Does cerclage wiring interfere with fracture healing of osteosynthesis in comminuted midshaft clavicle fractures? A multicenter study.

INTRODUCTION: Historically, cerclage wires were not used in the treatment of clavicle fractures because of their invasiveness. The purpose of this study was to evaluate the radiologic results and the incidence of complications following cerclage wire application and plate fixation in the treatment of comminuted mid-shaft clavicle fractures. MATERIALS AND METHODS: A total of 116 patients with comminuted mid-shaft clavicle fractures who underwent open reduction and internal fixation were reviewed. We analyzed the postoperative length ratio and bone union period according to the fracture classification, patient age, the number of fragments and the number of applied wires. The thickness of the fracture site was compared with the normal contralateral clavicle shaft. RESULTS: Bone union was confirmed in all enrolled patients at an average of 14.9±4.67 weeks. There are no significant differences in the length ratio or bone union period among the subgroups (including the fracture types, age, number of fragments and applied wires). The diameter at the occupied area was not significantly from that on the normal side (p=.505). CONCLUSIONS: The application of a single cerclage or multiple cerclage wires around the fracture site did not hamper the clavicle shaft fracture healing. This result suggests that cerclage wires should not be avoided, but can be used as a viable treatment option for clavicle shaft fractures. LEVEL OF EVIDENCE: IV.

Relationships between Femoral Offset Change and Clinical Score following Bipolar Hip Arthroplasty in Femoral Neck Fractures.

PURPOSE: This study aimed to investigate the relationship between femoral offset (FO) and clinical outcomes of patients with femoral neck fracture following bipolar hip arthroplasty (BHA). MATERIALS AND METHODS: Records for a total of 520 patients who underwent BHA for a femoral neck fracture between December 1, 2003, and September 30, 2018, were reviewed retrospectively. Patients with unclear medical records, a congenital deformity and preoperative trauma history of the hip, high-energy multiple trauma, or a history of neurodegenerative disease or cerebrovascular disease were excluded. The remaining 77 patients included in the analysis had a minimum follow-up period of one year. For clinical assessment, the postoperative pain visual analogue scale (VAS) and Harris hip score (HHS) were analyzed at each follow-up period. For radiological assessment, the difference in leg length discrepancy (LLD) and FO were measured. RESULTS: The difference in mean FO postoperatively was 6.7±4.8 mm, and the difference in mean postoperative LLD was 4.9±3.4 mm. The mean HHS was 77.1±7.7, 82.3±8.6, 83.4±7.7, and 86.4±6.7 at 1, 3, 6, and 12 months postoperative, respectively. The correlation coefficient between FO and HHS in 1-year follow-up was -0.38, and a statistically significant outcome was found (P=0.001). For the HHS domain, the correlation coefficient for function at 1-year follow-up was -0.42, revealing a statistically significant outcome (P=0.0001). CONCLUSION: There was a statistically significant correlation between clinical outcomes and FO difference at 1 year after BHA in patients over 65 years of age with femoral neck fractures.

Impact of renal impairment on platelet reactivity and clinical outcomes during chronic dual antiplatelet therapy following coronary stenting.

AIMS: Clinical utilization of dual antiplatelet therapy (DAPT) in patients with renal impairment (RI) following percutaneous coronary interventions (PCI) represents an urgent, unmet need choosing optimal agents, duration of treatment, and potential dose/regimen adjustment. The lack of any large randomized trials specifically in RI patients, and the absence of the uniformed clinical data reporting policy, clouds the reality. Moreover, triaging RI patients is problematic due to ongoing kidney deterioration, and the fact that RI patients are prone to both vascular occlusions and bleeding. METHODS AND RESULTS: Seven hundred and one Korean patients receiving DAPT with aspirin 100 mg/daily and clopidogrel 75 mg/daily after PCI were prospectively enrolled in the study. Patients were dichotomized into five groups according to RI: estimated glomerular filtration rate (eGFR) >90 mL/min/1.73 m(2) (RI1), 60-89 mL/min/1.73 m(2) (RI2), 30-59 mL/min/1.73 m(2) (RI3), <30 mL/min/1.73 m(2) (RI4), and undergoing dialysis (RI5). Major adverse clinical events (MACEs; cardiovascular death, myocardial infarction, stent thrombosis, and stroke) were collected for 1 year. Platelet reactivity by VerifyNow™ assay and eGFR were simultaneously assessed at 1 month after maintenance DAPT. Patients with RI exhibited a gradual significant increase of residual platelet reactivity during DAPT, dependent on eGFR deterioration [191 ± 72 PRU (RI1) vs. 216 ± 78 PRU (RI2) vs. 248 ± 80 PRU (RI3) vs. 264 ± 70 PRU (RI4) vs. 317 ± 96 PRU (RI5), P < 0.001] being the highest in the dialyses group. Declined eGFR has been gradually associated with advancing age (OR = 1.03, 95% CI = 1.00-1.05; P = 0.032), female gender (OR = 1.7, 95% CI = 1.1-2.5; P = 0.01), diminished smoking rates (OR = 0.6, 95% CI = 0.37-1.00; P = 0.05), hypertension (OR = 1.8, 95% CI = 1.3-2.5; P < 0.001); diabetes (OR = 1.5, 95% CI = 1.1-2.1; P = 0.007), and MACE (HR = 13.9; 95% CI = 1.6-124.3; P = 0.02 for RI4; and HR = 31.9; 95% CI = 2.9-351.9; P = 0.005 for dialysis), but not for bleeding (P = 0.143). Major adverse clinical event risks still remained significant for RI4 (P = 0.027) and RI5 (P = 0.002) by multivariate Cox hazard regression estimates. CONCLUSION: Renal impairment is associated with gradual elevation of residual platelet reactivity while on DAPT, enhancing MACE risks, but not bleeding events. These data should be confirmed in a large randomized outcome-driven trial, and may justify future maintenance-phase DAPT regimen/dose adjustment in RI patients.

Comparison of Three Tests to Distinguish Platelet Reactivity in Patients with Renal Impairment during Dual Antiplatelet Therapy.

BACKGROUND: Clopidogrel and aspirin combination remains a cornerstone for modern dual antiplatelet therapy (DAPT) following coronary stenting. Although monitoring is not currently recommended, certain high-risk cohorts may benefit from tailoring antiplatelet options to reduce thrombotic or/and hemorrhagic risks. Patients with diminished estimated glomerular filtration rate (eGFR) are prone to both vascular occlusions and bleeding events in whom monitoring may be especially advantageous. We compared the residual platelet reactivity assessed by 3 conventional tests during the maintenance antiplatelet therapy dependent on eGFR. METHODS: Post-stenting patients (n = 701) receiving aspirin 100 mg/daily and clopidogrel 75 mg/daily were prospectively enrolled in the cross-sectional single-center study. Patients were dichotomized into 5 groups: eGFR >90, 60-89, 30-59, <30 ml/min/1.73 m2, and dialysis. Platelet reactivity by VerifyNow™, light transmittance aggregometry (LTA), and Multiplate analyzer by multiple electrode platelet aggregometry (MEA) assays together with eGFR calculations were done simultaneously at 1 month after coronary stenting. RESULTS: VerifyNow assay distinguished residual platelet reactivity dependent on eGFR deterioration (191 ± 72 vs. 216 ± 78 vs. 248 ± 80 vs. 264 ± 70 vs. 317 ± 96 PRU; p < 0.001). In contrast, LTA (34.3 ± 18.1 vs. 34.7 ± 18.1 vs. 38.0 ± 16.6 vs. 33.0 ± 17.3 vs. 34.1 ± 29.3%; p = 0.242), or MEA (37.2 ± 19.6 vs. 33.8 ± 18.4 vs. 38.6 ± 21.4 vs. 36.5 ± 20.5 vs. 38.3 ± 28.3 AU/min; p = 0.086) failed to triage platelet reactivity in renal patients. Agreement among assays to identify patients with impaired platelet reactivity and eGFR during antiplatelet therapy was low. The multivariable regression analyses confirmed the VerifyNow advantage, since the differences in the platelet reactivity were highly significant for all renal impairment (RI) groups. In contrast, LTA did not distinguish RI patients, and for the MEA, only RI5 (dialysis) cohort exhibit borderline significant decline of residual platelet reactivity. CONCLUSION: Among 3 assays, VerifyNow was capable to reliably triage residual platelet reactivity in post-stenting DAPT patients dependent on the gradual decline of eGFR during therapy with clopidogrel and aspirin. These data should be confirmed in a large validation longitudinal trial, and may justify future platelet activity monitoring for potential regimen/dose adjustment in high-risk patients. The clinical implications of these data are still unclear, but may give an indication as to whether or when DAPT dose adjustment will become a reality.