How to Decrease Infection in Open Fractures
Infection in open fractures…a scourge in orthopedics. A new study from the University of North Carolina at Chapel Hill has found that using aminoglycosides (gentamicin and tobramycin) along with systemic antibiotics can drive down infection rates. Cheryl Lawing was a co-author on the study. She told OTW, “This study came about because the senior author, Laurence Dahners, M.D., looked back on his infection rates and was disappointed with how high they were. He therefore began looking into ways that he could decrease infection rates. He loves basic science research and began a series of animal (rat) studies investigating the most effective antibiotic regimen. His key studies were those by Cavanaugh et al. and Yarborough et al., which were cited in the paper. Based on the findings from these studies, he began using the locally injected aminoglycoside protocol used in our study and has noticed a dramatic drop in his infection rates.”
“We studied 351 open fractures; individuals assigned to the control group (183 fractures) received systemic antibiotics only, while those in the intervention group (168 fractures) received systemic antibiotics and a locally administered aminoglycoside. The infection rate (deep and superficial) in the control group was nearly 20%, while in the intervention group it was just under 10%. When we looked at deep infections alone, we found that the infection rate in the control group was 14.2% compared with 6% in the intervention group.”
“As a resident, I found it very interesting that a several dollar dose of tobramycin could have such a significant impact on outcome and I wanted to quantify this impact, to hopefully help it become a more recognized practice. While I suspected the aminoglycosides would result in lower infection rates, I was pleasantly surprised to see just how effective they were.”
Oral TXA Cheaper and Equally as Effective
Need to save money on TKA (total knee arthroplasty)? Craig Della Valle, M.D. knows how. Dr. Della Valle, a hip and knee specialist at Midwest Orthopaedics at Rush, got curious about whether oral tranexamic acid (TXA), which is cheaper than the IV formulation, could be used without a loss of efficacy. Dr. Della Valle told OTW, “Tranexamic acid has become very popular with orthopedic surgeons because it has shown to result in decreased blood loss after hip and knee replacement. Two years ago I saw an article on oral TXA indicating that it was much less expensive than the IV version of the drug. I set out to take a look at whether oral tranexamic acid could be used without any loss of efficacy.”
Dr. Della Valle, whose work was just honored with the James A. Rand Young Investigator’s Award from the American Association of Hip and Knee Surgeons, noted: “We enrolled 71 patients, 37 of whom received the IV form of the drug and compared them to 34 patients who were given the oral version of the drug. The oral formulation was given two hours preoperatively and the IV form was given at the time of wound closure. In addition we blinded everyone by giving IV saline to the oral group and placebo tablets to the IV patients. We found that patients who received the oral TXA experienced 3.45 g/dl of blood loss; that number was 3.31 g/dl for those who received the IV. This represents statistical equivalence between the two treatments. In addition, there were no differences in length of stay or transfusions between the groups; there were also no thromboembolic events in either group.”
“Regarding the cost issue, the oral formulation of TXA is about $14 for the three 650mg tablets that are needed. For the IV version it is about $57 for the generic form of the medication and up to $115 for non-generic. In some centers, surgeons will give 1g of IV TXA at the beginning of the cases and another dose at the end of the case which means the potential cost savings are even greater depending on how the IV drug is used.”
“It is interesting to note that doctors interpret the contraindications to using TXA differently. An anesthesiologist may say, ‘This patient had a myocardial infarction 22 years ago. I’m not going to use TXA.’ The orthopedic surgeon says, ‘I am not concerned about that. Give the TXA.’ The upshot is that if the drug is ordered preoperatively then the situation is more under the surgeon’s control.”
“We can always look to data from Mayo clinic for further evidence. They have an enormous data set and they are using TXA for nearly everything with few if any contraindications to its use.”
“This will definitely change practice. Everyone is looking to be as cost effective as possible these days and this is a relatively painless way to make that happen without decreasing efficacy.”
Obese Patients Require More Trauma Surgeries
It’s more bad news for those struggling with obesity. A new article in The Journal of Bone and Joint Surgery (JBJS) has found a link between obesity and a higher risk for surgery in orthopedic trauma patients. Also concerning is that obese patients had longer hospital stays and their treatment was more costly. And instead of going home, these patients were more likely to be discharged to a care facility.
The research team identified 301 patients at a Level I trauma center that experienced multiple orthopedic injuries from 2006 to 2011. They found that 72% of the obese patients required surgical treatment, compared to nearly 55% of non-obese patients. The mean hospital costs were $160, 606.02 for non-obese patients and $234, 863.58 for obese patients.
Lead author and orthopedic surgeon Heather Licht, M.D. is with Baylor, Scott & White Health in Temple, Texas. Dr. Licht told OTW, “I think the two most surprising things for our team were that those who were obese needed significantly more surgeries than those that were not obese and after we broke the data down further, it was the patients that were morbidly obese who required extensive surgical intervention. Another thing that was enlightening to us was, although we anticipated those that were obese to have higher hospital cost, surprisingly they required more intervention and accrued higher hospital cost despite having lower injury severity scores than those that were not obese. Meaning, despite having less injuries, they stayed longer, needed more surgical intervention, needed rehab or continued care after discharge, and ended up with higher hospital cost.”
Asked what might be possible as far as counseling patients, she noted, “I’m not sure what can be done at this moment to improve this. Counseling patients to keep their weight within or close to a normal BMI in the primary care setting would be a start and necessary to reduce obesity in our society. As orthopedic surgeons, we need to stress diet and exercise more in our clinics as well. In addition, with this information, we could potentially optimize our care in the hospital by mobilizing these patients more aggressively and optimizing their nutrition. Also, knowing that most obese patients required discharge to a continuing care facility or rehab, we need to get case management involved sooner to start working on placement of these patients to get them discharge from the hospital once medically stable.”
“We were hoping with our study that we could highlight and point out the facts about obese patients in the orthopedic trauma setting that were known but not necessarily said or documented. This information can hopefully one day be used by the medical system to optimize care for these patients, support counseling in the primary care field, and optimize payment for hospitals and physicians. In our study, we documented the increased amount of energy it takes to manage obese patients despite their injuries being less severe than those not obese however the increase in complexity of caring for obese patients are often not appreciated by insurance companies and thus reimbursement does not often reflect the realization of this complexity.”
