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Diabetes-related amputations on the rise in older adults
The recent resurgence in diabetes-related lower-extremity amputations in the United States is not limited to younger adults, according to the author of a recent study that documents similar increases among an older population of Medicare beneficiaries.
While the rate of amputations fell among these older adults from 2000 to 2009, it increased significantly from 2009 to 2017, albeit at a “less severe rate” than recently reported in younger populations, said study investigator Jessica Harding, PhD.
The rate of nontraumatic lower extremity amputation (NLEA) was ticking upward by more than 1% per year over the 2009-2017 period, according to Dr. Harding, assistant professor in the department of surgery at Emory University, Atlanta.
This latest report follows one from last year, published in Diabetes Care, that documented an annual percentage increase approaching 6% between 2009 and 2015, driven by larger increases among adults 18-64 years of age, as well as an increase among men.
It’s not clear why rates of NLEA would be on the rise among younger and older adults in the United States, Dr. Harding said, though factors she said could be implicated include changes in amputation practice, increased comorbidities, higher insulin costs, or shortcomings in early prevention programs.
“We need large-scale studies with granular data to tease out key risk factors that could help identify the drivers of these increases in amputations,” Dr. Harding said in a presentation at the virtual annual scientific sessions of the American Diabetes Association.
“In the interim, increased attention to preventive foot care across the age spectrum could benefit adults with diabetes,” she added.
Devastating complication in older adults
The latest findings from Dr. Harding and coauthors emphasize the importance of a “team approach” to early prevention in older adults with diabetes, said Derek LeRoith, MD, PhD, director of research in the division of endocrinology, diabetes, and bone diseases with Icahn School of Medicine at Mount Sinai, New York.
“If you take a 75-year-old or even an 80-year-old, their life expectancy can still be a good 10 years or more,” Dr. LeRoith said in an interview. “We shouldn’t give up on them – we should be treating them to prevent complications.”
Lower-extremity amputation is a “particularly devastating” complication that can compromise mobility, ability to exercise, and motivation, according to Dr. LeRoith, lead author of a recent Endocrine Society clinical practice guideline that urges referral of older adults with diabetes to a podiatrist, orthopedist, or vascular specialist for preventive care.
“Quite often, treating their glucose or high blood pressure will be much more difficult because of these changes,” he said.
Lower extremity amputation trends upward
Rates of NLEA declined for years, only to rebound by 50%, according to authors of a recent analysis of Nationwide Inpatient Sample (NIS) data reported last year. In their report, the age-standardized diabetes-related NLEA rate per 1,000 adults with diabetes went from 5.30 in 2000, down to 3.07 in 2009/2010, and back up to 4.62 by 2015 (Diabetes Care. 2019 Jan;42:50-4).
The resurgence was fueled mainly by an increased rate of amputations in younger and middle-aged adults and men, and through increases in minor amputations, notably the toe, according to the investigators. “These changes in trend are concerning because of the disabling and costly consequences of NLEAs as well as what they may mean for the direction of efforts to reduce diabetes-related complications,” authors of that report said at the time.
In the current study, Dr. Harding and colleagues included Medicare Parts A and B claims data for beneficiaries enrolled from 2000 to 2017. There were 4.6 million Medicare fee-for-service beneficiaries with diabetes in 2000, increasing to 6.9 million in 2017, she reported at the virtual ADA meeting.
Rates of NLEA followed a trajectory similar to what was seen in the earlier NIS report, falling from 8.5 per 1,000 persons in 2000 to 4.4 in 2009, for an annual percentage change of –7.9 (P < .001), Dr. Harding said. Then rates ticked upward again, to 4.8 in 2017, for an annual percentage change of 1.2 over that later period (P < .001).
While the trend was similar for most subgroups analyzed, the absolute rates were highest among men and black individuals in this older patient population, reported Dr. Harding and coauthors.
Dr. Harding said she and coauthors had no disclosures related to the research, which was performed as a collaboration between Emory University and the Centers for Disease Control and Prevention Division of Diabetes Translation.
SOURCE: Harding J. ADA 2020, Abstract 106-OR.
The recent resurgence in diabetes-related lower-extremity amputations in the United States is not limited to younger adults, according to the author of a recent study that documents similar increases among an older population of Medicare beneficiaries.
While the rate of amputations fell among these older adults from 2000 to 2009, it increased significantly from 2009 to 2017, albeit at a “less severe rate” than recently reported in younger populations, said study investigator Jessica Harding, PhD.
The rate of nontraumatic lower extremity amputation (NLEA) was ticking upward by more than 1% per year over the 2009-2017 period, according to Dr. Harding, assistant professor in the department of surgery at Emory University, Atlanta.
This latest report follows one from last year, published in Diabetes Care, that documented an annual percentage increase approaching 6% between 2009 and 2015, driven by larger increases among adults 18-64 years of age, as well as an increase among men.
It’s not clear why rates of NLEA would be on the rise among younger and older adults in the United States, Dr. Harding said, though factors she said could be implicated include changes in amputation practice, increased comorbidities, higher insulin costs, or shortcomings in early prevention programs.
“We need large-scale studies with granular data to tease out key risk factors that could help identify the drivers of these increases in amputations,” Dr. Harding said in a presentation at the virtual annual scientific sessions of the American Diabetes Association.
“In the interim, increased attention to preventive foot care across the age spectrum could benefit adults with diabetes,” she added.
Devastating complication in older adults
The latest findings from Dr. Harding and coauthors emphasize the importance of a “team approach” to early prevention in older adults with diabetes, said Derek LeRoith, MD, PhD, director of research in the division of endocrinology, diabetes, and bone diseases with Icahn School of Medicine at Mount Sinai, New York.
“If you take a 75-year-old or even an 80-year-old, their life expectancy can still be a good 10 years or more,” Dr. LeRoith said in an interview. “We shouldn’t give up on them – we should be treating them to prevent complications.”
Lower-extremity amputation is a “particularly devastating” complication that can compromise mobility, ability to exercise, and motivation, according to Dr. LeRoith, lead author of a recent Endocrine Society clinical practice guideline that urges referral of older adults with diabetes to a podiatrist, orthopedist, or vascular specialist for preventive care.
“Quite often, treating their glucose or high blood pressure will be much more difficult because of these changes,” he said.
Lower extremity amputation trends upward
Rates of NLEA declined for years, only to rebound by 50%, according to authors of a recent analysis of Nationwide Inpatient Sample (NIS) data reported last year. In their report, the age-standardized diabetes-related NLEA rate per 1,000 adults with diabetes went from 5.30 in 2000, down to 3.07 in 2009/2010, and back up to 4.62 by 2015 (Diabetes Care. 2019 Jan;42:50-4).
The resurgence was fueled mainly by an increased rate of amputations in younger and middle-aged adults and men, and through increases in minor amputations, notably the toe, according to the investigators. “These changes in trend are concerning because of the disabling and costly consequences of NLEAs as well as what they may mean for the direction of efforts to reduce diabetes-related complications,” authors of that report said at the time.
In the current study, Dr. Harding and colleagues included Medicare Parts A and B claims data for beneficiaries enrolled from 2000 to 2017. There were 4.6 million Medicare fee-for-service beneficiaries with diabetes in 2000, increasing to 6.9 million in 2017, she reported at the virtual ADA meeting.
Rates of NLEA followed a trajectory similar to what was seen in the earlier NIS report, falling from 8.5 per 1,000 persons in 2000 to 4.4 in 2009, for an annual percentage change of –7.9 (P < .001), Dr. Harding said. Then rates ticked upward again, to 4.8 in 2017, for an annual percentage change of 1.2 over that later period (P < .001).
While the trend was similar for most subgroups analyzed, the absolute rates were highest among men and black individuals in this older patient population, reported Dr. Harding and coauthors.
Dr. Harding said she and coauthors had no disclosures related to the research, which was performed as a collaboration between Emory University and the Centers for Disease Control and Prevention Division of Diabetes Translation.
SOURCE: Harding J. ADA 2020, Abstract 106-OR.
The recent resurgence in diabetes-related lower-extremity amputations in the United States is not limited to younger adults, according to the author of a recent study that documents similar increases among an older population of Medicare beneficiaries.
While the rate of amputations fell among these older adults from 2000 to 2009, it increased significantly from 2009 to 2017, albeit at a “less severe rate” than recently reported in younger populations, said study investigator Jessica Harding, PhD.
The rate of nontraumatic lower extremity amputation (NLEA) was ticking upward by more than 1% per year over the 2009-2017 period, according to Dr. Harding, assistant professor in the department of surgery at Emory University, Atlanta.
This latest report follows one from last year, published in Diabetes Care, that documented an annual percentage increase approaching 6% between 2009 and 2015, driven by larger increases among adults 18-64 years of age, as well as an increase among men.
It’s not clear why rates of NLEA would be on the rise among younger and older adults in the United States, Dr. Harding said, though factors she said could be implicated include changes in amputation practice, increased comorbidities, higher insulin costs, or shortcomings in early prevention programs.
“We need large-scale studies with granular data to tease out key risk factors that could help identify the drivers of these increases in amputations,” Dr. Harding said in a presentation at the virtual annual scientific sessions of the American Diabetes Association.
“In the interim, increased attention to preventive foot care across the age spectrum could benefit adults with diabetes,” she added.
Devastating complication in older adults
The latest findings from Dr. Harding and coauthors emphasize the importance of a “team approach” to early prevention in older adults with diabetes, said Derek LeRoith, MD, PhD, director of research in the division of endocrinology, diabetes, and bone diseases with Icahn School of Medicine at Mount Sinai, New York.
“If you take a 75-year-old or even an 80-year-old, their life expectancy can still be a good 10 years or more,” Dr. LeRoith said in an interview. “We shouldn’t give up on them – we should be treating them to prevent complications.”
Lower-extremity amputation is a “particularly devastating” complication that can compromise mobility, ability to exercise, and motivation, according to Dr. LeRoith, lead author of a recent Endocrine Society clinical practice guideline that urges referral of older adults with diabetes to a podiatrist, orthopedist, or vascular specialist for preventive care.
“Quite often, treating their glucose or high blood pressure will be much more difficult because of these changes,” he said.
Lower extremity amputation trends upward
Rates of NLEA declined for years, only to rebound by 50%, according to authors of a recent analysis of Nationwide Inpatient Sample (NIS) data reported last year. In their report, the age-standardized diabetes-related NLEA rate per 1,000 adults with diabetes went from 5.30 in 2000, down to 3.07 in 2009/2010, and back up to 4.62 by 2015 (Diabetes Care. 2019 Jan;42:50-4).
The resurgence was fueled mainly by an increased rate of amputations in younger and middle-aged adults and men, and through increases in minor amputations, notably the toe, according to the investigators. “These changes in trend are concerning because of the disabling and costly consequences of NLEAs as well as what they may mean for the direction of efforts to reduce diabetes-related complications,” authors of that report said at the time.
In the current study, Dr. Harding and colleagues included Medicare Parts A and B claims data for beneficiaries enrolled from 2000 to 2017. There were 4.6 million Medicare fee-for-service beneficiaries with diabetes in 2000, increasing to 6.9 million in 2017, she reported at the virtual ADA meeting.
Rates of NLEA followed a trajectory similar to what was seen in the earlier NIS report, falling from 8.5 per 1,000 persons in 2000 to 4.4 in 2009, for an annual percentage change of –7.9 (P < .001), Dr. Harding said. Then rates ticked upward again, to 4.8 in 2017, for an annual percentage change of 1.2 over that later period (P < .001).
While the trend was similar for most subgroups analyzed, the absolute rates were highest among men and black individuals in this older patient population, reported Dr. Harding and coauthors.
Dr. Harding said she and coauthors had no disclosures related to the research, which was performed as a collaboration between Emory University and the Centers for Disease Control and Prevention Division of Diabetes Translation.
SOURCE: Harding J. ADA 2020, Abstract 106-OR.
FROM ADA 2020
Difluoroethane Inhalant Abuse, Skeletal Fluorosis, and Withdrawal
Difluoroethane (DFE) is an easily acquired and inexpensive volatile substance that can be inhaled recreationally. 1 It is found in common household items, including compressed air dusters, refrigerants, and propellants. DFE is a central nervous system (CNS) depressant associated with a brief sensation of euphoria when inhaled.2 Prolonged or excessive use is associated with toxicity, and abrupt cessation can induce withdrawal.3-5 We present a case of DFE abuse associated with skeletal fluorosis and withdrawal psychosis.
Case Presentation
A 39-year-old man with a 6-month history of inhaling 20 to 25 cans of DFE per day presented to the emergency department after abruptly stopping use 6 days prior. He described irritability, agitation, auditory hallucinations, and delusions of “demons trying to harm him.”
On presentation, the patient was afebrile with a mild sinus tachycardia. He was calm and cooperative but reported delusions and auditory hallucinations. He denied suicidal or homicidal ideation. His physical examination was remarkable for bony deformities of his hands (Figure 1).
The initial workup included a complete blood count; basic metabolic panel; liver function tests; urine toxicology; and testing for hepatitis B/C and HIV; all unremarkable. Psychiatry and poison control were consulted, and he was admitted.
After 72 hours, the patient's irritability, agitation, and sinus tachycardia resolved; however, his psychosis and hallucinations persisted. He was started on olanzapine and transferred to inpatient psychiatry. Additional laboratory tests revealed a serum fluoride of 0.35 mg/L (normal, 1-47 ug/L), C-telopeptide of 2,663 pg/mL (normal, 70-780 pg/mL), and hand X-rays showing diffuse bilateral periosteal reaction in the phalanges and distal ulnas (Figure 2).6
Discussion
DFE acts as a CNS depressant via glutamate and γ-aminobutyric acid receptors, causing a brief euphoria when inhaled.2 Acute toxicity can cause nausea, vomiting, abdominal pain, and altered mental status. Severe complications include loss of consciousness, mucosal frostbite, angioedema, cardiac arrhythmias, and skeletal fluorosis.2,7
Skeletal fluorosis is a rare ramification of excessive or prolonged DFE inhalation. DFE is metabolized into a fluorinated compound that accumulates and leaches calcium from bone, altering its structure. This can manifest as bony deformities with diffuse periosteal reaction and elevated serum fluoride levels. Furthermore, the elevated C-telopeptide level seen in this case may suggest increased bone turnover.
Approximately 50% of patients report withdrawal symptoms, but the timing, duration, and associated symptoms are not well understood.3 Withdrawal can include tremors, diaphoresis, nausea, vomiting, depression, anxiety, irritability, psychosis, and hallucinations. Symptoms typically start within 24 to 48 hours of cessation and last for 3 to 7 days.5 Psychotic symptoms often abate quickly; however, anxiety and insomnia can persist for weeks.5 There are no formal treatment guidelines, but poison control suggests observation and as-needed benzodiazepines. Although this patient’s irritability and agitation resolved, his psychosis and hallucinations persisted, raising concern for an underlying psychiatric diagnosis and prompting transfer to inpatient psychiatry.
Conslusion
Health care providers should recognize the symptoms of DFE toxicity, its complications, and withdrawal. Collaborating with psychiatry and poison control is beneficial in providing guidelines for supportive care.
1. Arroyo JP, Johnson DC, Lewis JB, et al. Treatment of acute intoxication from inhaled 1,2-difluoroethane. Ann Intern Med. 2018;169(11):820‐822. doi:10.7326/L18-0186
2. National Library of Medicine, PubChem. Hazardous Substance Data Bank (HSDB) 1,1-Difluoroethane. https:// pubchem.ncbi.nlm.nih.gov/source/hsdb/5205. Updated October 25, 2016. Accessed May 20, 2020.
3. Perron BE, Glass JE, Ahmedani BK, Vaughn MG, Roberts DE, Wu LT. The prevalence and clinical significance of inhalant withdrawal symptoms among a national sample. Subst Abuse Rehabil. 2011;2011(2):69‐76. doi:10.2147/SAR.S14937
4. Perron BE, Howard MO, Vaughn MG, Jarman CN. Inhalant withdrawal as a clinically significant feature of inhalant dependence disorder. Med Hypotheses. 2009;73(6):935‐937. doi:10.1016/j.mehy.2009.06.036
5. Addiction Center. Inhalant withdrawal and detox. https://www.addictioncenter.com/drugs/inhalants /withdrawal-detox. Accessed May 18, 2020.
6. Torra M, Rodamilans M, Corbella J. Serum and urine ionic fluoride: normal range in a nonexposed population. Biol Trace Elem Res. 1998;63(1):67‐71. doi:10.1007/BF02785278 7. Cohen E, Hsu RY, Evangelista P, Aaron R, Rubin LE. Rapid-onset diffuse skeletal fluorosis from inhalant abuse: a case report. JBJS Case Connect. 2014;4(4):e108. doi:10.2106/JBJS.CC.N.00085
Difluoroethane (DFE) is an easily acquired and inexpensive volatile substance that can be inhaled recreationally. 1 It is found in common household items, including compressed air dusters, refrigerants, and propellants. DFE is a central nervous system (CNS) depressant associated with a brief sensation of euphoria when inhaled.2 Prolonged or excessive use is associated with toxicity, and abrupt cessation can induce withdrawal.3-5 We present a case of DFE abuse associated with skeletal fluorosis and withdrawal psychosis.
Case Presentation
A 39-year-old man with a 6-month history of inhaling 20 to 25 cans of DFE per day presented to the emergency department after abruptly stopping use 6 days prior. He described irritability, agitation, auditory hallucinations, and delusions of “demons trying to harm him.”
On presentation, the patient was afebrile with a mild sinus tachycardia. He was calm and cooperative but reported delusions and auditory hallucinations. He denied suicidal or homicidal ideation. His physical examination was remarkable for bony deformities of his hands (Figure 1).
The initial workup included a complete blood count; basic metabolic panel; liver function tests; urine toxicology; and testing for hepatitis B/C and HIV; all unremarkable. Psychiatry and poison control were consulted, and he was admitted.
After 72 hours, the patient's irritability, agitation, and sinus tachycardia resolved; however, his psychosis and hallucinations persisted. He was started on olanzapine and transferred to inpatient psychiatry. Additional laboratory tests revealed a serum fluoride of 0.35 mg/L (normal, 1-47 ug/L), C-telopeptide of 2,663 pg/mL (normal, 70-780 pg/mL), and hand X-rays showing diffuse bilateral periosteal reaction in the phalanges and distal ulnas (Figure 2).6
Discussion
DFE acts as a CNS depressant via glutamate and γ-aminobutyric acid receptors, causing a brief euphoria when inhaled.2 Acute toxicity can cause nausea, vomiting, abdominal pain, and altered mental status. Severe complications include loss of consciousness, mucosal frostbite, angioedema, cardiac arrhythmias, and skeletal fluorosis.2,7
Skeletal fluorosis is a rare ramification of excessive or prolonged DFE inhalation. DFE is metabolized into a fluorinated compound that accumulates and leaches calcium from bone, altering its structure. This can manifest as bony deformities with diffuse periosteal reaction and elevated serum fluoride levels. Furthermore, the elevated C-telopeptide level seen in this case may suggest increased bone turnover.
Approximately 50% of patients report withdrawal symptoms, but the timing, duration, and associated symptoms are not well understood.3 Withdrawal can include tremors, diaphoresis, nausea, vomiting, depression, anxiety, irritability, psychosis, and hallucinations. Symptoms typically start within 24 to 48 hours of cessation and last for 3 to 7 days.5 Psychotic symptoms often abate quickly; however, anxiety and insomnia can persist for weeks.5 There are no formal treatment guidelines, but poison control suggests observation and as-needed benzodiazepines. Although this patient’s irritability and agitation resolved, his psychosis and hallucinations persisted, raising concern for an underlying psychiatric diagnosis and prompting transfer to inpatient psychiatry.
Conslusion
Health care providers should recognize the symptoms of DFE toxicity, its complications, and withdrawal. Collaborating with psychiatry and poison control is beneficial in providing guidelines for supportive care.
Difluoroethane (DFE) is an easily acquired and inexpensive volatile substance that can be inhaled recreationally. 1 It is found in common household items, including compressed air dusters, refrigerants, and propellants. DFE is a central nervous system (CNS) depressant associated with a brief sensation of euphoria when inhaled.2 Prolonged or excessive use is associated with toxicity, and abrupt cessation can induce withdrawal.3-5 We present a case of DFE abuse associated with skeletal fluorosis and withdrawal psychosis.
Case Presentation
A 39-year-old man with a 6-month history of inhaling 20 to 25 cans of DFE per day presented to the emergency department after abruptly stopping use 6 days prior. He described irritability, agitation, auditory hallucinations, and delusions of “demons trying to harm him.”
On presentation, the patient was afebrile with a mild sinus tachycardia. He was calm and cooperative but reported delusions and auditory hallucinations. He denied suicidal or homicidal ideation. His physical examination was remarkable for bony deformities of his hands (Figure 1).
The initial workup included a complete blood count; basic metabolic panel; liver function tests; urine toxicology; and testing for hepatitis B/C and HIV; all unremarkable. Psychiatry and poison control were consulted, and he was admitted.
After 72 hours, the patient's irritability, agitation, and sinus tachycardia resolved; however, his psychosis and hallucinations persisted. He was started on olanzapine and transferred to inpatient psychiatry. Additional laboratory tests revealed a serum fluoride of 0.35 mg/L (normal, 1-47 ug/L), C-telopeptide of 2,663 pg/mL (normal, 70-780 pg/mL), and hand X-rays showing diffuse bilateral periosteal reaction in the phalanges and distal ulnas (Figure 2).6
Discussion
DFE acts as a CNS depressant via glutamate and γ-aminobutyric acid receptors, causing a brief euphoria when inhaled.2 Acute toxicity can cause nausea, vomiting, abdominal pain, and altered mental status. Severe complications include loss of consciousness, mucosal frostbite, angioedema, cardiac arrhythmias, and skeletal fluorosis.2,7
Skeletal fluorosis is a rare ramification of excessive or prolonged DFE inhalation. DFE is metabolized into a fluorinated compound that accumulates and leaches calcium from bone, altering its structure. This can manifest as bony deformities with diffuse periosteal reaction and elevated serum fluoride levels. Furthermore, the elevated C-telopeptide level seen in this case may suggest increased bone turnover.
Approximately 50% of patients report withdrawal symptoms, but the timing, duration, and associated symptoms are not well understood.3 Withdrawal can include tremors, diaphoresis, nausea, vomiting, depression, anxiety, irritability, psychosis, and hallucinations. Symptoms typically start within 24 to 48 hours of cessation and last for 3 to 7 days.5 Psychotic symptoms often abate quickly; however, anxiety and insomnia can persist for weeks.5 There are no formal treatment guidelines, but poison control suggests observation and as-needed benzodiazepines. Although this patient’s irritability and agitation resolved, his psychosis and hallucinations persisted, raising concern for an underlying psychiatric diagnosis and prompting transfer to inpatient psychiatry.
Conslusion
Health care providers should recognize the symptoms of DFE toxicity, its complications, and withdrawal. Collaborating with psychiatry and poison control is beneficial in providing guidelines for supportive care.
1. Arroyo JP, Johnson DC, Lewis JB, et al. Treatment of acute intoxication from inhaled 1,2-difluoroethane. Ann Intern Med. 2018;169(11):820‐822. doi:10.7326/L18-0186
2. National Library of Medicine, PubChem. Hazardous Substance Data Bank (HSDB) 1,1-Difluoroethane. https:// pubchem.ncbi.nlm.nih.gov/source/hsdb/5205. Updated October 25, 2016. Accessed May 20, 2020.
3. Perron BE, Glass JE, Ahmedani BK, Vaughn MG, Roberts DE, Wu LT. The prevalence and clinical significance of inhalant withdrawal symptoms among a national sample. Subst Abuse Rehabil. 2011;2011(2):69‐76. doi:10.2147/SAR.S14937
4. Perron BE, Howard MO, Vaughn MG, Jarman CN. Inhalant withdrawal as a clinically significant feature of inhalant dependence disorder. Med Hypotheses. 2009;73(6):935‐937. doi:10.1016/j.mehy.2009.06.036
5. Addiction Center. Inhalant withdrawal and detox. https://www.addictioncenter.com/drugs/inhalants /withdrawal-detox. Accessed May 18, 2020.
6. Torra M, Rodamilans M, Corbella J. Serum and urine ionic fluoride: normal range in a nonexposed population. Biol Trace Elem Res. 1998;63(1):67‐71. doi:10.1007/BF02785278 7. Cohen E, Hsu RY, Evangelista P, Aaron R, Rubin LE. Rapid-onset diffuse skeletal fluorosis from inhalant abuse: a case report. JBJS Case Connect. 2014;4(4):e108. doi:10.2106/JBJS.CC.N.00085
1. Arroyo JP, Johnson DC, Lewis JB, et al. Treatment of acute intoxication from inhaled 1,2-difluoroethane. Ann Intern Med. 2018;169(11):820‐822. doi:10.7326/L18-0186
2. National Library of Medicine, PubChem. Hazardous Substance Data Bank (HSDB) 1,1-Difluoroethane. https:// pubchem.ncbi.nlm.nih.gov/source/hsdb/5205. Updated October 25, 2016. Accessed May 20, 2020.
3. Perron BE, Glass JE, Ahmedani BK, Vaughn MG, Roberts DE, Wu LT. The prevalence and clinical significance of inhalant withdrawal symptoms among a national sample. Subst Abuse Rehabil. 2011;2011(2):69‐76. doi:10.2147/SAR.S14937
4. Perron BE, Howard MO, Vaughn MG, Jarman CN. Inhalant withdrawal as a clinically significant feature of inhalant dependence disorder. Med Hypotheses. 2009;73(6):935‐937. doi:10.1016/j.mehy.2009.06.036
5. Addiction Center. Inhalant withdrawal and detox. https://www.addictioncenter.com/drugs/inhalants /withdrawal-detox. Accessed May 18, 2020.
6. Torra M, Rodamilans M, Corbella J. Serum and urine ionic fluoride: normal range in a nonexposed population. Biol Trace Elem Res. 1998;63(1):67‐71. doi:10.1007/BF02785278 7. Cohen E, Hsu RY, Evangelista P, Aaron R, Rubin LE. Rapid-onset diffuse skeletal fluorosis from inhalant abuse: a case report. JBJS Case Connect. 2014;4(4):e108. doi:10.2106/JBJS.CC.N.00085
Restriction of Foley catheters in older trauma patients improved outcomes
and led to earlier discharge, findings from a study revealed. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“We reduced the use of Foley catheters in our target population by more than 50%, which led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes,” reported Sanjit R. Konda, MD, an orthopedic surgeon with New York University Langone Health.
The quality initiative was introduced about 2 years ago specifically to reduce the risk of UTI in older patients admitted for femur or hip fractures. Previously at the level 1 trauma center where this quality initiative was introduced, placement of Foley catheters in these types of patients had been routine.
After the policy change, Foley catheters were only offered to these trauma patients 55 years of age or older when more than three episodes or urinary retention had been documented with a bladder scan. Urinary retention was defined as a volume of at least 600 mL.
When outcomes in 184 patients treated in the 15 months after the policy change were compared with 393 treated in the prior 38 months, Foley catheter use was substantially and significantly reduced (43.5% vs. 95.5%; P < .001), Dr. Konda said in an interview.
Although the lower rate of UTI following the policy change fell short of statistical significance (10.33% vs. 14.5%; P = .167), the policy change was associated with a decreased time to surgery (33.27 vs. 38.54 hours; P = .001), shorter length of stay (6.89 vs. 8.34 days; P < .001), and higher rate of home discharge (22.8% vs. 15.6%; P = .038).
When those who avoided a Foley catheter were compared with those who did not after the policy change, there was a significant reduction in UTI (4.81% vs. 17.4%; P = .014). In addition, patients who avoided a Foley catheter had a decreased time to surgery (P = .014), shorter length of stay (P < .001) and an almost 900% greater likelihood of home discharge (odds ratio, 9.9; P < .001).
“This quality initiative does increase the number of bladder scans required, meaning more work for nurses, but the program was developed in collaboration with our nursing staff, who were supportive of the goals,” Dr. Konda reported.
Reducing the incidence of UTI is an important initiative because the Centers for Medicare & Medicaid Services and other third-party payers employ this as a quality metric, according to Dr. Konda. This explains why hospital administrators generally embrace effective strategies to reduce UTI rates.
The improvement in outcomes, including the reduction in UTIs and length of stay, has cost implications, which will be evaluated in a future analysis, according to Dr. Konda.
Although this quality initiative was undertaken in a level 1 trauma center, Dr. Konda believes the same principles can be applied to other settings.
Jennifer A. Meddings, MD, an associate professor of medicine at the University of Michigan, Ann Arbor, agreed. Active in the evaluation of strategies to reduce hospital-acquired complications, Dr. Meddings published a study of procedural appropriateness ratings to guide strategies for improving the likelihood that catheters are employed only when needed (BMJ Qual Saf. 2019;28:56-66).
“In addition to avoiding UTI, reducing unnecessary placement of Foley catheters also eliminates the risk of trauma to the urinary tract,” Dr. Meddings said. This is a complication that is not well appreciated because the trauma is not always documented, according to Dr. Meddings, who believes increased risk of both UTI and urinary tract trauma should discourage use of Foley catheters when there is not a specific indication.
Although there are criteria other than excess bladder volume to determine when to consider a Foley catheter, Dr. Meddings encourages any systematic approach that increases the likelihood that catheters are not placed unnecessarily. She emphasized that a hip fracture by itself “is not a criterion for catheterization.”
Dr. Konda reported a financial relationship with Stryker.
and led to earlier discharge, findings from a study revealed. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“We reduced the use of Foley catheters in our target population by more than 50%, which led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes,” reported Sanjit R. Konda, MD, an orthopedic surgeon with New York University Langone Health.
The quality initiative was introduced about 2 years ago specifically to reduce the risk of UTI in older patients admitted for femur or hip fractures. Previously at the level 1 trauma center where this quality initiative was introduced, placement of Foley catheters in these types of patients had been routine.
After the policy change, Foley catheters were only offered to these trauma patients 55 years of age or older when more than three episodes or urinary retention had been documented with a bladder scan. Urinary retention was defined as a volume of at least 600 mL.
When outcomes in 184 patients treated in the 15 months after the policy change were compared with 393 treated in the prior 38 months, Foley catheter use was substantially and significantly reduced (43.5% vs. 95.5%; P < .001), Dr. Konda said in an interview.
Although the lower rate of UTI following the policy change fell short of statistical significance (10.33% vs. 14.5%; P = .167), the policy change was associated with a decreased time to surgery (33.27 vs. 38.54 hours; P = .001), shorter length of stay (6.89 vs. 8.34 days; P < .001), and higher rate of home discharge (22.8% vs. 15.6%; P = .038).
When those who avoided a Foley catheter were compared with those who did not after the policy change, there was a significant reduction in UTI (4.81% vs. 17.4%; P = .014). In addition, patients who avoided a Foley catheter had a decreased time to surgery (P = .014), shorter length of stay (P < .001) and an almost 900% greater likelihood of home discharge (odds ratio, 9.9; P < .001).
“This quality initiative does increase the number of bladder scans required, meaning more work for nurses, but the program was developed in collaboration with our nursing staff, who were supportive of the goals,” Dr. Konda reported.
Reducing the incidence of UTI is an important initiative because the Centers for Medicare & Medicaid Services and other third-party payers employ this as a quality metric, according to Dr. Konda. This explains why hospital administrators generally embrace effective strategies to reduce UTI rates.
The improvement in outcomes, including the reduction in UTIs and length of stay, has cost implications, which will be evaluated in a future analysis, according to Dr. Konda.
Although this quality initiative was undertaken in a level 1 trauma center, Dr. Konda believes the same principles can be applied to other settings.
Jennifer A. Meddings, MD, an associate professor of medicine at the University of Michigan, Ann Arbor, agreed. Active in the evaluation of strategies to reduce hospital-acquired complications, Dr. Meddings published a study of procedural appropriateness ratings to guide strategies for improving the likelihood that catheters are employed only when needed (BMJ Qual Saf. 2019;28:56-66).
“In addition to avoiding UTI, reducing unnecessary placement of Foley catheters also eliminates the risk of trauma to the urinary tract,” Dr. Meddings said. This is a complication that is not well appreciated because the trauma is not always documented, according to Dr. Meddings, who believes increased risk of both UTI and urinary tract trauma should discourage use of Foley catheters when there is not a specific indication.
Although there are criteria other than excess bladder volume to determine when to consider a Foley catheter, Dr. Meddings encourages any systematic approach that increases the likelihood that catheters are not placed unnecessarily. She emphasized that a hip fracture by itself “is not a criterion for catheterization.”
Dr. Konda reported a financial relationship with Stryker.
and led to earlier discharge, findings from a study revealed. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“We reduced the use of Foley catheters in our target population by more than 50%, which led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes,” reported Sanjit R. Konda, MD, an orthopedic surgeon with New York University Langone Health.
The quality initiative was introduced about 2 years ago specifically to reduce the risk of UTI in older patients admitted for femur or hip fractures. Previously at the level 1 trauma center where this quality initiative was introduced, placement of Foley catheters in these types of patients had been routine.
After the policy change, Foley catheters were only offered to these trauma patients 55 years of age or older when more than three episodes or urinary retention had been documented with a bladder scan. Urinary retention was defined as a volume of at least 600 mL.
When outcomes in 184 patients treated in the 15 months after the policy change were compared with 393 treated in the prior 38 months, Foley catheter use was substantially and significantly reduced (43.5% vs. 95.5%; P < .001), Dr. Konda said in an interview.
Although the lower rate of UTI following the policy change fell short of statistical significance (10.33% vs. 14.5%; P = .167), the policy change was associated with a decreased time to surgery (33.27 vs. 38.54 hours; P = .001), shorter length of stay (6.89 vs. 8.34 days; P < .001), and higher rate of home discharge (22.8% vs. 15.6%; P = .038).
When those who avoided a Foley catheter were compared with those who did not after the policy change, there was a significant reduction in UTI (4.81% vs. 17.4%; P = .014). In addition, patients who avoided a Foley catheter had a decreased time to surgery (P = .014), shorter length of stay (P < .001) and an almost 900% greater likelihood of home discharge (odds ratio, 9.9; P < .001).
“This quality initiative does increase the number of bladder scans required, meaning more work for nurses, but the program was developed in collaboration with our nursing staff, who were supportive of the goals,” Dr. Konda reported.
Reducing the incidence of UTI is an important initiative because the Centers for Medicare & Medicaid Services and other third-party payers employ this as a quality metric, according to Dr. Konda. This explains why hospital administrators generally embrace effective strategies to reduce UTI rates.
The improvement in outcomes, including the reduction in UTIs and length of stay, has cost implications, which will be evaluated in a future analysis, according to Dr. Konda.
Although this quality initiative was undertaken in a level 1 trauma center, Dr. Konda believes the same principles can be applied to other settings.
Jennifer A. Meddings, MD, an associate professor of medicine at the University of Michigan, Ann Arbor, agreed. Active in the evaluation of strategies to reduce hospital-acquired complications, Dr. Meddings published a study of procedural appropriateness ratings to guide strategies for improving the likelihood that catheters are employed only when needed (BMJ Qual Saf. 2019;28:56-66).
“In addition to avoiding UTI, reducing unnecessary placement of Foley catheters also eliminates the risk of trauma to the urinary tract,” Dr. Meddings said. This is a complication that is not well appreciated because the trauma is not always documented, according to Dr. Meddings, who believes increased risk of both UTI and urinary tract trauma should discourage use of Foley catheters when there is not a specific indication.
Although there are criteria other than excess bladder volume to determine when to consider a Foley catheter, Dr. Meddings encourages any systematic approach that increases the likelihood that catheters are not placed unnecessarily. She emphasized that a hip fracture by itself “is not a criterion for catheterization.”
Dr. Konda reported a financial relationship with Stryker.
FROM AAOS 2020
Standardized protocol guides therapies to reduce VTE after arthroplasty
A simple tool to guide choice of antithrombotic therapy following total joint arthroplasty led to a reduction in pulmonary embolism (PE) after being introduced systemwide, according to a prospectively tracked evaluation of a large patient cohort. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“We developed a simplified scoring system for evaluating risk of thromboembolism and guiding prophylaxis that led to a significant reduction in events across a large integrated health care system,” reported James Wylie, MD, associate medical director for hip and knee preservation and orthopedic research at Intermountain Healthcare, Salt Lake City, Utah.
The goal of the methodology was to create a uniform and evidence-based approach to risk assessment in order to guide selection of appropriate venous thromboembolism (VTE) prophylaxis. The tool takes into account the need to individualize antithrombotic drugs for risk of both VTE and for bleeding.
“VTE is a major threat following total joint replacement, but not all patients require anticoagulants. Recent evidence supports a shift to aspirin for low-risk patients,” explained Dr. Wylie in an interview.
The risk tool assigns points for such factors as history of VTE, older age, history of coronary artery disease, history of cancer, and increased body mass index. There are two possible ratings to guide strategies. Those with standard risk are candidates for 81 mg of aspirin twice daily. Those with high risk are candidates for 2.5 mg of apixaban, also administered twice daily. Custom dosing of warfarin is an alternative for the latter group. Regardless of strategy, prophylaxis is administered for 30 days following arthroplasty
“The risk score is calculated automatically, because you have to click a box in the electronic medical record for all of those factors as part of admission orders,” Dr. Wylie said.
The protocol was introduced in July 2017 and adoption was tracked prospectively over 18 months. In an evaluable cohort of 20,284 patients, PE rates in the 71% of patients adherent to the protocol were compared with the 29% who were not.
Over the observation period, the rates of PE were 0.34% and 0.62% (P = .004) for those adherent and nonadherent, respectively. The rate of unplanned readmissions and death, which were secondary outcomes, were both numerically lower in the group treated by adherent surgeons, but the differences did not reach statistical significance.
Adoption of the protocol by surgeons did increase over the course of the observation period, and this correlated with a decrease in unplanned readmissions. Bleeding-related readmission was a rare event in this analysis and did not significantly increase over time, according to Dr. Wylie.
The risk assessment tool, developed by a multispecialty team at Intermountain Healthcare, was based on a review of hundreds of published papers and guidelines, according to Nathan Momberger, MD, who is the associate medical director of total joint replacement at Intermountain and was a coauthor on this study. A member of the team that developed the risk assessment tool, Dr. Momberger noted that new risk score was developed at a time when clinicians have been moving quickly away from warfarin to direct oral anticoagulants.
“None of our surgeons were using the same VTE prophylaxis when we started this project,” Dr. Momberger said. This was a motivation for developing a systemwide approach. In the 22 participating hospitals, there were 50 surgeons performing total knee arthroplasty and 40 surgeons were performing total hip surgery at the time the new protocol was introduced.
Further analyses will provide a more detailed analysis of the effect of the protocol on other thrombotic events, including deep vein thrombosis, and on cost. Since these data were analyzed, protocol adoption has increased and now exceeds 80%, according to Dr. Wylie.
Although a standardized approach to VTE prophylaxis following total joint arthroplasty is attractive, the ideal strategy remains controversial, according to Sunny Parikh, MD, an orthopedic surgeon affiliated with Colchester (England) General Hospital.
As a coauthor of a recent study that quantified symptomatic VTE rates at his and a neighboring hospital over a 3-year period (BMC Musculoskelet Disord. 2020;21:95), Dr. Parikh reported that VTE rates did not reach zero even with a prolonged course of the low-molecular-weight heparin enoxaparin.
At 90 days, the symptomatic VTE rate was only 0.3% for total knee arthroplasty but reached 1.2% for total hip arthroplasty.
“At the time of this study we were using enoxaparin for 28 days following total hip replacements and for 14 days following total knee replacements,” Dr. Parikh reported. Since this study, his institution has switched to a regimen recommended by the U.K.’s National Institute for Health and Clinical Excellence (NICE).
Under the NICE guidelines, VTE prophylaxis for total hip arthroplasty is 40 mg enoxaparin once daily for 14 days followed by 75 mg aspirin for another 14 days, according to Dr. Parikh. For total knee arthroplasty, the standard regimen is 75 mg aspirin for 14 days.
For those who might not be best managed with the standard approach, “there is no clear guideline.” Rather, in patients with renal or liver impairment, “we discuss the case with the hematology team to adjust the doses,” Dr. Parikh reported.
The advantage of a standardized approach applied to all or most patients is that is eliminates disparities, but Dr. Parikh agreed that risk-adjusted prophylaxis might be warranted for optimal outcomes.
Dr. Wylie reported a financial relationship with Arthrex.
A simple tool to guide choice of antithrombotic therapy following total joint arthroplasty led to a reduction in pulmonary embolism (PE) after being introduced systemwide, according to a prospectively tracked evaluation of a large patient cohort. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“We developed a simplified scoring system for evaluating risk of thromboembolism and guiding prophylaxis that led to a significant reduction in events across a large integrated health care system,” reported James Wylie, MD, associate medical director for hip and knee preservation and orthopedic research at Intermountain Healthcare, Salt Lake City, Utah.
The goal of the methodology was to create a uniform and evidence-based approach to risk assessment in order to guide selection of appropriate venous thromboembolism (VTE) prophylaxis. The tool takes into account the need to individualize antithrombotic drugs for risk of both VTE and for bleeding.
“VTE is a major threat following total joint replacement, but not all patients require anticoagulants. Recent evidence supports a shift to aspirin for low-risk patients,” explained Dr. Wylie in an interview.
The risk tool assigns points for such factors as history of VTE, older age, history of coronary artery disease, history of cancer, and increased body mass index. There are two possible ratings to guide strategies. Those with standard risk are candidates for 81 mg of aspirin twice daily. Those with high risk are candidates for 2.5 mg of apixaban, also administered twice daily. Custom dosing of warfarin is an alternative for the latter group. Regardless of strategy, prophylaxis is administered for 30 days following arthroplasty
“The risk score is calculated automatically, because you have to click a box in the electronic medical record for all of those factors as part of admission orders,” Dr. Wylie said.
The protocol was introduced in July 2017 and adoption was tracked prospectively over 18 months. In an evaluable cohort of 20,284 patients, PE rates in the 71% of patients adherent to the protocol were compared with the 29% who were not.
Over the observation period, the rates of PE were 0.34% and 0.62% (P = .004) for those adherent and nonadherent, respectively. The rate of unplanned readmissions and death, which were secondary outcomes, were both numerically lower in the group treated by adherent surgeons, but the differences did not reach statistical significance.
Adoption of the protocol by surgeons did increase over the course of the observation period, and this correlated with a decrease in unplanned readmissions. Bleeding-related readmission was a rare event in this analysis and did not significantly increase over time, according to Dr. Wylie.
The risk assessment tool, developed by a multispecialty team at Intermountain Healthcare, was based on a review of hundreds of published papers and guidelines, according to Nathan Momberger, MD, who is the associate medical director of total joint replacement at Intermountain and was a coauthor on this study. A member of the team that developed the risk assessment tool, Dr. Momberger noted that new risk score was developed at a time when clinicians have been moving quickly away from warfarin to direct oral anticoagulants.
“None of our surgeons were using the same VTE prophylaxis when we started this project,” Dr. Momberger said. This was a motivation for developing a systemwide approach. In the 22 participating hospitals, there were 50 surgeons performing total knee arthroplasty and 40 surgeons were performing total hip surgery at the time the new protocol was introduced.
Further analyses will provide a more detailed analysis of the effect of the protocol on other thrombotic events, including deep vein thrombosis, and on cost. Since these data were analyzed, protocol adoption has increased and now exceeds 80%, according to Dr. Wylie.
Although a standardized approach to VTE prophylaxis following total joint arthroplasty is attractive, the ideal strategy remains controversial, according to Sunny Parikh, MD, an orthopedic surgeon affiliated with Colchester (England) General Hospital.
As a coauthor of a recent study that quantified symptomatic VTE rates at his and a neighboring hospital over a 3-year period (BMC Musculoskelet Disord. 2020;21:95), Dr. Parikh reported that VTE rates did not reach zero even with a prolonged course of the low-molecular-weight heparin enoxaparin.
At 90 days, the symptomatic VTE rate was only 0.3% for total knee arthroplasty but reached 1.2% for total hip arthroplasty.
“At the time of this study we were using enoxaparin for 28 days following total hip replacements and for 14 days following total knee replacements,” Dr. Parikh reported. Since this study, his institution has switched to a regimen recommended by the U.K.’s National Institute for Health and Clinical Excellence (NICE).
Under the NICE guidelines, VTE prophylaxis for total hip arthroplasty is 40 mg enoxaparin once daily for 14 days followed by 75 mg aspirin for another 14 days, according to Dr. Parikh. For total knee arthroplasty, the standard regimen is 75 mg aspirin for 14 days.
For those who might not be best managed with the standard approach, “there is no clear guideline.” Rather, in patients with renal or liver impairment, “we discuss the case with the hematology team to adjust the doses,” Dr. Parikh reported.
The advantage of a standardized approach applied to all or most patients is that is eliminates disparities, but Dr. Parikh agreed that risk-adjusted prophylaxis might be warranted for optimal outcomes.
Dr. Wylie reported a financial relationship with Arthrex.
A simple tool to guide choice of antithrombotic therapy following total joint arthroplasty led to a reduction in pulmonary embolism (PE) after being introduced systemwide, according to a prospectively tracked evaluation of a large patient cohort. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“We developed a simplified scoring system for evaluating risk of thromboembolism and guiding prophylaxis that led to a significant reduction in events across a large integrated health care system,” reported James Wylie, MD, associate medical director for hip and knee preservation and orthopedic research at Intermountain Healthcare, Salt Lake City, Utah.
The goal of the methodology was to create a uniform and evidence-based approach to risk assessment in order to guide selection of appropriate venous thromboembolism (VTE) prophylaxis. The tool takes into account the need to individualize antithrombotic drugs for risk of both VTE and for bleeding.
“VTE is a major threat following total joint replacement, but not all patients require anticoagulants. Recent evidence supports a shift to aspirin for low-risk patients,” explained Dr. Wylie in an interview.
The risk tool assigns points for such factors as history of VTE, older age, history of coronary artery disease, history of cancer, and increased body mass index. There are two possible ratings to guide strategies. Those with standard risk are candidates for 81 mg of aspirin twice daily. Those with high risk are candidates for 2.5 mg of apixaban, also administered twice daily. Custom dosing of warfarin is an alternative for the latter group. Regardless of strategy, prophylaxis is administered for 30 days following arthroplasty
“The risk score is calculated automatically, because you have to click a box in the electronic medical record for all of those factors as part of admission orders,” Dr. Wylie said.
The protocol was introduced in July 2017 and adoption was tracked prospectively over 18 months. In an evaluable cohort of 20,284 patients, PE rates in the 71% of patients adherent to the protocol were compared with the 29% who were not.
Over the observation period, the rates of PE were 0.34% and 0.62% (P = .004) for those adherent and nonadherent, respectively. The rate of unplanned readmissions and death, which were secondary outcomes, were both numerically lower in the group treated by adherent surgeons, but the differences did not reach statistical significance.
Adoption of the protocol by surgeons did increase over the course of the observation period, and this correlated with a decrease in unplanned readmissions. Bleeding-related readmission was a rare event in this analysis and did not significantly increase over time, according to Dr. Wylie.
The risk assessment tool, developed by a multispecialty team at Intermountain Healthcare, was based on a review of hundreds of published papers and guidelines, according to Nathan Momberger, MD, who is the associate medical director of total joint replacement at Intermountain and was a coauthor on this study. A member of the team that developed the risk assessment tool, Dr. Momberger noted that new risk score was developed at a time when clinicians have been moving quickly away from warfarin to direct oral anticoagulants.
“None of our surgeons were using the same VTE prophylaxis when we started this project,” Dr. Momberger said. This was a motivation for developing a systemwide approach. In the 22 participating hospitals, there were 50 surgeons performing total knee arthroplasty and 40 surgeons were performing total hip surgery at the time the new protocol was introduced.
Further analyses will provide a more detailed analysis of the effect of the protocol on other thrombotic events, including deep vein thrombosis, and on cost. Since these data were analyzed, protocol adoption has increased and now exceeds 80%, according to Dr. Wylie.
Although a standardized approach to VTE prophylaxis following total joint arthroplasty is attractive, the ideal strategy remains controversial, according to Sunny Parikh, MD, an orthopedic surgeon affiliated with Colchester (England) General Hospital.
As a coauthor of a recent study that quantified symptomatic VTE rates at his and a neighboring hospital over a 3-year period (BMC Musculoskelet Disord. 2020;21:95), Dr. Parikh reported that VTE rates did not reach zero even with a prolonged course of the low-molecular-weight heparin enoxaparin.
At 90 days, the symptomatic VTE rate was only 0.3% for total knee arthroplasty but reached 1.2% for total hip arthroplasty.
“At the time of this study we were using enoxaparin for 28 days following total hip replacements and for 14 days following total knee replacements,” Dr. Parikh reported. Since this study, his institution has switched to a regimen recommended by the U.K.’s National Institute for Health and Clinical Excellence (NICE).
Under the NICE guidelines, VTE prophylaxis for total hip arthroplasty is 40 mg enoxaparin once daily for 14 days followed by 75 mg aspirin for another 14 days, according to Dr. Parikh. For total knee arthroplasty, the standard regimen is 75 mg aspirin for 14 days.
For those who might not be best managed with the standard approach, “there is no clear guideline.” Rather, in patients with renal or liver impairment, “we discuss the case with the hematology team to adjust the doses,” Dr. Parikh reported.
The advantage of a standardized approach applied to all or most patients is that is eliminates disparities, but Dr. Parikh agreed that risk-adjusted prophylaxis might be warranted for optimal outcomes.
Dr. Wylie reported a financial relationship with Arthrex.
REPORTING FROM AAOS 2020
Robotic and manual total knee arthroplasty found at least comparable
When results in a series of robotic-assisted total knee arthroplasties (TKA) were compared with a series of arthroplasties performed manually by the same surgeon, results were comparable even though the robotic procedures included a learning phase. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“Robotics appears to level the playing field for those who are less experienced, so that robotic total knee arthroplasty might be particularly well suited to low-volume surgeons,” reported Sridhar R. Rachala, MD, assistant professor of orthopaedic surgery, University of Buffalo (N.Y.).
In this retrospective cohort study, radiographic and clinical outcomes were evaluated in 164 total knee arthroplasties performed manually over an 8-month period and compared with 300 procedures performed robotically by the same experienced surgeon over the subsequent 15-month period.
There were no significant differences between patient groups for mean age or body mass index. Dr. Rachala, who performed both sets of procedures, reported inherent differences in technique. Specifically, the mechanical alignment was planned for a traditional neutral mechanical axis, while the robotic procedures were planned in kinematic alignment.
When evaluated at 1 year, the mean KOOS JR (Knee Injury and Osteoarthritis Outcome for Joint Replacement) scores were not significantly different for the robotic and manually performed procedures (76.0 vs. 73.9; P = .54). There were also no differences in the final extension (P = .64) or flexion (P = .59).
However, the difference in mean length of stay (2.0 vs. 2.4 days; P = .0002) favored the robotic approach, and the higher proportion of patients discharged to home after robotic surgery (73% vs. 66%; P = .11) suggested a favorable trend. Planned and postoperative alignment was within two degrees for both groups and not significantly different.
“The robotic series were at a disadvantage because it included cases that I performed when first switching to this approach,” reported Dr. Rachala in an interview.
Although a growing number of total hip arthroplasties are performed robotically, there have not so far been many comparisons of clinical outcomes among surgeons experienced with both approaches, according to Dr. Rachala. Acknowledging that a single-surgeon experience could be considered a limitation of this series, Dr. Rachala also considers it a potential strength. Dr. Rachala was highly experienced with manually instrumented total knee arthroplasty when he switched.
“Positioning and alignment are not just more accurate but easier to perform with robotic assistance,” he said, explaining why this approach is likely to offer a particular advantage to surgeons who perform these types of arthroplasties at low volume. He noted that robotic programming helps prevent errors and adopt alternative more personalized alignments.
Although Dr. Rachala acknowledged that long-term and controlled studies are needed, his experience suggests that robotic-assisted procedures are emerging as a viable alternative with advantages for the surgeon as well as the patient.
The principle that robotic assistance can add consistency to total joint arthroplasty is valid, according to Gwo-Chin Lee, MD, an associate professor of orthopaedic surgery, University of Pennsylvania, Philadelphia. “Robotic-assisted arthroplasty improves the accuracy and consistency of the procedure, which can potentially reduce the likelihood of failure. In knees, it is proven to be valuable in unicompartmental replacements in which results are correlated to a surgeon’s surgical volume. It has an equalizing effect relative to a surgeon with more extensive experience,” Dr. Lee said.
The senior author of a recent systematic review and meta-analysis of robotic-assisted unicompartmental knee arthroplasty (J Knee Surg. 2020 Jan 30; doi: 10.1055/s-0040-1701455), Dr. Lee said, “While the impact of robotics on other metrics including patient satisfaction and early recovery continues to be debated among surgeons who specialize in total knee arthroplasties, the technology can aid surgeons in component position, sizing, and ligament balance, particularly for the lower-volume surgeons and ultimately lead to more predictable outcomes.”
Dr. Rachala reports a financial relationship with Avanos and Stryker.
SOURCE: Rachala S et al. AAOS 2020. Abstract P0091.
When results in a series of robotic-assisted total knee arthroplasties (TKA) were compared with a series of arthroplasties performed manually by the same surgeon, results were comparable even though the robotic procedures included a learning phase. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“Robotics appears to level the playing field for those who are less experienced, so that robotic total knee arthroplasty might be particularly well suited to low-volume surgeons,” reported Sridhar R. Rachala, MD, assistant professor of orthopaedic surgery, University of Buffalo (N.Y.).
In this retrospective cohort study, radiographic and clinical outcomes were evaluated in 164 total knee arthroplasties performed manually over an 8-month period and compared with 300 procedures performed robotically by the same experienced surgeon over the subsequent 15-month period.
There were no significant differences between patient groups for mean age or body mass index. Dr. Rachala, who performed both sets of procedures, reported inherent differences in technique. Specifically, the mechanical alignment was planned for a traditional neutral mechanical axis, while the robotic procedures were planned in kinematic alignment.
When evaluated at 1 year, the mean KOOS JR (Knee Injury and Osteoarthritis Outcome for Joint Replacement) scores were not significantly different for the robotic and manually performed procedures (76.0 vs. 73.9; P = .54). There were also no differences in the final extension (P = .64) or flexion (P = .59).
However, the difference in mean length of stay (2.0 vs. 2.4 days; P = .0002) favored the robotic approach, and the higher proportion of patients discharged to home after robotic surgery (73% vs. 66%; P = .11) suggested a favorable trend. Planned and postoperative alignment was within two degrees for both groups and not significantly different.
“The robotic series were at a disadvantage because it included cases that I performed when first switching to this approach,” reported Dr. Rachala in an interview.
Although a growing number of total hip arthroplasties are performed robotically, there have not so far been many comparisons of clinical outcomes among surgeons experienced with both approaches, according to Dr. Rachala. Acknowledging that a single-surgeon experience could be considered a limitation of this series, Dr. Rachala also considers it a potential strength. Dr. Rachala was highly experienced with manually instrumented total knee arthroplasty when he switched.
“Positioning and alignment are not just more accurate but easier to perform with robotic assistance,” he said, explaining why this approach is likely to offer a particular advantage to surgeons who perform these types of arthroplasties at low volume. He noted that robotic programming helps prevent errors and adopt alternative more personalized alignments.
Although Dr. Rachala acknowledged that long-term and controlled studies are needed, his experience suggests that robotic-assisted procedures are emerging as a viable alternative with advantages for the surgeon as well as the patient.
The principle that robotic assistance can add consistency to total joint arthroplasty is valid, according to Gwo-Chin Lee, MD, an associate professor of orthopaedic surgery, University of Pennsylvania, Philadelphia. “Robotic-assisted arthroplasty improves the accuracy and consistency of the procedure, which can potentially reduce the likelihood of failure. In knees, it is proven to be valuable in unicompartmental replacements in which results are correlated to a surgeon’s surgical volume. It has an equalizing effect relative to a surgeon with more extensive experience,” Dr. Lee said.
The senior author of a recent systematic review and meta-analysis of robotic-assisted unicompartmental knee arthroplasty (J Knee Surg. 2020 Jan 30; doi: 10.1055/s-0040-1701455), Dr. Lee said, “While the impact of robotics on other metrics including patient satisfaction and early recovery continues to be debated among surgeons who specialize in total knee arthroplasties, the technology can aid surgeons in component position, sizing, and ligament balance, particularly for the lower-volume surgeons and ultimately lead to more predictable outcomes.”
Dr. Rachala reports a financial relationship with Avanos and Stryker.
SOURCE: Rachala S et al. AAOS 2020. Abstract P0091.
When results in a series of robotic-assisted total knee arthroplasties (TKA) were compared with a series of arthroplasties performed manually by the same surgeon, results were comparable even though the robotic procedures included a learning phase. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“Robotics appears to level the playing field for those who are less experienced, so that robotic total knee arthroplasty might be particularly well suited to low-volume surgeons,” reported Sridhar R. Rachala, MD, assistant professor of orthopaedic surgery, University of Buffalo (N.Y.).
In this retrospective cohort study, radiographic and clinical outcomes were evaluated in 164 total knee arthroplasties performed manually over an 8-month period and compared with 300 procedures performed robotically by the same experienced surgeon over the subsequent 15-month period.
There were no significant differences between patient groups for mean age or body mass index. Dr. Rachala, who performed both sets of procedures, reported inherent differences in technique. Specifically, the mechanical alignment was planned for a traditional neutral mechanical axis, while the robotic procedures were planned in kinematic alignment.
When evaluated at 1 year, the mean KOOS JR (Knee Injury and Osteoarthritis Outcome for Joint Replacement) scores were not significantly different for the robotic and manually performed procedures (76.0 vs. 73.9; P = .54). There were also no differences in the final extension (P = .64) or flexion (P = .59).
However, the difference in mean length of stay (2.0 vs. 2.4 days; P = .0002) favored the robotic approach, and the higher proportion of patients discharged to home after robotic surgery (73% vs. 66%; P = .11) suggested a favorable trend. Planned and postoperative alignment was within two degrees for both groups and not significantly different.
“The robotic series were at a disadvantage because it included cases that I performed when first switching to this approach,” reported Dr. Rachala in an interview.
Although a growing number of total hip arthroplasties are performed robotically, there have not so far been many comparisons of clinical outcomes among surgeons experienced with both approaches, according to Dr. Rachala. Acknowledging that a single-surgeon experience could be considered a limitation of this series, Dr. Rachala also considers it a potential strength. Dr. Rachala was highly experienced with manually instrumented total knee arthroplasty when he switched.
“Positioning and alignment are not just more accurate but easier to perform with robotic assistance,” he said, explaining why this approach is likely to offer a particular advantage to surgeons who perform these types of arthroplasties at low volume. He noted that robotic programming helps prevent errors and adopt alternative more personalized alignments.
Although Dr. Rachala acknowledged that long-term and controlled studies are needed, his experience suggests that robotic-assisted procedures are emerging as a viable alternative with advantages for the surgeon as well as the patient.
The principle that robotic assistance can add consistency to total joint arthroplasty is valid, according to Gwo-Chin Lee, MD, an associate professor of orthopaedic surgery, University of Pennsylvania, Philadelphia. “Robotic-assisted arthroplasty improves the accuracy and consistency of the procedure, which can potentially reduce the likelihood of failure. In knees, it is proven to be valuable in unicompartmental replacements in which results are correlated to a surgeon’s surgical volume. It has an equalizing effect relative to a surgeon with more extensive experience,” Dr. Lee said.
The senior author of a recent systematic review and meta-analysis of robotic-assisted unicompartmental knee arthroplasty (J Knee Surg. 2020 Jan 30; doi: 10.1055/s-0040-1701455), Dr. Lee said, “While the impact of robotics on other metrics including patient satisfaction and early recovery continues to be debated among surgeons who specialize in total knee arthroplasties, the technology can aid surgeons in component position, sizing, and ligament balance, particularly for the lower-volume surgeons and ultimately lead to more predictable outcomes.”
Dr. Rachala reports a financial relationship with Avanos and Stryker.
SOURCE: Rachala S et al. AAOS 2020. Abstract P0091.
FROM aaos 2020
DOACs linked to lower fracture risk versus warfarin in AFib patients
results of a recent population-based cohort study show.
The choice of direct oral anticoagulant (DOAC) didn’t appear to have an impact, as each individual agent yielded a substantially lower risk of fracture versus the vitamin K antagonist, with risk reductions ranging from 38% to 48%, according to the study authors.
This is one of the latest reports to suggest DOACs could have an edge over warfarin for preventing fractures, providing new evidence that “may help inform the benefit risk assessment” when it comes to choosing an anticoagulant for a patient with atrial fibrillation (AFib) in the clinic, wrote the authors, led by Wallis C.Y. Lau, PhD, with the University College London.
“There exists a compelling case for evaluating whether the risk for osteoporotic fractures should be considered at the point of prescribing an oral anticoagulant to minimize fracture risk,” Dr. Lau and coauthors wrote in a report on the study that appears in Annals of Internal Medicine.
The case is especially compelling since fracture risk is “often neglected” when choosing an anticoagulant, the authors wrote. Surgeries to treat fracture are difficult because of the need for perioperative management of anticoagulation as “a balance between the risk for stroke and excessive bleeding must be achieved,” they added.
Based on these data, physicians should strongly consider DOACs as an alternative to vitamin K antagonists to reduce the risk of osteoporosis over the long term in patients with AFib, according to Victor Lawrence Roberts, MD, a Florida endocrinologist.
“Osteoporosis takes years, sometimes decades to develop, and if you then overlay warfarin on top of a readily evolving metabolic bone disease, you probably accelerate that process, said Dr. Roberts, professor of internal medicine at the University of Central Florida, Orlando, and editorial advisory board member of Internal Medicine News.
There’s a considerable amount of concerning preclinical data that warfarin could increase osteoporotic fracture risk. Of note, vitamin K antagonists modulate osteocalcin, a calcium-binding bone matrix protein, Dr. Roberts said.
“Osteocalcin is important for bone metabolism and health, and inhibiting osteocalcin will inhibit the ability to have a healthy bone matrix,” he explained.
The impact of anticoagulants on fracture risk is particularly relevant to patients with AFib, according to Dr. Lau and colleagues, who referenced one 2017 report showing a higher incidence of hip fracture among AFib patients versus those without AFib.
In their more recent study, Dr. Lau and colleagues reviewed electronic health records in a Hong Kong database for 23,515 older adults with a new diagnosis of AFib who received a new prescription of warfarin or DOACs including apixaban, dabigatran, or rivaroxaban.
DOAC use was consistently associated with a lower risk of osteoporotic fractures versus warfarin, regardless of the DOAC considered. The hazard ratios were 0.62 (95% confidence interval, 0.41-0.94) for apixaban, 0.65 (95% CI, 0.49-0.86) for dabigatran, and 0.52 (95% CI, 0.37-0.73) for rivaroxaban versus warfarin, the report showed.
Head-to-head comparisons between DOACS didn’t yield any statistically significant differences, though the analyses were underpowered in this respect, according to the investigators.
“This study can only rule out more than a twofold higher or a 50% lower relative risk for osteoporotic fractures between individual DOACs,” they wrote. “However, any absolute risk differences were small and would likely be of minor clinical significance.”
The reduced risk of fracture for DOACs versus warfarin was consistent in men and women with AFib, suggesting that women may particularly benefit from DOACs, given that they have a higher risk of fracture than men, the investigators added.
The results of this study suggest yet another benefit of DOACs over warfarin in patients with AFib, according to internist Noel Deep, MD, who is the chief medical officer of Aspirus Langlade Hospital in Antigo, Wisconsin.
“The lower risk of osteoporotic fractures with DOACS, in addition to other advantages such as lower risk of intracranial bleeding, once- or twice-daily consistent dosing, no dietary restrictions, and no blood tests to regulate the dose might be another reason that physicians may favor them over warfarin in older individuals requiring anticoagulation,” Dr. Deep said in an interview.
Results of this and several other recent studies may help in recommending DOACs to internal medicine patients who have a diagnosis of AFib requiring anticoagulation, according to Dr. Deep, who is also a physician at Aspirus Antigo Clinic and a member of Internal Medicine News’ editorial advisory board. These include a 2019 U.S.-based study of more than 167,000 patients with AFib (JAMA Intern Med. 2019;180[2]:245‐253) showing that use of DOACs, particularly apixaban, were linked to lower fracture risk versus warfarin use. Similarly, a Danish national registry study also published in 2019 showed that the absolute risk of osteoporotic fractures was low overall and significantly lower in patients who received DOACs (J Am Coll Cardiol. 2019;74[17]:2150-2158).
Funding for the study came from the University of Hong Kong and University College London Strategic Planning Fund. The study authors reported disclosures related to Bayer, Bristol-Myers Squibb, Pfizer, Janssen, Amgen, Takeda, IQVIA, and others.
SOURCE: Lau WCY et al. Ann Intern Med. 2020 May 18. doi: 10.7326/M19-3671.
results of a recent population-based cohort study show.
The choice of direct oral anticoagulant (DOAC) didn’t appear to have an impact, as each individual agent yielded a substantially lower risk of fracture versus the vitamin K antagonist, with risk reductions ranging from 38% to 48%, according to the study authors.
This is one of the latest reports to suggest DOACs could have an edge over warfarin for preventing fractures, providing new evidence that “may help inform the benefit risk assessment” when it comes to choosing an anticoagulant for a patient with atrial fibrillation (AFib) in the clinic, wrote the authors, led by Wallis C.Y. Lau, PhD, with the University College London.
“There exists a compelling case for evaluating whether the risk for osteoporotic fractures should be considered at the point of prescribing an oral anticoagulant to minimize fracture risk,” Dr. Lau and coauthors wrote in a report on the study that appears in Annals of Internal Medicine.
The case is especially compelling since fracture risk is “often neglected” when choosing an anticoagulant, the authors wrote. Surgeries to treat fracture are difficult because of the need for perioperative management of anticoagulation as “a balance between the risk for stroke and excessive bleeding must be achieved,” they added.
Based on these data, physicians should strongly consider DOACs as an alternative to vitamin K antagonists to reduce the risk of osteoporosis over the long term in patients with AFib, according to Victor Lawrence Roberts, MD, a Florida endocrinologist.
“Osteoporosis takes years, sometimes decades to develop, and if you then overlay warfarin on top of a readily evolving metabolic bone disease, you probably accelerate that process, said Dr. Roberts, professor of internal medicine at the University of Central Florida, Orlando, and editorial advisory board member of Internal Medicine News.
There’s a considerable amount of concerning preclinical data that warfarin could increase osteoporotic fracture risk. Of note, vitamin K antagonists modulate osteocalcin, a calcium-binding bone matrix protein, Dr. Roberts said.
“Osteocalcin is important for bone metabolism and health, and inhibiting osteocalcin will inhibit the ability to have a healthy bone matrix,” he explained.
The impact of anticoagulants on fracture risk is particularly relevant to patients with AFib, according to Dr. Lau and colleagues, who referenced one 2017 report showing a higher incidence of hip fracture among AFib patients versus those without AFib.
In their more recent study, Dr. Lau and colleagues reviewed electronic health records in a Hong Kong database for 23,515 older adults with a new diagnosis of AFib who received a new prescription of warfarin or DOACs including apixaban, dabigatran, or rivaroxaban.
DOAC use was consistently associated with a lower risk of osteoporotic fractures versus warfarin, regardless of the DOAC considered. The hazard ratios were 0.62 (95% confidence interval, 0.41-0.94) for apixaban, 0.65 (95% CI, 0.49-0.86) for dabigatran, and 0.52 (95% CI, 0.37-0.73) for rivaroxaban versus warfarin, the report showed.
Head-to-head comparisons between DOACS didn’t yield any statistically significant differences, though the analyses were underpowered in this respect, according to the investigators.
“This study can only rule out more than a twofold higher or a 50% lower relative risk for osteoporotic fractures between individual DOACs,” they wrote. “However, any absolute risk differences were small and would likely be of minor clinical significance.”
The reduced risk of fracture for DOACs versus warfarin was consistent in men and women with AFib, suggesting that women may particularly benefit from DOACs, given that they have a higher risk of fracture than men, the investigators added.
The results of this study suggest yet another benefit of DOACs over warfarin in patients with AFib, according to internist Noel Deep, MD, who is the chief medical officer of Aspirus Langlade Hospital in Antigo, Wisconsin.
“The lower risk of osteoporotic fractures with DOACS, in addition to other advantages such as lower risk of intracranial bleeding, once- or twice-daily consistent dosing, no dietary restrictions, and no blood tests to regulate the dose might be another reason that physicians may favor them over warfarin in older individuals requiring anticoagulation,” Dr. Deep said in an interview.
Results of this and several other recent studies may help in recommending DOACs to internal medicine patients who have a diagnosis of AFib requiring anticoagulation, according to Dr. Deep, who is also a physician at Aspirus Antigo Clinic and a member of Internal Medicine News’ editorial advisory board. These include a 2019 U.S.-based study of more than 167,000 patients with AFib (JAMA Intern Med. 2019;180[2]:245‐253) showing that use of DOACs, particularly apixaban, were linked to lower fracture risk versus warfarin use. Similarly, a Danish national registry study also published in 2019 showed that the absolute risk of osteoporotic fractures was low overall and significantly lower in patients who received DOACs (J Am Coll Cardiol. 2019;74[17]:2150-2158).
Funding for the study came from the University of Hong Kong and University College London Strategic Planning Fund. The study authors reported disclosures related to Bayer, Bristol-Myers Squibb, Pfizer, Janssen, Amgen, Takeda, IQVIA, and others.
SOURCE: Lau WCY et al. Ann Intern Med. 2020 May 18. doi: 10.7326/M19-3671.
results of a recent population-based cohort study show.
The choice of direct oral anticoagulant (DOAC) didn’t appear to have an impact, as each individual agent yielded a substantially lower risk of fracture versus the vitamin K antagonist, with risk reductions ranging from 38% to 48%, according to the study authors.
This is one of the latest reports to suggest DOACs could have an edge over warfarin for preventing fractures, providing new evidence that “may help inform the benefit risk assessment” when it comes to choosing an anticoagulant for a patient with atrial fibrillation (AFib) in the clinic, wrote the authors, led by Wallis C.Y. Lau, PhD, with the University College London.
“There exists a compelling case for evaluating whether the risk for osteoporotic fractures should be considered at the point of prescribing an oral anticoagulant to minimize fracture risk,” Dr. Lau and coauthors wrote in a report on the study that appears in Annals of Internal Medicine.
The case is especially compelling since fracture risk is “often neglected” when choosing an anticoagulant, the authors wrote. Surgeries to treat fracture are difficult because of the need for perioperative management of anticoagulation as “a balance between the risk for stroke and excessive bleeding must be achieved,” they added.
Based on these data, physicians should strongly consider DOACs as an alternative to vitamin K antagonists to reduce the risk of osteoporosis over the long term in patients with AFib, according to Victor Lawrence Roberts, MD, a Florida endocrinologist.
“Osteoporosis takes years, sometimes decades to develop, and if you then overlay warfarin on top of a readily evolving metabolic bone disease, you probably accelerate that process, said Dr. Roberts, professor of internal medicine at the University of Central Florida, Orlando, and editorial advisory board member of Internal Medicine News.
There’s a considerable amount of concerning preclinical data that warfarin could increase osteoporotic fracture risk. Of note, vitamin K antagonists modulate osteocalcin, a calcium-binding bone matrix protein, Dr. Roberts said.
“Osteocalcin is important for bone metabolism and health, and inhibiting osteocalcin will inhibit the ability to have a healthy bone matrix,” he explained.
The impact of anticoagulants on fracture risk is particularly relevant to patients with AFib, according to Dr. Lau and colleagues, who referenced one 2017 report showing a higher incidence of hip fracture among AFib patients versus those without AFib.
In their more recent study, Dr. Lau and colleagues reviewed electronic health records in a Hong Kong database for 23,515 older adults with a new diagnosis of AFib who received a new prescription of warfarin or DOACs including apixaban, dabigatran, or rivaroxaban.
DOAC use was consistently associated with a lower risk of osteoporotic fractures versus warfarin, regardless of the DOAC considered. The hazard ratios were 0.62 (95% confidence interval, 0.41-0.94) for apixaban, 0.65 (95% CI, 0.49-0.86) for dabigatran, and 0.52 (95% CI, 0.37-0.73) for rivaroxaban versus warfarin, the report showed.
Head-to-head comparisons between DOACS didn’t yield any statistically significant differences, though the analyses were underpowered in this respect, according to the investigators.
“This study can only rule out more than a twofold higher or a 50% lower relative risk for osteoporotic fractures between individual DOACs,” they wrote. “However, any absolute risk differences were small and would likely be of minor clinical significance.”
The reduced risk of fracture for DOACs versus warfarin was consistent in men and women with AFib, suggesting that women may particularly benefit from DOACs, given that they have a higher risk of fracture than men, the investigators added.
The results of this study suggest yet another benefit of DOACs over warfarin in patients with AFib, according to internist Noel Deep, MD, who is the chief medical officer of Aspirus Langlade Hospital in Antigo, Wisconsin.
“The lower risk of osteoporotic fractures with DOACS, in addition to other advantages such as lower risk of intracranial bleeding, once- or twice-daily consistent dosing, no dietary restrictions, and no blood tests to regulate the dose might be another reason that physicians may favor them over warfarin in older individuals requiring anticoagulation,” Dr. Deep said in an interview.
Results of this and several other recent studies may help in recommending DOACs to internal medicine patients who have a diagnosis of AFib requiring anticoagulation, according to Dr. Deep, who is also a physician at Aspirus Antigo Clinic and a member of Internal Medicine News’ editorial advisory board. These include a 2019 U.S.-based study of more than 167,000 patients with AFib (JAMA Intern Med. 2019;180[2]:245‐253) showing that use of DOACs, particularly apixaban, were linked to lower fracture risk versus warfarin use. Similarly, a Danish national registry study also published in 2019 showed that the absolute risk of osteoporotic fractures was low overall and significantly lower in patients who received DOACs (J Am Coll Cardiol. 2019;74[17]:2150-2158).
Funding for the study came from the University of Hong Kong and University College London Strategic Planning Fund. The study authors reported disclosures related to Bayer, Bristol-Myers Squibb, Pfizer, Janssen, Amgen, Takeda, IQVIA, and others.
SOURCE: Lau WCY et al. Ann Intern Med. 2020 May 18. doi: 10.7326/M19-3671.
FROM ANNALS OF INTERNAL MEDICINE
Hydrogen peroxide reduces C. acnes cultures following shoulder surgery
Prior to shoulder surgery, application of 3% hydrogen peroxide is a simple and inexpensive strategy to reduce the risk of postoperative cultures of Cutibacterium acnes, according to findings from a prospective randomized trial. The results were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“This approach is simple, cheap, and does not rely on patient compliance,” explained Surena Namdari, MD, associate professor of orthopedic surgery at Thomas Jefferson University, Philadelphia.
C. acnes, formerly known as Propionibacterium acnes, is increasingly seen as an important target for prevention of postoperative shoulder infections because of published reports that it is the most commonly isolated bacterium from such infections, Dr. Namdari said in an interview.
In the prospective, randomized trial, male patients scheduled for shoulder arthroscopy were recruited if they did not have active acne, history of psoriatic or eczematous lesions, or recent antibiotic use. Most of the preoperative preparation of the surgical site was the same in the experimental and control arms. This included hair clipping, application of 2% chlorhexidine, and cleansing with saturated 7.5% povidone-iodine solution surgical scrub brushes.
The difference was that 3% hydrogen peroxide–soaked gauzes were applied to perioperative skin of those randomized to the experimental group but not to controls. All patients received routine preoperative oral antibiotics as well as perioperative applications of a formulation containing 2% chlorhexidine gluconate and 70% isopropyl alcohol.
Following surgery, 11 (18.6%) of the 59 patients in the experimental arm versus 23 (34.8%) of the 66 patients randomized to the control group had positive cultures for C. acnes (P = .047), according to the trial results, which have now been published (J Shoulder Elbow Surg. 2020;29:212-6).
There were no cases of skin reactions in either the experimental or control groups.
Topical skin cleansers that contain peroxide, such as benzoyl peroxide, have been shown to have a C. acnes decolonizing effect if applied repeatedly in the days prior to surgery, but Dr. Namdari suggested the problem with this approach is that it depends on patient compliance. A prophylaxis included in the preoperative routine eliminates this potential problem.
C. acnes is an anaerobic bacterium that is part of the resident flora of the skin around several joints, including the knee and the hip, but it is particularly common in the posterior shoulder. Colonization has been found substantially more common in men than in women, according to Dr. Namdari.
The specific threat posed by C. acnes to risk of postoperative infections “is still being defined,” and this trial was not large enough to associate the reduction in postoperative C. acnes cultures with a reduced risk of an adverse clinical outcome, but Dr. Namdari says that the data do show that the nearly 50% reduction in positive cultures was achieved efficiently and inexpensively with no apparent risk.
Several previous studies have also evaluated strategies for reducing C. acnes skin burden on the basis of expected protection against postoperative infection. In one, which associated a 3-day preoperative course of benzoyl peroxide with a reduction in the skin burden of C. acnes, the authors also concluded that this approach deserves consideration in routine skin preparation for shoulder arthroplasty (J Shoulder Elbow Surg. 2018;27:1539-44).
“We believe that a preoperative skin prep protocol that reduces C. acnes load on the skin would likely lead to reduced postoperative infections,” reported the senior author, Mohit N. Gilotra, MD, assistant professor, University of Maryland, Baltimore. Contacted about the rationale for reducing C. acnes skin burden without objective evidence of an impact on postoperative infection risk, Dr. Gilotra indicated these strategies make sense.
“It seems to be true for staph infections and is a reasonable assumption to make here,” he added. “Future work will help determine how much benzoyl peroxide, hydrogen peroxide, or other skin prep can reduce surgical site infection.”
Dr. Namdari reports financial relationships with multiple device and pharmaceutical companies but none relevant to this study.
SOURCE: Namdari S et al. AAOS 2020. Abstract P0808.
Prior to shoulder surgery, application of 3% hydrogen peroxide is a simple and inexpensive strategy to reduce the risk of postoperative cultures of Cutibacterium acnes, according to findings from a prospective randomized trial. The results were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“This approach is simple, cheap, and does not rely on patient compliance,” explained Surena Namdari, MD, associate professor of orthopedic surgery at Thomas Jefferson University, Philadelphia.
C. acnes, formerly known as Propionibacterium acnes, is increasingly seen as an important target for prevention of postoperative shoulder infections because of published reports that it is the most commonly isolated bacterium from such infections, Dr. Namdari said in an interview.
In the prospective, randomized trial, male patients scheduled for shoulder arthroscopy were recruited if they did not have active acne, history of psoriatic or eczematous lesions, or recent antibiotic use. Most of the preoperative preparation of the surgical site was the same in the experimental and control arms. This included hair clipping, application of 2% chlorhexidine, and cleansing with saturated 7.5% povidone-iodine solution surgical scrub brushes.
The difference was that 3% hydrogen peroxide–soaked gauzes were applied to perioperative skin of those randomized to the experimental group but not to controls. All patients received routine preoperative oral antibiotics as well as perioperative applications of a formulation containing 2% chlorhexidine gluconate and 70% isopropyl alcohol.
Following surgery, 11 (18.6%) of the 59 patients in the experimental arm versus 23 (34.8%) of the 66 patients randomized to the control group had positive cultures for C. acnes (P = .047), according to the trial results, which have now been published (J Shoulder Elbow Surg. 2020;29:212-6).
There were no cases of skin reactions in either the experimental or control groups.
Topical skin cleansers that contain peroxide, such as benzoyl peroxide, have been shown to have a C. acnes decolonizing effect if applied repeatedly in the days prior to surgery, but Dr. Namdari suggested the problem with this approach is that it depends on patient compliance. A prophylaxis included in the preoperative routine eliminates this potential problem.
C. acnes is an anaerobic bacterium that is part of the resident flora of the skin around several joints, including the knee and the hip, but it is particularly common in the posterior shoulder. Colonization has been found substantially more common in men than in women, according to Dr. Namdari.
The specific threat posed by C. acnes to risk of postoperative infections “is still being defined,” and this trial was not large enough to associate the reduction in postoperative C. acnes cultures with a reduced risk of an adverse clinical outcome, but Dr. Namdari says that the data do show that the nearly 50% reduction in positive cultures was achieved efficiently and inexpensively with no apparent risk.
Several previous studies have also evaluated strategies for reducing C. acnes skin burden on the basis of expected protection against postoperative infection. In one, which associated a 3-day preoperative course of benzoyl peroxide with a reduction in the skin burden of C. acnes, the authors also concluded that this approach deserves consideration in routine skin preparation for shoulder arthroplasty (J Shoulder Elbow Surg. 2018;27:1539-44).
“We believe that a preoperative skin prep protocol that reduces C. acnes load on the skin would likely lead to reduced postoperative infections,” reported the senior author, Mohit N. Gilotra, MD, assistant professor, University of Maryland, Baltimore. Contacted about the rationale for reducing C. acnes skin burden without objective evidence of an impact on postoperative infection risk, Dr. Gilotra indicated these strategies make sense.
“It seems to be true for staph infections and is a reasonable assumption to make here,” he added. “Future work will help determine how much benzoyl peroxide, hydrogen peroxide, or other skin prep can reduce surgical site infection.”
Dr. Namdari reports financial relationships with multiple device and pharmaceutical companies but none relevant to this study.
SOURCE: Namdari S et al. AAOS 2020. Abstract P0808.
Prior to shoulder surgery, application of 3% hydrogen peroxide is a simple and inexpensive strategy to reduce the risk of postoperative cultures of Cutibacterium acnes, according to findings from a prospective randomized trial. The results were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.
“This approach is simple, cheap, and does not rely on patient compliance,” explained Surena Namdari, MD, associate professor of orthopedic surgery at Thomas Jefferson University, Philadelphia.
C. acnes, formerly known as Propionibacterium acnes, is increasingly seen as an important target for prevention of postoperative shoulder infections because of published reports that it is the most commonly isolated bacterium from such infections, Dr. Namdari said in an interview.
In the prospective, randomized trial, male patients scheduled for shoulder arthroscopy were recruited if they did not have active acne, history of psoriatic or eczematous lesions, or recent antibiotic use. Most of the preoperative preparation of the surgical site was the same in the experimental and control arms. This included hair clipping, application of 2% chlorhexidine, and cleansing with saturated 7.5% povidone-iodine solution surgical scrub brushes.
The difference was that 3% hydrogen peroxide–soaked gauzes were applied to perioperative skin of those randomized to the experimental group but not to controls. All patients received routine preoperative oral antibiotics as well as perioperative applications of a formulation containing 2% chlorhexidine gluconate and 70% isopropyl alcohol.
Following surgery, 11 (18.6%) of the 59 patients in the experimental arm versus 23 (34.8%) of the 66 patients randomized to the control group had positive cultures for C. acnes (P = .047), according to the trial results, which have now been published (J Shoulder Elbow Surg. 2020;29:212-6).
There were no cases of skin reactions in either the experimental or control groups.
Topical skin cleansers that contain peroxide, such as benzoyl peroxide, have been shown to have a C. acnes decolonizing effect if applied repeatedly in the days prior to surgery, but Dr. Namdari suggested the problem with this approach is that it depends on patient compliance. A prophylaxis included in the preoperative routine eliminates this potential problem.
C. acnes is an anaerobic bacterium that is part of the resident flora of the skin around several joints, including the knee and the hip, but it is particularly common in the posterior shoulder. Colonization has been found substantially more common in men than in women, according to Dr. Namdari.
The specific threat posed by C. acnes to risk of postoperative infections “is still being defined,” and this trial was not large enough to associate the reduction in postoperative C. acnes cultures with a reduced risk of an adverse clinical outcome, but Dr. Namdari says that the data do show that the nearly 50% reduction in positive cultures was achieved efficiently and inexpensively with no apparent risk.
Several previous studies have also evaluated strategies for reducing C. acnes skin burden on the basis of expected protection against postoperative infection. In one, which associated a 3-day preoperative course of benzoyl peroxide with a reduction in the skin burden of C. acnes, the authors also concluded that this approach deserves consideration in routine skin preparation for shoulder arthroplasty (J Shoulder Elbow Surg. 2018;27:1539-44).
“We believe that a preoperative skin prep protocol that reduces C. acnes load on the skin would likely lead to reduced postoperative infections,” reported the senior author, Mohit N. Gilotra, MD, assistant professor, University of Maryland, Baltimore. Contacted about the rationale for reducing C. acnes skin burden without objective evidence of an impact on postoperative infection risk, Dr. Gilotra indicated these strategies make sense.
“It seems to be true for staph infections and is a reasonable assumption to make here,” he added. “Future work will help determine how much benzoyl peroxide, hydrogen peroxide, or other skin prep can reduce surgical site infection.”
Dr. Namdari reports financial relationships with multiple device and pharmaceutical companies but none relevant to this study.
SOURCE: Namdari S et al. AAOS 2020. Abstract P0808.
FROM AAOS 2020
Shoulder arthroplasty template data require careful interpretation
Proprietary templating software to guide the positioning of total shoulder arthroplasty (TSA) generate very different measures for inclination and version, according to a study that compared four programs and reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled due to COVID-19.
“It is not a question of one software being better than another. They are just different, and they are device specific,” reported Brent B. Wiesel, MD, chief of the shoulder service at the MedStar Georgetown Orthopaedic Institute, Washington.
The variations were substantial and clinically relevant, suggesting that surgeons need to be aware of these differences when switching between the devices, according to Dr. Wiesel. He said that there is no gold standard for positioning total shoulder arthroplasty, which prevents any conclusion about the superiority of one over the other.
In this study, 76 CT scans obtained from shoulders of patients with glenohumeral arthritis were analyzed for native glenoid version and inclination by the ArthrexVIP, Tornier BluePrint, Stryker TrueSight, and ExactechGPS software programs. Dr. Wiesel explained that these are among the most commonly used programs, but there are others.
After extracting the recommended version and inclination measures from each software program, agreement between measures was calculated with an analysis of variance (ANOVA) test. The variance across programs was highly significant for both native glenoid version and inclination (P < .001).
Inter-rater reliability of the software outputs analyzed with Krippendorff’s alpha, for which a value of 1.0 signals perfect agreement and a value of 0 signals complete disagreement, reinforced the discord. For the 76 scans, the values for version and inclination were 0.272 and 0.303, respectively. Both are extremely low.
“The suggested threshold for high reliability is a value of 0.8 or greater,” said Dr. Wiesel, who was contacted about these data after the AAOS annual meeting was canceled. “The lowest acceptable limit for reliability is 0.667 or greater.”
There was disagreement across all programs. The only agreement to reach an acceptable Krippendorff’s alpha was generated by the Tornier BluePrint and Stryker TrueSight programs. These programs modestly agreed on version (0.706 on the Krippendorff’s alpha), but agreement on inclination was below the acceptable threshold.
“In other words, if you take the same scan from the same patient, you will get different angles from these different templating software programs,” Dr. Wiesel said.
There are several messages from these data, according to Dr. Wiesel. In addition to demonstrating the programs generate outputs that do not agree, he suggested that the values provided by the programs should not be considered absolute. Rather, the software values should be interpreted in the context of the individual patient.
“It is easy to get lazy, but it is important to remember that the software is a tool rather than something that will do the procedure for you,” Dr. Wiesel said. He reported that when the software guidance is not consistent with his own experience, he proceeds cautiously.
“On several occasions when the software has provided measures that are not consistent with my own perception, I have not been happy when I went with the software,” he said. “So typically I go with my gut when there is a discrepancy, and the data from this study supports that.”
Because of the difficulty in creating a gold standard for templating when there are multiple variables that influence optimal positioning of components, Dr. Wiesel suggested that “crowd thinking” might eventually determine the values that produce the best results. By crowd thinking, he was referring to Big Data analysis, collating data from a large number of cases performed by a large number of surgeons.
“All of these software programs provide reasonable guidance, but each has different advantages and disadvantages, and it is important to be aware that they are different,” Dr. Wiesel reported.
There are differences in the templating software, and they should be taken into consideration, according to another expert who has looked at this issue. Senior author of a randomized trial evaluating planning strategies for total shoulder arthroplasty ( J Bone Joint Surg AM. 2019:101;446-57), Eric T. Ricchetti, MD, an orthopedic surgeon and director of the shoulder center at the Cleveland Clinic, offered a similar perspective on templating.
“I agree that surgeons should be familiar with the differences that exist in templating software,” Dr. Ricchetti said. Basing his remarks on his own experience and reiterating the conclusion of the AAOS study, he added, “the methods that are used to identify the bone anatomy of the shoulder can vary across software programs, potentially resulting in differences in subsequent measures of glenoid pathology, such as version and inclination, that may impact surgical decision making.”
Dr. Wiesel reports no potential conflicts of interest.
SOURCE: Wiesel B et al. AAOS 2020. Abstract 212.
Proprietary templating software to guide the positioning of total shoulder arthroplasty (TSA) generate very different measures for inclination and version, according to a study that compared four programs and reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled due to COVID-19.
“It is not a question of one software being better than another. They are just different, and they are device specific,” reported Brent B. Wiesel, MD, chief of the shoulder service at the MedStar Georgetown Orthopaedic Institute, Washington.
The variations were substantial and clinically relevant, suggesting that surgeons need to be aware of these differences when switching between the devices, according to Dr. Wiesel. He said that there is no gold standard for positioning total shoulder arthroplasty, which prevents any conclusion about the superiority of one over the other.
In this study, 76 CT scans obtained from shoulders of patients with glenohumeral arthritis were analyzed for native glenoid version and inclination by the ArthrexVIP, Tornier BluePrint, Stryker TrueSight, and ExactechGPS software programs. Dr. Wiesel explained that these are among the most commonly used programs, but there are others.
After extracting the recommended version and inclination measures from each software program, agreement between measures was calculated with an analysis of variance (ANOVA) test. The variance across programs was highly significant for both native glenoid version and inclination (P < .001).
Inter-rater reliability of the software outputs analyzed with Krippendorff’s alpha, for which a value of 1.0 signals perfect agreement and a value of 0 signals complete disagreement, reinforced the discord. For the 76 scans, the values for version and inclination were 0.272 and 0.303, respectively. Both are extremely low.
“The suggested threshold for high reliability is a value of 0.8 or greater,” said Dr. Wiesel, who was contacted about these data after the AAOS annual meeting was canceled. “The lowest acceptable limit for reliability is 0.667 or greater.”
There was disagreement across all programs. The only agreement to reach an acceptable Krippendorff’s alpha was generated by the Tornier BluePrint and Stryker TrueSight programs. These programs modestly agreed on version (0.706 on the Krippendorff’s alpha), but agreement on inclination was below the acceptable threshold.
“In other words, if you take the same scan from the same patient, you will get different angles from these different templating software programs,” Dr. Wiesel said.
There are several messages from these data, according to Dr. Wiesel. In addition to demonstrating the programs generate outputs that do not agree, he suggested that the values provided by the programs should not be considered absolute. Rather, the software values should be interpreted in the context of the individual patient.
“It is easy to get lazy, but it is important to remember that the software is a tool rather than something that will do the procedure for you,” Dr. Wiesel said. He reported that when the software guidance is not consistent with his own experience, he proceeds cautiously.
“On several occasions when the software has provided measures that are not consistent with my own perception, I have not been happy when I went with the software,” he said. “So typically I go with my gut when there is a discrepancy, and the data from this study supports that.”
Because of the difficulty in creating a gold standard for templating when there are multiple variables that influence optimal positioning of components, Dr. Wiesel suggested that “crowd thinking” might eventually determine the values that produce the best results. By crowd thinking, he was referring to Big Data analysis, collating data from a large number of cases performed by a large number of surgeons.
“All of these software programs provide reasonable guidance, but each has different advantages and disadvantages, and it is important to be aware that they are different,” Dr. Wiesel reported.
There are differences in the templating software, and they should be taken into consideration, according to another expert who has looked at this issue. Senior author of a randomized trial evaluating planning strategies for total shoulder arthroplasty ( J Bone Joint Surg AM. 2019:101;446-57), Eric T. Ricchetti, MD, an orthopedic surgeon and director of the shoulder center at the Cleveland Clinic, offered a similar perspective on templating.
“I agree that surgeons should be familiar with the differences that exist in templating software,” Dr. Ricchetti said. Basing his remarks on his own experience and reiterating the conclusion of the AAOS study, he added, “the methods that are used to identify the bone anatomy of the shoulder can vary across software programs, potentially resulting in differences in subsequent measures of glenoid pathology, such as version and inclination, that may impact surgical decision making.”
Dr. Wiesel reports no potential conflicts of interest.
SOURCE: Wiesel B et al. AAOS 2020. Abstract 212.
Proprietary templating software to guide the positioning of total shoulder arthroplasty (TSA) generate very different measures for inclination and version, according to a study that compared four programs and reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled due to COVID-19.
“It is not a question of one software being better than another. They are just different, and they are device specific,” reported Brent B. Wiesel, MD, chief of the shoulder service at the MedStar Georgetown Orthopaedic Institute, Washington.
The variations were substantial and clinically relevant, suggesting that surgeons need to be aware of these differences when switching between the devices, according to Dr. Wiesel. He said that there is no gold standard for positioning total shoulder arthroplasty, which prevents any conclusion about the superiority of one over the other.
In this study, 76 CT scans obtained from shoulders of patients with glenohumeral arthritis were analyzed for native glenoid version and inclination by the ArthrexVIP, Tornier BluePrint, Stryker TrueSight, and ExactechGPS software programs. Dr. Wiesel explained that these are among the most commonly used programs, but there are others.
After extracting the recommended version and inclination measures from each software program, agreement between measures was calculated with an analysis of variance (ANOVA) test. The variance across programs was highly significant for both native glenoid version and inclination (P < .001).
Inter-rater reliability of the software outputs analyzed with Krippendorff’s alpha, for which a value of 1.0 signals perfect agreement and a value of 0 signals complete disagreement, reinforced the discord. For the 76 scans, the values for version and inclination were 0.272 and 0.303, respectively. Both are extremely low.
“The suggested threshold for high reliability is a value of 0.8 or greater,” said Dr. Wiesel, who was contacted about these data after the AAOS annual meeting was canceled. “The lowest acceptable limit for reliability is 0.667 or greater.”
There was disagreement across all programs. The only agreement to reach an acceptable Krippendorff’s alpha was generated by the Tornier BluePrint and Stryker TrueSight programs. These programs modestly agreed on version (0.706 on the Krippendorff’s alpha), but agreement on inclination was below the acceptable threshold.
“In other words, if you take the same scan from the same patient, you will get different angles from these different templating software programs,” Dr. Wiesel said.
There are several messages from these data, according to Dr. Wiesel. In addition to demonstrating the programs generate outputs that do not agree, he suggested that the values provided by the programs should not be considered absolute. Rather, the software values should be interpreted in the context of the individual patient.
“It is easy to get lazy, but it is important to remember that the software is a tool rather than something that will do the procedure for you,” Dr. Wiesel said. He reported that when the software guidance is not consistent with his own experience, he proceeds cautiously.
“On several occasions when the software has provided measures that are not consistent with my own perception, I have not been happy when I went with the software,” he said. “So typically I go with my gut when there is a discrepancy, and the data from this study supports that.”
Because of the difficulty in creating a gold standard for templating when there are multiple variables that influence optimal positioning of components, Dr. Wiesel suggested that “crowd thinking” might eventually determine the values that produce the best results. By crowd thinking, he was referring to Big Data analysis, collating data from a large number of cases performed by a large number of surgeons.
“All of these software programs provide reasonable guidance, but each has different advantages and disadvantages, and it is important to be aware that they are different,” Dr. Wiesel reported.
There are differences in the templating software, and they should be taken into consideration, according to another expert who has looked at this issue. Senior author of a randomized trial evaluating planning strategies for total shoulder arthroplasty ( J Bone Joint Surg AM. 2019:101;446-57), Eric T. Ricchetti, MD, an orthopedic surgeon and director of the shoulder center at the Cleveland Clinic, offered a similar perspective on templating.
“I agree that surgeons should be familiar with the differences that exist in templating software,” Dr. Ricchetti said. Basing his remarks on his own experience and reiterating the conclusion of the AAOS study, he added, “the methods that are used to identify the bone anatomy of the shoulder can vary across software programs, potentially resulting in differences in subsequent measures of glenoid pathology, such as version and inclination, that may impact surgical decision making.”
Dr. Wiesel reports no potential conflicts of interest.
SOURCE: Wiesel B et al. AAOS 2020. Abstract 212.
FROM AAOS 2020
Hip hemiarthroplasty outcomes found better with cement vs. no cement
In older patients undergoing hemiarthroplasty for repair of a hip fracture, cemented fixation reduces the risk of aseptic revisions, according to a large retrospective cohort analysis reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled due to COVID-19.
“These data suggest surgeons should consider cemented over uncemented femoral stem fixation in the absence of contraindications,” reported Kanu M. Okike, MD, an orthopedic surgeon with the Hawaii Permanente Medical Group, Kaiser Moanalua Medical Center, Honolulu.
The finding was drawn from a cohort analysis conducted in the United States. Several studies conducted in Europe and elsewhere, including randomized trials, have also favored cement.
“Cemented fixation is becoming a standard of care for elderly individuals outside of the U.S., but this study was conducted to evaluate the U.S. experience,” explained Dr. Okike in an interview.
Citing 2018 American Joint Replacement Registry data, Dr. Okike reported that more than half of hemiarthroplasties in the United States are still being fixed without cement.
The retrospective cohort analysis was undertaken with the Kaiser Permanente Hip Fracture Registry, selecting patients age 60 years or older who underwent hemiarthroplasty for hip fracture between 2009 and 2017. Of the 12,491 patients, 6,449 (51.6%) included cement fixation, and the remaining were uncemented.
After controlling for confounders, including age, sex, body mass index, and comorbidities, the incidence of aseptic revision 1 year after repair was 3.0% in the uncemented group and 1.3% in the cemented group. By hazard ratio (HR), the risk of aseptic revision, which was the primary endpoint, was increased by more than 75% (HR 1.77; 95% confidence interval, 1.43-2.19; P < .001).
Of the secondary outcomes evaluated, such as medical complications at 90 days or mortality at 1 year, none were significantly different between the two arms.
A post hoc analysis suggested that a higher risk of periprosthetic fracture explained the higher rates of aseptic revision in the uncemented group, according to Dr. Okike, whose data have now been published (JAMA. 2020;323:1077-84).
Surgeon preference was also evaluated in this study as an instrumental variable. When patients treated by a surgeon with a preference for cemented fixation were compared with those treated by a surgeon with a preference for cementless repair, the relative advantage of cement for the primary outcome was similar (HR, 1.74; P = .02).
These data are consistent with trials outside of the United States. For example, a randomized trial with 160 patients conducted in New Zealand associated cemented fixation with a lower risk of periprosthetic fracture (1 vs. 18) and superior Oxford hip scores (J Bone Joint Surg Am. 2012;94:577-83). Similarly, a randomized trial of 141 patients conducted in Sweden associated cemented fixation with lower rate of periprosthetic fracture (0 vs. 9) and improved outcomes on several instruments, including the Harris Hip Scale (Bone Joint J. 2015;97-B:1475-80).
Cemented fixation generally requires a slightly longer operating time, but it is not otherwise more difficult or more expensive, according to Dr. Okike. He believes these results encourage cemented fixation in older patients without contraindications. This is already specifically recommended in AAOS guidelines for the management of hip fractures in elderly patients.
An orthopedic surgeon who has published frequently on total hip arthroplasty, Emil van Haaren, MD, of Zuyderland Medical Center, Heerlen, the Netherlands, confirmed that cemented hemiarthroplasty is considered “the golden standard of care” at his institution. In one study for which he served as the senior author, survival was characterized as excellent in older patients receiving cemented hip arthroplasty that were followed for more than 10 years (J Arthroplasty. 2016;31:194-8).
“We routinely use cemented prosthesis in hip fracture management when an arthroplasty is indicated,” he reported, echoing the contention by Dr. Okike that this approach is dominant in many centers outside of the United States.
Dr. Okike reports no potential conflicts of interest.
SOURCE: Okiki KM et al. JAMA. 2020;323:1077-84.
In older patients undergoing hemiarthroplasty for repair of a hip fracture, cemented fixation reduces the risk of aseptic revisions, according to a large retrospective cohort analysis reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled due to COVID-19.
“These data suggest surgeons should consider cemented over uncemented femoral stem fixation in the absence of contraindications,” reported Kanu M. Okike, MD, an orthopedic surgeon with the Hawaii Permanente Medical Group, Kaiser Moanalua Medical Center, Honolulu.
The finding was drawn from a cohort analysis conducted in the United States. Several studies conducted in Europe and elsewhere, including randomized trials, have also favored cement.
“Cemented fixation is becoming a standard of care for elderly individuals outside of the U.S., but this study was conducted to evaluate the U.S. experience,” explained Dr. Okike in an interview.
Citing 2018 American Joint Replacement Registry data, Dr. Okike reported that more than half of hemiarthroplasties in the United States are still being fixed without cement.
The retrospective cohort analysis was undertaken with the Kaiser Permanente Hip Fracture Registry, selecting patients age 60 years or older who underwent hemiarthroplasty for hip fracture between 2009 and 2017. Of the 12,491 patients, 6,449 (51.6%) included cement fixation, and the remaining were uncemented.
After controlling for confounders, including age, sex, body mass index, and comorbidities, the incidence of aseptic revision 1 year after repair was 3.0% in the uncemented group and 1.3% in the cemented group. By hazard ratio (HR), the risk of aseptic revision, which was the primary endpoint, was increased by more than 75% (HR 1.77; 95% confidence interval, 1.43-2.19; P < .001).
Of the secondary outcomes evaluated, such as medical complications at 90 days or mortality at 1 year, none were significantly different between the two arms.
A post hoc analysis suggested that a higher risk of periprosthetic fracture explained the higher rates of aseptic revision in the uncemented group, according to Dr. Okike, whose data have now been published (JAMA. 2020;323:1077-84).
Surgeon preference was also evaluated in this study as an instrumental variable. When patients treated by a surgeon with a preference for cemented fixation were compared with those treated by a surgeon with a preference for cementless repair, the relative advantage of cement for the primary outcome was similar (HR, 1.74; P = .02).
These data are consistent with trials outside of the United States. For example, a randomized trial with 160 patients conducted in New Zealand associated cemented fixation with a lower risk of periprosthetic fracture (1 vs. 18) and superior Oxford hip scores (J Bone Joint Surg Am. 2012;94:577-83). Similarly, a randomized trial of 141 patients conducted in Sweden associated cemented fixation with lower rate of periprosthetic fracture (0 vs. 9) and improved outcomes on several instruments, including the Harris Hip Scale (Bone Joint J. 2015;97-B:1475-80).
Cemented fixation generally requires a slightly longer operating time, but it is not otherwise more difficult or more expensive, according to Dr. Okike. He believes these results encourage cemented fixation in older patients without contraindications. This is already specifically recommended in AAOS guidelines for the management of hip fractures in elderly patients.
An orthopedic surgeon who has published frequently on total hip arthroplasty, Emil van Haaren, MD, of Zuyderland Medical Center, Heerlen, the Netherlands, confirmed that cemented hemiarthroplasty is considered “the golden standard of care” at his institution. In one study for which he served as the senior author, survival was characterized as excellent in older patients receiving cemented hip arthroplasty that were followed for more than 10 years (J Arthroplasty. 2016;31:194-8).
“We routinely use cemented prosthesis in hip fracture management when an arthroplasty is indicated,” he reported, echoing the contention by Dr. Okike that this approach is dominant in many centers outside of the United States.
Dr. Okike reports no potential conflicts of interest.
SOURCE: Okiki KM et al. JAMA. 2020;323:1077-84.
In older patients undergoing hemiarthroplasty for repair of a hip fracture, cemented fixation reduces the risk of aseptic revisions, according to a large retrospective cohort analysis reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled due to COVID-19.
“These data suggest surgeons should consider cemented over uncemented femoral stem fixation in the absence of contraindications,” reported Kanu M. Okike, MD, an orthopedic surgeon with the Hawaii Permanente Medical Group, Kaiser Moanalua Medical Center, Honolulu.
The finding was drawn from a cohort analysis conducted in the United States. Several studies conducted in Europe and elsewhere, including randomized trials, have also favored cement.
“Cemented fixation is becoming a standard of care for elderly individuals outside of the U.S., but this study was conducted to evaluate the U.S. experience,” explained Dr. Okike in an interview.
Citing 2018 American Joint Replacement Registry data, Dr. Okike reported that more than half of hemiarthroplasties in the United States are still being fixed without cement.
The retrospective cohort analysis was undertaken with the Kaiser Permanente Hip Fracture Registry, selecting patients age 60 years or older who underwent hemiarthroplasty for hip fracture between 2009 and 2017. Of the 12,491 patients, 6,449 (51.6%) included cement fixation, and the remaining were uncemented.
After controlling for confounders, including age, sex, body mass index, and comorbidities, the incidence of aseptic revision 1 year after repair was 3.0% in the uncemented group and 1.3% in the cemented group. By hazard ratio (HR), the risk of aseptic revision, which was the primary endpoint, was increased by more than 75% (HR 1.77; 95% confidence interval, 1.43-2.19; P < .001).
Of the secondary outcomes evaluated, such as medical complications at 90 days or mortality at 1 year, none were significantly different between the two arms.
A post hoc analysis suggested that a higher risk of periprosthetic fracture explained the higher rates of aseptic revision in the uncemented group, according to Dr. Okike, whose data have now been published (JAMA. 2020;323:1077-84).
Surgeon preference was also evaluated in this study as an instrumental variable. When patients treated by a surgeon with a preference for cemented fixation were compared with those treated by a surgeon with a preference for cementless repair, the relative advantage of cement for the primary outcome was similar (HR, 1.74; P = .02).
These data are consistent with trials outside of the United States. For example, a randomized trial with 160 patients conducted in New Zealand associated cemented fixation with a lower risk of periprosthetic fracture (1 vs. 18) and superior Oxford hip scores (J Bone Joint Surg Am. 2012;94:577-83). Similarly, a randomized trial of 141 patients conducted in Sweden associated cemented fixation with lower rate of periprosthetic fracture (0 vs. 9) and improved outcomes on several instruments, including the Harris Hip Scale (Bone Joint J. 2015;97-B:1475-80).
Cemented fixation generally requires a slightly longer operating time, but it is not otherwise more difficult or more expensive, according to Dr. Okike. He believes these results encourage cemented fixation in older patients without contraindications. This is already specifically recommended in AAOS guidelines for the management of hip fractures in elderly patients.
An orthopedic surgeon who has published frequently on total hip arthroplasty, Emil van Haaren, MD, of Zuyderland Medical Center, Heerlen, the Netherlands, confirmed that cemented hemiarthroplasty is considered “the golden standard of care” at his institution. In one study for which he served as the senior author, survival was characterized as excellent in older patients receiving cemented hip arthroplasty that were followed for more than 10 years (J Arthroplasty. 2016;31:194-8).
“We routinely use cemented prosthesis in hip fracture management when an arthroplasty is indicated,” he reported, echoing the contention by Dr. Okike that this approach is dominant in many centers outside of the United States.
Dr. Okike reports no potential conflicts of interest.
SOURCE: Okiki KM et al. JAMA. 2020;323:1077-84.
FROM AAOS 2020
Proximal fractures linked to higher mortality
Bone fracture in older adults is associated with greater mortality risk, but the location of the break may be a key factor, according to a new study of outcomes in a Danish database.
Over the follow-up period, those with proximal fractures – breaks in the hip, femur, pelvis, rib, clavicle, and humerus – were more likely to be hospitalized and to die, compared with their matched controls, than were those were with distal fractures in regions like the ankle, forearm, hand, or foot, where the mortality was similar to the matched controls.
“Compared with someone with similar comorbidities without a proximal fracture, there seemed to be an increased hospitalization rate for things like diabetes, heart disease, and lung disease, and then for some of those hospitalizations, there seemed to be an increased mortality, compared with people who hadn’t fractured who were hospitalized,” said Jacqueline Center, MBBS, PhD, of the Garvan Institute of Medical Research, Sydney, in an interview. The study abstract was released online by the Endocrine Society. It had been slated for presentation during ENDO 2020, the society's annual meeting, which was canceled because of the COVID-19 pandemic.*
The study included 212,498 women and 95,372 men aged over 50 years who had a fragility fracture between 2001 and 2014. The researchers excluded high-trauma fractures. They matched each fracture patient with four nonfracture patients, based on sex, age, and comorbidity status. There were 30,677 deaths among women over 384,995 person-years of follow-up, and 19,519 deaths in men over 163,482 person-years of follow-up. Women were a mean age of 72 at the time of fracture, while men were a mean age of 75.
The researchers found that proximal fractures were associated with increased risk of mortality, compared with nonfractured controls, with hazard ratios ranging between 1.5 and 4.0. Distal fractures were not associated with any increased mortality risk.
Comorbidities were common in the study population, with 75% of men and 60% of women having at least one. The risk of mortality increased with increasing numbers of comorbidities in each fracture type, but only proximal fractures were associated with an independent increase in mortality risk over and above comorbidity status.
In the 2 years following fracture, compared with matched controls, proximal fractures were associated with a greater risk of major hospital admission for conditions like cardiovascular disease, cancer, stroke, diabetes, pneumonia, and pulmonary disease. There was no significant difference between controls and those with distal fractures in hospital admission rate. The 2-year mortality risk was higher among subjects with proximal fractures, compared with patients in the no-fracture control group, regardless of whether they were admitted to the hospital, but there was no significant difference in those with distal fractures.
The differing clinical trajectories between those with proximal and distal fractures is a key finding, according to Dr. Center. The cause still isn’t clear, but she suspects that, in those patients who do badly, the fractures are either a signal that something is happening with existing comorbidities of the underlying frailty or that it may exacerbate them. Comorbidity independently and additively contributes to mortality, so that someone with a hip fracture and no comorbidities might have a similar mortality risk as someone with an upper-arm fracture and a couple of comorbidities. “I think it tells us that the person has to be treated as a whole. We need to treat the fracture to treat the underlying osteoporosis, but we also need to look closely at the person with the fracture and treat their comorbidities as well, because they seem to be more vulnerable,” Dr. Center said.
Although patients and clinicians are attuned to the concerns over hip fractures, other fractures should also be noted, according to Nelson Watts, MD, who is director of osteoporosis and bone-health services at Mercy Health in Cincinnati and was not involved in the research. “I think the message for clinicians and patients is that all of these [proximal] fractures need to be taken seriously. The good news is that that we have medications that can cut the risk of further fractures by 50%-70%,” he said in an interview.
Dr. Center has been on an advisory board for Amgen. Dr. Watts has been a speaker for Amgen and Radius and has conducted numerous clinical trials of osteoporosis drugs.
In addition to a series of news conferences, the Endocrine Society is also planning to host ENDO Online 2020 during June 8-22, which will feature on-demand and live programming for clinicians and researchers.
SOURCE: Center J et al. ENDO 2020, Abstract OR13-03.
Correction, 4/21/20: An earlier version of this article misstated when the interview with Dr. Center took place.
Bone fracture in older adults is associated with greater mortality risk, but the location of the break may be a key factor, according to a new study of outcomes in a Danish database.
Over the follow-up period, those with proximal fractures – breaks in the hip, femur, pelvis, rib, clavicle, and humerus – were more likely to be hospitalized and to die, compared with their matched controls, than were those were with distal fractures in regions like the ankle, forearm, hand, or foot, where the mortality was similar to the matched controls.
“Compared with someone with similar comorbidities without a proximal fracture, there seemed to be an increased hospitalization rate for things like diabetes, heart disease, and lung disease, and then for some of those hospitalizations, there seemed to be an increased mortality, compared with people who hadn’t fractured who were hospitalized,” said Jacqueline Center, MBBS, PhD, of the Garvan Institute of Medical Research, Sydney, in an interview. The study abstract was released online by the Endocrine Society. It had been slated for presentation during ENDO 2020, the society's annual meeting, which was canceled because of the COVID-19 pandemic.*
The study included 212,498 women and 95,372 men aged over 50 years who had a fragility fracture between 2001 and 2014. The researchers excluded high-trauma fractures. They matched each fracture patient with four nonfracture patients, based on sex, age, and comorbidity status. There were 30,677 deaths among women over 384,995 person-years of follow-up, and 19,519 deaths in men over 163,482 person-years of follow-up. Women were a mean age of 72 at the time of fracture, while men were a mean age of 75.
The researchers found that proximal fractures were associated with increased risk of mortality, compared with nonfractured controls, with hazard ratios ranging between 1.5 and 4.0. Distal fractures were not associated with any increased mortality risk.
Comorbidities were common in the study population, with 75% of men and 60% of women having at least one. The risk of mortality increased with increasing numbers of comorbidities in each fracture type, but only proximal fractures were associated with an independent increase in mortality risk over and above comorbidity status.
In the 2 years following fracture, compared with matched controls, proximal fractures were associated with a greater risk of major hospital admission for conditions like cardiovascular disease, cancer, stroke, diabetes, pneumonia, and pulmonary disease. There was no significant difference between controls and those with distal fractures in hospital admission rate. The 2-year mortality risk was higher among subjects with proximal fractures, compared with patients in the no-fracture control group, regardless of whether they were admitted to the hospital, but there was no significant difference in those with distal fractures.
The differing clinical trajectories between those with proximal and distal fractures is a key finding, according to Dr. Center. The cause still isn’t clear, but she suspects that, in those patients who do badly, the fractures are either a signal that something is happening with existing comorbidities of the underlying frailty or that it may exacerbate them. Comorbidity independently and additively contributes to mortality, so that someone with a hip fracture and no comorbidities might have a similar mortality risk as someone with an upper-arm fracture and a couple of comorbidities. “I think it tells us that the person has to be treated as a whole. We need to treat the fracture to treat the underlying osteoporosis, but we also need to look closely at the person with the fracture and treat their comorbidities as well, because they seem to be more vulnerable,” Dr. Center said.
Although patients and clinicians are attuned to the concerns over hip fractures, other fractures should also be noted, according to Nelson Watts, MD, who is director of osteoporosis and bone-health services at Mercy Health in Cincinnati and was not involved in the research. “I think the message for clinicians and patients is that all of these [proximal] fractures need to be taken seriously. The good news is that that we have medications that can cut the risk of further fractures by 50%-70%,” he said in an interview.
Dr. Center has been on an advisory board for Amgen. Dr. Watts has been a speaker for Amgen and Radius and has conducted numerous clinical trials of osteoporosis drugs.
In addition to a series of news conferences, the Endocrine Society is also planning to host ENDO Online 2020 during June 8-22, which will feature on-demand and live programming for clinicians and researchers.
SOURCE: Center J et al. ENDO 2020, Abstract OR13-03.
Correction, 4/21/20: An earlier version of this article misstated when the interview with Dr. Center took place.
Bone fracture in older adults is associated with greater mortality risk, but the location of the break may be a key factor, according to a new study of outcomes in a Danish database.
Over the follow-up period, those with proximal fractures – breaks in the hip, femur, pelvis, rib, clavicle, and humerus – were more likely to be hospitalized and to die, compared with their matched controls, than were those were with distal fractures in regions like the ankle, forearm, hand, or foot, where the mortality was similar to the matched controls.
“Compared with someone with similar comorbidities without a proximal fracture, there seemed to be an increased hospitalization rate for things like diabetes, heart disease, and lung disease, and then for some of those hospitalizations, there seemed to be an increased mortality, compared with people who hadn’t fractured who were hospitalized,” said Jacqueline Center, MBBS, PhD, of the Garvan Institute of Medical Research, Sydney, in an interview. The study abstract was released online by the Endocrine Society. It had been slated for presentation during ENDO 2020, the society's annual meeting, which was canceled because of the COVID-19 pandemic.*
The study included 212,498 women and 95,372 men aged over 50 years who had a fragility fracture between 2001 and 2014. The researchers excluded high-trauma fractures. They matched each fracture patient with four nonfracture patients, based on sex, age, and comorbidity status. There were 30,677 deaths among women over 384,995 person-years of follow-up, and 19,519 deaths in men over 163,482 person-years of follow-up. Women were a mean age of 72 at the time of fracture, while men were a mean age of 75.
The researchers found that proximal fractures were associated with increased risk of mortality, compared with nonfractured controls, with hazard ratios ranging between 1.5 and 4.0. Distal fractures were not associated with any increased mortality risk.
Comorbidities were common in the study population, with 75% of men and 60% of women having at least one. The risk of mortality increased with increasing numbers of comorbidities in each fracture type, but only proximal fractures were associated with an independent increase in mortality risk over and above comorbidity status.
In the 2 years following fracture, compared with matched controls, proximal fractures were associated with a greater risk of major hospital admission for conditions like cardiovascular disease, cancer, stroke, diabetes, pneumonia, and pulmonary disease. There was no significant difference between controls and those with distal fractures in hospital admission rate. The 2-year mortality risk was higher among subjects with proximal fractures, compared with patients in the no-fracture control group, regardless of whether they were admitted to the hospital, but there was no significant difference in those with distal fractures.
The differing clinical trajectories between those with proximal and distal fractures is a key finding, according to Dr. Center. The cause still isn’t clear, but she suspects that, in those patients who do badly, the fractures are either a signal that something is happening with existing comorbidities of the underlying frailty or that it may exacerbate them. Comorbidity independently and additively contributes to mortality, so that someone with a hip fracture and no comorbidities might have a similar mortality risk as someone with an upper-arm fracture and a couple of comorbidities. “I think it tells us that the person has to be treated as a whole. We need to treat the fracture to treat the underlying osteoporosis, but we also need to look closely at the person with the fracture and treat their comorbidities as well, because they seem to be more vulnerable,” Dr. Center said.
Although patients and clinicians are attuned to the concerns over hip fractures, other fractures should also be noted, according to Nelson Watts, MD, who is director of osteoporosis and bone-health services at Mercy Health in Cincinnati and was not involved in the research. “I think the message for clinicians and patients is that all of these [proximal] fractures need to be taken seriously. The good news is that that we have medications that can cut the risk of further fractures by 50%-70%,” he said in an interview.
Dr. Center has been on an advisory board for Amgen. Dr. Watts has been a speaker for Amgen and Radius and has conducted numerous clinical trials of osteoporosis drugs.
In addition to a series of news conferences, the Endocrine Society is also planning to host ENDO Online 2020 during June 8-22, which will feature on-demand and live programming for clinicians and researchers.
SOURCE: Center J et al. ENDO 2020, Abstract OR13-03.
Correction, 4/21/20: An earlier version of this article misstated when the interview with Dr. Center took place.
FROM ENDO 2020