Protocolized use of Factor Eight Inhibitor Bypassing Activity (FEIBA) for the reversal of warfarin induced coagulopathy.

INTRODUCTION: Coagulopathy due to warfarin in patients with major bleeding was traditionally reversed with fresh frozen plasma and intravenous (IV) vitamin K, but prothrombin complex concentrates (PCC) are increasingly used in the treatment of these patients. Factor Eight Inhibitor Bypassing Activity (FEIBA) is an activated four-factor PCC most commonly used in patients with hemophilia. We aimed to evaluate the efficacy and safety of FEIBA and IV vitamin K for the reversal of warfarin-associated coagulopathy in patients with major bleeding, by measuring the percentage of patients who achieved target INR ≤ 1.5 and the incidence of thrombotic adverse events (TAE). METHODS: In this prospective observational study, we enrolled patients presenting to the Emergency Department (ED) with warfarin associated coagulopathy (INR > 1.5) and major bleeding. Patients received FEIBA using an INR based dosing strategy and IV vitamin K. RESULTS: In 43 patients, median initial INR was 4.0 (2.7, 7.3 interquartile range (IQR)). Median time to result the second INR was 45 min (38, 55 IQR) and the median INR was 1.4 (1.3, 1.6 IQR). Out of the 43 patients, 93% achieved the target INR of ≤1.5. In-hospital mortality was 40% (17 patients). There were 11 TAEs in 6 patients (14%); 4 events in 2 patients (5%) were attributed to FEIBA. CONCLUSION: A protocolized use of FEIBA and IV vitamin K resulted in the efficacious reversal of warfarin-induced coagulopathy in patients with major bleeding. TAEs occurred in 14% of patients and were attributed to FEIBA in 5% of patients.

Erratum to: Clinical Results and Failure Mechanisms of a Nonmodular Constrained Knee Without Stem Extensions.

[This corrects the article DOI: 10.1007/s11420-012-9277-9.].

Ketamine for continuous sedation of mechanically ventilated patients.

CONTEXT: Long-term sedation with midazolam or propofol has been demonstrated to have serious adverse side effects, such as toxic accumulation or propofol infusion syndrome. Ketamine remains a viable alternative for continuous sedation as it is inexpensive and widely available, however, there are few analyses regarding its safety in this clinical setting. OBJECTIVE: To review the data related to safety and efficacy of ketamine as a potential sedative agent in mechanically ventilated patients admitted to the intensive care unit (ICU). MATERIALS AND METHODS: This was a single-center retrospective study from September 2011 to March 2012 of patients who required sedation for greater than 24 hours, in whom ketamine was selected as the primary sedative agent. All patients greater than 18 years of age, regardless of admitting diagnosis, were eligible for inclusion. Patients that received ketamine for continuous infusion but died prior to receiving it for 24 hours were not included. RESULTS: Thirty patients received ketamine for continuous sedation. In four patients, ketamine was switched to another sedative agent due to possible adverse side effects. Of these, two patients had tachydysrhythmias, both with new onset atrial fibrillation and two patients had agitation believed to be caused by ketamine. The adverse event rate in our patient population was 13% (4/30). CONCLUSIONS: Among ICU patients receiving prolonged mechanical ventilation, the use of ketamine appeared to have a frequency of adverse events similar to more common sedative agents, like propofol and benzodiazepines.

Intraarticular analgesia versus epidural plus femoral nerve block after TKA: a randomized, double-blind trial.

BACKGROUND: Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic. QUESTIONS/PURPOSES: We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. METHODS: Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. RESULTS: The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p < 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups. CONCLUSIONS: A continuous intraarticular infusion of ropivacaine can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB after TKA. Improved analgesic efficacy in the group that received epidural analgesia plus single-injection FNB must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach. LEVEL OF EVIDENCE: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Plasma 25-hydroxyvitamin d levels in operative patella fractures.

BACKGROUND: Patella fractures have not traditionally been considered "fragility" fractures. QUESTIONS/PURPOSE: The purpose of this study was to examine the demographic patterns (age and gender distribution) and plasma 25-hydroxyvitamin D levels of a cohort of patients with operative patella fractures. PATIENTS AND METHODS: Medical records were reviewed on all consecutive patients presenting to our institution with operative patella fractures from 2003 to 2009. Seventy-eight operative patella fractures (25 male, 53 female) were identified with a mean age of 58 years (range, 22-89 years). RESULTS: The majority of patients with patella fractures in this series were females over the age of 50 years who sustained low-energy falls from a standing height or less. Twenty-four patients (80%) had vitamin D insufficiency or deficiency at the time of injury. For 68 patients (87%), the patella fracture represented their first fracture. Patients with known osteoporosis risk factors did not have higher rates of vitamin D insufficiency/deficiency. CONCLUSIONS: The age and gender distribution, as well as the prevalence of vitamin D insufficiency/deficiency, of operative patella fractures, suggest that these patients likely have abnormal vitamin D levels and should undergo a metabolic bone work-up.

Revision ACL reconstruction in skeletally mature athletes younger than 18 years.

BACKGROUND: Young, active, skeletally mature patients have higher failure rates after various surgical procedures, including stabilization for shoulder instability and primary ACL reconstruction. It is unclear whether young, active, skeletally mature patients share similarly high failure rates after revision ACL reconstruction. QUESTIONS/PURPOSES: We therefore determined whether revision ACL reconstruction restores knee stability and allows young (younger than 18 years), active, skeletally mature patients to return to preinjury activity levels. PATIENTS AND METHODS: We retrospectively identified 36 patients who had an initial ACL reconstruction between the ages of 12 and 17 years (mean, 15.4 years) and subsequent revision between the ages of 13 and 18 years (mean, 16.9 years); of these, 2-year followup was available for 21 (75%). Mechanisms of primary graft failure included traumatic rerupture (23 noncontact, seven contact), persistent instability (five), and infection (one). One patient had open physes at the time of revision. All revisions were single-stage transosseous reconstructions. The minimum followup was 24 months (mean, 36 months; range, 24-63 months). RESULTS: At last followup, 19 of 21 patients had a negative or IA Lachman and 20 of 21 had a negative pivot shift. Mean International Knee Documentation Committee subjective score was 89 (range, 64-99). Eleven of the 21 patients returned to the same or higher activity/sport level as before their original injury. Two patients reported subjective knee instability, with two having repeat revision reconstruction for failure. CONCLUSIONS: Single-stage transosseous revision ACL reconstruction in young, active, skeletally mature patients restores knee stability but returns only 52% of patients to their prior level of activity or sport. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical results and failure mechanisms of a nonmodular constrained knee without stem extensions.

INTRODUCTION: In the setting of persistent knee instability despite appropriate ligament balancing for primary total knee arthroplasty, most surgeons advocate the use of an implant with increased articular constraint. These implants are commonly supplemented with stem extensions to improve stress transfer and decrease the risk of aseptic loosening. However, disadvantages exist with the use of stem extensions, including increased cost, intramedullary invasion, and diaphyseal pain. The objectives of this study were to (1) compare the clinical results as assessed by the Knee Society, Hospital for Special Surgery, and SF-12 scores, (2) determine the incidence of failure as defined by the need for a revision procedure, and (3) to analyze the causes or modes of failure of a nonmodular constrained condylar knee without the use of stem extensions versus a conventional, posterior-stabilized design. MATERIALS AND METHODS: From 2002 to 2007, 190 TKAs were implanted using a primary, nonmodular constrained (NMC) prosthesis without stem extensions. During the same time period, clinical data were available for 140 TKAs implanted using a standard, posterior-stabilized (PS) design. Preoperative demographic data was reviewed, in addition to the rate and reason for revision in each cohort. Clinical data included HSS, Knee Society, and SF-12 scores at the latest follow-up, and the results of the NMC and PS cohorts were statistically compared using a Student's two-tailed t test. RESULTS: The mean age of patients in the NMC cohort was 72.3 ± 10.2 years, and the mean length of follow-up was 7.3 ± 2.1 years. The mean age of the PS cohort was 67.1 ± 8.7 years, with a mean follow-up of 6.1 ± 2.2 years. No statistically significant differences in the HSS, Knee Society, or SF-12 scores were appreciated between the two cohorts. The revision rate in the NMC cohort was 4.2 % compared to 4.3 % for the PS cohort. The most common cause of failure in the NMC cohort was femoral component loosening, all of which occurred when Palacos cement was used for fixation. NMC components (55.6 %) implanted with Palacos cement failed due to femoral component loosening. In contrast, all PS components requiring revision were revised for persistent instability. DISCUSSION: At mid-term follow-up, NMC prostheses without stem extensions have excellent clinical results and are a viable option for patients with ligamentous instability. The use of Palacos cement in this scenario was associated with a high rate of femoral component loosening, possibly due to the decreased intrusion depth of Palacos when compared to Simplex cement.

Contemporary predictors of conversion from laparoscopic to open appendectomy.

BACKGROUND: We defined the contemporary conversion rate from laparoscopic appendectomy (LA) to open appendectomy and identified pre-operative factors associated with conversion. METHODS: Retrospective review of 941 consecutive LAs performed for suspected acute appendicitis in a single urban university hospital between 2000 and 2007. Patient characteristics, clinical features, physical examination findings, laboratory values, computed tomography (CT) findings, surgeon identity, operative findings, and pathologic results were assessed. Categorical variables were compared in patients undergoing LA and those in whom conversion was necessary using the Fisher exact test; the Student t-test was used to compare continuous variables. Multivariable analysis was performed with binomial logistic regression. Statistical significance was established at α = 0.05. RESULTS: The overall conversion rate was 4.1% and did not change significantly over the course of the study. By univariable analysis, conversion was significantly associated with older age, male gender, American Society of Anesthesiologists (ASA) score >2 points, longer duration of symptoms, rigidity on physical examination, increased percentage of neutrophils on admission white blood cell differential count, extraluminal air on CT, inexperience of the attending surgeon with LA, retrocecal location of the appendix, gross necrosis or perforation, murky or purulent ascites, and microscopic evidence of perforation. By multivariable analysis, advanced age (hazard ratio [HR] 1.02 per year; 95% confidence interval [CI] 1.01-1.04, p = 0.02), ASA score >2 points (HR 11.2; 95% CI 5.6-24.4; p < 0.001), CT inflammation grade ≥ 4 (HR 4.8; 95% CI 1.9-12.3; p = 0.001), and attending surgeon inexperience (HR 7.4; 95% CI 2.6-20.8; p < 0.001) were independent predictors of conversion. CONCLUSION: The conversion rate during laparoscopic appendectomy has not changed significantly over the past seven years and remains ~4%. Independent pre-operative predictors of conversion are advanced age, ASA score >2 points, attending surgeon inexperience, and extensive inflammation observed on pre-operative CT scan. Proceeding directly with open appendectomy under these circumstances may reduce operative time, expense, and morbidity.