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P & T Approvals, FDA Warnings About Testosterone Products, Treanda, Chantix

Pharmacy Focus

See highlights of the February meeting of the Pharmacy and Therapeutics Committee. Also, the U.S. Food and Drug Administration has issued warnings about prescription testosterone products, Treanda and Chantix.

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Surgery Grand Rounds

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Grand Rounds

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Surgery Scheduling

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Lin to Present Orthopedic Research at National Meeting

Carol A. Lin, MD

Carol A. Lin, MD, a faculty physician with the Cedars-Sinai Orthopaedic Center, will present her research on acetabular fractures March 25 at the national meeting of the American Academy of Orthopaedic Surgeons in Las Vegas. Her findings are summarized below.

Acetabular fractures are complex injuries, and treatments have evolved considerably over the past century. Prior to the development of modern implants for fracture fixation, these injuries were treated with bed rest and traction, often leading to debilitating hip arthritis. In recent decades, advances in implant technology and understanding of functional anatomy have allowed us to achieve good to excellent functional outcome in up to 80 percent of patients at 20 years with open reduction internal fixation.

However, many patients suffer early failures requiring a hip replacement within two years of the injury. Current research is focused on identifying which patients are at risk for early failure and how to prevent the need for additional surgeries. In these situations, it may be best to replace the joint immediately, rather than try to fix it. (Figure 1 below) Until now, the discussion has focused primarily on geriatric patients who are unlikely to wear out the artificial joint.

But what about the nongeriatric patient with a high-risk fracture pattern? As total-hip technology continues to improve, total-hip arthroplasty in primary osteoarthritis is being performed more frequently in patients in their 50s with excellent longevity and a low complication rate, and as such, its use in acetabular fractures may provide a benefit to these younger patients.

To investigate this question, we reviewed the charts of 16 patients under 65 years old who underwent total-hip arthroplasty for acetabular fractures and compared them to 32 patients of similar age and fracture pattern. We analyzed length of stay, complication rate, functional outcome and reoperation rates. Patients who underwent immediate hip arthroplasty had lower rates of reoperation than those who underwent traditional internal fixation. (Figure 2 below) This finding was statistically significant.

Ultimately, our study shows that, with appropriate patient selection, immediate total hip arthroplasty can provide good functional outcomes with complication rates similar to traditional internal fixation. Arthroplasty in high-risk fracture patterns also may reduce the likelihood of needing a second surgery in certain patients. While our sample size was small, it is the first to provide a direct comparison between the two treatment methods and lays the groundwork for future prospective investigations. With this information, we hope to continue to improve the outcomes of patients with these challenging injuries.

Figure 1: Example of an associated anterior column and posterior hemitransverse fracture with displacement of the anterior column and dome impaction and medial displacement of the femoral head. Part A — anteroposterior and Judet views of the injury. Note the displacement of the anterior column with a large step-off at the pelvic brim (arrows) on the obturator oblique projection (lower left). There is moderate displacement of the posterior column on the iliac oblique projection (lower right). Part B — after OFIR with a plate placed through the lateral window of the ilioinguinal approach used to reduce and buttress the anterior column.

Figure 2: Kaplan-Meier survival curve of the index surgery comparing acute or immediate total-hip arthroplasty (THA) versus traditional open reduction internal fixation (ORIF)