthesis arthroplasty [1], bilateral simultaneous total knee arthroplasty [1]) and reviewed the literature on the subject. An ischemic optic neuropathy was diagnosed in all cases, and visual loss was bilateral in 5 of 6 patients. Partial visual improvement occurred in only 3 of 11 eyes. No specific therapy is available for PVL. Postoperative visual disturbances should prompt without delay an ophthalmic evaluation because emergent correction of anemia, systemic hypotension, or hypovolemia might improve visual prognosis of PVL.

Analysis of patient flows for orthopedic procedures using small area analysis in Switzerland

BACKGROUND: In general cantons regulate and control the Swiss health service system; patient flows within and between cantons are thereby partially disregarded. This paper develops an alternative spatial model, based upon the construction of orthopedic hospital service areas (HSAOs), and introduces indices for the analysis of patient streams in order to identify areas, irrespective of canton, with diverse characteristics, importance, needs, or demands. METHODS: HSAOs were constructed using orthopedic discharge data. Patient streams between the HSAOs were analysed by calculating three indices: the localization index (% local residents discharged locally), the netindex (the ratio of discharges of nonlocal incoming residents to outgoing local residents), and the market share index (% of local resident discharges of all discharges in local hospitals). RESULTS: The 85 orthopedic HSAOs show a median localization index of 60.8%, a market share index of 75.1%, and 30% of HSAOs have a positive netindex. Insurance class of bed, admission type, and patient age are partially but significantly associated with those indicators. A trend to more centrally provided health services can be observed not only in large urban HSAOs such as Geneva, Bern, Basel, and Zurich, but also in HSAOs in mountain sport areas such as Sion, Davos, or St.Moritz. Furthermore, elderly and emergency patients are more frequently treated locally than younger people or those having elective procedures. CONCLUSION: The division of Switzerland into HSAOs provides an alternative spatial model for analysing and describing patient streams for health service utilization. Because this small area model allows more in-depth analysis of patient streams both within and between cantons, it may improve support and planning of resource allocation of in-patient care in the Swiss healthcare system.

Readmission from orthopedic surgical site infections: an integrative review

Abstract OBJECTIVE Characterizing readmissions from orthopedic surgical site infections. METHOD An integrative review of literature in the LILACS, IBECS, MEDLINE, Cochrane, SciELO and PUBMED databases, using the descriptors Patient readmission, Wound infection, Cross infection, Orthopedic procedures, Orthopedics. RESULTS 78 studies were identified and 10 publications were selected. Surgical site infections are the most common cause of unplanned orthopedic readmissions, representing long periods of hospitalization, new surgical procedures and high costs, and greater possibility of subsequent hospitalizations. Most significant predictors have indicated average length of hospitalization, need for intensive care, emergency status at admission, risk of death, age > 65 years, males and higher body mass index. CONCLUSION Readmission rates have increasingly become measures of quality and concerns about costs. New studies could involve issues related to indirect costs, specifically social and psychological costs.

Evaluation of hemostatic changes using thromboelastography after crystalloid or colloid fluid administration during major orthopedic surgery

The effects of Ringer lactate, 6% hydroxyethyl starch (HES) (130/0.4) or 4% succinylated gelatin solutions on perioperative coagulability were measured by thromboelastography (TEG). Seventy-five patients (ASA I-III) who were to undergo major orthopedic procedures performed under epidural anesthesia were included in the study. Patients were randomly divided into three groups of 25 each for the administration of maintenance fluids: group RL (Ringer lactate), group HES (6% HES 130/0.4), and group JEL (4% gelofusine solution). Blood samples were obtained during the perioperative period before epidural anesthesia (t1, baseline), at the end of the surgery (t2), and 24 h after the operation (t3). TEG data, reaction time (R), coagulation time (K), angle value (α), and maximum amplitude (MA) were recorded. TEG parameters changed from normal values in all patients. In group RL, R and K times decreased compared to perioperative values while the α angle and MA increased (P < 0.05). In group HES, R and K times increased, however, the α angle and MA decreased (P < 0.05). In group JEL, R time increased (P < 0.05), but K time, α angle and MA did not change significantly. In the present study, RL, 6% HES (130/0.4) and 4% JEL solutions caused changes in the coagulation system of all patients as measured by TEG, but these changes remained within normal limits.

Systematic review of randomized controlled trials of new anticoagulants for venous thromboembolism prophylaxis in major orthopedic surgeries, compared with enoxaparin

Background: In the past 10 years, new anticoagulants (NACs) have been studied for venous thromboembolism (VTE) prophylaxis. Objective: To evaluate the risk/benefit profile of NACs versus enoxaparin for VTE prophylaxis in major orthopedic surgery. Methods: A systematic review of double-blind randomized phase III studies was performed. The search strategy was run from 2000 to 2011 in the main medical electronic databases in any language. Independent extraction of articles was performed by 2 authors using predefined data fields, including study quality indicators. Results: Fifteen published clinical trials evaluating fondaparinux, rivaroxaban, dabigatran, and apixaban were included. Primary efficacy (any deep vein thrombosis [DVT], nonfatal pulmonary embolism, or all-cause mortality) favored fondaparinux (relative risk [RR] 0.50; 95% CI, 0.39, 0.63) and rivaroxaban (RR, 0.50; 95% CI, 0.34, 0.73) over enoxaparin, although significant heterogeneity was observed in both series. The primary efficacy of dabigatran at 220 mg, apixaban, and bemiparin were similar, with RRs of 1.02 (95% CI, 0.86, 1.20), 0.63 (95% CI, 0.39, 1.01), and 0.87 (95% CI, 0.65, 1.17), respectively. The primary efficacy of dabigatran at 150 mg (RR, 1.20; 95% CI, 1.03, 1.41), was inferior to enoxaparin. The incidence of proximal DVT favored apixaban (RR, 0.45; 95% CI, 0.27, 0.75) only. Rivaroxaban (RR, 0.45; 95% CI, 0.27, 0,77) and apixaban (RR, 0.38; 95% CI, 0.16, 0.90) produced significantly lower frequencies of symptomatic DVT. The incidence of major VTE favored rivaroxaban (RR, 0.44; 95% CI, 0.25, 0.81), only. Bleeding risk was similar for all NACs, except fondaparinux (RR, 1.27; 95% CI, 1.04, 1.55), which exhibited a significantly higher any-bleeding risk compared with enoxaparin, and apixaban (RR, 0.88; 95% CI, 0.79, 0.99), which was associated with a reduced risk of any bleeding. Alanine amino transferase was significantly lower with 220 mg of dabigatran, (RR, 0.67; 95% CI, 0.79, 0.99) than with enoxaparin. Conclusions: NACs can be considered alternatives to conventional thromboprophylaxis regimens in patients undergoing elective major orthopedic surgery, depending on clinical characteristics and cost-effectiveness. The knowledge of some differences concerning efficacy or safety profile, pointed out in this systematic review, along with the respective limitations, may be useful in clinical practice. © 2013 Elsevier Inc. All rights reserved.

Endovascular treatment of arterial injury as an uncommon complication after orthopedic surgery

PURPOSE: To evaluate selective and superselective catheter therapy of serious arterial damage associated with orthopedic surgery of the pelvis, hip joint, femur, and knee. MATERIALS AND METHODS: Between 1989 and 2005, 16 consecutive patients with arterial damage after orthopedic surgery (seven women, nine men; mean age, 62 years; age range, 21-82 y) underwent angiographic exploration. Seven patients were in hemodynamically unstable condition. Initial orthopedic procedures were iliac crest internal fixation (n = 1); total hip prosthesis (n = 3); revision of total hip prosthesis (n = 4); revision of acetabular cup prosthesis (n = 1); gamma-nailing, nail-plate fixation, or intramedullary nailing (n = 3); and total knee prosthesis (n = 4). RESULTS: Angiography showed pseudoaneurysms (n = 11), vascular lacerations with active extravasation (n = 3), and arteriovenous fistulas with extravasation (n = 2). After angiographic documentation of serious arterial injury, 14 patients were treated with a single or coaxial catheter technique in combination with coils alone, coils and polyvinyl alcohol particles, coils and Gelfoam pledgets, or Gelfoam pledgets; or balloon occlusion with isobutyl cyanoacrylate and coils. Two patients were treated with covered stents. In all, bleeding was effectively controlled in a single session in 16 patients, with immediate circulatory stabilization. Major complications included death, pulmonary embolism, and postprocedural hematoma. CONCLUSION: Selective and superselective catheter therapy may be used for effective, minimally invasive management of rare but potentially life-threatening vascular complications after orthopedic surgery.

Effect of triiodothyronine on the maxilla and masseter muscles of the rat stomatognathic system

The maxilla and masseter muscles are components of the stomatognathic system involved in chewing, which is frequently affected by physical forces such as gravity, and by dental, orthodontic and orthopedic procedures. Thyroid hormones (TH) are known to regulate the expression of genes that control bone mass and the oxidative properties of muscles; however, little is known about the effects of TH on the stomatognathic system. This study investigated this issue by evaluating: i) osteoprotegerin (OPG) and osteopontine (OPN) mRNA expression in the maxilla and ii) myoglobin (Mb) mRNA and protein expression, as well as fiber composition of the masseter. Male Wistar rats (~250 g) were divided into thyroidectomized (Tx) and sham-operated (SO) groups (N = 24/group) treated with T3 or saline (0.9%) for 15 days. Thyroidectomy increased OPG (~40%) and OPN (~75%) mRNA expression, while T3 treatment reduced OPG (~40%) and OPN (~75%) in Tx, and both (~50%) in SO rats. Masseter Mb mRNA expression and fiber type composition remained unchanged, despite the induction of hypo- and hyperthyroidism. However, Mb content was decreased in Tx rats even after T3 treatment. Since OPG and OPN are key proteins involved in the osteoclastogenesis inhibition and bone mineralization, respectively, and that Mb functions as a muscle store of O2 allowing muscles to be more resistant to fatigue, the present data indicate that TH also interfere with maxilla remodeling and the oxidative properties of the masseter, influencing the function of the stomatognathic system, which may require attention during dental, orthodontic and orthopedic procedures in patients with thyroid diseases.

Economic analysis of surgical treatment of hip fracture in older adults

OBJECTIVE To analyze the incremental cost-utility ratio for the surgical treatment of hip fracture in older patients.METHODS This was a retrospective cohort study of a systematic sample of patients who underwent surgery for hip fracture at a central hospital of a macro-region in the state of Minas Gerais, Southeastern Brazil between January 1, 2009 and December 31, 2011. A decision tree creation was analyzed considering the direct medical costs. The study followed the healthcare provider’s perspective and had a one-year time horizon. Effectiveness was measured by the time elapsed between trauma and surgery after dividing the patients into early and late surgery groups. The utility was obtained in a cross-sectional and indirect manner using the EuroQOL 5 Dimensions generic questionnaire transformed into cardinal numbers using the national regulations established by the Center for the Development and Regional Planning of the State of Minas Gerais. The sample included 110 patients, 27 of whom were allocated in the early surgery group and 83 in the late surgery group. The groups were stratified by age, gender, type of fracture, type of surgery, and anesthetic risk.RESULTS The direct medical cost presented a statistically significant increase among patients in the late surgery group (p < 0.005), mainly because of ward costs (p < 0.001). In-hospital mortality was higher in the late surgery group (7.4% versus 16.9%). The decision tree demonstrated the dominance of the early surgery strategy over the late surgery strategy: R$9,854.34 (USD4,387.17) versus R$26,754.56 (USD11,911.03) per quality-adjusted life year. The sensitivity test with extreme values proved the robustness of the results.CONCLUSIONS After controlling for confounding variables, the strategy of early surgery for hip fracture in the older adults was proven to be dominant, because it presented a lower cost and better results than late surgery.

Acute fractures of medial and lateral great toe sesamoids in an athlete.

We report a case of acute fracture of both sesamoids of the great toe in an athlete. The fractures healed uneventfully after non-surgical treatment.

Pedicle screw insertion: robotic assistance versus conventional C-arm fluoroscopy.

Bone-mounted robotic guidance for pedicle screw placement has been recently introduced, aiming at increasing accuracy. The aim of this prospective study was to compare this novel approach with the conventional fluoroscopy assisted freehand technique (not the two- or three-dimensional fluoroscopy-based navigation). Two groups were compared: 11 patients, constituting the robotical group, were instrumented with 64 pedicle screws; 23 other patients, constituting the fluoroscopic group, were also instrumented with 64 pedicle screws. Screw position was assessed by two independent observers on postoperative CT-scans using the Rampersaud A to D classification. No neurological complications were noted. Grade A (totally within pedicle margins) accounted for 79% of the screws in the robotically assisted and for 83% of the screws in the fluoroscopic group respectively (p = 0.8). Grade C and D screws, considered as misplacements, accounted for 4.7% of all robotically inserted screws and 7.8% of the fluoroscopically inserted screws (p = 0.71). The current study did not allow to state that robotically assisted screw placement supersedes the conventional fluoroscopy assisted technique, although the literature is more optimistic about the former.

Questions et réponses sur l'utilisation du rivaroxaban (Xarelto) dans la pratique [Questions and answers regarding the use of rivaroxaban in daily practice].

Several new oral anticoagulants are now on the Swiss market and the general practitioner faces new challenges regarding the management of these new drugs. This consensus document aims to answer to the most frequently asked questions regarding rivaroxaban and covers different topics such as indications, initiation of treatment, drug-drug interactions and perioperative management.

Les vertébroplasties: point de vue du rhumatologue [Vertebro-plasty: a rheumatologist's point of view]

Percutaneous vertebro-plasty is an efficient treatment of the symptomatic vertebral compression fracture refractory to optimal medical therapy. The procedure is used for neoplastic lesions, aggressive angioma, but also osteoporotic compression fractures. In order to adequately advice our patients, it is essential to know its indications and possible complications. However, to practice a vertebro-plasty for an osteoporotic compression fracture without any long term management of the osteoporotic disease is useless. Unfortunately, it still happens too often and it is essential that orthopedic surgeons, general practitioner, radiologist, rheumatologist, and any practitioners work together to guarantee the optimal management of our patients.

Vertébroplastie par voie percutanée [Percutaneous vertebroplasty]

Although vertebroplasty was initially a treatment of vertebral haemangioma or metastases, this procedure is now frequent option to the treatment of osteoporotic vertebral fractures. In this review article, we will discuss the indication, the techniques and the follow-up of the vertebroplasty. This is a risky procedure, which should be performed by experimented physicians working with high-resolution fluoroscopic equipments, by biplane fluoroscopy, to reduce the risk and irradiation to the patient. According to the available follow-up studies, there is clear evidence of a strong improvement of quality of life after vertebroplasty by rapid decreasing of back pain at least during the first six months. Other new studies will analyze the long-term follow-up after vertebroplasty.