Is It Safe to Resume Direct Oral Anticoagulants upon Discharge after Hip Fracture Surgery? A Retrospective Study.

This study aimed to examine the incidence rate of early reoperations following hip fracture surgery and determine the safety of resuming direct oral anticoagulants. Many orthopedic surgeons are reluctant to resume chronic anticoagulation therapy for patients after surgical intervention for hip fractures. One of the main reasons is the potential for reoperation in the case of surgical complications. We conducted a retrospective cohort study at an Academic Level I trauma center, reviewing the records of 425 geriatric patients (age > 60) who underwent hip fracture surgery between 2018 and 2020, including a subgroup treated with direct oral anticoagulants prior to hospitalization. The study assessed the incidence rate of complications requiring early reoperation. Out of the 425 patients, only nine (2%) required reoperation within a month after discharge, with two (0.5%) on chronic anticoagulation therapy. None of the reoperations were urgent, and all were performed at least 24 h after re-admission. The findings revealed a very low incidence rate of reoperations in patients who underwent hip fracture surgery, with no reoperations performed within 24 h of re-admission. Consequently, we believe that resuming chronic direct oral anticoagulants is a safe and effective approach when discharging patients after hip fracture surgery.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic.

BACKGROUND: Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance. OBJECTIVES: To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery. METHODS: We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage. RESULTS: We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation. CONCLUSIONS: Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Evolution of treatment of femoral shaft fracture in polytrauma: Did damage control orthopaedics improve the outcome? A retrospective study.

BACKGROUND: Treatment of polytrauma patients with femoral shaft fracture has changed considerably during the past few decades. A transition from early total care (ETC) to "Damage Control" Orthopaedics (DCO) in selected patients was proposed in order to decrease mortality. The aim of the study was to investigate whether this policy change resulted in improved patient outcome. METHODS: We present a retrospective, comparative study, held in a Level I trauma center in Jerusalem, Israel. Polytrauma patients with Injury Severity Score higher than 16 with femoral shaft fracture were included. Data was extracted from our institute's electronic trauma registry. The study examines two time periods: Between the years 1996 and 2006 patients were treated according to the ETC protocol, with immediate intramedullary nailing (IMN) within 12 h. From 2007 until 2019 a DCO policy was adopted, implementing temporary external fixator for high risk patients, according to the "Hannover" criteria. Following resolution of the acute phase, these were converted to IMN. Patients eligible for DCO were matched to controls who received ETC during the earlier period. RESULTS: A total of ninety-six patients were included (DCO n = 44, ETC n = 52). The groups were comparable in terms of age, gender, mechanism of injury, injury to surgery time and Injury severity score (DCO median 31.5, ETC median 29). No statistical difference was found between the groups in terms of mortality (P = 0.757), acute respiratory distress syndrome (P = 0.534), sepsis (P = 0.519) and hospital stay (DCO median 24 days, ETC median 21.5 days) or ICU stay (Median 7 days in both groups). CONCLUSIONS: This pilot study did not demonstrate better outcome by implementing DCO concepts in the polytrauma patient. LEVEL OF EVIDENCE: III prognostic.

Comparative outcome of bomb explosion injuries versus high-powered gunshot injuries of the upper extremity in a civilian setting.

BACKGROUND: Explosion injuries to the upper extremity have specific clinical characteristics that differ from injuries due to other mechanisms. OBJECTIVES: To evaluate the upper extremity injury pattern of attacks on civilian targets, comparing bomb explosion injuries to gunshot injuries and their functional recovery using standard outcome measures. METHODS: Of 157 patients admitted to the hospital between 2000 and 2004, 72 (46%) sustained explosion injuries and 85 (54%) gunshot injuries. The trauma registry files were reviewed and the patients completed the DASH Questionnaire (Disabilities of Arm, Shoulder and Hand) and SF-12 (Short Form-12) after a minimum period of 1 year. RESULTS: Of the 157 patients, 72 (46%) had blast injuries and 85 (54%) had shooting injuries. The blast casualties had higher Injury Severity Scores (47% vs. 22% with a score of > 16, P = 0.02) and higher percent of patients treated in intensive care units (47% vs. 28%, P = 0.02). Although the Abbreviated Injury Scale score of the upper extremity injury was similar in the two groups, the blast casualties were found to have more bilateral and complex soft tissue injuries and were treated surgically more often. No difference was found in the SF-12 or DASH scores between the groups at follow up. CONCLUSIONS: The casualties with upper extremity blast injuries were more severely injured and sustained more bilateral and complex soft tissue injuries to the upper extremity. However, the rating of the local injury to the isolated limb is similar, as was the subjective functional recovery.

Optimal fixation of acute scaphoid fractures: finite element analysis.

PURPOSE: The hypothesis of this study was that more stable fixation of acute scaphoid fractures may be achieved by a screw placed perpendicular to the fracture plane than along the long axis of the scaphoid, as previously suggested. We examined this assumption on different fracture patterns using a finite element analysis model. METHODS: A computed tomography scan of an intact scaphoid of a young man provided the data set for all fracture models. We used semiautomatic segmentation to create 3-dimensional computer models of the 3 simple fracture configurations: oblique, transverse waist, and proximal fractures, according to the Herbert classification. Each fracture type was analyzed, using finite elements, for its biomechanical response to 2 types of virtual fixation: a screw placed either perpendicular to the fracture plane or centrally along the long axis of the scaphoid. We measured motion at the fracture plane (in millimeters) and strain in the screw threads (in millipascals). RESULTS: Considerably less motion was measured at the fracture plane with the perpendicular screw compared with the long axis screw, especially in the oblique-type fractures: (1) Herbert-type B1 oblique fracture mean motion of 0.05 mm (+/-0.03) for the perpendicular screw versus 0.28 mm (+/-0.05) for the long axis screw; (2) B2 transverse waist fracture mean motion of 0.06 mm (+/-0.03) for the perpendicular screw versus 0.18 mm (+/-0.06) for the long axis screw; and (3) B3 proximal fracture mean motion of 0.07 mm (+/-0.01) for the perpendicular screw versus 0.28 mm (+/-0.011) for the long axis screw. Higher strains were measured on the screw placed perpendicular to the fracture. CONCLUSIONS: According to this model, higher fixation stability is achieved when the scaphoid is fixated perpendicular to the fracture. In transverse waist fractures, a centrally placed screw will also be perpendicular to the fracture, which explains the results of previous models.