The effect of intravenous tranexamic acid use on blood loss after revision shoulder arthroplasty

BackgroundRevision total- and reverse shoulder arthroplasties have become more common as the incidence of primary shoulder arthroplasties rise and the older population grows. The use of tranexamic acid (TXA) to decrease perioperative blood loss has been well established in literatures; however, its use in revision shoulder arthroplasty has yet to be explored. We retrospectively examined the effect of TXA use on perioperative blood loss during revision shoulder arthroplasties.MethodsThis was a retrospective review of patients ≥18 years of age, who underwent revision total- or reverse shoulder arthroplasties at the investigating institution between June 2013 and December 2020. Patients were stratified into 2 groups based on perioperative intravenous (IV) TXA vs. No TXA exposure. Contraindications to IV TXA included a history of blood clots and coagulopathies. Demographics, medical comorbidities, pre- and post-op hemoglobin, drain output, need for transfusion during hospitalization, duration of surgery, length of hospitalization, emergency department visits within 90 days of surgery, readmission to hospital within 90 days of surgery, and development of postoperative hematoma were analyzed.ResultsA total of 192 procedures (90 IV TXA vs. 102 No TXA) were analyzed. The cohorts did not significantly differ in age, gender, body mass index, breakdown of type of revision, or medical comorbidities. Analysis of the cohorts demonstrated that the IV TXA group had a significantly higher preoperative hemoglobin (12.9 vs. 13.5, P = .012) and postoperative hemoglobin (9.6 vs. 10.5, P < .001), as well as a significantly lower exposure to drain placement (75% vs. 43%, P < .001) and lower drain output per day (145 ml vs. 97.5 ml, P < .001) as compared to the No TXA group following revision shoulder arthroplasty. The results favored the IV TXA group with regard to blood loss, transfusions, duration of surgery, length of stay, and hospital readmissions within 90 days; however, these did not reach statistical significance.ConclusionsTXA use in revision shoulder arthroplasty significantly decreased the drain output; however had no significant effect on blood loss or transfusion rates.     

Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial

ObjectiveEarly excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery.MethodsPatients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA.ResultsTwenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542).DiscussionThis study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.     

Tranexamic Acid is Associated With Decreasing the Risk of Complications in Patients Undergoing Arthroplasty With Preoperative Coagulopathy

BackgroundPreoperative coagulopathy is a risk factor for perioperative blood loss. The antifibrinolytic effects of tranexamic acid (TXA) could negate the association between preoperative coagulopathy and adverse outcomes in patients undergoing total joint arthroplasty (TJA). However, no studies have evaluated this relationship. This study compared the perioperative outcomes of coagulopathic patients undergoing TJA who did and did not receive TXA.MethodsWe retrospectively reviewed 2123 primary TJAs (975 knees and 1148 hips) performed in patients with a preoperative coagulopathy. Coagulopathy was defined as international normalized ratio >1.2, partial thromboplastin time >35 seconds, or platelet count <150,000/μL. TXA was administered in 240 patients and not administered in 1883 patients. Demographics, comorbidities, and surgical details including operative time, blood loss, and thromboprophylaxis agent were recorded. Multivariate regression was used to identify factors associated with 90-day outcomes.ResultsPatients who received TXA had less intraoperative blood loss and 2.3 times decreased risk of 90-day complications (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20-0.85, P = .021), especially cardiovascular (2.92% vs 12.1%, P <.001) and wound complications (0.0% vs 1.59%, P = .042). TXA was also associated with shorter length of stay (beta 0.74, 95% CI 0.67-0.82, P <.001) and decreased risk of nonhome discharge (OR 0.50, 95% CI 0.29-0.83, P = .009). There was no difference in mortality or 90-day readmissions between the groups.ConclusionTXA administration decreased the incidence of perioperative complications and resource utilization in patients undergoing arthroplasty with a preoperative coagulopathy identified on preadmission testing. These findings support the broader adoption of TXA in patients undergoing TJA, particularly when the patient has a preoperative coagulopathy.     

Safety and efficacy of perioperative tranexamic acid infusion in acetabular fracture fixation: A randomized placebo-controlled double-blind prospective study

IntroductionOpen reduction and internal fixation of acetabular fracture is associated with significant blood loss. Although Tranexamic acid (TXA) infusion effectively reduces perioperative blood loss and transfusion requirements in elective orthopedic surgery, its efficacy in major orthopedic trauma surgery is controversial.Material and methodsSixty-three patients undergoing open reduction and internal fixation of acetabular fracture were randomized into either TXA (n = 36) or placebo (n = 27) group. TXA group received a bolus dose of TXA (10 mg/kg) 15 min prior to incision, followed by another similar dose after 3 h of surgery. The placebo group received the same volume of normal saline similarly. All patients were operated on by a single pelviacetabular surgeon with a uniform perioperative protocol. The intraoperative blood loss, drain output, the number of blood transfusions, postoperative hemoglobin (Hb) drop, and hematocrit (Hct) drop were calculated.ResultsBoth groups were similar in relation to age, sex, BMI, preoperative Hb, the timing of surgery, fracture pattern, operative time, and surgical approaches. The mean postoperative Hb was 10.35 ± 1.36 gm% in TXA group and 9.74 ± 1.98 gm% in placebo group (p-value 0.158). There were no differences in intraoperative blood loss (438.11 ml vs. 442.81, p=.947), drain output (131.94 ml vs. 129.63, p=.870), and blood transfusion (8 patients vs. five patients, p=.719) between the groups. The drop in Hb and Hct in the postoperative period was also statistically not significant between the groups.ConclusionThere is no significant reduction in blood loss and blood transfusion with the use of intravenous Tranexamic acid in open reduction and internal fixation of acetabular fractures.     

Hemostatic and Anti-Inflammatory Effects of Carbazochrome Sodium Sulfonate in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundPostoperative recovery after total knee arthroplasty (TKA) is associated with postoperative anemia, allogeneic transfusion, and stress immune responses to surgery. Carbazochrome sodium sulfonate (CSS) reduces bleeding through several mechanisms. We assessed the effect of CSS combined with tranexamic acid (TXA) on postoperative anemia, blood transfusion, and inflammatory responses.MethodsThis study was designed as a randomized, placebo-controlled trial of 200 patients undergoing unilateral primary TKA. Patients were divided into 4 groups: group A received TXA plus topical and intravenous CSS; group B received TXA plus topical CSS only; group C received TXA plus intravenous CSS only; group D received TXA only.ResultsTotal blood loss in groups A (609.92 ± 221.24 mL), B (753.16 ± 247.67 mL), and C (829.23 ± 297.45 mL) was lower than in group D (1158.26 ± 334.13 mL, P < .05). There was no difference in total blood loss between groups B and C. We also found that compared with group D, the postoperative swelling rate, biomarker level of inflammation, visual analog scale pain score, and range of motion at discharge in groups A, B, and C were significantly improved (P < .05). No thromboembolic complications occurred. There were no differences in transfusion rate, intraoperative blood loss, platelet count, or average length of stay among the 4 groups (P > .05).ConclusionCSS combined with TXA was more effective than TXA alone in reducing perioperative blood loss and inflammatory response and did not increase the incidence of thromboembolism complications.     

The efficacy and safety of tranexamic acid in foot and ankle surgery: A systematic review and meta-analysis of comparative clinical studies

BackgroundA comprehensive review of the current evidence investigating the potential therapeutic effects of tranexamic acid (TXA) and its safety in foot and ankle surgery is provided in this research study.MethodsWe followed the PRISMA guidelines to conduct a systematic review on TXA administration in foot and ankle surgeries. MEDLINE/PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane Library were searched comprehensively from inception to June 2022, as well as hand searching to include level I and III studies. A total of 970 records were reviewed, and seven comparative studies with a total of 514 patients were included in two groups: intervention (n = 257) and control (n = 257). Two studies used local TXA, and five studies used intravenous TXA. Three studies included calcaneal fractures, three included total ankle arthroplasty (TAA), and one had all ambulatory foot and ankle surgeries. Outcome variables were postoperative blood loss, hemoglobin change, and postoperative complications.ResultsPooled mean difference (MD) of postoperative blood loss after 24 h was ? 142.08 ml (95% CI, ?177.92 to ?106.24; P < 0.001; I² = 14%) showing a significant decrease in blood loss due to TXA use in both TAA and calcaneal fracture. Also hemoglobin drop was significantly lower in TXA group with a pooled MD of 0.56 g/dL (95% CI, 0.34–0.77; P < 0.001; I² = 73%). The odds ratio of wound complication after using TXA was 0.71 (95% CI, 0.42–1.21; P = 0.21; I² = 9.4%), revealing no significant correlation between TXA use and wound complications. Moreover our meta-analysis revealed no correlation between TXA use and thromboembolic events [OR = 0.67; P = 0.71; I² = 0% ).ConclusionsThe use of TXA has been demonstrated to reduce blood loss during foot and ankle surgery in an effective and safe manner. The optimum time of administration, optimum dosage, and the administration way (local vs. IV) should be researched in future studies.Level of evidenceIII     

Simultaneous Bilateral Primary Total Knee Arthroplasty With TXA and Restrictive Transfusion Protocols: Still a 1 in 5 Risk of Allogeneic Transfusion

BackgroundHistorically, there was up to a 60% risk of blood transfusion for patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). As such, the goal of this study was to analyze the rate and risk factors for allogeneic blood transfusions in patients undergoing SBTKA with tranexamic acid (TXA).MethodsWe retrospectively identified 475 patients who underwent SBTKA with a double dose TXA regimen at a single institution from 2016 to 2019. Mean age was 65 years. Two hundred fifty-seven patients (54%) were female. Mean body mass index was 30 kg/m². Drains were utilized in 143 patients (30%). Mean preoperative hemoglobin (Hgb) was 13.7 g/dL. Multivariate logistic regression analysis adjusting for age ≥70 years, sex, body mass index, drain use, and preoperative Hgb of <12.5 g/dL was utilized to identify risk factors for transfusion.ResultsOne hundred six patients (22%) received an allogeneic transfusion, including 28 patients (6%) who received ≥2 units. Multivariate analysis showed that preoperative Hgb <12.5 (OR = 3.99, P < .0001), female sex (OR = 2.34, P = .002), and drain use (OR = 2.13, P = .004) were risk factors for transfusion. Forty-two patients (42/83, 51%) with a preoperative Hgb <12.5 received a transfusion compared with 64 patients (64/392, 16%) with a Hgb ≥12.5 (P < .001).ConclusionPatients undergoing SBTKA with contemporary blood management still have a 1 in 5 rate of allogeneic transfusion. Drain use independently increases transfusion risk by 2-fold and should be avoided. Patients with a preoperative Hgb <12.5 have a transfusion rate of 50% and, as such, should either not undergo SBTKA or have extensive perioperative blood optimization.     

The effect of tranexamic acid on the values of activated clotting time in patients undergoing cardiac surgery: A PRISMA-compliant systematic review and meta-analysis

Study objectiveActivated clotting time (ACT) is a non-specific test to evaluate the adequacy of systemic heparinization whose value could be influenced by many factors. Tranexamic acid (TXA) is a widely used antifibrinolytic agent worldwide and whether TXA influences ACT value in cardiac surgical patients remains unknown. Current study was performed to address this question.DesignSystematic review and meta-analysis. PUBMED, Cochrane Library, EMBASE, OVID and Chinese BioMedical Literature & Retrieval System were searched using search terms “tranexamic acid”, “activated clotting time”, “cardiac surgery”, “randomized controlled trial” till May 7th, 2020, to identify all relevant randomized controlled trials (RCTs).SettingOperating room.PatientsCardiac surgical patients.InterventionsTXA or placebo.MeasurementsPrimary outcomes of interest included peri-operative ACT values. Secondary outcomes of interest include heparin dosage, protamine dosage, postoperative bleeding and blood transfusion.Main resultsSearch yielded 13 studies including 1168 patients, and 619 patients were allocated into Group TXA and 549 into Group Control (placebo). Meta-analysis suggested that, ACT values after heparinization [(WMD = −1.45; 95%CI: −12.52 to 15.43; P = 0.84)] and after protamine [(WMD = −1.18; 95%CI: −2.81 to 0.46; P = 0.16)] were comparable between Group TXA and Group Control, and that TXA did not influence heparin dose in adult patients [(WMD = 0.38; 95%CI: 0.30 to 0.46; P<0.00001) with no heterogeneity (I² = 4%, P = 0.35)] and protamine dose for heparin reversal [(WMD = 5.23; 95%CI: −0.33 to 10.80; P = 0.07) with no heterogeneity (I² = 0, P = 0.58)]. Meta-analysis also demonstrated that, TXA administration significantly reduced post-operative bleeding volume [(WMD = −126.33; 95%CI: −177.46 to −75.19; P < 0.0001), post-operative red blood cell (RBC) transfusion volume [(WMD = −71.86; 95% CI: −88.22 to −55.50; P < 0.00001), fresh frozen plasma (FFP) transfusion volume [(WMD = −13.83; 95% CI: −23.67 to −4.00; P = 0.006) and platelet concentrate (PC) transfusion volume [(WMD = −0.20; 95% CI: −0.29 to −0.10; P < 0.0001).ConclusionThis meta-analysis suggested that, TXA administration did not influence ACT value, heparin and protamine doses, but significantly reduced post-operative blood loss and transfusion requirement in cardiac surgical patients.     

Long-term Outcomes of Staged Complete Repair of Pulmonary Atresia With Ventricular Septal Defect

BackgroundThe optimal strategy for pulmonary atresia with ventricular septal defect (PA-VSD) without major aortopulmonary collateral arteries is yet to be defined. It remains unclear how primary complete repair compares with staged repair.MethodsThis study reviewed the records of 107 patients with PA-VSD who were managed with systemic-to-pulmonary shunts from February 1989 to November 2019. Tables presenting summary statistics of patient and surgical data and Kaplan-Meier curves showing repair, mortality, and reoperation were created. Logistic regression analysis was performed to identify risk factors for repair, morbidity, and mortality.ResultsA total of 91 (85%) patients achieved complete repair at a median age of 1 year (interquartile range [IQR], 8-20 months). Survival was as follows: 97 (90%) patients at 6 months, 91 (85%) at 20 months, and 87 (81%) at 10 years. A shunt diameter of 3.5 mm or less (P = .006) and shunt after 2009 (P < .001) were associated with earlier progression to complete repair. A shunt diameter of 3.5 mm or less was an independent risk factor for interstage morbidity (hazard ratio, 4.5; IQR, 1.1-18.5; P = .039), but it was not associated with complete repair (P = .75) or mortality (P = .62). The median follow-up period was 10.5 years (IQR, 3.6-18.8 years) from birth.ConclusionsThe complete repair and long-term survival rates of staged PA-VSD repair are high. The use of smaller shunts has resulted in earlier complete repair and is associated with increased risk of morbidity but not mortality.     

The Impact of Perioperative Use of Nonbiologic Disease-Modifying Anti-rheumatic Drugs on Perioperative Blood Loss and Complications in Patients Who Have Rheumatoid Arthritis Undergoing Total Knee Arthroplasty

BackgroundThe use of disease-modifying antirheumatic drugs (DMARDs) before total knee arthroplasty (TKA) was associated with increased risk of postoperative periprosthetic joint and wound infections as well as worse platelet function in patients who have knee rheumatoid arthritis (RA). This study investigated the effects of DMARDS on perioperative blood loss, complications, and blood transfusion in patients undergoing TKA for knee RA.MethodsWe retrospectively enrolled patients undergoing TKA for knee RA at our hospital between 2017 and 2021 who received DMARDs (n = 73) or not (n = 84). Every RA patient was matched with patients who had osteoarthritis (OA) in a ratio of 1:1 or 1:2. Primary outcomes were intraoperative and perioperative blood losses, while secondary outcomes were complications and allogeneic transfusions.ResultsThe mean total (804 versus 728 mL (mL), P = .114), mean intraoperative (113 versus 101 mL, P = .488), or hidden blood losses (705 versus 640 mL, P = .340) did not differ statistically between RA patients who received DMARDs versus those who did not. RA patients who received DMARDs showed significantly greater mean total (804 versus 654 mL, P = .001), intraoperative (113 versus 75 mL, P = .002), and hidden blood losses (705 versus 560 mL, P = .016) than OA patients. No statistical differences were found in complications or allogeneic transfusions.ConclusionAlthough RA patients experienced greater perioperative blood loss than OA patients, there was no statistical difference in perioperative blood loss, complications, or allogeneic transfusions between RA patients who received DMARDs and those who did not.     

Axillary lymphadenectomy for breast cancer. A randomized controlled trial comparing a bipolar vessel sealing system to the conventional technique

AimTo compare safety and efficacy of a bipolar vessel sealing system (BVSS) to the conventional technique in axillary node dissection.Methods116 women with breast cancer were randomized to conventional node dissection surgical technique (control; n = 58) by scalpel and monopolar cautery or using an electrothermal BVSS (study group; n = 58).ResultsThe median (range) total volume of fluid collected by drain and aspirations was 305 (30–1420) mL in the study group and 335 (80–1070) mL in the control group (p = 0.325). The median (range) total volume of lymph collected by percutaneous aspirations was 207.5 (40–1050) mL in the study group and 505 (270–705) mL in the control group (p = 0.010). The incidence of seroma was similar in both groups (p = 0.845). The axillary drain was removed earlier in the study group than in controls (p = 0.046).ConclusionThe use of a BVSS offers marginal advantages when compared to the conventional technique.     

Assessment of serum and drain fluid bilirubin concentrations in liver transplantation patients

BackgroundBile leakage is a major complication after liver transplantation and remains as a significant source of morbidity and mortality. In 2011, the International Study Group of Liver Surgery (ISGLS) defined bile leakage as a drain/serum bilirubin ratio ≥3. However, to our knowledge there is no literature assessing serum and drain bilirubin concentrations after liver transplantation. The aim of this study was to describe the natural postoperative changes in serum and drain fluid bilirubin concentrations in patients after liver transplantation.MethodsWe included 32 patients who underwent liver transplantation at Kobe University Hospital from January 2007 to December 2020. We enrolled 34 living donors who had no complications as the control group.ResultsThe recipient serum total/direct bilirubin concentration were higher compared with the donors from postoperative day (POD) 1 to 5 with a statistical difference (P < .05). The recipient drain/serum total bilirubin ratio was lower than donors on POD 3 (0.89 ± 0.07 vs 1.53 ± 0.07: P < .0001), which was also confirmed by the recipient drain/serum direct bilirubin ratio (0.64 ± 0.10 vs 1.18 ± 0.09: P < .0001). On POD 3, the drain fluid volume (647.38 ± 89.47 vs 113.43 ± 86.8 mL: P < .001) and serum total bilirubin concentration (6.73 ± 0.61 vs 1.23 ± 0.60 mg/dL: P < .001) was higher in the recipients than in donors. Categorized in 2 groups, the higher drain fluid volume and bilirubin concentration recipients showed lower drain/serum total bilirubin ratio compared with the other group (P = .03)ConclusionThe drain/serum bilirubin ratio in the transplanted patients could be calculated lower compared with the hepatectomy patients because of high drain fluid volume and hyperbilirubinemia. Great care should be taken when assessing the bile leakage in liver transplant recipients using the ISGLS definition.     

Outcomes of Interventional Management of Coronary Artery Disease in Kidney Transplant Recipients

BackgroundCardiovascular disease is the most common cause of death among kidney transplant (KT) recipients. Trials routinely exclude patients with end-stage renal disease when assessing the effect of coronary artery revascularization. We looked to compare long-term outcomes in patients who underwent percutaneous coronary intervention (PCI) before KT with those managed medically.MethodsWe identified all patients who underwent coronary artery catheterization before KT from January 2008 to November 2019 at the Cleveland Clinic. The primary endpoint was all-cause mortality.ResultsA total of 272 patients were included, of whom 52 (19.11%) underwent PCI, and the remaining 220 patients were managed medically. The median age in the PCI group was 57.4 years (interquartile range [IQR], 46.9-61.2 years), whereas it was 53.9 years (IQR, 44.6-61 years) in the group medically managed. Baseline characteristics including sex, race, hypertension, diabetes, smoking, and hyperlipidemia were comparable in both groups. The median time to KT was 2.4 years (IQR, 1-5 years) in the PCI group vs 1.2 years (IQR, 0.6-3.3 years) in the medically managed group (P = .001). Among patients who underwent PCI, 40.4% had single vessel disease and 59.6% had multivessel disease compared with 16.8% and 28.6%, respectively, in the medically managed group (P < .001). Overall, there was no difference in mortality in the PCI group compared with the medically managed group after 10 years of follow-up (P = .416).ConclusionsPatients with coronary artery disease can be safely treated with PCI before KT and have comparable outcomes to those who are managed medically.     

Tranexamic acid in non-elective primary total hip arthroplasty

PurposeBlood loss during and following elective total hip arthroplasty (THA) can be substantial and may require allogeneic blood transfusions which carries significant risks and morbidity for patients. Intraoperative use of tranexamic acid (TXA) has been proven to reduce the need for allogeneic blood transfusion in elective THA patients. Data regarding TXA efficacy in reducing blood loss in trauma patients undergoing non-elective primary THA is sparse, and its routine use is not well established.MethodsThis is a retrospective analysis of a consecutive cohort of patients who underwent non-elective primary THA in a tertiary medical center between January 1st 2011- December 31st 2019. The cohort was divided into two groups; one received perioperative TXA treatment while the other did not. Blood loss, blood product administration, peri and postoperative complications, readmissions and 1-year mortality were compared between groups.ResultsA total of 419 patients (146 males, 273 females) who underwent THA were included in this study. The "TXA" group consisted 315 patients compared to 104 patients in the "no TXA" group. TXA use reduced postoperative bleeding, as indicated by changes in hemoglobin levels before and after surgery (ΔHb= -2.75 gr/dL vs. ΔHb= -3.34 gr/dL, p<0.001) and by administration of allogeneic blood transfusions (7.0% vs. 16.3%, p = 0.004).ConclusionSimilar to the known effect of TXA in elective THA patients, the use of TXA treatment in patients undergoing non-elective THA led to a significant reduction in postoperative blood loss and in the proportion of patients requiring allogeneic blood transfusions.     

Impaction Bone Grafting or Uncemented Modular Stems for the Treatment of Type B3 Periprosthetic Femoral Fractures? A Complication Rate Analysis

BackgroundBecause the gold standard for the treatment of Vancouver type-B3 periprosthetic femoral fractures (PFFs) is yet to be defined, we sought to analyze the complication rate between the impaction bone grafting (IBG) technique with a cemented stem and reconstruction with an uncemented distally-fixed modular stem (DFMS).MethodsWe retrospectively studied 54 B3 PFFs operated between 2000 and 2016, comparing the complication rate of 33 patients treated with the IBG technique (group A) with 21 patients treated with a DFMS (group B). Median follow-up of groups A and B were 75 months (interquartile range [IQR], 36-111 months) and 55 months (IQR, 32-73 months), respectively (P = .008). Median age of groups A and B were 78 years (IQR, 74-83 years) and 81 years (IQR, 74-86 years), respectively (P = .30). Median grade of Endo-Klink femoral bone defect was 3 (IQR, 3-3) for both groups (P = .11). We performed a multiple regression analysis to determine risk factors for complications including the following variables: age, initial diagnosis, and surgical technique.ResultsAs for infection outcomes, 2-stage revision surgery was more frequent in group A than in group B (4 vs 0, P = .003). Group A presented more implant failures than group B (5 vs 1, P = .195). We found 4 dislocations in group B and 2 in group A (P = .192). Multiple regression analysis showed a significant association between surgical technique and complication rate (P = .01). The IBG technique presented an odds risk for complications of 4.77 (P = .016; IQR, 1.33-17.21).ConclusionFemoral reconstruction with the IBG technique evidenced an ostensibly higher complication rate than that of DFMS for the treatment of B3 PFF.     

Racial disparities in presentation and outcomes for endovascular abdominal aortic aneurysm repair

ObjectiveIn the present study, we used a national database to identify racial differences in the presentation and outcomes for patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (EVAR) and identified areas for improving their care.MethodsWe queried the EVAR-targeted National Surgical Quality Improvement Program database (2016-2019) to identify patients who had undergone EVAR for both ruptured and nonruptured AAAs. The patients were categorized according to race (White, Black, and Asian). Patients with a history of abdominal aortic surgery or an indication other than AAAs were excluded. The data was analyzed using the χ² and Kruskal-Wallis tests, presented as frequencies and percentages or median and interquartile range (IQR) for categorical and continuous variables, respectively.ResultsWe identified 3629 patients (16.6% female), including 3312 White (91.3%), 248 Black (6.8%), and 69 Asian (1.9%) patients. Black patients were more frequently women (27.0%) compared with White patients (15.9%) and were younger (median age, 71 years; IQR, 64-77 years) than White (median age, 73 years; IQR, 67-79 years) and Asian (median age, 76 years; IQR, 67-81 years) patients (P < .001 for both). The incidence of smoking, congestive heart failure, and dialysis dependency was highest for Black patients, and the incidence of obesity was lowest for Asian patients. The AAAs in Black patients extended more frequently beyond the aortic bifurcation (P = .047). In Asian patients, the internal iliac arteries were more involved (P = .040). For Black patients, 29.8% of the EVARs were performed in a nonelective setting compared with 20.2% for the White and 15.9% for the Asian patients (P < .001). The aneurysm diameter, nonruptured symptomatic rate, and rupture rate were similar across the groups (P = .807). The operative time was prolonged for Black (median, 128 minutes; IQR, 96-177 minutes) compared with White (median, 114 minutes; IQR, 84-162 minutes) patients (P < .001). Postoperatively, Black patients were more likely to require blood transfusion (16.5%) and had prolonged length of hospital stay (median, 2 days; IQR, 1-4 days) compared with White (10.0%; median, 1 day; IQR, 1-3 days) and Asian (4.3%; median, 1 day; IQR, 1-3 days) patients (P = .001 and P < .001, respectively). Black patients also had a higher 30-day readmission rate (P = .038). On multivariate analysis, Black race was an independent factor for length of stay >1 day after both elective and nonelective EVAR and 30-day readmission for elective EVAR, but not 30-day mortality after elective and nonelective EVAR.ConclusionsIn the present nationwide sample of EVAR cases, Black patients were more often women and younger. Despite similar rates of symptomatic and ruptured AAAs at presentation and 30-day mortality, Black patients more often presented and were treated during the same nonelective admission; they also had associated increased length of hospital stay and readmission. These findings signal a missed opportunity to diagnose, optimize, and treat this particular group of patients in an elective setting.     

Hip Arthroplasty Outcomes for Femoral Neck Fractures in Transplant Patients

BackgroundThe purpose of this study was to compare the short-term complications between transplant and nontransplant patients who undergo hip arthroplasty for femoral neck fractures (FNFs). Additionally, we sought to further compare the outcomes of total hip arthroplasty (THA) versus hemiarthroplasty (HA) within the transplant group.MethodsThis was a retrospective review utilizing the Nationwide Readmissions Database. Transplant patients were identified and stratified based on transplant type: kidney, liver, or other (heart, lung, bone marrow, and pancreas). Outcomes of interest included index hospitalization mortality, perioperative complications, length of stay, costs, hospital readmission, and surgical complications within 90 days of discharge.ResultsFrom 2010 to 2018, a total of 881,061 patients underwent THA or HA for FNFs, of which 2163 (0.2%) were transplant patients. When compared with nontransplant patients, all transplant patients had an increased risk of requiring blood transfusion (odds ratio [OR] = 1.51, P = .001), acute kidney injury (OR = 2.02, P < .001), and discharge to facility (OR = 1.67, P = .001) while having increased index hospitalization length of stay and costs. Liver and other transplant patients had an increased risk of readmission within 90 days (OR = 1.82, P < .001 and OR = 1.60, P = .014 respectively). Subgroup analysis for transplant patients comparing HA with THA demonstrated no differences in perioperative complication rates and decreased hospitalization length of stay and cost associated with THA.ConclusionIn this retrospective cohort study, transplant patients had an increased risk of requiring blood transfusions and acute kidney injury after hip arthroplasty for FNFs. There were no differences in short-term complications between transplant patients treated with HA versus THA.Level of evidence3 (Retrospective cohort study).     

Evaluation of the Correlation Between Responders and Non-Responders to the Second Coronavirus Disease Vaccination In Kidney Transplant Recipients: A Retrospective Single-Center Cohort Study

BackgroundThe immune response to COVID-19 vaccination in kidney transplant (KTx) recipients is significantly lower than that in healthy controls. We evaluated immune responses after the COVID-19 vaccine and their possible relationship with other cofactors in KTx recipients.MethodsThis retrospective single-center cohort study included 29 KTx recipients 2-8 weeks after receiving 2 doses of the Pfizer-BioNTech SARS-CoV-2 messenger RNA vaccine. Anti-SARS-CoV-2 spike (S) immunoglobulin (Ig)-G levels were evaluated to define cofactors influencing the immune response between the responder (anti-SARS-CoV-2 IgG level ≥0.8 U/mL) (n = 16) and nonresponder groups (anti-SARS-CoV-2 IgG level <0.8 U/mL) (n = 13). The kinetics of antibodies between 2 and 6 months after the second vaccination was also compared between the groups.ResultsKTx recipients with IgG levels ≥0.8 U/mL were younger (54 [interquartile range {IQR}, 46.5-61] years vs 65 [IQR, 55-71.5] years; P = .01), had been transplanted for a longer median time (1588 [IQR, 1382-4751] days vs 1034 [IQR, 548.5-1833] days; P = .02), and were more often treated with a lower mycophenolate mofetil dosage (765.6 ± 119.6 vs 1077 ± 76.9 mg; P = .04) than KTx recipients with IgG levels <0.8 U/mL. There was no significant difference in antibody titers between time periods after the second dose in the responder group. At the 6-month follow-up, a serologic response against the SARS-CoV-2 S was observed in 44.4% of KTx recipients in the nonresponder group.ConclusionsMore than 50% of KTx recipients developed a higher antibody response after the second dose of COVID-19 vaccination.