Early hip fracture surgery is safe for patients on direct oral anticoagulants.

Objectives: To determine how preoperative direct oral anticoagulant (DOAC) use affects rates of blood transfusion, clinically important blood loss, and 30-day mortality in patients with hip fracture undergoing surgery within 48 hours of presentation to the emergency department. Design: Retrospective cohort study. Setting: Academic trauma center. Patients: A total of 535 patients with hip fracture who underwent open cephalomedullary nail fixation or arthroplasty either taking a direct oral anticoagulant or no form of chemical anticoagulant/antiplatelet agent before presentation (control). Main Outcome Measures: Demographics, time to surgery, type of surgery, blood transfusion requirement, clinically important blood loss, and 30-day mortality. Results: Forty-one patients (7.7%) were taking DOACs. DOAC patients were older (81.7 vs. 77 years, P = 0.02) and had higher BMI (26.9 vs. 24.2 kg/m2, P = 0.01). Time from admission to surgery was similar between DOAC users (20.1 hours) and the control (18.7 hours, P > 0.4). There was no difference in receipt of blood transfusion (P = 0.4), major bleeding diagnosis (P = 0.2), acute blood loss anemia diagnosis (P = 0.5), and 30-day mortality (P = 1) between the DOAC and control group. This was true when stratifying by type of surgery as well. Conclusions: Our results suggest that early surgery may be safe in patients with hip fracture taking DOACs despite theoretical risk of increased bleeding. Because early surgery has previously been associated with decreased morbidity and mortality, we suggest that hip fracture surgery should not be delayed because a patient is taking direct oral anticoagulants. Level of Evidence: Prognostic Level III.

Drain options after vertebral body tethering.

PURPOSE: Since the introduction of vertebral body tethering (VBT) for adolescent idiopathic scoliosis (AIS), a variety of post-operative chest drainage systems have been utilized. Most surgeons use formal chest tubes with a Pleur-evac, while others use smaller bulb suction drains (e.g., Blake drain). In addition, some centers utilize pleural closure. This multicenter study evaluates whether drain type or pleural closure impact perioperative and 90 day complication rates. METHODS: A retrospective review was conducted from three institutions with established VBT programs. All preoperative, perioperative and 90 day postoperative data were analyzed to determine differences in outcomes between three cohorts: standard chest tube (SCT), standard chest tube with pleural closure (SCTPC) and 10 French Bulb drain (BD). RESULTS: 104 patients were identified for the study. 57 SCT, 25 SCTPC and 22 BD. All data are listed in order: SCT, SCTPC, BD. Length of stay (3.7, 4.3, 3.0 days) was less in the BD group (p = 0.009); post-operative drainage (460, 761, 485 cc) was less in the SCT and BD groups (p < 0.001); intra-operative estimated blood loss (EBL) 146, 382, 64 cc was less in the BD group (p < 0.001). No significant difference in number of days (3.2, 3.2, and 2.8 days) drainage was in place, groups (p = 0.311). Complication profile was similar with 2 chest tube reinsertions in the SCT and one hemothorax that resolved spontaneously in BD group. CONCLUSIONS: In this series of 104 patients, SCT, SCTPC and BD all had a similar safety profile. All three methods were safe and effective in managing post-operative chest drainage after thoracic VBT. In the series, BD group had significantly shorter LOS than both groups that used chest tubes. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Patient Characteristics Independently Associated With Knee Osteoarthritis Symptom Severity at Initial Orthopedic Consultation.

BACKGROUND/OBJECTIVE: The objective of this study was to identify patient and disease characteristics associated with the symptomatic severity of knee osteoarthritis (OA) at the time of initial knee OA diagnosis by an orthopedist. METHODS: This medical records review included patients initially diagnosed with knee OA during 2016 to 2017 by a single orthopedic surgeon in a university-based tertiary care setting. All variables were assessed at first OA diagnosis. Main outcomes were subscales of the Knee Injury and Osteoarthritis Outcome Score-Pain, other Symptoms, knee-related quality of life, and function in daily living. Multivariable regression analyses examined the following predictors of main outcomes: sex, race, age, insurance type, body mass index, Charlson comorbidity index, and radiographic OA severity (Kellgren-Lawrence grade). RESULTS: Of the 559 patients included in the study, most were African American (52.1%), female (71.7%), and had severe radiographic OA (Kellgren-Lawrence grade, 4; 68.7%). Female sex, African American racial/ethnic group, Medicaid insurance, younger age, and severe radiographic OA were independently statistically significantly associated with worse symptoms, pain, and function (p < 0.05 for all). Body mass index and Charlson comorbidity index were not statistically significant predictors of any outcome. CONCLUSIONS: This study identified disparities in the perception of knee OA problems at initial orthopedist diagnosis based on sex, age, race, insurance, and radiographic OA severity. Because most of these variables are also associated with more rapid progression of OA, identifying their biopsychosocial underpinnings may help determine which interventions are most likely to redress these disparities and delay progression to end-stage knee OA.

Total Knee Arthroplasty Outcomes in Patients with Medicare, Medicare Advantage, and Commercial Insurance.

As more commercial insurance companies adopt a bundled reimbursement model, similar to the Comprehensive Care for Joint Replacement (CJR) algorithm for Medicare beneficiaries, accurate risk adjustment of patient-reported outcomes (PROs) is critical to ensure success. With this movement toward bundled reimbursement, it is unknown if a formula adjusting for similar risks in the Medicare population could be applied to PROs in commercially insured and Medicare Advantage populations undergoing total knee arthroplasty (TKA). This study was performed to compare PROs after TKA in these insurance groups after adjusting for proposed risks. Demographics and clinical data were abstracted from medical records of 302 patients who underwent TKA performed by a single surgeon at a university-based orthopaedic practice during 2013 to 2017. Differences in PROs between commercially insured, Medicare Advantage, and Medicare patients during the 6 months following surgery were evaluated while controlling for demographics, clinical data, and baseline PRO scores. Medicare and Medicare Advantage patients were older (p < 0.001) and had more comorbidities (p = 0.001) than commercial patients. During the first 3 months following TKA, patients in all three groups experienced similar rates of recovery. At 6 months after surgery, outcomes began to diverge by insurance group. Medicare patients reported significantly less ability to perform activities of daily living (78.6 vs. 63.2; p = 0.001), worse physical function (39.6 vs. 44.9; p = 0.003), and more pain interference (57.9 vs. 52.4; p = 0.018) at day 180 than commercially insured patients. There were no statistically significant differences between Medicare Advantage patients and either commercially insured or Medicare patients. Therefore, commercial insurance companies that intend to apply a risk-adjusted equation similar to the CJR algorithm to commercial populations should be cautioned since the postoperative outcomes in this investigation differed after adjusting for the same risk factors that have been proposed for inclusion in the CJR algorithm. Nonetheless, further studies should be performed to ensure that companies participating in bundled reimbursement models have a positive influence on comprehensive health care for patients and providers. This is a level III, retrospective prognostic study.

The formation of a medical student research committee and its impact on involvement in departmental research.

Over the past ten years, medical students have increased their research activity to be competitive for orthopaedic residency positions throughout the country. This increase may favor students at institutions with a strong history of research production and well-established research departments with supporting staff. To compete with these institutions, a Musculoskeletal Research Committee was developed at a southern academic institution to provide a mutually beneficial link between orthopaedic research faculty and medical students. This manuscript describes the formation of this committee and the resultant involvement of young medical students in departmental research over a one year period. Composed of students and faculty, the committee developed a Research Guide for Medical Students, Research Database and Student List, Medical Students' Webpage, and Routing Form, and holds quarterly meetings for those students active in orthopaedic research. With this platform, the committee aimed to increase young student involvement in research and provide a stratified level of study participation among upper-level students for continued mentorship. In one calendar year, the total number of first and second-year students participating in department research increased 460% (5 to 28). Also, the total number of research projects with student involvement from these two classes increased 780% (5 to 44). The introduction of a research committee is an effective method of stimulating student interest in departmental research. Early participation results are promising, and this method may be applicable to other departments and institutions hoping to increase research productivity. ABBREVIATIONS: IRB: Institutional Review Board.

Near-infrared-absorbing gold nanopopcorns with iron oxide cluster core for magnetically amplified photothermal and photodynamic cancer therapy.

We present the synthesis and application of a new type of dual magnetic and plasmonic nanostructures for magnetic-field-guided drug delivery and combined photothermal and photodynamic cancer therapy. Near-infrared-absorbing gold nanopopcorns containing a self-assembled iron oxide cluster core were prepared via a seed-mediated growth method. The hybrid nanostructures are superparamagnetic and show great photothermal conversion efficiency (η=61%) under near-infrared irradiation. Compact and stable nanocomplexes for photothermal-photodynamic therapy were formed by coating the nanoparticles with near-infrared-absorbing photosensitizer silicon 2,3-naphthalocyannie dihydroxide and stabilization with poly(ethylene glycol) linked with 11-mercaptoundecanoic acid. The nanocomplex showed enhanced release and cellular uptake of the photosensitizer with the use of a gradient magnetic field. In vitro studies using two different cell lines showed that the dual mode photothermal and photodynamic therapy with the assistance of magnetic-field-guided drug delivery dramatically improved the therapeutic efficacy of cancer cells as compared to the combination treatment without using a magnetic field and the two treatments alone. The "three-in-one" nanocomplex has the potential to carry therapeutic agents deep into a tumor through magnetic manipulation and to completely eradicate tumors by subsequent photothermal and photodynamic therapies without systemic toxicity.