With today’s rapid health care transformation from fee for service to fee for value, it is imperative that gynecologic surgeons understand, engage in, and lead this transformation. The value equation is defined as patient experience times clinical outcome divided by cost. This 2-part special issue highlights some of the key content shared at the 2018 SGS annual meeting, held in Orlando, Florida, to help you engage and lead.

The keynote address was “Patient Experience: It is not about making people happy” and was presented by James Merlino, MD (author of Service Fanatics: How to Build Superior Patient Experience the Cleveland Clinic Way), who is former Chief Experience Officer and colorectal surgeon at the Cleveland Clinic and currently President and Chief Medical Officer, Strategic Consulting at Press Ganey. Dr. Merlino clearly defines that the patient experience is really about patient safety and quality. He shares practical tips to help physicians improve communication with patients, which not only increases patient satisfaction but also physician satisfaction. His wife Amy Merlino, MD, an ObGyn, coauthored the piece with him and shares their journey to implement programs that were impactful and designed to create greater personal appreciation and mindfulness of physicians’ clinical work.

Optimal surgical outcomes delivered at lowest cost are the other key components of value health care. Endometriosis and the management of stage 3 and 4 pelvic organ prolapse remain challenging clinical scenarios that we face often. Rosanne Kho, MD, and colleagues taught a postgraduate course on contemporary management of deep infiltrating endometriosis and, in part 2 of this special section, share key highlights and pearls from that course. A highpoint of the meeting was a debate on the optimal management of stage 3 and 4 pelvic organ prolapse. Peter Rosenblatt, MD, moderated a lively discussion involving Rebecca Rogers, MD, who advocated for native tissue repair; Patrick Culligan, MD, who promoted abdominal sacrocolpopexy; and Vincent Lucente, MD, backing transvaginal mesh. They summarize their arguments beginning on page SS4 for you to decide.

Lastly, with increasing demand for minimally invasive hysterectomy, many surgeons could benefit from simulation training to enhance their practice, hone up on skills, and provide warm-up to sharpen technical skills prior to the day in the operating room. Simulation training improves patient safety and outcomes and lowers cost. Simulation training is also key in training residents and fellows. Christine Vaccaro, MD, and colleagues taught a postgraduate course on what is new in simulation training for hysterectomy and summarize important technologies in part 2 of this special section.

I hope you enjoy the content of this special section and find it impactful to your practice and future.

With today’s rapid health care transformation from fee for service to fee for value, it is imperative that gynecologic surgeons understand, engage in, and lead this transformation. The value equation is defined as patient experience times clinical outcome divided by cost. This 2-part special issue highlights some of the key content shared at the 2018 SGS annual meeting, held in Orlando, Florida, to help you engage and lead.

The keynote address was “Patient Experience: It is not about making people happy” and was presented by James Merlino, MD (author of Service Fanatics: How to Build Superior Patient Experience the Cleveland Clinic Way), who is former Chief Experience Officer and colorectal surgeon at the Cleveland Clinic and currently President and Chief Medical Officer, Strategic Consulting at Press Ganey. Dr. Merlino clearly defines that the patient experience is really about patient safety and quality. He shares practical tips to help physicians improve communication with patients, which not only increases patient satisfaction but also physician satisfaction. His wife Amy Merlino, MD, an ObGyn, coauthored the piece with him and shares their journey to implement programs that were impactful and designed to create greater personal appreciation and mindfulness of physicians’ clinical work.

Optimal surgical outcomes delivered at lowest cost are the other key components of value health care. Endometriosis and the management of stage 3 and 4 pelvic organ prolapse remain challenging clinical scenarios that we face often. Rosanne Kho, MD, and colleagues taught a postgraduate course on contemporary management of deep infiltrating endometriosis and, in part 2 of this special section, share key highlights and pearls from that course. A highpoint of the meeting was a debate on the optimal management of stage 3 and 4 pelvic organ prolapse. Peter Rosenblatt, MD, moderated a lively discussion involving Rebecca Rogers, MD, who advocated for native tissue repair; Patrick Culligan, MD, who promoted abdominal sacrocolpopexy; and Vincent Lucente, MD, backing transvaginal mesh. They summarize their arguments beginning on page SS4 for you to decide.

Lastly, with increasing demand for minimally invasive hysterectomy, many surgeons could benefit from simulation training to enhance their practice, hone up on skills, and provide warm-up to sharpen technical skills prior to the day in the operating room. Simulation training improves patient safety and outcomes and lowers cost. Simulation training is also key in training residents and fellows. Christine Vaccaro, MD, and colleagues taught a postgraduate course on what is new in simulation training for hysterectomy and summarize important technologies in part 2 of this special section.

I hope you enjoy the content of this special section and find it impactful to your practice and future.

With today’s rapid health care transformation from fee for service to fee for value, it is imperative that gynecologic surgeons understand, engage in, and lead this transformation. The value equation is defined as patient experience times clinical outcome divided by cost. This 2-part special issue highlights some of the key content shared at the 2018 SGS annual meeting, held in Orlando, Florida, to help you engage and lead.

The keynote address was “Patient Experience: It is not about making people happy” and was presented by James Merlino, MD (author of Service Fanatics: How to Build Superior Patient Experience the Cleveland Clinic Way), who is former Chief Experience Officer and colorectal surgeon at the Cleveland Clinic and currently President and Chief Medical Officer, Strategic Consulting at Press Ganey. Dr. Merlino clearly defines that the patient experience is really about patient safety and quality. He shares practical tips to help physicians improve communication with patients, which not only increases patient satisfaction but also physician satisfaction. His wife Amy Merlino, MD, an ObGyn, coauthored the piece with him and shares their journey to implement programs that were impactful and designed to create greater personal appreciation and mindfulness of physicians’ clinical work.

Optimal surgical outcomes delivered at lowest cost are the other key components of value health care. Endometriosis and the management of stage 3 and 4 pelvic organ prolapse remain challenging clinical scenarios that we face often. Rosanne Kho, MD, and colleagues taught a postgraduate course on contemporary management of deep infiltrating endometriosis and, in part 2 of this special section, share key highlights and pearls from that course. A highpoint of the meeting was a debate on the optimal management of stage 3 and 4 pelvic organ prolapse. Peter Rosenblatt, MD, moderated a lively discussion involving Rebecca Rogers, MD, who advocated for native tissue repair; Patrick Culligan, MD, who promoted abdominal sacrocolpopexy; and Vincent Lucente, MD, backing transvaginal mesh. They summarize their arguments beginning on page SS4 for you to decide.

Lastly, with increasing demand for minimally invasive hysterectomy, many surgeons could benefit from simulation training to enhance their practice, hone up on skills, and provide warm-up to sharpen technical skills prior to the day in the operating room. Simulation training improves patient safety and outcomes and lowers cost. Simulation training is also key in training residents and fellows. Christine Vaccaro, MD, and colleagues taught a postgraduate course on what is new in simulation training for hysterectomy and summarize important technologies in part 2 of this special section.

I hope you enjoy the content of this special section and find it impactful to your practice and future.

The Food and Drug Administration has granted accelerated approval to blinatumomab for treatment of adults and children with B-cell precursor acute lymphoblastic leukemia (ALL) who are in remission but still have minimal residual disease (MRD).

This is the first FDA-approved treatment for those with MRD, the FDA said in a statement.

Common side effects include bacterial and pathogen-unspecified infections, pyrexia, headache, infusion-related reactions, neutropenia, anemia, febrile neutropenia, and thrombocytopenia. The drug carries a boxed warning about cytokine release syndrome at the start of the first treatment. The FDA also warns that children weighing less than 22 kg should receive the drug prepared with preservative-free saline because of the risk of serious adverse reactions in pediatric patients from a benzyl alcohol preservative.

Blinatumomab is marketed as Blincyto by Amgen.

[email protected]

The Food and Drug Administration has granted accelerated approval to blinatumomab for treatment of adults and children with B-cell precursor acute lymphoblastic leukemia (ALL) who are in remission but still have minimal residual disease (MRD).

This is the first FDA-approved treatment for those with MRD, the FDA said in a statement.

Common side effects include bacterial and pathogen-unspecified infections, pyrexia, headache, infusion-related reactions, neutropenia, anemia, febrile neutropenia, and thrombocytopenia. The drug carries a boxed warning about cytokine release syndrome at the start of the first treatment. The FDA also warns that children weighing less than 22 kg should receive the drug prepared with preservative-free saline because of the risk of serious adverse reactions in pediatric patients from a benzyl alcohol preservative.

Blinatumomab is marketed as Blincyto by Amgen.

[email protected]

The Food and Drug Administration has granted accelerated approval to blinatumomab for treatment of adults and children with B-cell precursor acute lymphoblastic leukemia (ALL) who are in remission but still have minimal residual disease (MRD).

This is the first FDA-approved treatment for those with MRD, the FDA said in a statement.

Common side effects include bacterial and pathogen-unspecified infections, pyrexia, headache, infusion-related reactions, neutropenia, anemia, febrile neutropenia, and thrombocytopenia. The drug carries a boxed warning about cytokine release syndrome at the start of the first treatment. The FDA also warns that children weighing less than 22 kg should receive the drug prepared with preservative-free saline because of the risk of serious adverse reactions in pediatric patients from a benzyl alcohol preservative.

Blinatumomab is marketed as Blincyto by Amgen.

[email protected]

Halsted’s surgical principles

Dr. William Steward Halsted, the first chief of surgery at Johns Hopkins Hospital, articulated a set of surgical principles that included strict aseptic technique, gentle tissue handling, meticulous hemostasis, minimum tension on tissue, accurate tissue apposition, preservation of blood supply, and obliteration of dead space where appropriate. These principles of “safe surgery” are believed to improve surgical outcomes and reduce the risk of surgical site infection.¹

Preoperative antibiotics

All obstetricians who perform cesarean delivery know the importance of administering a narrow-spectrum antibiotic, such as cefazolin or ampicillin, prior to the skin incision, but not more than 60 minutes before the incision, to help reduce the risk of wound infection and endometritis. In a meta-analysis of 82 studies involving more than 13,000 women the administration of a preoperative antibiotic compared with placebo reduced the risk of wound infection (relative risk [RR], 0.40; 95% confidence interval [CI], 0.35–0.46) and endometritis (RR, 0.38; 95% CI, 0.34–0.42).²

Cefazolin 3 g versus 2 g for obese patients

There are no data from randomized trials of cesarean delivery that directly compare the efficacy of preoperative cefazolin at doses of 2 g and 3 g to reduce the risk of infection. However, based on the observation that, for any given dose of cefazolin, circulating levels are reduced in obese patients, many authorities recommend that if the patient weighs ≥120 kg that 3 g of cefazolin should be administered.³

Extended-spectrum preoperative antibiotics

Some experts recommend that, for women in labor and for women with more than 4 hours of ruptured membranes, IV azithromycin 500 mg be added to the standard narrow-spectrum cefazolin regimen to reduce the rate of postoperative infection. In one trial, 2,013 women who were in labor or had more than 4 hours of ruptured membranes were randomly assigned to IV cefazolin alone or IV cefazolin plus azithromycin 500 mg prior to cesarean delivery.⁴ The cefazolin dose was reported to be weight-based utilizing the BMI at the time of delivery. The rates of endometritis (3.8% vs 6.1%) and wound infection (2.4% vs 6.6%) were lower in the women receiving extended-spectrum antibiotics versus cefazolin monotherapy.

Concerns have been raised about the impact of extended-spectrum antibiotics on the newborn microbiome and risk of accelerating the emergence of bacteria resistant to available antibiotics. Limiting the use of azithromycin to those cesarean delivery cases in which the patient is immunosuppressed, diabetic, obese, in labor and/or with prolonged ruptured membranes would reduce the number of women and newborns exposed to the drug and achieve the immediate health goal of reducing surgical infection.

Preoperative vaginal preparation

Many authorities recommend the use of a preoperative povidone- iodine vaginal scrub for 30 seconds prior to cesarean delivery for women in labor and women with ruptured membranes. In a meta-analysis of 16 trials involving 4,837 women, the women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% vs 8.8%) and postoperative fever (9.4% vs 14.9%) compared with those who did not have vaginal cleansing.⁵ Most of the benefit in reducing the risk of endometritis was confined to women in labor before the cesarean delivery (8.1% vs 13.8%) and women with ruptured membranes (4.3% vs 20.1%).⁵

Metronidazole gel 5 g also has been reported to be effective in reducing the rate of endometritis associated with cesarean delivery. In one study, 224 women having a cesarean delivery for various indications were randomly assigned to preoperative treatment with vaginally administered metronidazole gel 5 g or placebo gel. All women also received one dose of preoperative intravenous antibiotics. The rates of endometritis were 7% and 17% in the metronidazole and placebo groups, respectively.⁶

Povidone-iodine is approved for vaginal surgical site cleansing. For women with allergies to iodine or povidone-iodine, the options for vaginal cleansing are limited. The American College of Obstetricians and Gynecologists has noted the chlorhexidine gluconate solutions with a high concentration of alcohol should not be used for vaginal cleansing because the alcohol can irritate the mucosal epithelium. However, although not US Food and Drug Administration–approved for vaginal cleansing, solutions of chlorhexidine with a low alcohol content (Hibiclens, chlorhexidine with 4% alcohol concentration) are thought to be safe and may be considered for off-label use in vaginal cleansing.⁷

Preoperative abdominal preparation with chlorhexidine

Some authorities recommend skin preparation with chlorhexidine rather than povidone-iodine prior to cesarean delivery. Two recent randomized trials in women undergoing cesarean delivery^8,9 and one trial in patients undergoing general surgery operations¹⁰ reported a reduction in surgical site infection with chlorhexidine. However, other trials have reported no difference in the rate of surgical site infection with these two skin preparation methods.^11,12

Changing gloves and equipment after delivery of the newborn

Currently there is no high-quality evidence that changing gloves after delivery of the newborn or using new surgical instruments for closure reduces the risk of postcesarean infection. Two small clinical trials reported that changing gloves after delivery of the newborn did not reduce the rate of postcesarean infection.^13,14

Postoperative antibiotics (a heretical challenge to the central dogma of antibiotic prophylaxis in surgery)

The central dogma of antibiotic prevention of postoperative infection is that antibiotics administered just before skin incision are effective, and postoperative antibiotics to prevent surgical infection generally are not useful. For the case of cesarean delivery, where the rate of postcesarean infection is very high, that dogma is being questioned. In a recent clinical trial, 403 women with a prepregnancy BMI ≥30 kg/m² were randomly assigned to postcesarean treatment with oral cephalexin plus metronidazole (500 mg of each medication every 8 hours for 6 doses) or placebo pills.¹⁵ All women received preoperative IV cefazolin 2 g, indicating that the dosing was probably not weight-based. The surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 6.4% and 15.4%, respectively (RR, 0.41; 95% CI, 0.22–0.77; P = .01). In a subgroup analysis based on the presence or absence of ruptured membranes, postoperative oral cephalexin plus metronidazole was most beneficial for the women with ruptured membranes. Among women with ruptured membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 9.5% and 30.2%, respectively. Among women with intact membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 5% and 8.7%, respectively.

Given that these findings are not consistent with current dogma, clinicians should be cautious about using postcesarean antibiotics and await confirmation in additional trials. Of relevance, a randomized study of women with chorioamnionitis who were treated precesarean delivery with ampicillin, gentamicin, and clindamycin did not benefit from the administration of additional postoperative antibiotics (one additional dose of gentamicin and clindamycin) compared with no postdelivery antibiotics.¹⁶

Does suture selection matter?

In one randomized trial comparing two suture types, 550 women undergoing nonemergent cesarean delivery were randomly assigned to subcuticular skin closure with polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl) suture. The poliglecaprone 25 suture was associated with a lower rate of wound complications (8.8% vs 14.4%; 95% CI, 0.37–99; P = .04).¹⁷ However, a post-hoc analysis of a randomized trial of skin preparation did not observe a difference in wound complications between the use of polyglactinor poliglecaprone suture for skin closure.¹⁸

Prophylactic negative-pressure wound therapy: An evolving best practice?

A meta-analysis of 6 randomized trials and 3 cohort studies reported that in high-risk obese women the use of prophylactic negative-pressure wound therapy compared with standard wound dressing resulted in a decrease in surgical site infection (RR, 0.45; 95% CI, 0.31–0.66).¹⁹ The number needed to treat was 17. In one recent study, the wound outcomes following cesarean delivery among women with a BMI ≥40 kg/m² were compared in 234 women who received and 233 women who did not receive negative-pressure wound therapy.²⁰ Wound infection was observed in 5.6% and 9.9% of the treated and untreated women, respectively.²⁰ However, another meta-analysis of prophylactic negative-pressure wound therapy for obese women undergoing cesarean delivery did not report any benefit.²¹

Let’s work on continuous improvement

Cesarean delivery is a common major operation and is associated with wound infections and endometritis at rates much greater than those observed after vaginal delivery or other major intra-abdominal operations. As obstetricians, we can do more to guide practice toward continuous improvement in surgical outcomes. Systematically using a bundle of evidence-based interventions, including proper antibiotic selection, timing, and dosing; use of hair removal with clippers; use of chlorhexidine abdominal prep; removal of the placenta with gentle traction; and closure of the subcutaneous layer if tissue depth is ≥2 cm, will reduce the rate of postcesarean infection.²² Although aspirational, we may, someday, achieve a post‑cesarean infection rate less than 1%!

CASE Conclusion
The patient was noted to be at high risk for postcesarean infection because she had both an elevated BMI and ruptured membranes. The surgeon astutely decided to administer cefazolin 3 g and azithromycin 500 mg, cleanse the vagina with povidone-iodine, use chlorhexidine for the abdominal prep, use poliglecaprone 25 subcuticular skin closure, and did not use postoperative antibiotics or prophylactic wound vacuum. Following an uneventful cesarean delivery, the patient was discharged without an infection on postoperative day 4.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Halsted’s surgical principles

Dr. William Steward Halsted, the first chief of surgery at Johns Hopkins Hospital, articulated a set of surgical principles that included strict aseptic technique, gentle tissue handling, meticulous hemostasis, minimum tension on tissue, accurate tissue apposition, preservation of blood supply, and obliteration of dead space where appropriate. These principles of “safe surgery” are believed to improve surgical outcomes and reduce the risk of surgical site infection.¹

Preoperative antibiotics

All obstetricians who perform cesarean delivery know the importance of administering a narrow-spectrum antibiotic, such as cefazolin or ampicillin, prior to the skin incision, but not more than 60 minutes before the incision, to help reduce the risk of wound infection and endometritis. In a meta-analysis of 82 studies involving more than 13,000 women the administration of a preoperative antibiotic compared with placebo reduced the risk of wound infection (relative risk [RR], 0.40; 95% confidence interval [CI], 0.35–0.46) and endometritis (RR, 0.38; 95% CI, 0.34–0.42).²

Cefazolin 3 g versus 2 g for obese patients

There are no data from randomized trials of cesarean delivery that directly compare the efficacy of preoperative cefazolin at doses of 2 g and 3 g to reduce the risk of infection. However, based on the observation that, for any given dose of cefazolin, circulating levels are reduced in obese patients, many authorities recommend that if the patient weighs ≥120 kg that 3 g of cefazolin should be administered.³

Extended-spectrum preoperative antibiotics

Some experts recommend that, for women in labor and for women with more than 4 hours of ruptured membranes, IV azithromycin 500 mg be added to the standard narrow-spectrum cefazolin regimen to reduce the rate of postoperative infection. In one trial, 2,013 women who were in labor or had more than 4 hours of ruptured membranes were randomly assigned to IV cefazolin alone or IV cefazolin plus azithromycin 500 mg prior to cesarean delivery.⁴ The cefazolin dose was reported to be weight-based utilizing the BMI at the time of delivery. The rates of endometritis (3.8% vs 6.1%) and wound infection (2.4% vs 6.6%) were lower in the women receiving extended-spectrum antibiotics versus cefazolin monotherapy.

Concerns have been raised about the impact of extended-spectrum antibiotics on the newborn microbiome and risk of accelerating the emergence of bacteria resistant to available antibiotics. Limiting the use of azithromycin to those cesarean delivery cases in which the patient is immunosuppressed, diabetic, obese, in labor and/or with prolonged ruptured membranes would reduce the number of women and newborns exposed to the drug and achieve the immediate health goal of reducing surgical infection.

Preoperative vaginal preparation

Many authorities recommend the use of a preoperative povidone- iodine vaginal scrub for 30 seconds prior to cesarean delivery for women in labor and women with ruptured membranes. In a meta-analysis of 16 trials involving 4,837 women, the women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% vs 8.8%) and postoperative fever (9.4% vs 14.9%) compared with those who did not have vaginal cleansing.⁵ Most of the benefit in reducing the risk of endometritis was confined to women in labor before the cesarean delivery (8.1% vs 13.8%) and women with ruptured membranes (4.3% vs 20.1%).⁵

Metronidazole gel 5 g also has been reported to be effective in reducing the rate of endometritis associated with cesarean delivery. In one study, 224 women having a cesarean delivery for various indications were randomly assigned to preoperative treatment with vaginally administered metronidazole gel 5 g or placebo gel. All women also received one dose of preoperative intravenous antibiotics. The rates of endometritis were 7% and 17% in the metronidazole and placebo groups, respectively.⁶

Povidone-iodine is approved for vaginal surgical site cleansing. For women with allergies to iodine or povidone-iodine, the options for vaginal cleansing are limited. The American College of Obstetricians and Gynecologists has noted the chlorhexidine gluconate solutions with a high concentration of alcohol should not be used for vaginal cleansing because the alcohol can irritate the mucosal epithelium. However, although not US Food and Drug Administration–approved for vaginal cleansing, solutions of chlorhexidine with a low alcohol content (Hibiclens, chlorhexidine with 4% alcohol concentration) are thought to be safe and may be considered for off-label use in vaginal cleansing.⁷

Preoperative abdominal preparation with chlorhexidine

Some authorities recommend skin preparation with chlorhexidine rather than povidone-iodine prior to cesarean delivery. Two recent randomized trials in women undergoing cesarean delivery^8,9 and one trial in patients undergoing general surgery operations¹⁰ reported a reduction in surgical site infection with chlorhexidine. However, other trials have reported no difference in the rate of surgical site infection with these two skin preparation methods.^11,12

Changing gloves and equipment after delivery of the newborn

Currently there is no high-quality evidence that changing gloves after delivery of the newborn or using new surgical instruments for closure reduces the risk of postcesarean infection. Two small clinical trials reported that changing gloves after delivery of the newborn did not reduce the rate of postcesarean infection.^13,14

Postoperative antibiotics (a heretical challenge to the central dogma of antibiotic prophylaxis in surgery)

The central dogma of antibiotic prevention of postoperative infection is that antibiotics administered just before skin incision are effective, and postoperative antibiotics to prevent surgical infection generally are not useful. For the case of cesarean delivery, where the rate of postcesarean infection is very high, that dogma is being questioned. In a recent clinical trial, 403 women with a prepregnancy BMI ≥30 kg/m² were randomly assigned to postcesarean treatment with oral cephalexin plus metronidazole (500 mg of each medication every 8 hours for 6 doses) or placebo pills.¹⁵ All women received preoperative IV cefazolin 2 g, indicating that the dosing was probably not weight-based. The surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 6.4% and 15.4%, respectively (RR, 0.41; 95% CI, 0.22–0.77; P = .01). In a subgroup analysis based on the presence or absence of ruptured membranes, postoperative oral cephalexin plus metronidazole was most beneficial for the women with ruptured membranes. Among women with ruptured membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 9.5% and 30.2%, respectively. Among women with intact membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 5% and 8.7%, respectively.

Given that these findings are not consistent with current dogma, clinicians should be cautious about using postcesarean antibiotics and await confirmation in additional trials. Of relevance, a randomized study of women with chorioamnionitis who were treated precesarean delivery with ampicillin, gentamicin, and clindamycin did not benefit from the administration of additional postoperative antibiotics (one additional dose of gentamicin and clindamycin) compared with no postdelivery antibiotics.¹⁶

Does suture selection matter?

In one randomized trial comparing two suture types, 550 women undergoing nonemergent cesarean delivery were randomly assigned to subcuticular skin closure with polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl) suture. The poliglecaprone 25 suture was associated with a lower rate of wound complications (8.8% vs 14.4%; 95% CI, 0.37–99; P = .04).¹⁷ However, a post-hoc analysis of a randomized trial of skin preparation did not observe a difference in wound complications between the use of polyglactinor poliglecaprone suture for skin closure.¹⁸

Prophylactic negative-pressure wound therapy: An evolving best practice?

A meta-analysis of 6 randomized trials and 3 cohort studies reported that in high-risk obese women the use of prophylactic negative-pressure wound therapy compared with standard wound dressing resulted in a decrease in surgical site infection (RR, 0.45; 95% CI, 0.31–0.66).¹⁹ The number needed to treat was 17. In one recent study, the wound outcomes following cesarean delivery among women with a BMI ≥40 kg/m² were compared in 234 women who received and 233 women who did not receive negative-pressure wound therapy.²⁰ Wound infection was observed in 5.6% and 9.9% of the treated and untreated women, respectively.²⁰ However, another meta-analysis of prophylactic negative-pressure wound therapy for obese women undergoing cesarean delivery did not report any benefit.²¹

Let’s work on continuous improvement

Cesarean delivery is a common major operation and is associated with wound infections and endometritis at rates much greater than those observed after vaginal delivery or other major intra-abdominal operations. As obstetricians, we can do more to guide practice toward continuous improvement in surgical outcomes. Systematically using a bundle of evidence-based interventions, including proper antibiotic selection, timing, and dosing; use of hair removal with clippers; use of chlorhexidine abdominal prep; removal of the placenta with gentle traction; and closure of the subcutaneous layer if tissue depth is ≥2 cm, will reduce the rate of postcesarean infection.²² Although aspirational, we may, someday, achieve a post‑cesarean infection rate less than 1%!

CASE Conclusion
The patient was noted to be at high risk for postcesarean infection because she had both an elevated BMI and ruptured membranes. The surgeon astutely decided to administer cefazolin 3 g and azithromycin 500 mg, cleanse the vagina with povidone-iodine, use chlorhexidine for the abdominal prep, use poliglecaprone 25 subcuticular skin closure, and did not use postoperative antibiotics or prophylactic wound vacuum. Following an uneventful cesarean delivery, the patient was discharged without an infection on postoperative day 4.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Halsted’s surgical principles

Dr. William Steward Halsted, the first chief of surgery at Johns Hopkins Hospital, articulated a set of surgical principles that included strict aseptic technique, gentle tissue handling, meticulous hemostasis, minimum tension on tissue, accurate tissue apposition, preservation of blood supply, and obliteration of dead space where appropriate. These principles of “safe surgery” are believed to improve surgical outcomes and reduce the risk of surgical site infection.¹

Preoperative antibiotics

All obstetricians who perform cesarean delivery know the importance of administering a narrow-spectrum antibiotic, such as cefazolin or ampicillin, prior to the skin incision, but not more than 60 minutes before the incision, to help reduce the risk of wound infection and endometritis. In a meta-analysis of 82 studies involving more than 13,000 women the administration of a preoperative antibiotic compared with placebo reduced the risk of wound infection (relative risk [RR], 0.40; 95% confidence interval [CI], 0.35–0.46) and endometritis (RR, 0.38; 95% CI, 0.34–0.42).²

Cefazolin 3 g versus 2 g for obese patients

There are no data from randomized trials of cesarean delivery that directly compare the efficacy of preoperative cefazolin at doses of 2 g and 3 g to reduce the risk of infection. However, based on the observation that, for any given dose of cefazolin, circulating levels are reduced in obese patients, many authorities recommend that if the patient weighs ≥120 kg that 3 g of cefazolin should be administered.³

Extended-spectrum preoperative antibiotics

Some experts recommend that, for women in labor and for women with more than 4 hours of ruptured membranes, IV azithromycin 500 mg be added to the standard narrow-spectrum cefazolin regimen to reduce the rate of postoperative infection. In one trial, 2,013 women who were in labor or had more than 4 hours of ruptured membranes were randomly assigned to IV cefazolin alone or IV cefazolin plus azithromycin 500 mg prior to cesarean delivery.⁴ The cefazolin dose was reported to be weight-based utilizing the BMI at the time of delivery. The rates of endometritis (3.8% vs 6.1%) and wound infection (2.4% vs 6.6%) were lower in the women receiving extended-spectrum antibiotics versus cefazolin monotherapy.

Concerns have been raised about the impact of extended-spectrum antibiotics on the newborn microbiome and risk of accelerating the emergence of bacteria resistant to available antibiotics. Limiting the use of azithromycin to those cesarean delivery cases in which the patient is immunosuppressed, diabetic, obese, in labor and/or with prolonged ruptured membranes would reduce the number of women and newborns exposed to the drug and achieve the immediate health goal of reducing surgical infection.

Preoperative vaginal preparation

Many authorities recommend the use of a preoperative povidone- iodine vaginal scrub for 30 seconds prior to cesarean delivery for women in labor and women with ruptured membranes. In a meta-analysis of 16 trials involving 4,837 women, the women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% vs 8.8%) and postoperative fever (9.4% vs 14.9%) compared with those who did not have vaginal cleansing.⁵ Most of the benefit in reducing the risk of endometritis was confined to women in labor before the cesarean delivery (8.1% vs 13.8%) and women with ruptured membranes (4.3% vs 20.1%).⁵

Metronidazole gel 5 g also has been reported to be effective in reducing the rate of endometritis associated with cesarean delivery. In one study, 224 women having a cesarean delivery for various indications were randomly assigned to preoperative treatment with vaginally administered metronidazole gel 5 g or placebo gel. All women also received one dose of preoperative intravenous antibiotics. The rates of endometritis were 7% and 17% in the metronidazole and placebo groups, respectively.⁶

Povidone-iodine is approved for vaginal surgical site cleansing. For women with allergies to iodine or povidone-iodine, the options for vaginal cleansing are limited. The American College of Obstetricians and Gynecologists has noted the chlorhexidine gluconate solutions with a high concentration of alcohol should not be used for vaginal cleansing because the alcohol can irritate the mucosal epithelium. However, although not US Food and Drug Administration–approved for vaginal cleansing, solutions of chlorhexidine with a low alcohol content (Hibiclens, chlorhexidine with 4% alcohol concentration) are thought to be safe and may be considered for off-label use in vaginal cleansing.⁷

Preoperative abdominal preparation with chlorhexidine

Some authorities recommend skin preparation with chlorhexidine rather than povidone-iodine prior to cesarean delivery. Two recent randomized trials in women undergoing cesarean delivery^8,9 and one trial in patients undergoing general surgery operations¹⁰ reported a reduction in surgical site infection with chlorhexidine. However, other trials have reported no difference in the rate of surgical site infection with these two skin preparation methods.^11,12

Changing gloves and equipment after delivery of the newborn

Currently there is no high-quality evidence that changing gloves after delivery of the newborn or using new surgical instruments for closure reduces the risk of postcesarean infection. Two small clinical trials reported that changing gloves after delivery of the newborn did not reduce the rate of postcesarean infection.^13,14

Postoperative antibiotics (a heretical challenge to the central dogma of antibiotic prophylaxis in surgery)

The central dogma of antibiotic prevention of postoperative infection is that antibiotics administered just before skin incision are effective, and postoperative antibiotics to prevent surgical infection generally are not useful. For the case of cesarean delivery, where the rate of postcesarean infection is very high, that dogma is being questioned. In a recent clinical trial, 403 women with a prepregnancy BMI ≥30 kg/m² were randomly assigned to postcesarean treatment with oral cephalexin plus metronidazole (500 mg of each medication every 8 hours for 6 doses) or placebo pills.¹⁵ All women received preoperative IV cefazolin 2 g, indicating that the dosing was probably not weight-based. The surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 6.4% and 15.4%, respectively (RR, 0.41; 95% CI, 0.22–0.77; P = .01). In a subgroup analysis based on the presence or absence of ruptured membranes, postoperative oral cephalexin plus metronidazole was most beneficial for the women with ruptured membranes. Among women with ruptured membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 9.5% and 30.2%, respectively. Among women with intact membranes the surgical site infection rates in the cephalexin plus metronidazole and placebo groups were 5% and 8.7%, respectively.

Given that these findings are not consistent with current dogma, clinicians should be cautious about using postcesarean antibiotics and await confirmation in additional trials. Of relevance, a randomized study of women with chorioamnionitis who were treated precesarean delivery with ampicillin, gentamicin, and clindamycin did not benefit from the administration of additional postoperative antibiotics (one additional dose of gentamicin and clindamycin) compared with no postdelivery antibiotics.¹⁶

Does suture selection matter?

In one randomized trial comparing two suture types, 550 women undergoing nonemergent cesarean delivery were randomly assigned to subcuticular skin closure with polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl) suture. The poliglecaprone 25 suture was associated with a lower rate of wound complications (8.8% vs 14.4%; 95% CI, 0.37–99; P = .04).¹⁷ However, a post-hoc analysis of a randomized trial of skin preparation did not observe a difference in wound complications between the use of polyglactinor poliglecaprone suture for skin closure.¹⁸

Prophylactic negative-pressure wound therapy: An evolving best practice?

A meta-analysis of 6 randomized trials and 3 cohort studies reported that in high-risk obese women the use of prophylactic negative-pressure wound therapy compared with standard wound dressing resulted in a decrease in surgical site infection (RR, 0.45; 95% CI, 0.31–0.66).¹⁹ The number needed to treat was 17. In one recent study, the wound outcomes following cesarean delivery among women with a BMI ≥40 kg/m² were compared in 234 women who received and 233 women who did not receive negative-pressure wound therapy.²⁰ Wound infection was observed in 5.6% and 9.9% of the treated and untreated women, respectively.²⁰ However, another meta-analysis of prophylactic negative-pressure wound therapy for obese women undergoing cesarean delivery did not report any benefit.²¹

Let’s work on continuous improvement

Cesarean delivery is a common major operation and is associated with wound infections and endometritis at rates much greater than those observed after vaginal delivery or other major intra-abdominal operations. As obstetricians, we can do more to guide practice toward continuous improvement in surgical outcomes. Systematically using a bundle of evidence-based interventions, including proper antibiotic selection, timing, and dosing; use of hair removal with clippers; use of chlorhexidine abdominal prep; removal of the placenta with gentle traction; and closure of the subcutaneous layer if tissue depth is ≥2 cm, will reduce the rate of postcesarean infection.²² Although aspirational, we may, someday, achieve a post‑cesarean infection rate less than 1%!

CASE Conclusion
The patient was noted to be at high risk for postcesarean infection because she had both an elevated BMI and ruptured membranes. The surgeon astutely decided to administer cefazolin 3 g and azithromycin 500 mg, cleanse the vagina with povidone-iodine, use chlorhexidine for the abdominal prep, use poliglecaprone 25 subcuticular skin closure, and did not use postoperative antibiotics or prophylactic wound vacuum. Following an uneventful cesarean delivery, the patient was discharged without an infection on postoperative day 4.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Opioid-related drug overdose deaths jumped 28% from 2015 to 2016, with the largest increase coming from synthetic opioids, such as illicitly manufactured fentanyl, according to the Centers for Disease Control and Prevention.

The age-adjusted death rate for opioid overdoses increased from 10.4 per 100,000 population in 2015 to 13.3 per 100,000 in 2016, and the 42,249 opioid deaths in 2016 represented more than 66% of all overdose deaths that year, Puja Seth, PhD, and her associates at the CDC reported in the Morbidity and Mortality Weekly Report.

[email protected]

SOURCE: Seth P et al. MMWR. 2018 Mar 30;67(12):349-58.

Opioid-related drug overdose deaths jumped 28% from 2015 to 2016, with the largest increase coming from synthetic opioids, such as illicitly manufactured fentanyl, according to the Centers for Disease Control and Prevention.

The age-adjusted death rate for opioid overdoses increased from 10.4 per 100,000 population in 2015 to 13.3 per 100,000 in 2016, and the 42,249 opioid deaths in 2016 represented more than 66% of all overdose deaths that year, Puja Seth, PhD, and her associates at the CDC reported in the Morbidity and Mortality Weekly Report.

[email protected]

SOURCE: Seth P et al. MMWR. 2018 Mar 30;67(12):349-58.

Opioid-related drug overdose deaths jumped 28% from 2015 to 2016, with the largest increase coming from synthetic opioids, such as illicitly manufactured fentanyl, according to the Centers for Disease Control and Prevention.

The age-adjusted death rate for opioid overdoses increased from 10.4 per 100,000 population in 2015 to 13.3 per 100,000 in 2016, and the 42,249 opioid deaths in 2016 represented more than 66% of all overdose deaths that year, Puja Seth, PhD, and her associates at the CDC reported in the Morbidity and Mortality Weekly Report.

[email protected]

SOURCE: Seth P et al. MMWR. 2018 Mar 30;67(12):349-58.

ABSTRACT

As the operative management of displaced distal radius fractures evolves, intraoperative techniques and fixation strategies evolve as well. Achieving and maintaining an acceptable reduction is paramount but can be difficult with particular fracture patterns. In this article, we describe the use of a radial column plate as a reduction tool in the management of unstable distal radius fractures, along with clinical and radiographic clinical outcomes. This technique can be useful in situations where multiplanar instability exists, or simply when intraoperative assistance is limited. Surgeons can expect acceptable radiographic and clinical outcomes when using this technique, although effects on scar formation and wrist range of motion are currently not known.

Continue to: Distal radius fractures...

Distal radius fractures are among the most common orthopedic injuries encountered; their reported incidence is >640,000 annually and is estimated to increase.^1-4 The management of these injuries has evolved from closed reduction and casting to percutaneous pinning and internal fixation, as the importance of achieving and maintaining an anatomic reduction has become more apparent.^5-7 More recently, volar locking plates have emerged as a way to prevent complications associated with dorsal plating. Most authors agree that volar locked plating achieves stable fixation and allows for early postoperative wrist range of motion (ROM).^5,8-11 However, a volar approach to a dorsally unstable fracture creates difficulty with regard to reduction at the time of surgery and several reports have noted mechanical failure with utilization of locked volar plating alone.^12-15

Dual plating of unstable distal radius fractures with a volar locking plate and a radial column plate has been described in the past in the setting of severely comminuted fractures or in patterns with a large radial styloid fragment that was not addressed with a volar locking plate alone.^16-19 The purpose of this study is to present the use of the radial column plate as a tool that allows a surgeon to achieve and maintain reduction during open reduction and internal fixation (ORIF) of an unstable distal radius fracture.

OPERATIVE TECHNIQUE

Patients for whom ORIF is indicated include those with unstable distal radius fractures, with or without intra-articular extension and involvement of both the intermediate and lateral columns.

The patient is positioned supine on the operating table with the operative hand placed palm-up on a radiolucent hand table. A volar approach to the distal radius is undertaken, utilizing the interval between the flexor carpi radialis (FCR) tendon and the radial artery. The floor of the FCR sheath is incised, and a self-retaining retractor with blunt tips can be placed to permit visualization. The pronator quadratus (PQ) is sharply reflected off the radial boarder of the distal radius and approximately 1 mm to 2 mm proximal to the radiocarpal joint with an L-shaped incision for fracture site exposure. The brachioradialis is then identified and tenotomized with a scalpel (Figure 1).

A preliminary reduction is then performed using a combination of axial traction and palmar translation of the carpus. The surgeon should not be concerned with radial height or inclination at this point; however, volar tilt should be established as best as possible. A rolled towel is placed dorsal to the metacarpals, holding the wrist in a flexed position as it is placed back onto the radiolucent hand table.

Continue to: A 7 to 8 hole...

A 7 to 8 hole 2.0-mm reconstruction plate (DePuy Synthes) is bent to the shape of the radial boarder of the distal radius. Undercontouring of the plate is necessary to allow for its use as a reduction tool. The plate is then applied to the radial column ensuring that the distal aspect of the plate engages the distal fracture fragment(s) (Figure 2). A single 2.4-mm fully threaded cortical screw in the radial to ulnar direction is then placed bicortically in the proximal fragment in the hole nearest the fracture site. As the screw is tightened, the plate will push the distal fragment(s) due to its undercontoured shape, and in doing so, will restore radial height and inclination (Figure 3). As this screw is being used as a “working screw,” it will be longer than needed after final tightening. A second screw is then placed proximally to prevent rotation of the plate, and the initial screw can be replaced if its length is of concern. If it is the intention of the surgeon to remove the plate prior to wound closure, the second screw is typically not necessary, and there is no indication for exchanging the first screw if it is long.

At this point, final changes to the reduction can still be performed, as the distal fragment(s) has no fixation except for a buttress plate on its radial border. However, the pressure applied by this plate is still typically adequate to maintain a reduction without the use of percutaneous pins or an assistant holding the reduction. Volar fixation is then applied and positioned under both direct visualization and fluoroscopic aid, and cortical and locking screws are inserted as needed (Figure 4). The radial styloid plate can then be removed; however, it is our preference to leave it in place, as we have not seen any postoperative issues that we can attribute to this technique. The PQ is then repaired over the volar locking plate directly to the radial column plate.

At our institution, patients are maintained in a plaster volar-based wrist splint for a period of 2 weeks postoperatively. After splint and suture removal, active and passive ROM exercises of the wrist and hand are initiated, and a custom thermoplast volar wrist splint is manufactured. This splint is to be worn at all times except during physical therapy. At the 6-week postoperative visit, all restrictions are lifted, assuming there are no complications or unexpected issues. Patients are then seen for follow-up at 3 and 6 months postoperatively. Continued follow-up is indicated if patients are following an abnormal clinical or radiographic course.

MATERIALS AND METHODS

After Institutional Review Board approval was obtained, a clinical outcomes registry was queried to identify all patients treated operatively by the senior author (DGL) for a distal radius fracture at our Level 1 trauma center between August 2002 and December 2013. Adult (age >18 years) patients with isolated distal radius fractures treated with a radial styloid plate were included for initial review (N = 261). Patients for whom 6-month clinical or radiographic outcomes were unknown were then excluded (n = 225).

Patient demographics were recorded from the existing database along with visual analog scale, Quick Disabilities of the Arm, Shoulder and Hand (DASH), and short form 36 (SF-36) physical component scores (PCS) and mental component scores (MCS) from the final follow-up visit. Injury and intraoperative and final radiographs were assessed by a single reviewer (MRG) using calibrated radiographs on our institution’s picture archiving and communication system. Radial height, radial inclination, and volar tilt were documented for each time point except for radial height, which was not recorded for intraoperative fluoroscopy images due to lack of calibration. Intra-articular extension was noted on injury films. Wound complications, the presence of a deep or superficial infection, and removal of implants after union were recorded.

Continue to: RESULTS

 

 

RESULTS

Thirty-six patients met the inclusion criteria and were therefore included in the study. The average age at the time of surgery was 60.6 years (range, 25-87 years), 27 patients (75%) were female, and 21 (58%) had left-sided injuries. Patient comorbidities can be seen in Table 1. Twenty-six fractures (72.2%) had intra-articular extension. Average follow-up was 15.6 months (range, 6-53.9 months).

Table 1. Comorbidities of Patients Treated with Radial Column Plating

Radiographic measurements at the time of injury, surgery, and final follow-up can be seen in Table 2. As previously noted, radial height could not be recorded on intraoperative films due to the use of fluoroscopy, which is not calibrated at our institution. The average changes in radial inclination and volar tilt from the time of surgery (intraoperative fluoroscopy) to final follow-up were 0.46° (range, −4.4°-4.3°) and 0.24° (range, −10.6°-9.6°), respectively. All patients had acceptable radial height, radial inclination, and volar tilt at final follow-up. Clinical outcomes were obtained at a mean of 15.6 months (range, 6-54 months) and were generally good, with a mean DASH score of 20.7 (range, 0-57.5), SF-36 PCS of 45.4 (range, 22.7-68.0), and SF-36 MCS of 50.5 (range, 22.3-64.1) (Table 3). Of the 36 patients with 6-month outcome scores, 13 (36.1%) elected for implant removal after fracture union at a mean of 7.6 months after index surgery (range, 3.2-49.8 months). No infections or wound complications were noted.

Table 2. Radiographic Measurements for Patients Treated with Radial Column Plating

DISCUSSION

In this article, we described the use of a radial column plate as a tool to achieve and maintain a reduction during the surgical fixation of an unstable distal radius fracture with a volar locking plate. We have further presented a series of 36 patients treated in this manner and their clinical and radiographic outcomes. This technique permits the maintenance of coronal alignment, thereby limiting the use of percutaneous techniques or the need to manually hold fracture fragments in a reduced position, which may be valuable to the surgeon who is operating without a surgical assistant.

Table 3. Clinical Outcome Scores at Final Follow-Up for Patients Treated with Radial Column Plating

Abbreviations: DASH, Quick Disabilities of the Arm, Shoulder and Hand; MCS, mental component scores; PCS, physical component scores; VAS, visual analog scale.

In addition to its value as a reduction tool, unlike traditional temporary k-wire fixation, we believe that the utilization of a radial styloid plate allows for increased stability until fracture union is achieved. Biomechanical studies have demonstrated favorable results with the use of a radial column plate. Grindel and colleagues²⁰ evaluated dual radial styloid and volar radius plating vs volar plating alone in their biomechanical comparison of 8 cadaveric matched hand and forearm pairs. Specimens were fixated with a volar locking plate, and a 1-cm wedge osteotomy was created dorsally approximately 2 cm from the articular margin. The distal fragment was then osteotomized longitudinally between the 2 ulnar and 2 radial distal locking screws to create a fracture pattern that mimics a dorsally unstable injury with intra-articular extension. Half of the specimens then underwent radial styloid plating with 2 screws securing the construct proximally, and load-to-failure testing was performed. The authors found that utilization of both the volar and radial styloid plates resulted in 50% increased stiffness and 76% increased force-to-failure as compared with radial styloid plating alone. Similar, although not statistically significant, results were found by Blythe and colleagues.²¹ In their cadaveric study, dorsal and volar plating with an additional radial column plate resulted in improved stiffness with axial loading compared to volar or dorsal plating alone ²¹.

Two prior studies have presented outcome data after fixation of distal radius fractures with radial column and volar radius dual plating. Tang and colleagues¹⁶ described this technique and presented postoperative outcomes in 8 patients followed for an average of 35 weeks. They reported a 100% union rate, no loss of reduction, and a mean DASH score of 19.9. Jacobi and colleagues¹⁷ also described this technique in their 2010 report. In their cohort of 10 patients treated by multiple surgeons, they found a mean of 39° of flexion, 49° of extension, 75° of pronation, and 75° of supination at 24 months postoperatively. Eight patients were rated as “excellent,” 1 as “good,” and 1 as “fair” according to the Gartland and Werley score, with all 10 cases achieving bony union. No cases demonstrated loss of volar tilt, radial length, or radial inclination. In both studies, however, the use of the radial column plate was advocated as a fragment-specific fixation tool and not as a reduction tool.

Continue to: Although 1-year DASH scores...

Although 1-year DASH scores for volar plating alone have been shown in the literature to be consistently within 6 and 13, 3-month and 6-month scores have historically been >18.^22-27 Our short-term clinical results (Table 3) are comparable to these historic controls. Further, within our cohort there were no cases of nonunion, postoperative infection, or wound complications, and radiographic measures show maintenance of reduction at final follow-up (Table 2).

We do recognize that 36.1% (13/36) of our cohort had their distal radius implants removed. Although this incidence is high, it stems from the fact that patients who elect for implant removal are more likely to have had an atypical postoperative course and are therefore followed for longer than 6 months. Those who do not elect for removal are typically discharged from care after their 3-month postoperative visit, and were therefore not eligible for inclusion in this study. Overall, a total of 261 patients have been treated with this technique by the senior surgeon. Of those patients, only 28 (10.7%) underwent removal of surgical implants. If the remaining patients had been followed for the full 6 months, it is likely that outcome scores would have been skewed in a more favorable direction.

Surgeons electing to utilize radial styloid plating for displaced distal radius fractures should recognize that the required increased surgical dissection might lead to increased scar formation and postoperative stiffness. A limitation of this study is the lack of quantitative wrist ROM data. Future studies may compare final clinical outcomes and ROM for patients treated with and without radial column fixation.

CONCLUSION

We advocate for the use of a radial column plate as a tool to help achieve and maintain fracture reduction in the setting of an unstable distal radius fracture being treated with ORIF. This technique may be particularly useful when a surgical assistant is not available. Surgeons can expect clinical and radiographic results that are similar to those of volar locked plating alone.

ABSTRACT

As the operative management of displaced distal radius fractures evolves, intraoperative techniques and fixation strategies evolve as well. Achieving and maintaining an acceptable reduction is paramount but can be difficult with particular fracture patterns. In this article, we describe the use of a radial column plate as a reduction tool in the management of unstable distal radius fractures, along with clinical and radiographic clinical outcomes. This technique can be useful in situations where multiplanar instability exists, or simply when intraoperative assistance is limited. Surgeons can expect acceptable radiographic and clinical outcomes when using this technique, although effects on scar formation and wrist range of motion are currently not known.

Continue to: Distal radius fractures...

Distal radius fractures are among the most common orthopedic injuries encountered; their reported incidence is >640,000 annually and is estimated to increase.^1-4 The management of these injuries has evolved from closed reduction and casting to percutaneous pinning and internal fixation, as the importance of achieving and maintaining an anatomic reduction has become more apparent.^5-7 More recently, volar locking plates have emerged as a way to prevent complications associated with dorsal plating. Most authors agree that volar locked plating achieves stable fixation and allows for early postoperative wrist range of motion (ROM).^5,8-11 However, a volar approach to a dorsally unstable fracture creates difficulty with regard to reduction at the time of surgery and several reports have noted mechanical failure with utilization of locked volar plating alone.^12-15

Dual plating of unstable distal radius fractures with a volar locking plate and a radial column plate has been described in the past in the setting of severely comminuted fractures or in patterns with a large radial styloid fragment that was not addressed with a volar locking plate alone.^16-19 The purpose of this study is to present the use of the radial column plate as a tool that allows a surgeon to achieve and maintain reduction during open reduction and internal fixation (ORIF) of an unstable distal radius fracture.

OPERATIVE TECHNIQUE

Patients for whom ORIF is indicated include those with unstable distal radius fractures, with or without intra-articular extension and involvement of both the intermediate and lateral columns.

The patient is positioned supine on the operating table with the operative hand placed palm-up on a radiolucent hand table. A volar approach to the distal radius is undertaken, utilizing the interval between the flexor carpi radialis (FCR) tendon and the radial artery. The floor of the FCR sheath is incised, and a self-retaining retractor with blunt tips can be placed to permit visualization. The pronator quadratus (PQ) is sharply reflected off the radial boarder of the distal radius and approximately 1 mm to 2 mm proximal to the radiocarpal joint with an L-shaped incision for fracture site exposure. The brachioradialis is then identified and tenotomized with a scalpel (Figure 1).

A preliminary reduction is then performed using a combination of axial traction and palmar translation of the carpus. The surgeon should not be concerned with radial height or inclination at this point; however, volar tilt should be established as best as possible. A rolled towel is placed dorsal to the metacarpals, holding the wrist in a flexed position as it is placed back onto the radiolucent hand table.

Continue to: A 7 to 8 hole...

A 7 to 8 hole 2.0-mm reconstruction plate (DePuy Synthes) is bent to the shape of the radial boarder of the distal radius. Undercontouring of the plate is necessary to allow for its use as a reduction tool. The plate is then applied to the radial column ensuring that the distal aspect of the plate engages the distal fracture fragment(s) (Figure 2). A single 2.4-mm fully threaded cortical screw in the radial to ulnar direction is then placed bicortically in the proximal fragment in the hole nearest the fracture site. As the screw is tightened, the plate will push the distal fragment(s) due to its undercontoured shape, and in doing so, will restore radial height and inclination (Figure 3). As this screw is being used as a “working screw,” it will be longer than needed after final tightening. A second screw is then placed proximally to prevent rotation of the plate, and the initial screw can be replaced if its length is of concern. If it is the intention of the surgeon to remove the plate prior to wound closure, the second screw is typically not necessary, and there is no indication for exchanging the first screw if it is long.

At this point, final changes to the reduction can still be performed, as the distal fragment(s) has no fixation except for a buttress plate on its radial border. However, the pressure applied by this plate is still typically adequate to maintain a reduction without the use of percutaneous pins or an assistant holding the reduction. Volar fixation is then applied and positioned under both direct visualization and fluoroscopic aid, and cortical and locking screws are inserted as needed (Figure 4). The radial styloid plate can then be removed; however, it is our preference to leave it in place, as we have not seen any postoperative issues that we can attribute to this technique. The PQ is then repaired over the volar locking plate directly to the radial column plate.

At our institution, patients are maintained in a plaster volar-based wrist splint for a period of 2 weeks postoperatively. After splint and suture removal, active and passive ROM exercises of the wrist and hand are initiated, and a custom thermoplast volar wrist splint is manufactured. This splint is to be worn at all times except during physical therapy. At the 6-week postoperative visit, all restrictions are lifted, assuming there are no complications or unexpected issues. Patients are then seen for follow-up at 3 and 6 months postoperatively. Continued follow-up is indicated if patients are following an abnormal clinical or radiographic course.

MATERIALS AND METHODS

After Institutional Review Board approval was obtained, a clinical outcomes registry was queried to identify all patients treated operatively by the senior author (DGL) for a distal radius fracture at our Level 1 trauma center between August 2002 and December 2013. Adult (age >18 years) patients with isolated distal radius fractures treated with a radial styloid plate were included for initial review (N = 261). Patients for whom 6-month clinical or radiographic outcomes were unknown were then excluded (n = 225).

Patient demographics were recorded from the existing database along with visual analog scale, Quick Disabilities of the Arm, Shoulder and Hand (DASH), and short form 36 (SF-36) physical component scores (PCS) and mental component scores (MCS) from the final follow-up visit. Injury and intraoperative and final radiographs were assessed by a single reviewer (MRG) using calibrated radiographs on our institution’s picture archiving and communication system. Radial height, radial inclination, and volar tilt were documented for each time point except for radial height, which was not recorded for intraoperative fluoroscopy images due to lack of calibration. Intra-articular extension was noted on injury films. Wound complications, the presence of a deep or superficial infection, and removal of implants after union were recorded.

Continue to: RESULTS

 

 

RESULTS

Thirty-six patients met the inclusion criteria and were therefore included in the study. The average age at the time of surgery was 60.6 years (range, 25-87 years), 27 patients (75%) were female, and 21 (58%) had left-sided injuries. Patient comorbidities can be seen in Table 1. Twenty-six fractures (72.2%) had intra-articular extension. Average follow-up was 15.6 months (range, 6-53.9 months).

Table 1. Comorbidities of Patients Treated with Radial Column Plating

Radiographic measurements at the time of injury, surgery, and final follow-up can be seen in Table 2. As previously noted, radial height could not be recorded on intraoperative films due to the use of fluoroscopy, which is not calibrated at our institution. The average changes in radial inclination and volar tilt from the time of surgery (intraoperative fluoroscopy) to final follow-up were 0.46° (range, −4.4°-4.3°) and 0.24° (range, −10.6°-9.6°), respectively. All patients had acceptable radial height, radial inclination, and volar tilt at final follow-up. Clinical outcomes were obtained at a mean of 15.6 months (range, 6-54 months) and were generally good, with a mean DASH score of 20.7 (range, 0-57.5), SF-36 PCS of 45.4 (range, 22.7-68.0), and SF-36 MCS of 50.5 (range, 22.3-64.1) (Table 3). Of the 36 patients with 6-month outcome scores, 13 (36.1%) elected for implant removal after fracture union at a mean of 7.6 months after index surgery (range, 3.2-49.8 months). No infections or wound complications were noted.

Table 2. Radiographic Measurements for Patients Treated with Radial Column Plating

DISCUSSION

In this article, we described the use of a radial column plate as a tool to achieve and maintain a reduction during the surgical fixation of an unstable distal radius fracture with a volar locking plate. We have further presented a series of 36 patients treated in this manner and their clinical and radiographic outcomes. This technique permits the maintenance of coronal alignment, thereby limiting the use of percutaneous techniques or the need to manually hold fracture fragments in a reduced position, which may be valuable to the surgeon who is operating without a surgical assistant.

Table 3. Clinical Outcome Scores at Final Follow-Up for Patients Treated with Radial Column Plating

Abbreviations: DASH, Quick Disabilities of the Arm, Shoulder and Hand; MCS, mental component scores; PCS, physical component scores; VAS, visual analog scale.

In addition to its value as a reduction tool, unlike traditional temporary k-wire fixation, we believe that the utilization of a radial styloid plate allows for increased stability until fracture union is achieved. Biomechanical studies have demonstrated favorable results with the use of a radial column plate. Grindel and colleagues²⁰ evaluated dual radial styloid and volar radius plating vs volar plating alone in their biomechanical comparison of 8 cadaveric matched hand and forearm pairs. Specimens were fixated with a volar locking plate, and a 1-cm wedge osteotomy was created dorsally approximately 2 cm from the articular margin. The distal fragment was then osteotomized longitudinally between the 2 ulnar and 2 radial distal locking screws to create a fracture pattern that mimics a dorsally unstable injury with intra-articular extension. Half of the specimens then underwent radial styloid plating with 2 screws securing the construct proximally, and load-to-failure testing was performed. The authors found that utilization of both the volar and radial styloid plates resulted in 50% increased stiffness and 76% increased force-to-failure as compared with radial styloid plating alone. Similar, although not statistically significant, results were found by Blythe and colleagues.²¹ In their cadaveric study, dorsal and volar plating with an additional radial column plate resulted in improved stiffness with axial loading compared to volar or dorsal plating alone ²¹.

Two prior studies have presented outcome data after fixation of distal radius fractures with radial column and volar radius dual plating. Tang and colleagues¹⁶ described this technique and presented postoperative outcomes in 8 patients followed for an average of 35 weeks. They reported a 100% union rate, no loss of reduction, and a mean DASH score of 19.9. Jacobi and colleagues¹⁷ also described this technique in their 2010 report. In their cohort of 10 patients treated by multiple surgeons, they found a mean of 39° of flexion, 49° of extension, 75° of pronation, and 75° of supination at 24 months postoperatively. Eight patients were rated as “excellent,” 1 as “good,” and 1 as “fair” according to the Gartland and Werley score, with all 10 cases achieving bony union. No cases demonstrated loss of volar tilt, radial length, or radial inclination. In both studies, however, the use of the radial column plate was advocated as a fragment-specific fixation tool and not as a reduction tool.

Continue to: Although 1-year DASH scores...

Although 1-year DASH scores for volar plating alone have been shown in the literature to be consistently within 6 and 13, 3-month and 6-month scores have historically been >18.^22-27 Our short-term clinical results (Table 3) are comparable to these historic controls. Further, within our cohort there were no cases of nonunion, postoperative infection, or wound complications, and radiographic measures show maintenance of reduction at final follow-up (Table 2).

We do recognize that 36.1% (13/36) of our cohort had their distal radius implants removed. Although this incidence is high, it stems from the fact that patients who elect for implant removal are more likely to have had an atypical postoperative course and are therefore followed for longer than 6 months. Those who do not elect for removal are typically discharged from care after their 3-month postoperative visit, and were therefore not eligible for inclusion in this study. Overall, a total of 261 patients have been treated with this technique by the senior surgeon. Of those patients, only 28 (10.7%) underwent removal of surgical implants. If the remaining patients had been followed for the full 6 months, it is likely that outcome scores would have been skewed in a more favorable direction.

Surgeons electing to utilize radial styloid plating for displaced distal radius fractures should recognize that the required increased surgical dissection might lead to increased scar formation and postoperative stiffness. A limitation of this study is the lack of quantitative wrist ROM data. Future studies may compare final clinical outcomes and ROM for patients treated with and without radial column fixation.

CONCLUSION

We advocate for the use of a radial column plate as a tool to help achieve and maintain fracture reduction in the setting of an unstable distal radius fracture being treated with ORIF. This technique may be particularly useful when a surgical assistant is not available. Surgeons can expect clinical and radiographic results that are similar to those of volar locked plating alone.

ABSTRACT

As the operative management of displaced distal radius fractures evolves, intraoperative techniques and fixation strategies evolve as well. Achieving and maintaining an acceptable reduction is paramount but can be difficult with particular fracture patterns. In this article, we describe the use of a radial column plate as a reduction tool in the management of unstable distal radius fractures, along with clinical and radiographic clinical outcomes. This technique can be useful in situations where multiplanar instability exists, or simply when intraoperative assistance is limited. Surgeons can expect acceptable radiographic and clinical outcomes when using this technique, although effects on scar formation and wrist range of motion are currently not known.

Continue to: Distal radius fractures...

Distal radius fractures are among the most common orthopedic injuries encountered; their reported incidence is >640,000 annually and is estimated to increase.^1-4 The management of these injuries has evolved from closed reduction and casting to percutaneous pinning and internal fixation, as the importance of achieving and maintaining an anatomic reduction has become more apparent.^5-7 More recently, volar locking plates have emerged as a way to prevent complications associated with dorsal plating. Most authors agree that volar locked plating achieves stable fixation and allows for early postoperative wrist range of motion (ROM).^5,8-11 However, a volar approach to a dorsally unstable fracture creates difficulty with regard to reduction at the time of surgery and several reports have noted mechanical failure with utilization of locked volar plating alone.^12-15

Dual plating of unstable distal radius fractures with a volar locking plate and a radial column plate has been described in the past in the setting of severely comminuted fractures or in patterns with a large radial styloid fragment that was not addressed with a volar locking plate alone.^16-19 The purpose of this study is to present the use of the radial column plate as a tool that allows a surgeon to achieve and maintain reduction during open reduction and internal fixation (ORIF) of an unstable distal radius fracture.

OPERATIVE TECHNIQUE

Patients for whom ORIF is indicated include those with unstable distal radius fractures, with or without intra-articular extension and involvement of both the intermediate and lateral columns.

The patient is positioned supine on the operating table with the operative hand placed palm-up on a radiolucent hand table. A volar approach to the distal radius is undertaken, utilizing the interval between the flexor carpi radialis (FCR) tendon and the radial artery. The floor of the FCR sheath is incised, and a self-retaining retractor with blunt tips can be placed to permit visualization. The pronator quadratus (PQ) is sharply reflected off the radial boarder of the distal radius and approximately 1 mm to 2 mm proximal to the radiocarpal joint with an L-shaped incision for fracture site exposure. The brachioradialis is then identified and tenotomized with a scalpel (Figure 1).

A preliminary reduction is then performed using a combination of axial traction and palmar translation of the carpus. The surgeon should not be concerned with radial height or inclination at this point; however, volar tilt should be established as best as possible. A rolled towel is placed dorsal to the metacarpals, holding the wrist in a flexed position as it is placed back onto the radiolucent hand table.

Continue to: A 7 to 8 hole...

A 7 to 8 hole 2.0-mm reconstruction plate (DePuy Synthes) is bent to the shape of the radial boarder of the distal radius. Undercontouring of the plate is necessary to allow for its use as a reduction tool. The plate is then applied to the radial column ensuring that the distal aspect of the plate engages the distal fracture fragment(s) (Figure 2). A single 2.4-mm fully threaded cortical screw in the radial to ulnar direction is then placed bicortically in the proximal fragment in the hole nearest the fracture site. As the screw is tightened, the plate will push the distal fragment(s) due to its undercontoured shape, and in doing so, will restore radial height and inclination (Figure 3). As this screw is being used as a “working screw,” it will be longer than needed after final tightening. A second screw is then placed proximally to prevent rotation of the plate, and the initial screw can be replaced if its length is of concern. If it is the intention of the surgeon to remove the plate prior to wound closure, the second screw is typically not necessary, and there is no indication for exchanging the first screw if it is long.

At this point, final changes to the reduction can still be performed, as the distal fragment(s) has no fixation except for a buttress plate on its radial border. However, the pressure applied by this plate is still typically adequate to maintain a reduction without the use of percutaneous pins or an assistant holding the reduction. Volar fixation is then applied and positioned under both direct visualization and fluoroscopic aid, and cortical and locking screws are inserted as needed (Figure 4). The radial styloid plate can then be removed; however, it is our preference to leave it in place, as we have not seen any postoperative issues that we can attribute to this technique. The PQ is then repaired over the volar locking plate directly to the radial column plate.

At our institution, patients are maintained in a plaster volar-based wrist splint for a period of 2 weeks postoperatively. After splint and suture removal, active and passive ROM exercises of the wrist and hand are initiated, and a custom thermoplast volar wrist splint is manufactured. This splint is to be worn at all times except during physical therapy. At the 6-week postoperative visit, all restrictions are lifted, assuming there are no complications or unexpected issues. Patients are then seen for follow-up at 3 and 6 months postoperatively. Continued follow-up is indicated if patients are following an abnormal clinical or radiographic course.

MATERIALS AND METHODS

After Institutional Review Board approval was obtained, a clinical outcomes registry was queried to identify all patients treated operatively by the senior author (DGL) for a distal radius fracture at our Level 1 trauma center between August 2002 and December 2013. Adult (age >18 years) patients with isolated distal radius fractures treated with a radial styloid plate were included for initial review (N = 261). Patients for whom 6-month clinical or radiographic outcomes were unknown were then excluded (n = 225).

Patient demographics were recorded from the existing database along with visual analog scale, Quick Disabilities of the Arm, Shoulder and Hand (DASH), and short form 36 (SF-36) physical component scores (PCS) and mental component scores (MCS) from the final follow-up visit. Injury and intraoperative and final radiographs were assessed by a single reviewer (MRG) using calibrated radiographs on our institution’s picture archiving and communication system. Radial height, radial inclination, and volar tilt were documented for each time point except for radial height, which was not recorded for intraoperative fluoroscopy images due to lack of calibration. Intra-articular extension was noted on injury films. Wound complications, the presence of a deep or superficial infection, and removal of implants after union were recorded.

Continue to: RESULTS

 

 

RESULTS

Thirty-six patients met the inclusion criteria and were therefore included in the study. The average age at the time of surgery was 60.6 years (range, 25-87 years), 27 patients (75%) were female, and 21 (58%) had left-sided injuries. Patient comorbidities can be seen in Table 1. Twenty-six fractures (72.2%) had intra-articular extension. Average follow-up was 15.6 months (range, 6-53.9 months).

Table 1. Comorbidities of Patients Treated with Radial Column Plating

Radiographic measurements at the time of injury, surgery, and final follow-up can be seen in Table 2. As previously noted, radial height could not be recorded on intraoperative films due to the use of fluoroscopy, which is not calibrated at our institution. The average changes in radial inclination and volar tilt from the time of surgery (intraoperative fluoroscopy) to final follow-up were 0.46° (range, −4.4°-4.3°) and 0.24° (range, −10.6°-9.6°), respectively. All patients had acceptable radial height, radial inclination, and volar tilt at final follow-up. Clinical outcomes were obtained at a mean of 15.6 months (range, 6-54 months) and were generally good, with a mean DASH score of 20.7 (range, 0-57.5), SF-36 PCS of 45.4 (range, 22.7-68.0), and SF-36 MCS of 50.5 (range, 22.3-64.1) (Table 3). Of the 36 patients with 6-month outcome scores, 13 (36.1%) elected for implant removal after fracture union at a mean of 7.6 months after index surgery (range, 3.2-49.8 months). No infections or wound complications were noted.

Table 2. Radiographic Measurements for Patients Treated with Radial Column Plating

DISCUSSION

In this article, we described the use of a radial column plate as a tool to achieve and maintain a reduction during the surgical fixation of an unstable distal radius fracture with a volar locking plate. We have further presented a series of 36 patients treated in this manner and their clinical and radiographic outcomes. This technique permits the maintenance of coronal alignment, thereby limiting the use of percutaneous techniques or the need to manually hold fracture fragments in a reduced position, which may be valuable to the surgeon who is operating without a surgical assistant.

Table 3. Clinical Outcome Scores at Final Follow-Up for Patients Treated with Radial Column Plating

Abbreviations: DASH, Quick Disabilities of the Arm, Shoulder and Hand; MCS, mental component scores; PCS, physical component scores; VAS, visual analog scale.

In addition to its value as a reduction tool, unlike traditional temporary k-wire fixation, we believe that the utilization of a radial styloid plate allows for increased stability until fracture union is achieved. Biomechanical studies have demonstrated favorable results with the use of a radial column plate. Grindel and colleagues²⁰ evaluated dual radial styloid and volar radius plating vs volar plating alone in their biomechanical comparison of 8 cadaveric matched hand and forearm pairs. Specimens were fixated with a volar locking plate, and a 1-cm wedge osteotomy was created dorsally approximately 2 cm from the articular margin. The distal fragment was then osteotomized longitudinally between the 2 ulnar and 2 radial distal locking screws to create a fracture pattern that mimics a dorsally unstable injury with intra-articular extension. Half of the specimens then underwent radial styloid plating with 2 screws securing the construct proximally, and load-to-failure testing was performed. The authors found that utilization of both the volar and radial styloid plates resulted in 50% increased stiffness and 76% increased force-to-failure as compared with radial styloid plating alone. Similar, although not statistically significant, results were found by Blythe and colleagues.²¹ In their cadaveric study, dorsal and volar plating with an additional radial column plate resulted in improved stiffness with axial loading compared to volar or dorsal plating alone ²¹.

Two prior studies have presented outcome data after fixation of distal radius fractures with radial column and volar radius dual plating. Tang and colleagues¹⁶ described this technique and presented postoperative outcomes in 8 patients followed for an average of 35 weeks. They reported a 100% union rate, no loss of reduction, and a mean DASH score of 19.9. Jacobi and colleagues¹⁷ also described this technique in their 2010 report. In their cohort of 10 patients treated by multiple surgeons, they found a mean of 39° of flexion, 49° of extension, 75° of pronation, and 75° of supination at 24 months postoperatively. Eight patients were rated as “excellent,” 1 as “good,” and 1 as “fair” according to the Gartland and Werley score, with all 10 cases achieving bony union. No cases demonstrated loss of volar tilt, radial length, or radial inclination. In both studies, however, the use of the radial column plate was advocated as a fragment-specific fixation tool and not as a reduction tool.

Continue to: Although 1-year DASH scores...

Although 1-year DASH scores for volar plating alone have been shown in the literature to be consistently within 6 and 13, 3-month and 6-month scores have historically been >18.^22-27 Our short-term clinical results (Table 3) are comparable to these historic controls. Further, within our cohort there were no cases of nonunion, postoperative infection, or wound complications, and radiographic measures show maintenance of reduction at final follow-up (Table 2).

We do recognize that 36.1% (13/36) of our cohort had their distal radius implants removed. Although this incidence is high, it stems from the fact that patients who elect for implant removal are more likely to have had an atypical postoperative course and are therefore followed for longer than 6 months. Those who do not elect for removal are typically discharged from care after their 3-month postoperative visit, and were therefore not eligible for inclusion in this study. Overall, a total of 261 patients have been treated with this technique by the senior surgeon. Of those patients, only 28 (10.7%) underwent removal of surgical implants. If the remaining patients had been followed for the full 6 months, it is likely that outcome scores would have been skewed in a more favorable direction.

Surgeons electing to utilize radial styloid plating for displaced distal radius fractures should recognize that the required increased surgical dissection might lead to increased scar formation and postoperative stiffness. A limitation of this study is the lack of quantitative wrist ROM data. Future studies may compare final clinical outcomes and ROM for patients treated with and without radial column fixation.

CONCLUSION

We advocate for the use of a radial column plate as a tool to help achieve and maintain fracture reduction in the setting of an unstable distal radius fracture being treated with ORIF. This technique may be particularly useful when a surgical assistant is not available. Surgeons can expect clinical and radiographic results that are similar to those of volar locked plating alone.

SAN DIEGO – An estimated 41% of patients who experienced a venous thromboembolism (VTE) fear another clot often or almost all the time. In addition, about 25% report abnormal levels of anxiety, and 12% have abnormal depression scores.

Those are key findings from a large survey that set out to estimate the number of bleeding harms and emotional harms experienced by a U.S. population of adults who have experienced a VTE.

Doug Brunk/MDedge News

“There is emerging research in Europe that shows high levels of stress and anxiety in people who have a thrombosis event,” lead study author Michael Feehan, PhD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We interviewed people around the country and found that a lot of them were living with fear, anxiety, and distress. We did a projective exercise and asked, ‘If VTE was an animal, what would it be?’ Many responded with snakes and bears, hostile things. Snakes came up a lot. Snakes can be dormant, and then they can suddenly come out and bite you. That was the kind of language they were using.”

In what he said is the largest study of its kind, Dr. Feehan, a psychologist in the College of Pharmacy at the University of Utah, Salt Lake City, and his associates conducted an online survey of 907 patients aged 18 and older who had experienced a VTE event in the previous 24 months.

The survey was administered in May 2016 and excluded patients with cancer-related VTE. It took about 30 minutes to complete and included questions about the bleeding harms that have occurred since their VTE diagnosis, such as nosebleeds or a cut difficult to control, excessive bruising, vomiting blood, bloody urine, and blood in stools. It also included standardized measures of anxiety, depression, cognitive function, and ratings on eight items of current distress, feeling tense, anxious, confused, depressed, afraid, angry, frustrated, or annoyed.

Self-reported bleeding events included excessive bruising (45%), bleeding from cuts difficult to control (33%), and epistaxis (16%). As for emotional harm, 41% of respondents lived in fear of getting another clot “often” or “almost all the time,” while 25% experienced abnormally high levels of anxiety, and 12% experienced abnormally high levels of depression.

A multivariate structural equation model revealed the following principal factors significantly associated with a composite latent variable of emotional harm: poor health literacy, younger age, the lack of perceived self-control over one’s health, history of medical mistakes in care, and overt barriers to health care access such as transportation limitations and financial limitations (P less than .05 for all associations).

“If you’re working with patients who believe they don’t have any control over their own care, or if they’re younger or have other disease states, or if they have difficulty getting to and from the hospital, all of those things contribute to elevated emotional harms,” Dr. Feehan said. “That level of emotional harm is clinically relevant.”

After the research team shared the study results with staff of the university’s thrombosis services, clinicians started changing how they interview patients. “For example, instead of asking just ‘Have you experienced any VTE symptoms?’ they now ask things like, ‘How are you feeling?’ or ‘How are things going for you living with the disease?’” Dr. Feehan noted. “Then, patients might say, ‘I’m actually quite worried.’ Such questions can help patients open up about how they feel and foster a better relationship with their provider. A better relationship with their provider might help them feel more in control.”

The study was supported by Pfizer Independent Grants for Learning & Change, Bristol-Myers Squibb Independent Medical Education, the Joint Commission, the National Eye Institute, and an unrestricted grant from Research to Prevent Blindness. Dr. Feehan disclosed that he has consulted for Pfizer in the past.

[email protected]

SOURCE: Feehan et al. THSNA 2018, Poster 75.

SAN DIEGO – An estimated 41% of patients who experienced a venous thromboembolism (VTE) fear another clot often or almost all the time. In addition, about 25% report abnormal levels of anxiety, and 12% have abnormal depression scores.

Those are key findings from a large survey that set out to estimate the number of bleeding harms and emotional harms experienced by a U.S. population of adults who have experienced a VTE.

Doug Brunk/MDedge News

“There is emerging research in Europe that shows high levels of stress and anxiety in people who have a thrombosis event,” lead study author Michael Feehan, PhD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We interviewed people around the country and found that a lot of them were living with fear, anxiety, and distress. We did a projective exercise and asked, ‘If VTE was an animal, what would it be?’ Many responded with snakes and bears, hostile things. Snakes came up a lot. Snakes can be dormant, and then they can suddenly come out and bite you. That was the kind of language they were using.”

In what he said is the largest study of its kind, Dr. Feehan, a psychologist in the College of Pharmacy at the University of Utah, Salt Lake City, and his associates conducted an online survey of 907 patients aged 18 and older who had experienced a VTE event in the previous 24 months.

The survey was administered in May 2016 and excluded patients with cancer-related VTE. It took about 30 minutes to complete and included questions about the bleeding harms that have occurred since their VTE diagnosis, such as nosebleeds or a cut difficult to control, excessive bruising, vomiting blood, bloody urine, and blood in stools. It also included standardized measures of anxiety, depression, cognitive function, and ratings on eight items of current distress, feeling tense, anxious, confused, depressed, afraid, angry, frustrated, or annoyed.

Self-reported bleeding events included excessive bruising (45%), bleeding from cuts difficult to control (33%), and epistaxis (16%). As for emotional harm, 41% of respondents lived in fear of getting another clot “often” or “almost all the time,” while 25% experienced abnormally high levels of anxiety, and 12% experienced abnormally high levels of depression.

A multivariate structural equation model revealed the following principal factors significantly associated with a composite latent variable of emotional harm: poor health literacy, younger age, the lack of perceived self-control over one’s health, history of medical mistakes in care, and overt barriers to health care access such as transportation limitations and financial limitations (P less than .05 for all associations).

“If you’re working with patients who believe they don’t have any control over their own care, or if they’re younger or have other disease states, or if they have difficulty getting to and from the hospital, all of those things contribute to elevated emotional harms,” Dr. Feehan said. “That level of emotional harm is clinically relevant.”

After the research team shared the study results with staff of the university’s thrombosis services, clinicians started changing how they interview patients. “For example, instead of asking just ‘Have you experienced any VTE symptoms?’ they now ask things like, ‘How are you feeling?’ or ‘How are things going for you living with the disease?’” Dr. Feehan noted. “Then, patients might say, ‘I’m actually quite worried.’ Such questions can help patients open up about how they feel and foster a better relationship with their provider. A better relationship with their provider might help them feel more in control.”

The study was supported by Pfizer Independent Grants for Learning & Change, Bristol-Myers Squibb Independent Medical Education, the Joint Commission, the National Eye Institute, and an unrestricted grant from Research to Prevent Blindness. Dr. Feehan disclosed that he has consulted for Pfizer in the past.

[email protected]

SOURCE: Feehan et al. THSNA 2018, Poster 75.

SAN DIEGO – An estimated 41% of patients who experienced a venous thromboembolism (VTE) fear another clot often or almost all the time. In addition, about 25% report abnormal levels of anxiety, and 12% have abnormal depression scores.

Those are key findings from a large survey that set out to estimate the number of bleeding harms and emotional harms experienced by a U.S. population of adults who have experienced a VTE.

Doug Brunk/MDedge News

“There is emerging research in Europe that shows high levels of stress and anxiety in people who have a thrombosis event,” lead study author Michael Feehan, PhD, said in an interview at the biennial summit of the Thrombosis & Hemostasis Societies of North America. “We interviewed people around the country and found that a lot of them were living with fear, anxiety, and distress. We did a projective exercise and asked, ‘If VTE was an animal, what would it be?’ Many responded with snakes and bears, hostile things. Snakes came up a lot. Snakes can be dormant, and then they can suddenly come out and bite you. That was the kind of language they were using.”

In what he said is the largest study of its kind, Dr. Feehan, a psychologist in the College of Pharmacy at the University of Utah, Salt Lake City, and his associates conducted an online survey of 907 patients aged 18 and older who had experienced a VTE event in the previous 24 months.

The survey was administered in May 2016 and excluded patients with cancer-related VTE. It took about 30 minutes to complete and included questions about the bleeding harms that have occurred since their VTE diagnosis, such as nosebleeds or a cut difficult to control, excessive bruising, vomiting blood, bloody urine, and blood in stools. It also included standardized measures of anxiety, depression, cognitive function, and ratings on eight items of current distress, feeling tense, anxious, confused, depressed, afraid, angry, frustrated, or annoyed.

Self-reported bleeding events included excessive bruising (45%), bleeding from cuts difficult to control (33%), and epistaxis (16%). As for emotional harm, 41% of respondents lived in fear of getting another clot “often” or “almost all the time,” while 25% experienced abnormally high levels of anxiety, and 12% experienced abnormally high levels of depression.

A multivariate structural equation model revealed the following principal factors significantly associated with a composite latent variable of emotional harm: poor health literacy, younger age, the lack of perceived self-control over one’s health, history of medical mistakes in care, and overt barriers to health care access such as transportation limitations and financial limitations (P less than .05 for all associations).

“If you’re working with patients who believe they don’t have any control over their own care, or if they’re younger or have other disease states, or if they have difficulty getting to and from the hospital, all of those things contribute to elevated emotional harms,” Dr. Feehan said. “That level of emotional harm is clinically relevant.”

After the research team shared the study results with staff of the university’s thrombosis services, clinicians started changing how they interview patients. “For example, instead of asking just ‘Have you experienced any VTE symptoms?’ they now ask things like, ‘How are you feeling?’ or ‘How are things going for you living with the disease?’” Dr. Feehan noted. “Then, patients might say, ‘I’m actually quite worried.’ Such questions can help patients open up about how they feel and foster a better relationship with their provider. A better relationship with their provider might help them feel more in control.”

The study was supported by Pfizer Independent Grants for Learning & Change, Bristol-Myers Squibb Independent Medical Education, the Joint Commission, the National Eye Institute, and an unrestricted grant from Research to Prevent Blindness. Dr. Feehan disclosed that he has consulted for Pfizer in the past.

[email protected]

SOURCE: Feehan et al. THSNA 2018, Poster 75.

South Dakota’s nickname may be the Mount Rushmore State, but for physicians it’s the land of opportunity, according to personal finance website WalletHub.

South Dakota took the top spot in the 2018 list of the “best states to practice medicine” with 75.97 out of a possible 100 points while New Jersey took up residence at the other end of the list by finishing 51st (the District of Columbia was included) with a score of 40.24, WalletHub reported.

South Dakota headed a solid block of states in the upper Midwest and Rocky Mountain regions that made up the entire top 10, with Nebraska second overall, Idaho third, Iowa (last year’s winner) fourth, and Minnesota fifth. Finishing just above New Jersey were Rhode Island in 50th, New York in 49th, Hawaii in 48th, and D.C. in 47th.

WalletHub compared the 50 states and D.C. using 16 different metrics across two broad categories: “opportunity and competition” (11 metrics worth 70 points) and “medical environment” (5 metrics worth 30 points). Metrics included physicians’ average annual wage (adjusted for cost of living), employer-based insurance rates, projected share of elderly population, physician assistants per capita, and malpractice award payout amount per capita.

South Dakota, which ranked first in the medical environment category and third in opportunity and competition, posted top-5 scores in such areas as adjusted physician annual wage, lowest projected competition, and annual malpractice liability insurance rate, according to the survey.

[email protected]

South Dakota’s nickname may be the Mount Rushmore State, but for physicians it’s the land of opportunity, according to personal finance website WalletHub.

South Dakota took the top spot in the 2018 list of the “best states to practice medicine” with 75.97 out of a possible 100 points while New Jersey took up residence at the other end of the list by finishing 51st (the District of Columbia was included) with a score of 40.24, WalletHub reported.

South Dakota headed a solid block of states in the upper Midwest and Rocky Mountain regions that made up the entire top 10, with Nebraska second overall, Idaho third, Iowa (last year’s winner) fourth, and Minnesota fifth. Finishing just above New Jersey were Rhode Island in 50th, New York in 49th, Hawaii in 48th, and D.C. in 47th.

WalletHub compared the 50 states and D.C. using 16 different metrics across two broad categories: “opportunity and competition” (11 metrics worth 70 points) and “medical environment” (5 metrics worth 30 points). Metrics included physicians’ average annual wage (adjusted for cost of living), employer-based insurance rates, projected share of elderly population, physician assistants per capita, and malpractice award payout amount per capita.

South Dakota, which ranked first in the medical environment category and third in opportunity and competition, posted top-5 scores in such areas as adjusted physician annual wage, lowest projected competition, and annual malpractice liability insurance rate, according to the survey.

[email protected]

South Dakota’s nickname may be the Mount Rushmore State, but for physicians it’s the land of opportunity, according to personal finance website WalletHub.

South Dakota took the top spot in the 2018 list of the “best states to practice medicine” with 75.97 out of a possible 100 points while New Jersey took up residence at the other end of the list by finishing 51st (the District of Columbia was included) with a score of 40.24, WalletHub reported.

South Dakota headed a solid block of states in the upper Midwest and Rocky Mountain regions that made up the entire top 10, with Nebraska second overall, Idaho third, Iowa (last year’s winner) fourth, and Minnesota fifth. Finishing just above New Jersey were Rhode Island in 50th, New York in 49th, Hawaii in 48th, and D.C. in 47th.

WalletHub compared the 50 states and D.C. using 16 different metrics across two broad categories: “opportunity and competition” (11 metrics worth 70 points) and “medical environment” (5 metrics worth 30 points). Metrics included physicians’ average annual wage (adjusted for cost of living), employer-based insurance rates, projected share of elderly population, physician assistants per capita, and malpractice award payout amount per capita.

South Dakota, which ranked first in the medical environment category and third in opportunity and competition, posted top-5 scores in such areas as adjusted physician annual wage, lowest projected competition, and annual malpractice liability insurance rate, according to the survey.

[email protected]