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Ghanem D, Kagabo W, Engels R, Srikumaran U, Shafiq B. Implementing a Hospitalist Comanagement Service in Orthopaedic Surgery. J Bone Joint Surg Am 2024; 106:823-830. [PMID: 38512993 DOI: 10.2106/jbjs.23.00789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
➤ Hospitalist comanagement of patients undergoing orthopaedic surgery is a growing trend across the United States, yet its implementation in an academic tertiary care hospital can be complex and even contentious.➤ Hospitalist comanagement services lead to better identification of at-risk patients, optimization of patient care to prevent adverse events, and streamlining of the admission process, thereby enhancing the overall service efficiency.➤ A successful hospitalist comanagement service includes the identification of service stakeholders and leaders; frequent consensus meetings; a well-defined standardized framework, with goals, program metrics, and unified commands; and an occasional satisfaction assessment to update and improve the program.➤ In this article, we establish a step-by-step protocol for the implementation of a comanagement structure between orthopaedic and hospitalist services at a tertiary care center, outlining specific protocols and workflows for patient care and transfer procedures among various departments, particularly in emergency and postoperative situations.
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Affiliation(s)
- Diane Ghanem
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
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Ghanem D, Covarrubias O, Maxson R, Sabharwal S, Shafiq B. Readability of Trauma-related Patient Education Materials From the American Academy of Orthopaedic Surgeons and Orthopaedic Trauma Association Websites. J Am Acad Orthop Surg 2024:00124635-990000000-00946. [PMID: 38684136 DOI: 10.5435/jaaos-d-23-00449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/03/2023] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION Web-based resources serve as a fundamental educational platform for orthopaedic trauma patients; however, they are frequently written above the recommended sixth-grade reading level, and previous studies have demonstrated this for the American Academy of Orthopaedic Surgeons (AAOS) web-based articles. In this study, we perform an updated assessment of the readability of AAOS trauma-related educational articles as compared with injury-matched education materials developed by the Orthopaedic Trauma Association (OTA). METHODS All 46 AAOS trauma-related web-based (https://www.orthoinfo.org/) patient education articles were analyzed for readability. Two independent reviewers used (1) the Flesch-Kincaid Grade Level (FKGL) and (2) the Flesch Reading Ease (FRE) algorithms to calculate the readability level. Mean readability scores were compared across body part categories. A one-sample t-test was done to compare mean FKGL with the recommended sixth-grade readability level and the average American adult reading level. A two-sample t-test was used to compare the readability scores of the AAOS trauma-related articles with those of the OTA. RESULTS The average (SD) FKGL and FRE for the AAOS articles were 8.9 (0.74) and 57.2 (5.8), respectively. All articles were written above the sixth-grade reading level. The average readability of the AAOS articles was significantly greater than the recommended sixth-grade reading level (P < 0.001). The average FKGL and FRE for all AAOS articles were significantly higher compared with those of the OTA articles (8.9 ± 0.74 versus 8.1 ± 1.14, P < 0.001 and 57.2 ± 5.8 versus 65.6 ± 6.6, P < 0.001, respectively). Excellent agreement was observed between raters for the FKGL 0.956 (95% confidence interval, 0.922 to 0.975) and FRE 0.993 (95% confidence interval, 0.987 to 0.996). DISCUSSION Our findings suggest that after almost a decade, the readability of the AAOS trauma-related articles remains unchanged. The AAOS and OTA trauma patient education materials have high readability levels and may be too difficult for patient comprehension. A need remains to improve the readability of these commonly used trauma education materials.
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Affiliation(s)
- Diane Ghanem
- From the Department of Orthopaedic Surgery, The Johns Hopkins Hospital (Ghanem, Sabharwal, and Shafiq), and the School of Medicine, The Johns Hopkins University, Baltimore, MD (Covarrubias, and Maxson)
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Shu HT, Ghanem D, Rogers DL, Covarrubias O, Izard P, Hacquebord J, Lim P, Gupta R, Osgood GM, Shafiq B. Failure after operative repair is higher for ballistic femoral neck fractures than for closed, blunt-injury fractures: a multicenter retrospective cohort study. Trauma Surg Acute Care Open 2024; 9:e001241. [PMID: 38347891 PMCID: PMC10860054 DOI: 10.1136/tsaco-2023-001241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Introduction The purpose of this study was to describe the outcomes after operative repair of ballistic femoral neck fractures. To better highlight the devastating nature of these injuries, we compared a cohort of ballistic femoral neck fractures to a cohort of young, closed, blunt-injury femoral neck fractures treated with open reduction and internal fixation (ORIF). Methods Retrospective chart review identified all patients presenting with ballistic femoral neck fractures treated at three academic trauma centers between January 2016 and December 2021, as well as patients aged ≤50 with closed, blunt-injury femoral neck fractures who received ORIF. The primary outcome was failure of ORIF, which includes the diagnosis of non-union, avascular necrosis, conversion to total hip arthroplasty, and conversion to Girdlestone procedure. Additional outcomes included deep infection, postoperative osteoarthritis, and ambulatory status at last follow-up. Results Fourteen ballistic femoral neck fractures and 29 closed blunt injury fractures were identified. Of the ballistic fractures, 7 (50%) patients had a minimum of 1-year follow-up or met the failure criteria. Of the closed fractures, 16 (55%) patients had a minimum of 1-year follow-up or met the failure criteria. Median follow-up was 21 months. 58% of patients with ballistic fractures were active tobacco users. Five of 7 (71%) ballistic fractures failed, all of which involved non-union, whereas 8 of 16 (50%) closed fractures failed (p=0.340). No outcomes were significantly different between cohorts. Conclusion Our results demonstrate that ballistic femoral neck fractures are associated with high rates of non-union. Large-scale multicenter studies are necessary to better determine optimal treatment techniques for these fractures. Level of evidence Level III. Retrospective cohort study.
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Affiliation(s)
- Henry Tout Shu
- Orthopedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Diane Ghanem
- Orthopedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Davis L. Rogers
- Orthopedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Oscar Covarrubias
- Orthopedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Paul Izard
- Orthopaedic Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Jacques Hacquebord
- Orthopaedic Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Philip Lim
- Orthopaedic Surgery, University of California Irvine School of Medicine, Irvine, California, USA
| | - Ranjan Gupta
- Orthopaedic Surgery, University of California Irvine School of Medicine, Irvine, California, USA
| | - Greg M. Osgood
- Orthopedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Babar Shafiq
- Orthopedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Ghanem D, Rogers DL, Benes G, Siler B, Lobaton G, Shafiq B. Gluteal compartment syndrome: who is most at risk? Eur J Orthop Surg Traumatol 2024; 34:773-779. [PMID: 37695367 DOI: 10.1007/s00590-023-03704-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/17/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Gluteal compartment syndrome (GCS) is a rare but devastating condition with a paucity of literature to help guide diagnosis and management. This study aims to identify and describe the risk factors and patient characteristics associated with GCS to facilitate early diagnosis. METHODS This is a retrospective case series of patients undergoing gluteal compartment release between 2015 and 2022 at an academic Level I trauma center. Chart reviews were performed to extract data on patient demographics, presenting symptoms, risk factors, operative findings, and postoperative outcomes. RESULTS 14 cases of GCS were identified. 12 (85.7%) were male, with a mean age of 39.4 ± 13 years and a mean BMI of 25.1 ± 4.1 kg/m2. 12 (85.7%) patients did not present as traumas and only 3 had ≥ 1 fracture. 9 patients reported drug use. Hemoglobin (Hgb) (11.7 ± 4 g/dL) was generally low (5 had Hgb < 10 g/dL). Creatine kinase (49,617 ± 60,068 units/L) was consistently elevated in all cases, and lactate (2.8 ± 1.6 mmol/L) was elevated in 9. 13 had non-viable muscle requiring debridement. Postoperatively, the mean ICU length of stay was 12 ± 23 days. 2 patients died during admission and all remaining patients required discharge to rehabilitation facilities. CONCLUSION GCS is more likely to present in a young to middle-aged, otherwise healthy, male using drugs who is either found down or experienced an iatrogenic injury. Recognizing that GCS is different from that of the leg, in terms of etiology, may help avoid delays in diagnosis and treatment.
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Affiliation(s)
- Diane Ghanem
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, 21287, USA.
| | - Davis L Rogers
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Gregory Benes
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Brad Siler
- School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Gilberto Lobaton
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, 21287, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, 21287, USA
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Shu HT, Covarrubias O, Shah MM, Muquit ST, Yang VB, Zhao X, Kagabo W, Shou BL, Kalra A, Whitman G, Kim BS, Cho SM, LaPorte DM, Shafiq B. What Factors Are Associated With Arterial Line-Related Limb Ischemia in Patients on Extracorporeal Membrane Oxygenation? A Single-Center Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2023; 37:2489-2498. [PMID: 37735020 DOI: 10.1053/j.jvca.2023.08.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/27/2023] [Accepted: 08/14/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES The primary purpose of this study was to identify factors associated with the development of arterial line-related limb ischemia in patients on extracorporeal membrane oxygenation (ECMO). The authors also sought to characterize and report the outcomes of patients who developed arterial line-related limb ischemia. DESIGN Retrospective cohort study. SETTING A single academic tertiary referral ECMO center. PARTICIPANTS Consecutive patients who were treated with ECMO over 6 years. INTERVENTIONS Use of arterial line. MEASUREMENTS AND MAIN RESULTS A total of 278 consecutive ECMO patients were included, with 19 (7%) patients developing arterial line-related limb ischemia during the ECMO run. Postcannulation Sequential Organ Failure Assessment (SOFA) (adjusted odds ratio [aOR] 1.20, 95% CI 1.08-1.32), Acute Physiology and Chronic Health Evaluation-II (aOR 0.84, 95% CI 0.74-0.95), and adjusted Vasopressor Dose Equivalence (aOR 1.03, 95% CI 1.01-1.05) scores were independently associated with the development of arterial line-associated limb ischemia. A SOFA score of ≥17 at the time of ECMO cannulation had an 80% sensitivity and 87% specificity for predicting arterial line-related limb ischemia. CONCLUSIONS Arterial line-related limb ischemia is much more common in ECMO patients than in the typical intensive care unit setting. The SOFA score may be useful in identifying which patients may be at risk for arterial line-related limb ischemia. As this was a single-center retrospective study, these results are inherently exploratory, and prospective multicenter studies are necessary to validate these results.
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Affiliation(s)
- Henry T Shu
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Oscar Covarrubias
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Manuj M Shah
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Siam T Muquit
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor B Yang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiyu Zhao
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Whitney Kagabo
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dawn M LaPorte
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Babar Shafiq
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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McLaughlin KH, Archer KR, Shafiq B, Wegener ST, Reider L. Orthopedic surgeons and physical therapists differ regarding rehabilitative needs after lower extremity fracture repair. Physiother Theory Pract 2023; 39:2446-2453. [PMID: 35594136 PMCID: PMC9860373 DOI: 10.1080/09593985.2022.2078753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Little evidence is available to guide physical therapy (PT) following lower extremity fracture repair distal to the hip. As such, variability has been reported in the way PT is utilized post-operatively. Examination of current practice by orthopedic surgeons (OS) and physical therapists is needed to inform clinical practice guidelines in this area. OBJECTIVE To describe current PT referral practices among OS, identify patient and clinical factors that affect PT referral, and examine differences between OS and physical therapists with regard to visit frequency, duration, and use of specific PT interventions. METHODS Provider surveys. RESULTS Surveys were completed by 100 OS and 347 physical therapists. Over half (54%) of OS reported referring "most patients" to PT and identified joint stiffness and strength limitations as top reasons for PT referral. Over 80% of OS and physical therapists indicated that joint stiffness, strength limitations, and patients' functional goals affected their recommendations for PT visit frequency. More physical therapists than OS reported that pain severity (55% vs 25%, p < .001), maladaptive pain behaviors (64% vs. 33%, p < .001), and patient self-efficacy (70% vs. 49%, p = .003) affected their visit frequency recommendations. While OS recommended more frequent PT for patients with peri-articular fractures, fracture type had minimal impact on the visit frequencies recommended by physical therapists. CONCLUSION OS and physical therapists consider similar physical impairments when determining the need for PT and visit frequencies, however, physical therapists consider pain and psychosocial factors more often, with OS focusing more on injury type.
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Affiliation(s)
- Kevin H. McLaughlin
- Johns Hopkins University, School of Medicine, Department of Physical Medicine and Rehabilitation, 600 N. Wolfe Street, Baltimore, MD 21287
| | - Kristin R. Archer
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232
| | - Babar Shafiq
- Johns Hopkins University, School of Medicine, Department of Physical Medicine and Rehabilitation, 600 N. Wolfe Street, Baltimore, MD 21287
| | - Stephen T. Wegener
- Johns Hopkins University, School of Medicine, Department of Physical Medicine and Rehabilitation, 600 N. Wolfe Street, Baltimore, MD 21287
| | - Lisa Reider
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205
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Ghanem D, Covarrubias O, Raad M, LaPorte D, Shafiq B. ChatGPT Performs at the Level of a Third-Year Orthopaedic Surgery Resident on the Orthopaedic In-Training Examination. JB JS Open Access 2023; 8:e23.00103. [PMID: 38638869 PMCID: PMC11025881 DOI: 10.2106/jbjs.oa.23.00103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024] Open
Abstract
Introduction Publicly available AI language models such as ChatGPT have demonstrated utility in text generation and even problem-solving when provided with clear instructions. Amidst this transformative shift, the aim of this study is to assess ChatGPT's performance on the orthopaedic surgery in-training examination (OITE). Methods All 213 OITE 2021 web-based questions were retrieved from the AAOS-ResStudy website (https://www.aaos.org/education/examinations/ResStudy). Two independent reviewers copied and pasted the questions and response options into ChatGPT Plus (version 4.0) and recorded the generated answers. All media-containing questions were flagged and carefully examined. Twelve OITE media-containing questions that relied purely on images (clinical pictures, radiographs, MRIs, CT scans) and could not be rationalized from the clinical presentation were excluded. Cohen's Kappa coefficient was used to examine the agreement of ChatGPT-generated responses between reviewers. Descriptive statistics were used to summarize the performance (% correct) of ChatGPT Plus. The 2021 norm table was used to compare ChatGPT Plus' performance on the OITE to national orthopaedic surgery residents in that same year. Results A total of 201 questions were evaluated by ChatGPT Plus. Excellent agreement was observed between raters for the 201 ChatGPT-generated responses, with a Cohen's Kappa coefficient of 0.947. 45.8% (92/201) were media-containing questions. ChatGPT had an average overall score of 61.2% (123/201). Its score was 64.2% (70/109) on non-media questions. When compared to the performance of all national orthopaedic surgery residents in 2021, ChatGPT Plus performed at the level of an average PGY3. Discussion ChatGPT Plus is able to pass the OITE with an overall score of 61.2%, ranking at the level of a third-year orthopaedic surgery resident. It provided logical reasoning and justifications that may help residents improve their understanding of OITE cases and general orthopaedic principles. Further studies are still needed to examine their efficacy and impact on long-term learning and OITE/ABOS performance.
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Affiliation(s)
- Diane Ghanem
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Oscar Covarrubias
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Dawn LaPorte
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
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Shafiq B, Zhang B, Zhu D, Gupta DK, Cubberly M, Stepanyan H, Rezzadeh K, Lim PK, Hacquebord J, Gupta R. Reducing Complications in Pilon Fracture Surgery: Surgical Time Matters. J Orthop Trauma 2023; 37:532-538. [PMID: 37226911 DOI: 10.1097/bot.0000000000002637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To correlate patient-specific and surgeon-specific factors with outcomes after operative management of distal intra-articular tibia fractures. DESIGN Retrospective cohort study. SETTING 3 Level 1 tertiary academic trauma centers. PATIENTS/PARTICIPANTS The study included a consecutive series of 175 patients with OTA/AO 43-C pilon fractures. MAIN OUTCOME MEASUREMENTS Primary outcomes included superficial and deep infection. Secondary outcomes included nonunion, loss of articular reduction, and implant removal. RESULTS The following patient-specific factors correlated with poor surgical outcomes: increased age with superficial infection rate ( P < 0.05), smoking with rate of nonunion ( P < 0.05), and Charlson Comorbidity Index with loss of articular reduction ( P < 0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with the addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with an increased rate of implant removal, as did fibular plating. CONCLUSIONS While many of the patient-specific factors that negatively affect surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined because these may be addressed. Pilon fracture fixation has evolved to increasingly use fragment-specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection, while additional fibular plate fixation was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Bo Zhang
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Diana Zhu
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Deven K Gupta
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Mark Cubberly
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Hayk Stepanyan
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Kevin Rezzadeh
- Department of Orthopaedic Surgery, New York University Langone Health, New York, NY
| | - Philip K Lim
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
| | - Jacques Hacquebord
- Department of Orthopaedic Surgery, New York University Langone Health, New York, NY
| | - Ranjan Gupta
- Department of Orthopaedic Surgery, University of California, Irvine, CA; and
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Yang VB, Shu H, Shah MM, Zhao X, Muquit ST, Greenberg M, Whitman G, Cho SM, Kim BS, Shafiq B. Atraumatic Polycompartment Syndrome Secondary to Cardiogenic Shock: A Case Report. Cureus 2023; 15:e44519. [PMID: 37790054 PMCID: PMC10544627 DOI: 10.7759/cureus.44519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
We report the case of a 53-year-old male who developed polycompartment syndrome (PCS) secondary to cardiogenic shock. After suffering a cardiac arrest, a self-perpetuating cycle of intra-abdominal hypertension (IAH) and vital organ damage led to abdominal compartment syndrome (AbCS), which then contributed to the precipitation of extremity compartment syndrome (CS) in bilateral thighs, legs, forearms, and hands. This report is followed by a review of the literature regarding the pathophysiology of this rare sequela of cardiogenic shock. While the progression from cardiogenic shock to AbCS and ultimately to PCS has been hypothesized, no prior case reports demonstrate this. Furthermore, this case suggests more generally that IAH may be a risk factor for extremity CS. Future studies should examine the potential interplay between IAH and extremity CS in patients at risk, such as polytrauma patients with tibial fractures.
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Affiliation(s)
- Victor B Yang
- Critical Care, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Henry Shu
- Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Manuj M Shah
- General Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Xiyu Zhao
- Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Siam T Muquit
- Cardiology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Marc Greenberg
- Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Glenn Whitman
- Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Sung-Min Cho
- Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Bo Soo Kim
- Critical Care, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Babar Shafiq
- Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
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Shu HT, Cho SM, Harris AB, Jami M, Shou BL, Griffee MJ, Zaaqoq AM, Wilcox CJ, Anders M, Rycus P, Whitman G, Kim BS, Shafiq B. Is Fasciotomy Associated With Increased Mortality in Extracorporeal Cardiopulmonary Resuscitation? ASAIO J 2023; 69:795-801. [PMID: 37171978 DOI: 10.1097/mat.0000000000001969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
Our primary objective was to identify if fasciotomy was associated with increased mortality in patients who developed acute compartment syndrome (ACS) on extracorporeal cardiopulmonary resuscitation (ECPR). Additionally, we sought to identify any additional risk factors for mortality in these patients and report the amputation-free survival following fasciotomy. We retrospectively reviewed adult ECPR patients from the Extracorporeal Life Support Organization registry who were diagnosed with ACS between 2013 and 2021. Of 764 ECPR patients with limb complications, 127 patients (17%) with ACS were identified, of which 78 (63%) had fasciotomies, and 14 (11%) had amputations. Fasciotomy was associated with a 23% rate of amputation-free survival. There were no significant differences in demographics or baseline laboratory values between those with and without fasciotomy. Overall, 88 of 127 (69%) patients with ACS died. With or without fasciotomy, the mortality of ACS patients was similar, 68% vs. 71%. Multivariable logistic regression demonstrated that body mass index (BMI; adjusted odds ratio [aOR] = 1.22, 95% confidence interval [CI] = 1.01-1.48) and 24 hour mean blood pressure (BP; aOR = 0.93, 95% CI = 0.88-0.99) were independently associated with mortality. Fasciotomy was not an independent risk factor for mortality (aOR = 0.24, 95% CI = 0.03-1.88). The results of this study may help guide surgical decision-making for patients who develop ACS after ECPR. However, the retrospective nature of this study does not preclude selection bias in patients who have received fasciotomy. Thus, prospective studies are necessary to confirm these findings.
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Affiliation(s)
- Henry T Shu
- From the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew B Harris
- From the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Meghana Jami
- From the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J Griffee
- Department of Anesthesiology, University of Utah Health, Salt Lake City, Utah
| | - Akram M Zaaqoq
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC
| | - Christopher J Wilcox
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marc Anders
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Babar Shafiq
- From the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Shu HT, Yang VB, Badin D, Rogers DL, Covell MM, Osgood GM, Shafiq B. What Factors Are Associated With Delayed Wound Closure in Open Reduction and Internal Fixation of Adult Both-bone Forearm Fractures? Clin Orthop Relat Res 2023; 481:1388-1395. [PMID: 36722772 PMCID: PMC10263215 DOI: 10.1097/corr.0000000000002543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/06/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Delayed wound closure is often used after open reduction and internal fixation (ORIF) of both-bone forearm fractures to reduce the risk of skin necrosis and subsequent infection caused by excessive swelling. However, no studies we are aware of have evaluated factors associated with the use of delayed wound closure after ORIF. QUESTIONS/PURPOSES (1) What proportion of patients undergo delayed wound closure after ORIF of adult both-bone forearm fractures? (2) What factors are associated with delayed wound closure? METHODS The medical records of all patients who underwent ORIF with plate fixation for both-bone fractures by the adult orthopaedic trauma service at our institution were considered potentially eligible for analysis. Between January 2010 and April 2022, we treated 74 patients with ORIF for both-bone forearm fractures. Patients were excluded if they had fractures that were fixed more than 2 weeks from injury (six patients), if their fracture was treated with an intramedullary nail (one patient), or if the patient experienced compartment syndrome preoperatively (one patient). No patients with Gustilo-Anderson Type IIIB and C open fractures were included. Based on these criteria, 89% (66 of 74) of the patients were eligible. No further patients were excluded for loss of follow-up because the primary endpoint was the use of delayed wound closure, which was performed at the time of ORIF. However, one further patient was excluded for having bilateral forearm fractures to ensure that each patient had a single fracture for statistical analysis. Thus, 88% (65 of 74) of patients were included in the analysis. These patients were captured by an electronic medical record search of CPT code 25575. The mean ± SD age was 34 ± 15 years and mean BMI was 28 ± 7 kg/m 2 . The mean follow-up duration was 4 ± 5 months. The primary endpoint was the use of delayed wound closure, which was determined at the time of definitive fixation if tension-free closure could not be achieved. All surgeons used a volar Henry or modified Henry approach and a dorsal subcutaneous approach to the ulna for ORIF. Univariate logistic regression was used to identify which factors might be associated with delayed wound closure. A multivariable logistic regression analysis was then performed for male gender, open fractures, age, and BMI. RESULTS Twenty percent (13 of 65) of patients underwent delayed wound closure, 18% (12 of 65) of which occurred in patients who had high-energy injuries and 14% (nine of 65) in patients who had open fractures. Being a man (adjusted odds ratio 9.9 [95% confidence interval 1 to 87]; p = 0.04) was independently associated with delayed wound closure, after adjusting for open fractures, age, and BMI. CONCLUSION One of five patients had delayed wound closure after ORIF of both-bone forearm fractures. Being a man was independently associated with greater odds of delayed wound closure. Surgeons should counsel all patients with these fractures about the possibility of delayed wound closure, with particular attention to men with high-energy and open fractures. Future larger-scale studies are necessary to confirm which factors are associated with the use of delayed wound closure in ORIF of both-bone fractures and its effects on fracture healing. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Henry T. Shu
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Victor B. Yang
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Daniel Badin
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Davis L. Rogers
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Greg M. Osgood
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Doermann A, Gupta DK, Wright DJ, Shafiq B, Hacquebord J, Rafijah G, Lim PK, Gupta R. Distal Radius Fracture Management: Surgeon Factors Markedly Influence Decision Making. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202303000-00001. [PMID: 36867522 PMCID: PMC9984156 DOI: 10.5435/jaaosglobal-d-23-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/06/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION It is our hypothesis that physician-specific variables affect the management of distal radius (DR) fractures in addition to patient-specific factors. METHODS A prospective cohort study was conducted evaluating treatment differences between Certificate of Additional Qualification hand surgeons (CAQh) and board-certified orthopaedic surgeons who treat patients at level 1 or level 2 trauma centers (non-CAQh). After institutional review board approval, 30 DR fractures were selected and classified (15 AO/OTA type A and B and 15 AO/OTA type C) to create a standardized patient data set. The patient-specific demographics and surgeon's information regarding the volume of DR fractures treated per year, practice setting, and years posttraining were obtained. Statistical analysis was done using chi-square analysis with a postanalysis regression model. RESULTS A notable difference was observed between CAQh and non-CAQh surgeons. Surgeons in practice longer than 10 years or who treat >100 DR fractures/year were more likely to choose surgical intervention and obtain a preoperative CT scan. The two most influential factors in decision making were the patients' age and medical comorbidities, with physician-specific factors being the third most influential in medical decision making. DISCUSSION Physician-specific variables have a notable effect on decision making and are critical for the development of consistent treatment algorithms for DR fractures.
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Vijayan RC, Venkataraman K, Wei J, Sheth NM, Shafiq B, Siewerdsen JH, Zbijewski W, Li G, Cleary K, Uneri A. Multi-Body 3D-2D Registration for Robot-Assisted Joint Reduction: Preclinical Evaluation in the Ankle Syndesmosis. Proc SPIE Int Soc Opt Eng 2023; 12466:124661F. [PMID: 37143861 PMCID: PMC10155864 DOI: 10.1117/12.2654481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Purpose Existing methods to improve the accuracy of tibiofibular joint reduction present workflow challenges, high radiation exposure, and a lack of accuracy and precision, leading to poor surgical outcomes. To address these limitations, we propose a method to perform robot-assisted joint reduction using intraoperative imaging to align the dislocated fibula to a target pose relative to the tibia. Methods The approach (1) localizes the robot via 3D-2D registration of a custom plate adapter attached to its end effector, (2) localizes the tibia and fibula using multi-body 3D-2D registration, and (3) drives the robot to reduce the dislocated fibula according to the target plan. The custom robot adapter was designed to interface directly with the fibular plate while presenting radiographic features to aid registration. Registration accuracy was evaluated on a cadaveric ankle specimen, and the feasibility of robotic guidance was assessed by manipulating a dislocated fibula in a cadaver ankle. Results Using standard AP and mortise radiographic views registration errors were measured to be less than 1 mm and 1° for the robot adapter and the ankle bones. Experiments in a cadaveric specimen revealed up to 4 mm deviations from the intended path, which was reduced to <2 mm using corrective actions guided by intraoperative imaging and 3D-2D registration. Conclusions Preclinical studies suggest that significant robot flex and tibial motion occur during fibula manipulation, motivating the use of the proposed method to dynamically correct the robot trajectory. Accurate robot registration was achieved via the use of fiducials embedded within the custom design. Future work will evaluate the approach on a custom radiolucent robot design currently under construction and verify the solution on additional cadaveric specimens.
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Affiliation(s)
- R. C. Vijayan
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore MD
| | - K. Venkataraman
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore MD
| | - J. Wei
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore MD
| | - N. M. Sheth
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore MD
| | - B. Shafiq
- Department of Orthopedic Surgery, Johns Hopkins Medicine, Baltimore MD
| | - J. H. Siewerdsen
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore MD
- Department of Imaging Physics, The University of Texas M. D. Anderson Cancer Center, Houston TX
| | - W. Zbijewski
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore MD
| | - G. Li
- Children’s National Hospital, Washington DC
| | - K. Cleary
- Children’s National Hospital, Washington DC
| | - A. Uneri
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore MD
- ; phone: +1-276-614-7743; website: carnegie.jhu.edu
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14
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Gupta R, Jung J, Johnston TR, Wright DJ, Uong J, Lim PK, Shafiq B, Navarro RA. Surgeon-Specific Factors Have a Larger Impact on Decision-Making for the Management of Proximal Humerus Fractures than Patient-Specific Factors: A Prospective Cohort Study. J Shoulder Elbow Surg 2023:S1058-2746(23)00025-3. [PMID: 36690172 DOI: 10.1016/j.jse.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is significant variability both in how proximal humerus fractures (PHFs) are treated and the ensuing patient outcomes. The purpose of this study was to investigate which surgeon- and patient-specific factors contribute to decision-making in the treatment of adult PHFs. We hypothesized that orthopedic sub-specialty training creates inherent bias and plays an important role in management algorithms for PHFs. METHODS We performed a prospective cohort investigation in two groups of surgeons - traumatologists (N=25) and shoulder & elbow/sports surgeons (SES) (N=26) - and asked them to provide treatment recommendations for 30 distinct clinical cases with standardized radiographic and clinical data. This is a population-based sample of surgeons who take trauma call and treat PHFs with different sub-specializations and practice settings including academic, hospital-employed, and private. Surgeons characterized based on subspecialty (trauma vs. SES), experience level (>10 vs. ≤10-years), and employment type (hospital- vs. non-hospital-employed). Chi-square analyses, logistic mixed-effects modeling, and relative importance analysis were used to evaluate the data. RESULTS Of the patient-specific factors, we found that the management of PHFs is largely dependent on initial radiographs obtained. Traumatologists were more likely to offer open reduction internal fixation (ORIF) and less likely to offer arthroplasty: 69% ORIF (traumatologists) versus 51% ORIF (SES, p<0.001), 8% arthroplasty (traumatologists) versus 17% (SES, p<0.001). Traumatologists were less likely to change from operative (either ORIF or arthroplasty) to non-operative management compared to SES surgeons when presented with additional patient demographic data. Surgeon-specific factors contributed to more than one-half of the variability in decision-making of PHF management while patient-specific factors contributed to about one-third of the variability in decision-making. CONCLUSIONS As physicians strive to advance the treatment for PHFs and optimize patient outcomes, our findings highlight the complex overlap between surgeon-, fracture-, and patient-specific factors in the final decision-making process.
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Affiliation(s)
- Ranjan Gupta
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA.
| | - James Jung
- Department of Orthopaedic Surgery, Kaiser Permanente- Pasadena, CA, USA
| | - Tyler R Johnston
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA
| | - David J Wright
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA
| | - Jennifer Uong
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA
| | - Philip K Lim
- Department of Orthopaedic Surgery, University of California, Irvine-Irvine, CA, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins University- Baltimore, MD, USA
| | - Ronald A Navarro
- Department of Orthopaedic Surgery, Kaiser Permanente- Pasadena, CA, USA
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MacKenzie JS, Suresh KV, Margalit A, Shafiq B, Zirkle L, Ficke J. Rate of Tibiotalocalcaneal (TTC) Fusion Using the Surgical Implant Generation Network (SIGN) Intramedullary Nail in Developing Countries. J Surg Orthop Adv 2023; 32:187-192. [PMID: 38252607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Outcomes of the Surgical Implant Generation Network (SIGN) nail have been reported for femur and tibial fractures, but its use in tibiotalocalcaneal arthrodesis (TTCA) is not well studied. Radiographic and clinical outcomes of TTCA using the SIGN database in patients with > 6 months of radiographic follow up were analyzed. Rates of tibiotalar (TT) fusion and subtalar (ST) fusion at final follow up were assessed by two independent reviewers. Of the 62 patients identified, use of the SIGN nail for TCCA resulted in 53% rate of fusion in the TT joint and 20% in the ST joint. Thirty-seven patients (60%) demonstrated painless weight bearing at final follow up. There were no differences in incidence of painless weight bearing between consensus fused and not fused cohorts for TT and ST joints (p > 0.05). There were five implant failures, no cases of infection, and seven cases of reoperation. (Journal of Surgical Orthopaedic Advances 32(3):187-192, 2023).
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Affiliation(s)
- James S MacKenzie
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Krishna V Suresh
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam Margalit
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lewis Zirkle
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James Ficke
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Xu AL, Raad M, Shafiq B, Srikumaran U, Aiyer AA. Racial Disparities in Early Adverse Events and Unplanned Readmission after Open Fixation of Below- Knee Fractures. Foot & Ankle Orthopaedics 2022. [DOI: 10.1177/2473011421s01007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Category: Trauma; Ankle; Hindfoot; Other Introduction/Purpose: Race-based differences in the surgical management of hip fractures are well-established. Studies assessing these disparities for below-knee fractures have yet to be conducted despite their high volume. Our purpose was to determine whether 1) early postoperative complications and 2) time to surgery for operative fixation of below-knee fractures differ for black versus white patients, and to assess whether disparities exist between fracture subtypes. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients (>=18 years) undergoing open fixation of below-knee fractures between 2010-2019. This yielded 9,172 patients; 1,120 (12%) were black. We collected patient demographics and preoperative risk factors. Primary outcomes were 30-day postoperative complications and time to surgical fixation. Fractures were further subclassified as tibia and/or fibula shaft, isolated malleolar, bi/trimalleolar, and pilon fractures. Nearest-neighbor propensity score matching in a 1:1 ratio was applied to compare outcomes by race. Alpha = 0.05. Results: After matching, we identified 1,120 white patients with equal propensity scores as our black patients. Black patients had 1.5 times higher odds (95% confidence interval [CI]: 1.0-2.0) of experiencing any early adverse event when compared with matched white counterparts. Blacks also had 1.9 times higher odds (95% CI: 1.2-3.0) of requiring unplanned readmission within 30 days of operative fixation. Fifty-eight black patients (5.3%) required short-term readmission, compared with 351 white patients (4.5%) - 32 (2.9%) in the matched cohort. The most common reasons for readmission were wound, gastrointestinal, thromboembolic, and recurrent musculoskeletal complications for both races. There were no significant differences by race in time to surgery. Fracture subtype was not associated with postoperative complications or time to surgery in the multivariable analysis. Conclusion: Racial disparities in the early postoperative course after open fixation of below-knee fractures exist, with significantly higher rates of early adverse events and unplanned readmission for black versus white patients that persist after propensity matching. These trends may be secondary to a host of community- and hospital-level factors, illustrating the importance of interventions that consider the differences between hip and non-hip fractures and increase resources to vulnerable areas.
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17
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Rezzadeh K, Zhang B, Zhu D, Cubberly M, Stepanyan H, Shafiq B, Lim P, Gupta R, Hacquebord J, Egol K. Is Psychiatric Illness Associated With Worse Outcomes Following Pilon Fracture? Iowa Orthop J 2022; 42:63-68. [PMID: 35821955 PMCID: PMC9210398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Patients with psychiatric comorbidities represent a significant subset of those sustaining pilon fractures. The purpose of this study is to examine the association of psychiatric comorbidities (PC) in patients with pilon fractures and clinical outcomes. METHODS A multi-institution, retrospective review was conducted. Inclusion/exclusion criteria were skeletally mature patients with a tibia pilon fracture (OTA Type 43B/C) who underwent definitive fracture fixation utilizing open reduction internal fixation (ORIF) with a minimum of 24 weeks of follow-up. Patients were stratified into two groups for comparison: PC group and no PC group. RESULTS There were 103 patients with pilon fractures that met the inclusion/exclusion criteria of this study. Of these patients, 22 (21.4%) had at least one psychiatric comorbidity (PC) and 81 (78.6%) did not have psychiatric comorbidities (no PC). There was a higher percentage of female patients (PC: 59.1% vs no PC: 25.9%, p=0.0.005), smokers (PC: 40.9% vs no PC: 16.0%, p=0.02), and drug users (PC: 22.7% vs no PC: 8.6%, p=0.08) amongst PC patients. Fracture comminution (PC: 54.5% vs no PC: 32.1%, p=0.05) occurred more frequently in PC patients. The PC group had a higher incidence of weightbearing noncompliance (22.7% vs 7.5%, p=0.04) and reoperation (PC: 54.5% vs no PC: 29.6%, p=0.03). CONCLUSION Patients with psychiatric comorbidities represent a significant percentage of pilon fracture patients and appear to be at higher risk for postoperative complication. Risk factors that may predispose patients in the PC group include smoking/substance use, weightbearing noncompliance, and fracture comminution. Level of Evidence: III.
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Affiliation(s)
- Kevin Rezzadeh
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Bo Zhang
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Diana Zhu
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mark Cubberly
- Department of Orthopaedic Surgery, UC Irvine Medical Center, Orange, California, USA
| | - Hayk Stepanyan
- Department of Orthopaedic Surgery, UC Irvine Medical Center, Orange, California, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Phillip Lim
- Department of Orthopaedic Surgery, UC Irvine Medical Center, Orange, California, USA
| | - Ranjan Gupta
- Department of Orthopaedic Surgery, UC Irvine Medical Center, Orange, California, USA
| | - Jacques Hacquebord
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York, USA
| | - Kenneth Egol
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York, USA
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Abstract
BACKGROUND Studies have shown conflicting results regarding associations of preoperative comorbidities with outcomes after total ankle arthroplasty (TAA). Our aim was to analyze preoperative risk factors for complications, longer hospital stay, and readmission within 30 days after TAA. METHODS We conducted a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. We included 294 patients who underwent TAA from 2009 through 2012. We used multivariate logistic regression to identify risk factors for complications, longer hospital stay, and hospital readmission. RESULTS Surgical site infection was the most common complication. Diabetes was associated with greater odds of complications as was current smoker status. Notably, obesity was not associated with greater odds of complications. Age, chronic obstructive pulmonary disease, and diabetes mellitus were associated with longer hospital stays. Surgical site infection was the most common reason for hospital readmission. CONCLUSIONS TAA has a low complication rate, with surgical site infection being the most common complication and the most common reason for hospital readmission. Patients with diabetes have greater odds of poor outcomes and prolonged hospital stays after TAA than patients without diabetes. Obesity was not associated with poor outcomes after TAA. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland (MJB, BS, JRF).,Department of Urological Surgery, University of California, Sacramento, California (SN)
| | - Son Nguyen
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland (MJB, BS, JRF).,Department of Urological Surgery, University of California, Sacramento, California (SN)
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland (MJB, BS, JRF).,Department of Urological Surgery, University of California, Sacramento, California (SN)
| | - James R Ficke
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland (MJB, BS, JRF).,Department of Urological Surgery, University of California, Sacramento, California (SN)
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19
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Hsu MR, Shu HT, Luksameearunothai K, Margalit A, Yu AT, Hasenboehler EA, Shafiq B. Is there an increased risk for subtrochanteric stress fracture with the Femoral Neck System versus multiple cannulated screws fixation? J Orthop 2022; 30:127-133. [PMID: 35280450 PMCID: PMC8907549 DOI: 10.1016/j.jor.2022.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/14/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose This study sought to compare the risk of subtrochanteric stress-riser fractures and biomechanical stability of the Femoral Neck System (FNS) versus multiple screw fixation (MSF). Methods Eight paired cadaveric femurs were randomly assigned to FNS or MSF. Physiologic load mimicking single leg stance at the subtrochanteric region was applied to the constructs. Results No constructs failed in the subtrochanteric region during loading. There was no significant difference in force (P = 0.364) or loading cycles (P = 0.348) between groups. Conclusion FNS constructs were not associated with an increased incidence of iatrogenic subtrochanteric fractures or biomechanical stability versus MSF.
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Affiliation(s)
- Megan R. Hsu
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Henry T. Shu
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Kitchai Luksameearunothai
- Department of Orthopaedic Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Adam Margalit
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Andrew T. Yu
- Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
| | | | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA,Corresponding author. Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N Caroline St 5th floor, Baltimore, MD, 21205, USA.
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20
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Thamyongkit S, Abbasi P, Parks BG, Shafiq B, Hasenboehler EA. Weightbearing after combined medial and lateral plate fixation of AO/OTA 41-C2 bicondylar tibial plateau fractures: a biomechanical study. BMC Musculoskelet Disord 2022; 23:86. [PMID: 35078451 PMCID: PMC8790864 DOI: 10.1186/s12891-022-05024-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022] Open
Abstract
Background Combined medial and lateral plate fixation is recommended for complex tibial plateau fractures with medial fragments or no cortical bone contact. Although such fixation is adequate to resist forces during range of motion, it may be insufficient to support immediate postoperative weightbearing. Here, we analyzed displacement, stiffness, and fixation failure during simulated full weightbearing of bicondylar tibial plateau fractures treated with combined medial and lateral locking plate fixation. Methods We used 10 fresh-frozen adult human cadaveric tibias and mated femurs. Osteotomies were performed with an oscillating saw and cutting template to simulate an AO Foundation and Orthopaedic Trauma Association (AO/OTA) 41-C2 fracture (simple articular, multifragmentary metaphyseal fracture). Specimens were anatomically reduced and stabilized with combined medial and lateral locking plates (AxSOS, Stryker, Mahwah, NJ). Specimens were loaded axially to simulate 4 weeks of walking in a person weighing 70 kg. The specimens were cyclically loaded from 200 N to a maximum of 2800 N. Then, if no failure, loading continued for 200,000 cycles. We measured displacement of each bone fragment and defined fixation failure as ≥5 mm of displacement. Construct stiffness and load at failure were calculated. Categorical and continuous data were analyzed using Chi-squared and unpaired t-tests, respectively. Results Mean total displacement values after 10,000 loading cycles were as follows: lateral, 0.4 ± 0.8 mm; proximal medial, 0.3 ± 0.7 mm; distal medial, 0.3 ± 0.6 mm; and central 0.4 ± 0.5 mm. Mean stiffness of the construct was 562 ± 164 N/mm. Fixation failure occurred in 6 of 10 specimens that reached 5 mm of plastic deformation before test completion. In the failure group, the mean load at failure was 2467 ± 532 N, and the mean number of cycles before failure was 53,155. After test completion, the greatest displacement was found at the distal medial fracture site (2.3 ± 1.4 mm) and lateral fracture site (2.2 ± 1.7 mm). Conclusions Although combined medial and lateral plate fixation of complex tibial plateau fractures provides adequate stability to allow early range of motion, immediate full weightbearing is not recommended.
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Affiliation(s)
- Sorawut Thamyongkit
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA.,Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan, Thailand
| | - Pooyan Abbasi
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Brent G Parks
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA.
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Shu HT, Mikula JD, Yu AT, Shafiq B. Tranexamic acid use in pelvic and/or acetabular fracture surgery: A systematic review and meta-analysis. J Orthop 2021; 28:112-116. [PMID: 34924726 DOI: 10.1016/j.jor.2021.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/28/2021] [Indexed: 01/28/2023] Open
Abstract
Purpose The purpose of this study is to determine whether tranexamic acid (TXA) use was associated with lower rates of blood transfusion in patients undergoing pelvic and/or acetabular fracture surgery. Methods Four studies were included, 3 of which were included in the pooled data analysis for a total of 308 patients. Results The transfusion rate was significantly lower in the TXA group (44%) compared with the non-TXA group (57%) (P = 0.02). Conclusion TXA use was associated with a significantly lower transfusion rate in patients who underwent pelvic and/or acetabular fracture surgery. Level of evidence Level 3. Systematic review of retrospective cohort studies and prospective randomized controlled trials.
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Affiliation(s)
- Henry T Shu
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Jacob D Mikula
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Andrew T Yu
- Department of Neurology, The Johns Hopkins University, Baltimore, MD, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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22
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Gordon O, Lee DE, Liu B, Langevin B, Ordonez AA, Dikeman DA, Shafiq B, Thompson JM, Sponseller PD, Flavahan K, Lodge MA, Rowe SP, Dannals RF, Ruiz-Bedoya CA, Read TD, Peloquin CA, Archer NK, Miller LS, Davis KM, Gobburu JVS, Jain SK. Dynamic PET-facilitated modeling and high-dose rifampin regimens for Staphylococcus aureus orthopedic implant-associated infections. Sci Transl Med 2021; 13:eabl6851. [PMID: 34851697 PMCID: PMC8693472 DOI: 10.1126/scitranslmed.abl6851] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Staphylococcus aureus is a major human pathogen causing serious implant–associated infections. Combination treatment with rifampin (10 to 15 mg/kg per day), which has dose-dependent activity, is recommended to treat S. aureus orthopedic implant–associated infections. Rifampin, however, has limited bone penetration. Here, dynamic 11C-rifampin positron emission tomography (PET) performed in prospectively enrolled patients with confirmed S. aureus bone infection (n = 3) or without orthopedic infection (n = 12) demonstrated bone/plasma area under the concentration-time curve ratio of 0.14 (interquartile range, 0.09 to 0.19), exposures lower than previously thought. PET-based pharmacokinetic modeling predicted rifampin concentration-time profiles in bone and facilitated studies in a mouse model of S. aureus orthopedic implant infection. Administration of high-dose rifampin (human equipotent to 35 mg/kg per day) substantially increased bone concentrations (2 mg/liter versus <0.2 mg/liter with standard dosing) in mice and achieved higher bacterial killing and biofilm disruption. Treatment for 4 weeks with high-dose rifampin and vancomycin was noninferior to the recommended 6-week treatment of standard-dose rifampin with vancomycin in mice (risk difference, −6.7% favoring high-dose rifampin regimen). High-dose rifampin treatment ameliorated antimicrobial resistance (0% versus 38%; P = 0.04) and mitigated adverse bone remodeling (P < 0.01). Last, whole-genome sequencing demonstrated that administration of high-dose rifampin in mice reduced selection of bacterial mutations conferring rifampin resistance (rpoB) and mutations in genes potentially linked to persistence. These data suggest that administration of high-dose rifampin is necessary to achieve optimal bone concentrations, which could shorten and improve treatments for S. aureus orthopedic implant infections.
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Affiliation(s)
- Oren Gordon
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Donald E. Lee
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Bessie Liu
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Brooke Langevin
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Alvaro A. Ordonez
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Dustin A. Dikeman
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Babar Shafiq
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - John M. Thompson
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Paul D. Sponseller
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Kelly Flavahan
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Martin A. Lodge
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Steven P. Rowe
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Robert F. Dannals
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Camilo A. Ruiz-Bedoya
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Timothy D. Read
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL 32610, USA
| | - Nathan K. Archer
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lloyd S. Miller
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Immunology, Janssen Research and Development, Spring House, PA 19477, USA
| | - Kimberly M. Davis
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Jogarao V. S. Gobburu
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA
| | - Sanjay K. Jain
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Division of Nuclear Medicine and Molecular Imaging, Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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23
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Rogers D, Raad M, Srikumaran U, Shafiq B. Proximal Humerus Fracture-Open Reduction Internal Fixation With an Expandable Intramedullary Nitinol Scaffold. J Orthop Trauma 2021; 35:S1-S2. [PMID: 34227586 DOI: 10.1097/bot.0000000000002177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY For the treatment of proximal humerus fractures, the intramedullary nitinol scaffold is a novel implant that has gained popularity and demonstrated promising 1-year outcomes as an alternative to bone grafting for providing intramedullary structural support to the humeral head. The aim of this video is to demonstrate the insertion of this device safely, while highlighting potential pitfalls, in a 67-year-old patient with a displaced, varus angulated 2-part proximal humerus fracture.
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Affiliation(s)
- Davis Rogers
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD
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24
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Shu HT, Elhessy AH, Conway JD, Burnett AL, Shafiq B. Orthopedic management of pubic symphysis osteomyelitis: a case series. J Bone Jt Infect 2021; 6:273-281. [PMID: 34345575 PMCID: PMC8320518 DOI: 10.5194/jbji-6-273-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/04/2021] [Indexed: 01/21/2023] Open
Abstract
Objectives: The purpose of this case series is to describe the orthopedic
management of pubic symphysis osteomyelitis with an emphasis on the key
principles of treating bony infection. Furthermore, we sought to identify whether debridement of the pubic symphysis without subsequent internal fixation
would result in pelvic instability.
Methods: A retrospective chart review was performed to identify all cases of
pubic symphysis osteomyelitis treated at both institutions from 2011 to 2020. Objective outcomes collected included infection recurrence, change in pubic
symphysis diastasis, sacroiliac (SI) joint diastasis, and ambulatory status.
Subjective outcome measures collected included the numeric pain rating scale
(NPRS) and the 36-Item Short Form Survey (SF-36). Pubic symphysis diastasis
was measured as the distance between the two superior tips of the pubis on a
standard anterior–posterior (AP) view of the pelvis. SI joint diastasis was measured bilaterally as the joint space between the ileum and sacrum
approximately at the level of the sacral promontory on the inlet view of the
pelvis. A paired t test was utilized to compare the differences in outcome measures. An α value of 0.05 was utilized. Results: Six patients were identified, of which five were males and one was
female (16.7 %), with a mean ± standard deviation (SD) follow-up of 19 ± 12 months (range 6–37 months). Mean ± SD age was 76.2 ± 9.6 years (range 61.0–88.0 years) and body mass index (BMI) was 28.0 ± 2.9 kg/m2 (range 23.0–30.8 kg/m2). When postoperative
radiographs were compared to final follow-up radiographs, there were no
significant differences in pubic symphysis diastasis (P = 0.221) or SI
joint diastasis (right, P = 0.529 and left, P = 0.186). All patients were ambulatory without infection recurrence at final follow-up. Mean improvement
for NPRS was 5.6 ± 3.4 (P = 0.020) and mean improvement for SF-36
physical functioning was 53.0 ± 36.8 (P = 0.032).
Conclusion: This case series highlights our treatment strategy for pubic
symphysis osteomyelitis of aggressive local debridement with local
antibiotic therapy. Additionally, debridement of the pubic symphysis without
subsequent internal fixation did not result in pelvic instability, as
determined by pelvic radiographs and ability to fully weight bear postoperatively.
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Affiliation(s)
- Henry T Shu
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ahmed H Elhessy
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopaedics, Sinai Hospital, Baltimore, MD, USA
| | - Janet D Conway
- International Center for Limb Lengthening, Rubin Institute for Advanced Orthopaedics, Sinai Hospital, Baltimore, MD, USA
| | - Arthur L Burnett
- Department of Urology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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25
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O'Toole RV, Joshi M, Carlini AR, Murray CK, Allen LE, Huang Y, Scharfstein DO, O'Hara NN, Gary JL, Bosse MJ, Castillo RC, Bishop JA, Weaver MJ, Firoozabadi R, Hsu JR, Karunakar MA, Seymour RB, Sims SH, Churchill C, Brennan ML, Gonzales G, Reilly RM, Zura RD, Howes CR, Mir HR, Wagstrom EA, Westberg J, Gaski GE, Kempton LB, Natoli RM, Sorkin AT, Virkus WW, Hill LC, Hymes RA, Holzman M, Malekzadeh AS, Schulman JE, Ramsey L, Cuff JAN, Haaser S, Osgood GM, Shafiq B, Laljani V, Lee OC, Krause PC, Rowe CJ, Hilliard CL, Morandi MM, Mullins A, Achor TS, Choo AM, Munz JW, Boutte SJ, Vallier HA, Breslin MA, Frisch HM, Kaufman AM, Large TM, LeCroy CM, Riggsbee C, Smith CS, Crickard CV, Phieffer LS, Sheridan E, Jones CB, Sietsema DL, Reid JS, Ringenbach K, Hayda R, Evans AR, Crisco MJ, Rivera JC, Osborn PM, Kimmel J, Stawicki SP, Nwachuku CO, Wojda TR, Rehman S, Donnelly JM, Caroom C, Jenkins MD, Boulton CL, Costales TG, LeBrun CT, Manson TT, Mascarenhas DC, Nascone JW, Pollak AN, Sciadini MF, Slobogean GP, Berger PZ, Connelly DW, Degani Y, Howe AL, Marinos DP, Montalvo RN, Reahl GB, Schoonover CD, Schroder LK, Vang S, Bergin PF, Graves ML, Russell GV, Spitler CA, Hydrick JM, Teague D, Ertl W, Hickerson LE, Moloney GB, Weinlein JC, Zelle BA, Agarwal A, Karia RA, Sathy AK, Au B, Maroto M, Sanders D, Higgins TF, Haller JM, Rothberg DL, Weiss DB, Yarboro SR, McVey ED, Lester-Ballard V, Goodspeed D, Lang GJ, Whiting PS, Siy AB, Obremskey WT, Jahangir AA, Attum B, Burgos EJ, Molina CS, Rodriguez-Buitrago A, Gajari V, Trochez KM, Halvorson JJ, Miller AN, Goodman JB, Holden MB, McAndrew CM, Gardner MJ, Ricci WM, Spraggs-Hughes A, Collins SC, Taylor TJ, Zadnik M. Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial. JAMA Surg 2021; 156:e207259. [PMID: 33760010 DOI: 10.1001/jamasurg.2020.7259] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration ClinicalTrials.gov Identifier: NCT02227446.
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Affiliation(s)
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Manjari Joshi
- Department of Infectious Diseases, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Anthony R Carlini
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Clinton K Murray
- Department of Medicine, San Antonio Military Medical Center, San Antonio, Texas
| | - Lauren E Allen
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yanjie Huang
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel O Scharfstein
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Joshua L Gary
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Michael J Bosse
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Renan C Castillo
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Julius A Bishop
- Department of Orthopaedic Surgery, Stanford University, Palo Alto, California
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center/University of Washington, Seattle
| | - Joseph R Hsu
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Madhav A Karunakar
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Rachel B Seymour
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Stephen H Sims
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Christine Churchill
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael L Brennan
- Department of Orthopaedic Surgery, Baylor Scott and White Memorial Center, Temple, Texas
| | - Gabriela Gonzales
- Department of Orthopaedic Surgery, Baylor Scott and White Memorial Center, Temple, Texas
| | - Rachel M Reilly
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Robert D Zura
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Cameron R Howes
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Hassan R Mir
- Florida Orthopaedic Institute/Tampa General Hospital, Tampa
| | - Emily A Wagstrom
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Jerald Westberg
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Greg E Gaski
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Laurence B Kempton
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Anthony T Sorkin
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Walter W Virkus
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Lauren C Hill
- Department of Orthopaedic Surgery, Indiana University Methodist Hospital, Indianapolis
| | - Robert A Hymes
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Michael Holzman
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - A Stephen Malekzadeh
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Jeff E Schulman
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Lolita Ramsey
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Jaslynn A N Cuff
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Sharon Haaser
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Fairfax, Virginia
| | - Greg M Osgood
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Vaishali Laljani
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Olivia C Lee
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Peter C Krause
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Cara J Rowe
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Colette L Hilliard
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans
| | - Massimo Max Morandi
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, Shreveport
| | - Angela Mullins
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, Shreveport
| | - Timothy S Achor
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Andrew M Choo
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - John W Munz
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | - Sterling J Boutte
- Department of Orthopedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston
| | | | - Mary A Breslin
- Department of Orthopaedics, MetroHealth, Cleveland, Ohio
| | - H Michael Frisch
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | - Adam M Kaufman
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | - Thomas M Large
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | - C Michael LeCroy
- Orthopaedic Trauma Service, Mission Health, Asheville, North Carolina
| | | | - Christopher S Smith
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Colin V Crickard
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Laura S Phieffer
- Department of Orthopaedics, Ohio State University, Wexner Medical Center, Columbus
| | - Elizabeth Sheridan
- Department of Orthopaedics, Ohio State University, Wexner Medical Center, Columbus
| | | | | | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Penn State Health, Hershey, Pennsylvania
| | - Kathy Ringenbach
- Department of Orthopaedics and Rehabilitation, Penn State Health, Hershey, Pennsylvania
| | - Roman Hayda
- Department of Orthopedic Surgery, Brown University/Rhode Island Hospital, Providence
| | - Andrew R Evans
- Department of Orthopedic Surgery, Brown University/Rhode Island Hospital, Providence
| | - M J Crisco
- Department of Orthopedic Surgery, Brown University/Rhode Island Hospital, Providence
| | - Jessica C Rivera
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Patrick M Osborn
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Joseph Kimmel
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, Texas
| | - Stanislaw P Stawicki
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Chinenye O Nwachuku
- Department of Orthopedic Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Thomas R Wojda
- Department of Family Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - Saqib Rehman
- Department of Orthopaedic Surgery and Sports Medicine, Temple University, Philadelphia, Pennsylvania
| | - Joanne M Donnelly
- Department of Orthopaedic Surgery and Sports Medicine, Temple University, Philadelphia, Pennsylvania
| | - Cyrus Caroom
- Department of Orthopaedics, Texas Tech University Health Sciences Center, Lubbock
| | - Mark D Jenkins
- Department of Orthopaedics, Texas Tech University Health Sciences Center, Lubbock
| | - Christina L Boulton
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Timothy G Costales
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Christopher T LeBrun
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Theodore T Manson
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Daniel C Mascarenhas
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Jason W Nascone
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Andrew N Pollak
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Marcus F Sciadini
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Gerard P Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Peter Z Berger
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Daniel W Connelly
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Yasmin Degani
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Andrea L Howe
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Dimitrius P Marinos
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Ryan N Montalvo
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - G Bradley Reahl
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Carrie D Schoonover
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Lisa K Schroder
- Department of Orthopaedic Surgery, University of Minnesota-Regions Hospital, St Paul
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota-Regions Hospital, St Paul
| | - Patrick F Bergin
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - Matt L Graves
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - George V Russell
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - Clay A Spitler
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - Josie M Hydrick
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson
| | - David Teague
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City
| | - William Ertl
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City
| | - Lindsay E Hickerson
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City
| | - Gele B Moloney
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John C Weinlein
- Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis
| | - Boris A Zelle
- Department of Orthopaedics, University of Texas Health at San Antonio, San Antonio
| | - Animesh Agarwal
- Department of Orthopaedics, University of Texas Health at San Antonio, San Antonio
| | - Ravi A Karia
- Department of Orthopaedics, University of Texas Health at San Antonio, San Antonio
| | - Ashoke K Sathy
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Brigham Au
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Medardo Maroto
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Drew Sanders
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas
| | | | - Justin M Haller
- Department of Orthopaedics, University of Utah, Salt Lake City
| | | | - David B Weiss
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - Eric D McVey
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - Veronica Lester-Ballard
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville
| | - David Goodspeed
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - Gerald J Lang
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - Paul S Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - Alexander B Siy
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - A Alex Jahangir
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Basem Attum
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eduardo J Burgos
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cesar S Molina
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Vamshi Gajari
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen M Trochez
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jason J Halvorson
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - Anna N Miller
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - James Brett Goodman
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - Martha B Holden
- Department of Orthopaedic Surgery and Rehabilitation, Wake Forest Baptist University Medical Center, Winston-Salem, North Carolina
| | - Christopher M McAndrew
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - Michael J Gardner
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - William M Ricci
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - Amanda Spraggs-Hughes
- Department of Orthopedic Surgery, Washington University in St Louis/Barnes Jewish Hospital, St Louis, Missouri
| | - Susan C Collins
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Tara J Taylor
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mary Zadnik
- Major Extremity Trauma Research Consortium Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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O’Daly AE, Kreulen RT, Thamyongkit S, Pisano A, Luksameearunothai K, Hasenboehler EA, Helgeson MD, Shafiq B. Biomechanical Evaluation of a New Suture Button Technique for Reduction and Stabilization of the Distal Tibiofibular Syndesmosis. Foot & Ankle Orthopaedics 2020; 5:2473011420969140. [PMID: 35097415 PMCID: PMC8564924 DOI: 10.1177/2473011420969140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Stabilization methods for distal tibiofibular syndesmotic injuries present risk of malreduction. We compared reduction accuracy and biomechanical properties of a new syndesmotic reduction and stabilization technique using 2 suture buttons placed through a sagittal tunnel in the fibula and across the tibia just proximal to the incisura with those of the conventional method. Methods: Syndesmotic injury was created in 18 fresh-frozen cadaveric lower leg specimens. Nine ankles were repaired with the conventional method and 9 with the new technique. Reduction for the conventional method was performed using thumb pressure under direct visualization and for the new method by tightening both suture buttons passed through the fibular and tibial tunnels. Computed tomography was used to assess reduction accuracy. Torsional resistance, fibular rotation, and fibular translation were evaluated during biomechanical testing. Results: The new technique showed less lateral translation of the fibula on CT measurements after reduction (0.06 ± 0.06 mm) than the conventional method (0.26 ± 0.31 mm), P = .02. The new technique produced less fibular rotation during internal rotation after 0 cycles (new –2.4 ± 1.4 degrees; conventional –5.0 ± 1.2 degrees, P = .001), 100 cycles (new –2.1 ± 1.9 degrees; conventional –4.6 ± 1.4 degrees, P = .01), and 500 cycles (new –2.2 ± 1.6 degrees; conventional –5.3 ± 2.5 degrees, P = .01) and during external rotation after 100 cycles (new 3.9 ± 3.3 degrees; conventional 5.9 ± 3.5 degrees, P = .02) and 500 cycles (new 3.3 ± 3.2 degrees; conventional 6.3 ± 2.6 degrees, P = .03). Fixation failed in 3 specimens. Conclusion: The new syndesmotic reduction and fixation technique resulted in more accurate reduction of the fibula in the tibial incisura in the coronal plane and better rotational stability compared with the conventional method. Clinical Relevance: This new technique of syndesmosis reduction and stabilization may be a reliable alternative to current methods.
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Affiliation(s)
| | - R. Timothy Kreulen
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sorawut Thamyongkit
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alfred Pisano
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Erik A. Hasenboehler
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Melvin D. Helgeson
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Nayar SK, Marrache M, Ali I, Bressner J, Raad M, Shafiq B, Srikumaran U. Racial Disparity in Time to Surgery and Complications for Hip Fracture Patients. Clin Orthop Surg 2020; 12:430-434. [PMID: 33274018 PMCID: PMC7683194 DOI: 10.4055/cios20019] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 03/05/2020] [Indexed: 11/06/2022] Open
Abstract
Backgroud Racial and ethnic disparities in orthopedic surgery may be associated with worse perioperative complications. For patients with hip fractures, studies have shown that early surgery, typically within 24 to 48 hours of admission, may decrease postoperative morbidity and mortality. Our objective was to determine whether race is associated with longer time to surgery from hospital presentation and increased postoperative complications. Methods We queried the National Surgical Quality Improvement Program database from 2011 to 2017 for patients (> 65 years) with hip fractures who underwent surgical fixation. Patients were identified using Current Procedural Terminology codes (27235, 27236, 27244, and 27245). Delayed surgery was defined as time to surgery from hospital admission that was greater than 48 hours. Time to surgery was compared between races using analysis of variance. A multivariate logistic regression analysis adjusting for comorbidities, age, sex, and surgery was performed to determine the likelihood of delayed surgery and rate of postoperative complications. Results A total of 58,456 patients who underwent surgery for a hip fracture were included in this study. Seventy-two percent were female patients and the median age was 87 years. The median time to surgery across all patients was 24 hours. African Americans had the longest time to surgery (30.4 ± 27.6 hours) compared to Asians (26.5 ± 24.6 hours), whites (25.8 ± 23.4 hours), and other races (22.7 ± 22.0 hours) (p < 0.001). After adjusting for comorbidities, age, sex, and surgery, there was a 43% increase in the odds of delayed surgery among American Africans compared to whites (odds ratio, 1.43; 95% confidence interval, 1.29-1.58; p < 0.001). Despite higher odds of reintubation, pulmonary embolism, renal insufficiency or failure, and cardiac arrest in African Americans, mortality was significantly lower compared to white patients (4.41% vs. 6.02%, p < 0.001). Asian Americans had the lowest mortality rate (3.84%). Conclusions A significant disparity in time to surgery and perioperative complications was seen amongst different races with only African Americans having a longer time to surgery than whites. Further study is needed to determine the etiology of this disparity and highlights the need for targeted strategies to help at-risk patient populations.
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Affiliation(s)
- Suresh K Nayar
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Iman Ali
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Jarred Bressner
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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Nayar SK, Bansal A, Kreulen RT, Weiner S, Shafiq B, Srikumaran U. Intramedullary Cage Removal for a Consolidated Proximal Humerus Fracture: A Case Report. JBJS Case Connect 2020; 10:e19.00565. [PMID: 32773713 DOI: 10.2106/jbjs.cc.19.00565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE The expandable intramedullary cage (Conventus Orthopaedics) may treat 3- and 4-part proximal humerus fractures. Cage removal for symptomatic avascular necrosis with humeral head collapse requiring conversion to arthroplasty can be challenging because the cage's collapsing mechanism becomes inoperable after fracture consolidation. We present cage explantation followed by reverse total shoulder prosthesis placement in a 54-year-old man who underwent plate/cage fixation for a 3-part proximal humerus fracture 10 months earlier. CONCLUSION The proximal humeral cage can be extracted safely while preserving adequate bone stock for subsequent arthroplasty. Additional time and exposure are necessary compared with removing a locking plate alone.
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Affiliation(s)
- Suresh K Nayar
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
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El Dafrawy MH, Shafiq B, Vaswani R, Osgood GM, Hasenboehler EA, Kebaish KM. Minimally Invasive Fixation for Spinopelvic Dissociation: Percutaneous Triangular Osteosynthesis with S2 Alar-Iliac and Iliosacral Screws: A Case Report. JBJS Case Connect 2019; 9:e0119. [PMID: 31833978 DOI: 10.2106/jbjs.cc.19.00119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Traumatic U- and H-type sacral fractures are often unstable, causing spinopelvic dissociation. We describe a minimally invasive approach that allows percutaneous spinopelvic fixation of unstable H-type sacral fractures using a triangular osteosynthesis construct with S2 alar-iliac screws. We present the case of a patient with traumatic lumbopelvic dissociation who underwent percutaneous S2 alar-iliac and iliosacral screw fixation. CONCLUSIONS Combined percutaneous S2 alar-iliac and iliosacral screw fixation is a safe option for spinopelvic fixation and avoids the soft-tissue compromise of open approaches. The triangular osteosynthesis construct provides adequate pelvic anchor points to allow immediate weight-bearing.
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Affiliation(s)
- Mostafa H El Dafrawy
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Ravi Vaswani
- UPMC Orthopaedic Surgery, Pittsburgh, Pennsylvania
| | - Greg M Osgood
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
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Amin RM, Loeb AE, Hasenboehler EA, Levin AS, Osgood GM, Sterling RS, Stahel PF, Shafiq B. Reducing routine laboratory tests in patients with isolated extremity fractures: a prospective safety and feasibility study in 246 patients. Patient Saf Surg 2019; 13:22. [PMID: 31249624 PMCID: PMC6570870 DOI: 10.1186/s13037-019-0203-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/04/2019] [Indexed: 11/10/2022] Open
Abstract
Background Daily routine laboratory testing is unnecessary in most admitted patients. The opportunity to reduce daily laboratory testing in orthopaedic trauma patients has not been previously investigated. Methods A prospective observational study was performed based on a new laboratory testing reduction protocol for 12 months at two tertiary care trauma centers. Admitted patients with surgically treated isolated upper or lower extremity fractures were included (n = 246). The testing protocol consisted of a complete blood count (CBC) and basic metabolic panel (BMP) on postoperative day 2. Thereafter, tests were obtained at individual providers' discretion. Patients were followed for 30 days postoperatively. The primary outcome was number of laboratory tests reduced. Secondary outcomes included provider protocol compliance, and adverse patient outcomes. Chi-squared tests were used to compare differences in categorical variables among the cohorts. Analysis of variance tests were used for continuous variables. The relative reductions in testing utilization were calculated using our division's standard-of-care before program implementation (1 CBC and 1 BMP per patient per inpatient day). Significance was defined as P < 0.05. Results Of the 246 patients, there were 45 protocol fall outs due to provider deviation (n = 24) or medically justified necessity for additional testing (n = 21). Across all groups, a total of 778 CBC or BMP tests were avoided, amounting to a 69% reduction in testing compared to the pre-implementation baseline. Ninety-five percent of protocol group patients were safely discharged either without laboratory testing or with one set of tests obtained on postoperative day 2. There were no 30-day readmissions or reported complications associated with the new laboratory testing protocol. Conclusions In patients with surgically treated fractures about the elbow and knee, obtaining a single set of laboratory tests on postoperative day 2 is safe and efficacious in terms of reducing inappropriate resource utilization. Trial registration retrospectively registered.
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Affiliation(s)
- Raj M Amin
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Alexander E Loeb
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Erik A Hasenboehler
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Adam S Levin
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Greg M Osgood
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Robert S Sterling
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
| | - Philip F Stahel
- 2Department of Specialty Medicine, Rocky Vista University College of Osteopathic Medicine, 777 Bannock St., Denver, CO 80204 Parker USA
| | - Babar Shafiq
- 1Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 N Caroline Street, 5th Floor, Baltimore, MD 21287 USA
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Shakoor D, Osgood GM, Brehler M, Zbijewski WB, de Cesar Netto C, Shafiq B, Orapin J, Thawait GK, Shon LC, Demehri S. Cone-beam CT measurements of distal tibio-fibular syndesmosis in asymptomatic uninjured ankles: does weight-bearing matter? Skeletal Radiol 2019; 48:583-594. [PMID: 30242446 DOI: 10.1007/s00256-018-3074-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/31/2018] [Accepted: 09/09/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the influence of weight-bearing (WB) load in standard axial ankle syndesmotic measurements using cone beam CT (CBCT) examination of asymptomatic uninjured ankles. MATERIALS AND METHODS In this IRB approved, prospective study, patients with previous unilateral ankle fractures were recruited. We simultaneously scanned the injured ankles and asymptomatic contralateral ankles of 27 patients in both WB and NWB modes. For this study, only asymptomatic contralateral ankles with normal plain radiographs were included. Twelve standardized syndesmosis measurements at two axial planes (10 mm above the tibial plafond and 5 mm below the talar dome) were obtained by two expert readers using a custom CBCT viewer with the capability for geometric measurements between user-identified anatomical landmarks. Inter-reader reliability between two readers was obtained using the intra-class correlation coefficient (ICC). We compared the WB and NWB measurements using paired t test. RESULTS Significant agreement was observed between two readers for both WB and NWB measurements (p <0.05). ICC values for WB and NWB measurements had a range of 50-95 and 31-71 respectively. Mean values of the medial clear space on WB images (1.75, 95% confidence interval [95% CI]: 1.6, 1.9) were significantly lower than on NWB images (2.05, 95% CI: 1.8, 2.2) measurements (p <0.001). There was no significant difference between the remaining WB and NWB measurements. CONCLUSION Measurements obtained from WB images are reliable. Except for the medial clear space, no significant difference in syndesmotic measurements were observed during the WB mode of CBCT acquisition, implying that the tibio-fibular relationship remains unchanged when the physiological axial weight-bearing load is applied.
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Affiliation(s)
- Delaram Shakoor
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, USA.
| | - Greg M Osgood
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Brehler
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Wojciech B Zbijewski
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Cesar de Cesar Netto
- Department of Orthopedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Babar Shafiq
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jakrapong Orapin
- Department of Orthopedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Gaurav K Thawait
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, USA
| | - Lew C Shon
- Department of Orthopedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Shadpour Demehri
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, USA
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Abstract
BACKGROUND Venous thromboembolism (VTE) has been studied in lower extremity fractures but little is known of its relation with upper extremity (UE) fractures. As an often overlooked but serious complication, VTE may compromise patient outcomes. METHODS Using data on inpatients (aged ≥ 18 years) at a level-I trauma center and patients in the National Surgical Quality Improvement Program database who sustained UE fractures (clavicle, humerus, or radius/ulna) and VTE in the same hospitalization between 2007 and 2014, the authors analyzed data on demographic characteristics, fracture type, VTE location (pulmonary embolism, lower extremity, or UE), VTE onset, polytrauma, operative or nonoperative management, comorbidities, and mortality. RESULTS Of 1984 inpatients with UE fractures at 1 instution, 9 experienced VTE on admission, and 17 (15 received thromboprophylaxis) experienced VTE during hospitalization, for an overall VTE rate of 1.3%. VTE occurred most often in patients with fractures of the proximal humerus (3.0%) followed by the clavicle (2.0%), midshaft humerus (1.9%), distal radius/ulna (0.95%), and distal humerus/elbow (0.36%) (p = 0.0035). There were no significant trends in the incidence of PE (p = 0.33) over the study period, but there was a sharp rise since 2011. In the national database, 42 of 11570 (0.36%) patients with UE fracture had VTE, with incidence by fracture location ranging from 0.14% (radius/ulna) to 0.98% (proximal humerus) (p = 0.00001). Predictors were chronic steroid use (odds ratio [OR] = 6.22, p = .030), inpatient status (OR = 4.09, p = .002), and totally disabled functional status (OR = 3.31, p = .021). CONCLUSIONS VTE incidence was highest following proximal humerus or clavicle fractures and are rarely associated with radius/ulna fractures. There may have been a rise in the incidence of PE since 2007, warranting further investigation.
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Affiliation(s)
- Suresh K Nayar
- * Department of Orthopaedic Surgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Anne M Kuwabara
- * Department of Orthopaedic Surgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - José M Flores
- † Bloomberg School of Public Health, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Greg M Osgood
- * Department of Orthopaedic Surgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Dawn M LaPorte
- * Department of Orthopaedic Surgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Babar Shafiq
- * Department of Orthopaedic Surgery, The Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Loeb AE, Mitchell SL, Osgood GM, Shafiq B. Catastrophic Failure of a Carbon-Fiber-Reinforced Polyetheretherketone Tibial Intramedullary Nail: A Case Report. JBJS Case Connect 2018; 8:e83. [PMID: 30601766 DOI: 10.2106/jbjs.cc.18.00096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
CASE We present a case of a rare low-energy catastrophic failure of a carbon-fiber-reinforced polyetheretherketone tibial intramedullary nail at 10 weeks after placement in a 36-year-old man. We describe our experience with extraction of the device. CONCLUSION Carbon-fiber composite implants are approved for clinical use in orthopaedic trauma applications. The rare failure of carbon-fiber implants presents unique challenges because typical extraction techniques cannot be used. With the patient described herein, a terminally threaded guidewire was used to cannulate and extract the distal segment of the nail.
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Affiliation(s)
- Alexander E Loeb
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
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Thamyongkit S, Fayad LM, Jones LC, Hasenboehler EA, Sirisreetreerux N, Shafiq B. The distal femur is a reliable guide for tibial plateau fracture reduction: a study of measurements on 3D CT scans in 84 healthy knees. J Orthop Surg Res 2018; 13:224. [PMID: 30180898 PMCID: PMC6123997 DOI: 10.1186/s13018-018-0933-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 08/27/2018] [Indexed: 11/30/2022] Open
Abstract
Background Limited data have been published regarding the typical coronal dimensions of the femur and tibia and how they relate to each other. This can be used to aid in judging optimal operative reduction of tibial plateau fractures. The purpose of the present study was to quantify the width of tibial plateau in relation to the distal femur. Methods We reviewed 3D computed tomography (CT) scans taken between 2013 and 2016 of 42 patients (84 knees). We measured positions of the lateral tibial condyle with respect to the lateral femoral condyle (dLC) and the medial tibial condyle with respect to the medial femoral condyle (dMC) in the coronal plane. Positions of the articular edges of the lateral and medial tibia were also measured with respect to the femur (dLA and dMA). Results The mean (± standard deviation) measurements were as follows: dLC, − 0.1 ± 1.9 mm; dMC, − 4.7 ± 4.1 mm; dLA, 0.9 ± 1.0 mm; and dMA, 0.1 ± 1.5 mm. The mean (± standard deviation) ratio of tibial to femoral condylar width was 0.91 ± 0.03, and the ratio of tibial to femoral articular width was 1.01 ± 0.04. Conclusions The articular width of the tibia laterally and medially was slightly wider than the femoral articular width. These small differences and deviations indicate that the femur might be used as a reference to judge tibial plateau width reduction.
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Affiliation(s)
- Sorawut Thamyongkit
- Department of Orthopaedic Surgery, The Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD, 21224, USA.,Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400, Thailand
| | - Laura M Fayad
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD, 21224, USA
| | - Lynne C Jones
- Department of Orthopaedic Surgery, The Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, The Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Norachart Sirisreetreerux
- Department of Orthopaedic Surgery, The Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD, 21224, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University, 4940 Eastern Avenue, Baltimore, MD, 21224, USA. .,Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline St., Fl. 5, Baltimore, MD, 21205, USA.
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Carson JT, Shah SG, Ortega G, Thamyongkit S, Hasenboehler EA, Shafiq B. Complications of pelvic and acetabular fractures in 1331 morbidly obese patients (BMI ≥ 40): a retrospective observational study from the National Trauma Data Bank. Patient Saf Surg 2018; 12:26. [PMID: 30181776 PMCID: PMC6114733 DOI: 10.1186/s13037-018-0172-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/20/2018] [Indexed: 01/19/2023] Open
Abstract
Background There have been no large-scale epidemiological studies of outcomes and perioperative complications in morbidly obese trauma patients who have sustained closed pelvic ring or acetabular fractures. We examined this population and compared their rate of inpatient complications with that of control patients. Methods We retrospectively reviewed the records of patients treated for closed pelvic ring or acetabular fracture, aged 16–85 years, with Injury Severity Scores ≤15 from the National Trauma Data Bank Research Dataset for the years 2007 through 2010. The primary outcome of interest was rate of in-hospital complications. Secondary outcomes were length of hospital stay and discharge disposition. Unadjusted differences in complication rates were evaluated using Student t tests and Chi-squared analyses. Multiple logistic and Poisson regression were used to analyze binary outcomes and length of hospital stay, respectively, adjusting for several variables. Statistical significance was defined as p < 0.05. Results We included 46,450 patients in our study. Of these patients, 1331 (3%) were morbidly obese (body mass index ≥40) and 45,119 (97%) were used as controls. Morbidly obese patients had significantly higher odds of complication and longer hospital stay in all groups considered except those with pelvic fractures that were treated operatively. In all groups, morbidly obese patients were more likely to be discharged to a skilled nursing/rehabilitation facility compared with control patients. Conclusions Morbidly obese patients had higher rates of complications and longer hospital stays and were more likely to be discharged to rehabilitation facilities compared with control patients after pelvic ring or acetabular fracture.
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Affiliation(s)
- James T Carson
- 1Department of Orthopaedic Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Sabin G Shah
- 2Department of Orthopaedic Surgery, University of California Irvine, Orange, CA USA
| | - Gezzer Ortega
- 3Outcomes Research Center, Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Sorawut Thamyongkit
- 4Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Fl 5, Baltimore, MD 21205 USA
| | - Erik A Hasenboehler
- 4Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Fl 5, Baltimore, MD 21205 USA
| | - Babar Shafiq
- 4Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Fl 5, Baltimore, MD 21205 USA
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Thamyongkit S, MacKenzie JS, Sirisreetreerux N, Shafiq B, Hasenboehler EA. Outcomes after unstable pertrochanteric femur fracture: intermediate versus long cephalomedullary nails. Eur J Trauma Emerg Surg 2018; 46:963-968. [PMID: 30143808 DOI: 10.1007/s00068-018-1002-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/20/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE Optimal cephalomedullary nail (CMN) length for unstable pertrochanteric femur fractures is controversial. Long CMNs (L-CMNs) are currently recommended; however, intermediate-length CMNs (I-CMNs) may provide stable fixation without the additional surgical steps required by L-CMNs. We analyzed outcomes after unstable pertrochanteric femur fractures treated with L-CMNs or I-CMNs to determine whether functional outcomes, perioperative measures, complications, and mortality and reoperation rates differ by CMN length. METHODS We retrospectively reviewed medical records at our institution for 100 patients who received surgical treatment for pertrochanteric femur fractures from June 2014 to June 2016. Data from 43 unstable pertrochanteric femur fractures treated with L-CMNs (n = 25) or I-CMNs (n = 18) were analyzed. We evaluated operative time, fluoroscopy time, intraoperative blood loss, blood transfusions, and perioperative complications; peri-implant fracture, malunion, reoperation, and death; and neck-shaft angle, tip-apex distance, and 6-month postoperative functional scores. We analyzed categorical data with Fisher exact tests and continuous data with Student t tests. P < 0.05 was considered significant. RESULTS The I-CMN group had shorter operative time (68 versus 92 min; P = 0.048), shorter fluoroscopy time (72 versus 110 s; P = 0.019), and less intraoperative blood loss (80 versus 168 mL; P < 0.001) than the L-CMN group. The groups were similar in rates of blood transfusion, perioperative complications, peri-implant fracture, malunion, reoperation, and death. Six-month postoperative functional scores were similar between groups (P > 0.05). CONCLUSIONS We found operative advantages of I-CMNs over L-CMNs with no difference in treatment outcomes. LEVEL OF EVIDENCE Level IV, Retrospective case series study.
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Affiliation(s)
- Sorawut Thamyongkit
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA.,Chakri Naruebodindra Medical Institute, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400, Thailand
| | - James S MacKenzie
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA
| | - Norachart Sirisreetreerux
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA.
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Thamyongkit S, Bachabi M, Thompson JM, Shafiq B, Hasenboehler EA. Use of reprocessed external fixators in orthopaedic surgery: a survey of 243 orthopaedic trauma surgeons. Patient Saf Surg 2018; 12:10. [PMID: 29930708 PMCID: PMC5991444 DOI: 10.1186/s13037-018-0156-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background The increasing financial burden of orthopaedic implants on our health care system has prompted cost-control measures, such as implant reprocessing. The purpose of this study was to describe the current usage by orthopaedic trauma surgeons of reprocessed external fixators (EFs) for treatment of complex fractures. Methods A 16-question survey about use and perceptions of reprocessed EFs was distributed to 894 Orthopaedic Trauma Association members between August 2016 and June 2017 using a web-based survey system. Results The authors received 243 responses (27%). Thirty-seven percent of respondents reported using reprocessed EFs. Nonprofit hospitals used reprocessed EFs more commonly than did for-profit hospitals (41% vs 15%, P = .0004). Eighty-seven percent of respondents believed reprocessing could be cost-effective. The most common reason (32%) for not using reprocessed EFs was coordination/logistics of reprocessing. Concern about litigation was also reported as a main reason for not using (20%) or having recently stopped using (21%) reprocessed EFs. Conclusions Many orthopaedic traumatologists are interested in the reprocessing of EF components but few have reprocessing systems in place at their institutions. A major barrier to implementation is concern about litigation, which is likely unwarranted on the basis of Food and Drug Administration approval and a lack of previous litigation. Reprocessing by the original device manufacturers has yielded substantial savings at our institution and is an example of the cost savings that can be expected when implementing an EF reprocessing system.
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Affiliation(s)
- Sorawut Thamyongkit
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA.,2Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400 Thailand
| | - Malick Bachabi
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA
| | - John M Thompson
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA
| | - Babar Shafiq
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA
| | - Erik A Hasenboehler
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA
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MacKenzie JS, Banskota B, Sirisreetreerux N, Shafiq B, Hasenboehler EA. A review of the epidemiology and treatment of orthopaedic injuries after earthquakes in developing countries. World J Emerg Surg 2017; 12:9. [PMID: 28203271 PMCID: PMC5301447 DOI: 10.1186/s13017-017-0115-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Earthquakes in developing countries are devastating events. Orthopaedic surgeons play a key role in treating earthquake-related injuries to the extremities. We describe orthopaedic injury epidemiology to help guide response planning for earthquake-related disasters. METHODS Several databases were searched for articles reporting primary injury after major earthquakes from 1970 to June 2016. We used the following key words: "earthquake" AND "fracture" AND "injury" AND "orthopedic" AND "treatment" AND "epidemiology." The initial search returned 528 articles with 253 excluded duplicates. The remaining 275 articles were screened using inclusion criteria, of which the main one was the description of precise anatomic location of fracture. This yielded 17 articles from which we analyzed the ratio of orthopaedic to nonorthopaedic injuries; orthopaedic injury location, type, and frequency; fracture injury characteristics (open vs. closed, single vs. multiple, and simple vs. comminuted); and first-line treatments. RESULTS Most injuries requiring treatment after earthquakes (87%) were orthopaedic in nature. Nearly two-thirds of these injuries (65%) were fractures. The most common fracture locations were the tibia/fibula (27%), femur (17%), and foot/ankle (16%). Forty-two percent were multiple fractures, 22% were open, and 16% were comminuted. The most common treatment for orthopaedic injuries in the setting of earthquakes was debridement (33%). CONCLUSIONS Orthopaedic surgeons play a critical role after earthquake disasters in the developing world. A strong understanding of orthopaedic injury epidemiology and treatment is critical to providing effective preparation and assistance in future earthquake disasters.
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Affiliation(s)
- James S MacKenzie
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, 21287 MD USA
| | - Bibek Banskota
- Department of Orthopaedics, Hospital and Rehabilitation Centre for Disabled Children, Adhikari Gaoun, Urgratara VDC-6, Janagal Kavre Nepal
| | - Norachart Sirisreetreerux
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, 21287 MD USA.,Department of Orthopaedics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchatewi, Bangkok, 10400 Thailand
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, 21287 MD USA
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline Street, Baltimore, 21287 MD USA.,Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, 21224-2780 MD USA
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Brock AK, Tan EW, Shafiq B. Post-Traumatic Periprosthetic Tibial and Fibular Fracture After Total Ankle Arthroplasty: A Case Report. J Foot Ankle Surg 2016; 56:196-200. [PMID: 26946999 DOI: 10.1053/j.jfas.2016.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Indexed: 02/03/2023]
Abstract
Periprosthetic fractures after total ankle arthroplasty are uncommon, with most cases occurring intraoperatively. We describe a post-traumatic periprosthetic fracture of the distal tibia and fibula after total ankle arthroplasty that was treated with minimally invasive plate osteosynthesis. It is important for orthopedic surgeons not only to recognize the risk factors for postoperative periprosthetic total ankle arthroplasty fractures, but also to be familiar with the treatment options available to maximize function and minimize complications. The design of the tibial prosthesis and surgical techniques required to prepare the ankle joint for implantation are important areas of future research to limit the risk of periprosthetic fractures.
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Affiliation(s)
- Amanda K Brock
- Medical Student, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Eric W Tan
- Orthopedic Surgeon, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Babar Shafiq
- Assistant Professor, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD.
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Nelson-Williams H, Kodadek L, Canner J, Schneider E, Efron D, Haut E, Shafiq B, Haider A, Velopulos CG. Do trauma center levels matter in older isolated hip fracture patients? J Surg Res 2015; 198:468-74. [PMID: 26038246 DOI: 10.1016/j.jss.2015.03.074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/16/2015] [Accepted: 03/25/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Younger, multi-trauma patients have improved survival when treated at a trauma center. Many regions now propose that older patients be triaged to a higher level trauma centers (HLTCs-level I or II) versus lower level trauma centers (LLTCs-level III or nondesignated TC), even for isolated injury, despite the absence of an established benefit in this elderly cohort. We therefore sought to determine if older isolated hip fracture patients have improved survival outcomes based on trauma center level. METHODS A retrospective cohort of 1.07 million patients in The Nationwide Emergency Department Sample from 2006-2010 was used to identify 239,288 isolated hip fracture patients aged ≥65 y. Multivariable logistic regression was performed controlling for patient- and hospital-level variables. The main outcome measures were inhospital mortality and discharge disposition. RESULTS Unadjusted logistic regression analyses revealed 8% higher odds of mortality (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.00-1.16) and 10% lower odds of being discharged home (OR, 0.90; 95% CI, 0.80-1.00) among patients admitted to an HLTC versus LLTC. After controlling for patient- and hospital-level factors, neither the odds of mortality (OR, 1.06; 95% CI, 0.97-1.15) nor the odds of discharge to home (OR, 0.98; 95% CI, 0.85-1.12) differed significantly between patients treated at an HLTC versus LLTC. CONCLUSIONS Among patients with isolated hip fractures admitted to HLTCs, mortality and discharge disposition do not differ from similar patients admitted to LLTCs. These findings have important implications for trauma systems and triage protocols.
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Affiliation(s)
- Howard Nelson-Williams
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland
| | - Lisa Kodadek
- Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Joseph Canner
- Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Eric Schneider
- Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David Efron
- Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Division of Acute Care Surgery and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Elliott Haut
- Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Department of Surgery, Anesthesiology / Critical Care Medicine (ACCM), Emergency Medicine, Johns Hopkins University, Baltimore, Maryland; Health Policy & Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Babar Shafiq
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Adil Haider
- Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, Massachusetts
| | - Catherine Garrison Velopulos
- Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Division of Acute Care Surgery and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
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Shafiq B, Zuckerman RL, Queale WS, Cosgarea AJ. Hypertensive crisis secondary to pheochromocytoma during routine knee surgery. J Knee Surg 2004; 17:170-1. [PMID: 15366273 DOI: 10.1055/s-0030-1248217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Babar Shafiq
- College of Medicine, Howard University, Washington, DC, USA
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