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Patterson JT, Brown M, Hasegawa IG, Becerra JA, Duong AM, Reddy A, Gary JL. Incidence of Suboptimal Fluoroscopic Outlet Imaging of the Sacrum and Pelvic Retroversion Necessary for Optimal Views. J Orthop Trauma 2024; 38:299-305. [PMID: 38470146 DOI: 10.1097/bot.0000000000002795] [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] [Received: 10/13/2023] [Accepted: 03/04/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVES To estimate the prevalence of suboptimal fluoroscopy of sacral outlet images due to anatomic and equipment dimensions. Pelvic retroversion is hypothesized to mitigate this issue. METHODS DESIGN In silico simulations using retrospectively collected computed tomography (CT) data from human patients. SETTING Level I trauma center. PATIENT SELECTION CRITERIA Adults with OTA/AO 61 pelvic ring disruptions treated with posterior pelvic fixation between July and December 2021. OUTCOME MEASURES AND COMPARISONS C-arm tilt angles required to obtain 3 optimal fluoroscopic sacral outlet images, defined as vectors from pubic symphysis to S2 and parallel to the first and second sacral neural foramina, were calculated from sagittal CT images. A suboptimal view was defined as collision of the C-arm radiation source or image intensifier with the patient/operating table at the required tilt angle simulated using the dimensions of 5 commercial C-arm models and trigonometric calculations. Incidence of suboptimal outlet views and pelvic retroversion necessary to obtain optimal views without collision, which may be obtained by placement of a sacral bump, was determined for each view for all patients and C-arm models. RESULTS CT data from 72 adults were used. Collision between patient and C-arm would occur at the optimal tilt angle for 17% of simulations and at least 1 view in 68% of patients. Greater body mass index was associated with greater odds of suboptimal imaging (standard outlet: odds ratio [OR] 0.84, confidence interval [CI] 0.79-0.89, P < 0.001; S1: OR 0.91, CI 0.87-0.97, P = 0.002; S2: OR 0.85, CI 0.80-0.91, P < 0.001). S1 anterior sacral slope was associated with suboptimal S1 outlet views (OR 1.12, Cl 1.07-1.17, P < 0.001). S2 anterior sacral slope was associated with suboptimal standard outlet (OR 1.07, Cl 1.02-1.13, P = 0.004) and S2 outlet (OR 1.16, Cl 1.09-1.23, P < 0.001) views. Retroversion of the pelvis 15-20 degrees made optimal outlet views possible without collision in 95%-99% of all simulations, respectively. CONCLUSIONS Suboptimal outlet imaging of the sacrum is associated with greater body mass index and sacral slope at S1 and S2. Retroversion of the pelvis by 15-20 degrees with a bump under the distal sacrum may offer a low-tech solution to ensure optimal fluoroscopic imaging for percutaneous fixation of the posterior pelvic ring. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA; and
| | - Michael Brown
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA; and
| | - Ian G Hasegawa
- Department of Orthopaedic Surgery and Rehabilitation, Queen's Medical Center, Honolulu, HI
| | - Jacob A Becerra
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA; and
| | - Andrew M Duong
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA; and
| | - Akhil Reddy
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA; and
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA; and
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Fram BR, Bosse MJ, Odum SM, Reider L, Gary JL, Gordon WT, Teague D, Alkhoury D, MacKenzie EJ, Seymour RB, Karunakar MA. Do Transtibial Amputations Outperform Amputations of the Hind- and Midfoot Following Severe Limb Trauma?: A Secondary Analysis of the OUTLET Study. J Bone Joint Surg Am 2024; 106:776-781. [PMID: 38512987 DOI: 10.2106/jbjs.23.00878] [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
BACKGROUND The purpose of this study was to compare 18-month clinical and patient-reported outcomes between patients with severe lower-limb injuries treated with a transtibial amputation or a hind- or midfoot amputation. Despite the theoretical benefits of hind- and midfoot-level amputation, we hypothesized that patients with transtibial amputations would report better function and have fewer complications. METHODS The study included patients 18 to 60 years of age who were treated with a transtibial amputation (n = 77) or a distal amputation (n = 17) and who were enrolled in the prospective, multicenter Outcomes Following Severe Distal Tibial, Ankle, and/or Foot Trauma (OUTLET) study. The primary outcome was the difference in Short Musculoskeletal Function Assessment (SMFA) scores, and secondary outcomes included pain, complications, amputation revision, and amputation healing. RESULTS There were no significant differences between patients with distal versus transtibial amputation in any of the domains of the SMFA: dysfunction index [distal versus transtibial], 31.2 versus 22.3 (p = 0.13); daily activities, 37.3 versus 26.0 (p = 0.17); emotional status, 41.4 versus 29.3 (p = 0.07); mobility, 36.5 versus 27.8 (p = 0.20); and bother index, 34.4 versus 23.6 (p = 0.14). Rates of complications requiring revision were higher for distal amputations but not significantly so (23.5% versus 13.3%; p = 0.28). One distal and no transtibial amputees required revision to a higher level (p = 0.18). A higher proportion of patients with distal compared with transtibial amputation required local surgical revision (17.7% versus 13.3%; p = 0.69). There was no significant difference between the distal and transtibial groups in scores on the Brief Pain Index at 18 months post-injury. CONCLUSIONS Surgical complication rates did not differ significantly between patients who underwent transtibial versus hind- or midfoot amputation for severe lower-extremity injury. The average SMFA scores were higher (worse), although not significantly different, for patients undergoing distal compared with transtibial amputation, and more patients with distal amputation had a complication requiring surgical revision. Of note, more patients with distal amputation required closure with an atypical flap, which likely contributed to less favorable outcomes. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Brianna R Fram
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Michael J Bosse
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Susan M Odum
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Lisa Reider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Joshua L Gary
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Wade T Gordon
- Kirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, Nevada
| | | | - Dana Alkhoury
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ellen J MacKenzie
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rachel B Seymour
- Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
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O'Hara NN, Frey KP, Stein DM, Levy JF, Slobogean GP, Castillo R, Firoozabadi R, Karunakar MA, Gary JL, Obremskey WT, Seymour RB, Cuschieri J, Mullins CD, O'Toole RV. Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial. J Bone Joint Surg Am 2024; 106:590-599. [PMID: 38381842 PMCID: PMC10980176 DOI: 10.2106/jbjs.23.00824] [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: 02/23/2024]
Abstract
BACKGROUND Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin. METHODS This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales. RESULTS The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001). CONCLUSIONS Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deborah M Stein
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Gerard P Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Renan Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Madhav A Karunakar
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Joseph Cuschieri
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - C Daniel Mullins
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
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Kutzler M, Patterson JT, Anz H, Siahaan J, Warner SJ, Gary JL. Titanium versus stainless steel alloy bridge plates for distal femur fractures: Does callus form earlier with titanium? Eur J Orthop Surg Traumatol 2024:10.1007/s00590-024-03919-5. [PMID: 38564013 DOI: 10.1007/s00590-024-03919-5] [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] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/14/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Distal femur fractures account for 3-6% of all femur fractures. Internal fixation of most distal femur fractures with an anatomic lateral locking plate should permit some motion at the metaphyseal portion of the fracture when secondary bone healing is planned by the operating surgeon. While several studies have been performed evaluating union rates for distal femur fractures with stainless steel and titanium plates, the timing of callus formation between stainless steel and titanium implants used as bridge plates for distal femur fractures (AO/OTA 33-A and -C) has been investigated to a lesser extent. We hypothesize that callus will be visualized earlier with post-operative radiographs with titanium versus stainless steel bridge plates. METHODS We retrospectively reviewed a consecutive cohort of patients over 18 years of age with acute AO/OTA 33-A and 33-C fracture patterns treated with an isolated stainless steel or titanium lateral bridge plate within 4 weeks of injury by a single fellowship-trained orthopedic trauma surgeon from 2011 to 2020 at one academic Level 1 trauma center. An independent, fellowship-trained orthopedic trauma attending surgeon reviewed anterior-posterior (AP) and lateral radiographs from every available post-operative clinic visit and graded them using the Modified Radiographic Score for Tibia (mRUST). RESULTS Twenty-five subjects were included in the study with 10 with stainless steel and 15 with titanium plates. There were no significant differences in demographics between both groups, including age, sex, BMI, injury classification, open versus closed, mechanism, and laterality. Statistically significant increased mRUST scores, indicating increased callus formation, were seen on 12-week radiographs (8.4 vs. 11.9, p = 0.02) when titanium bridge plates were used. There were no statistically significant differences in mRUST scores at 6 or 24-weeks, but scores in the titanium group were higher in at every timepoint. DISCUSSION In conclusion, we observed greater callus formation at 12 weeks after internal fixation of 33-A and 33-C distal femur fractures treated with titanium locked lateral distal femoral bridge plates compared to stainless steel plates. Our data suggest that titanium metallurgy may have quicker callus formation compared to stainless steel if an isolated, lateral locked bridge plate is chosen for distal femur fracture fixation.
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Affiliation(s)
- Michael Kutzler
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, 6400 Fannin St. Suite 1700, Houston, TX, 77030, USA
| | - Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, 1520 San Pablo St. Suite 2000, Los Angeles, CA, 90033, USA
| | - Hayden Anz
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, 6400 Fannin St. Suite 1700, Houston, TX, 77030, USA
| | - Jacob Siahaan
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, 6400 Fannin St. Suite 1700, Houston, TX, 77030, USA
| | - Stephen J Warner
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, 6400 Fannin St. Suite 1700, Houston, TX, 77030, USA
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, 1520 San Pablo St. Suite 2000, Los Angeles, CA, 90033, USA.
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Joshi M, O'Toole RV, Carlini AR, Gary JL, Obremskey WT, Murray CK, Gaski G, Reid JS, Degani Y, Taylor TJ, Collins SC, Huang Y, Whiting PS, Patterson JT, Lee OC, Castillo RC. Does Topical Vancomycin Powder Use in Fracture Surgery Change Bacteriology and Antibiotic Susceptibilities? An Analysis of the VANCO Trial. J Orthop Trauma 2024; 38:183-189. [PMID: 38206761 DOI: 10.1097/bot.0000000000002767] [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] [Received: 08/21/2023] [Accepted: 01/05/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To determine whether intrawound vancomycin changes the bacteriology of surgical site infection pathogens and investigate the emergence of antibiotic-resistant pathogens. METHODS DESIGN Secondary analysis of phase III, prospective, randomized clinical trial. SETTING Thirty-six US trauma centers. PATIENT SELECTION CRITERIA Patients who became infected after fixation of tibial plateau or pilon fracture. OUTCOME MEASURES AND COMPARISONS Pathogen types and bacterial susceptibilities as determined from routine clinical culture in the operating room. RESULTS Seventy-four patients were studied who were 67.5% male with a mean age of 48.6 years. A lower proportion of gram-positive cocci was observed in the vancomycin powder compared with the standard-of-care group (3.7% vs. 8.0%, P = 0.01). Methicillin-resistant Staphylococcus aureus infection incidence was comparable in both the vancomycin powder and the standard-of-care groups, but rates of methicillin-susceptible S. aureus infections were lower in the treatment group (1.4% vs. 4.8%, P = 0.01). The incidence of coagulase-negative Staphylococci and gram-negative rod infections were similar in both groups. There was no significant difference in susceptibilities between groups in rates of vancomycin-resistant enterococcus. CONCLUSIONS Topical vancomycin powder decreases the likelihood of gram-positive infections consistent with the biologic activity of vancomycin. Fewer methicillin-susceptible S. aureus and coagulase-negative Staphylococci infections were observed in the group treated with vancomycin powder. An effect of vancomycin powder on methicillin-resistant S. aureus infection risk was not detected given the low incidence in both the intrawound vancomycin and the standard-of-care groups. There was no emergence of gram-negative rod infections or increased resistance patterns observed. Use of topical vancomycin powder does not seem to produce infections in these patients with greater antibiotic resistance than would have occurred without its use. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Manjari Joshi
- Division of Infectious Disease, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Anthony R Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Yasmin Degani
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Tara J Taylor
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan C Collins
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yanjie Huang
- University of Michigan School of Dentistry, Ann Arbor, MI
| | - Paul S Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI; and
| | - Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Olivia C Lee
- Department of Orthopaedics, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Hasegawa IG, Gary JL. Intraoperative Imaging Challenges During Pelvic Ring Disruptions and Acetabular Fracture Surgery. Orthop Clin North Am 2024; 55:73-87. [PMID: 37980105 DOI: 10.1016/j.ocl.2023.07.004] [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] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Achieving high-quality intraoperative imaging is crucial for successful pelvic ring and acetabular fracture surgery, yet it remains clinically challenging. Due to the complex anatomy of the pelvic ring and acetabulum, it is necessary to obtain multiple images oriented in different planes to reliably confirm reduction accuracy and implant positioning. Intraoperative image quality can be compromised by factors such as patient body habitus, bowel gas, abdominal packing, contrast dye, and nonstandardized language between surgeon and radiology technician. This article reviews common intraoperative imaging challenges encountered during pelvic ring and acetabular fracture surgery, while providing practical and evidence-based solutions and prevention strategies.
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Affiliation(s)
- Ian G Hasegawa
- Keck School of Medicine of USC, 1520 San Pablo Street. HC2 - Suite 2000, Los Angeles, CA 90033, USA
| | - Joshua L Gary
- Keck School of Medicine of USC, 1520 San Pablo Street. HC2 - Suite 2000, Los Angeles, CA 90033, USA.
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Patterson JT, Slobogean GP, Gary JL, Castillo RC, Firoozabadi R, Carlini AR, Joshi M, Allen LE, Huang Y, Bosse MJ, Obremskey WT, McKinley TO, Reid JS, O'Toole RV, O'Hara NN. The VANCO Trial Findings Are Generalizable to a North American Trauma Registry. J Orthop Trauma 2024; 38:10-17. [PMID: 38093438 DOI: 10.1097/bot.0000000000002704] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVES To estimate the generalizability of treatment effects observed in the VANCO trial to a broader population of patients with tibial plateau or pilon fractures. METHODS Design and Setting: Clinical trial data from 36 United States trauma centers and Trauma Quality Programs registry data from more than 875 Level I-III trauma centers in the United States and Canada.Patient Selection Criteria: Patients enrolled in the VANCO trial treated with intrawound vancomycin powder from January 2015 to June 2017 and 31,924 VANCO-eligible TQP patients admitted in 2019 with tibial plateau and pilon fractures.Outcome Measure and Comparisons: Deep surgical site infection and gram-positive deep surgical site infection estimated in the TQP sample weighed by the inverse probability of trial participation. RESULTS The 980 patients in the VANCO trial were highly representative of 31,924 TQP VANCO-eligible patients (Tipton generalizability index 0.96). It was estimated that intrawound vancomycin powder reduced the odds of deep surgical infection by odds ratio (OR) = 0.46 (95% confidence interval [CI] 0.25-0.86) and gram-positive deep surgical infection by OR = 0.39 (95% CI, 0.18-0.84) within the TQP sample of VANCO-eligible patients. For reference, the trial average treatment effects for deep surgical infection and gram-positive deep surgical infection were OR = 0.60 (95% CI, 0.37-0.98) and OR = 0.44 (95% CI, 0.23-0.80), respectively. CONCLUSIONS This generalizability analysis found that the inferences of the VANCO trial generalize and might even underestimate the effects of intrawound vancomycin powder when observed in a wider population of patients with tibial plateau and pilon fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA
| | - Anthony R Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Manjari Joshi
- Department of Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Lauren E Allen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yanjie Huang
- University of Michigan School of Dentistry, Ann Arbor, MI
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Todd O McKinley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN; and
| | - J Spence Reid
- Department of Orthopaedic Surgery, Penn State College of Medicine, Hershey, PA
| | - Robert V O'Toole
- Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD
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Gitajn IL, Werth PM, Carlini AR, Bosse MJ, Gary JL, Firoozabadi R, Obremskey W, McKinley TO, Castillo RC, O’Toole RV. Deep Surgical Site Infection after Fracture Has a Profound Effect on Functional Outcomes. JB JS Open Access 2024; 9:e23.00042. [PMID: 38196850 PMCID: PMC10773708 DOI: 10.2106/jbjs.oa.23.00042] [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: 01/11/2024] Open
Abstract
Background Fracture-related infection is one of the most challenging complications in orthopaedic trauma surgery. However, the effect of infection on functional and pain-related outcomes has not been well established. The aims of this study were to evaluate functional recovery for patients with fracture and a deep surgical site infection compared with patients with fracture without infection and to evaluate whether pain severity, social support, and preinjury mental health have a moderating effect on the magnitude and direction of the relationship between deep surgical site infection and functional recovery. Methods This is a secondary retrospective cohort study using prospectively collected data from the VANCO trial (Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection) and the OXYGEN (Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High Energy Fracture Surgery) trial. In this study, 2,116 patients with tibial plateau, pilon, or calcaneal fractures at high risk for infection were included. Patients were divided into cohorts of patients who experienced a deep surgical site infection and those who did not. The primary outcome measure was the functional outcome using the Veterans RAND 12-Item Health Survey (VR-12). Results After controlling for covariates, deep surgical site infection was independently associated with functional outcome, with a 3.3-point reduction in the VR-12 Physical Component Score, and pain severity was independently associated with functional outcome, with a 2.5-point reduction in the VR-12 Physical Component Score. Furthermore, the Brief Pain Inventory pain severity demonstrated an important moderating effect on the relationship between infection and functional outcome. In patients with lower pain scores, infection had a large negative impact on functional outcome, whereas, in patients with higher pain scores, infection had no significant impact on functional outcome. Furthermore, the functional outcome in the entire cohort remains at only 61% of baseline. Conclusions This study documents the negative impact of postoperative infection on functional recovery after injury, as well as the novel finding of pain severity as an important moderating factor. This study emphasizes not only the importance of developing effective interventions designed to reduce postoperative infection, but also the role that factors that moderate pain severity plays in limiting recovery of physical function. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Paul M. Werth
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Michael J. Bosse
- Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Joshua L. Gary
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Reza Firoozabadi
- University of Washington Harborview Medical Center, Seattle, Washington
| | | | - Todd O. McKinley
- Indiana University School of Medicine, Indianapolis, Indiana and
| | - Renan C. Castillo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Patterson JT, Mayfield CK, Gary JL, Chung P, Hasegawa IG, Becerra JA. Pelvic binder radiography detects occult instability in cadaveric simulated lateral compression type I (LC1) pelvic fractures. Injury 2023; 54:111067. [PMID: 37777368 DOI: 10.1016/j.injury.2023.111067] [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] [Indexed: 10/02/2023]
Abstract
OBJECTIVES Occult instability in minimally displaced lateral compression (LC) pelvic ring injuries may have clinical relevance for treatment. We describe two novel LC pelvis fracture stress examinations - pelvic binder stress radiography (PBR) and pelvic binder stress bladder manometry (PBM) - which do not require sedation, anesthesia, patient transport, or radiation of personnel. METHODS A biomechanical study was performed with five fresh elderly cadavers. Sequential osteotomies of the pelvis simulated increasingly unstable LC pelvis fracture patterns (OTA/AO 61A2.2, 61B1.1a, 61B1.1b, 61B2.1). Compressive force was quantitatively applied using a pelvic binder and scale. Pelvis fracture displacement was measured on AP and inlet fluoroscopic views. Pelvic bladder pressure (PBM) was measured using a Foley catheter as a water column. RESULTS Fracture displacement strongly correlated with force applied (R2=0.600-0.963). PBR discriminated between simulated LC injuries. Mean displacement of 61B1.1b injuries >1cm was observed at 3.8kg on AP view and 5kg on inlet view. Mean displacement of 61B1.1a injuries >1cm was observed at 8.2kg on AP view and 9.3kg on inlet view. 61A2.2 injuries did not displace >1cm at forces up to 10kg. >95% of 61B1.1a and 61B1.1b injuries displaced >1cm at 10kg. PBM moderately correlated with force applied (R2=0.517-0.842) but did not discriminate between LC injuries. CONCLUSIONS PBR is feasible, precisely quantified occult mechanical instability in simulated LC pelvis fractures in response to reproducible applied force, and discriminated between simulated LC pelvis fractures. PBM did not discriminate between simulated LC fractures. A clinical trial to validate the safety and efficacy of PBR for assessing occult instability in LC pelvis fracture is warranted.
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Affiliation(s)
- Joseph T Patterson
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery.
| | - Cory K Mayfield
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Joshua L Gary
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Phillip Chung
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Ian G Hasegawa
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Jacob A Becerra
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
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Saiz AM, Kellam PJ, Amin A, Arambula Z, Rashiwala A, Gary JL, Warner SJ, Routt M, Eastman JG. Percutaneous sacral screw fixation alone sufficient for mildly displaced U-type sacral fractures with preserved osseous fixation pathways. Eur J Orthop Surg Traumatol 2023:10.1007/s00590-023-03661-4. [PMID: 37874399 DOI: 10.1007/s00590-023-03661-4] [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] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/25/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE To describe U-type sacral fracture characteristics amenable to percutaneous sacral screw fixation. METHODS U-type sacral fractures were identified from a trauma registry at a level 1 trauma center from 2014 to 2020. Patient demographics, injury mechanism, fracture characteristics, and fixation construct were retrospectively retrieved. Associations between fracture pattern and surgical fixation were identified. RESULTS 82 U-type sacral fractures were reviewed. Six treated with lumbopelvic fixation (LPF) and 76 were treated with percutaneous sacral screws (PSS) alone. Patients receiving LBF had greater sacral fracture displacement in coronal, sagittal, and axial planes compared to patients receiving PSS alone (P < 0.05), negating osseous fixation pathways. All patients went onto sacral union and there were no implant failures or unplanned reoperations for either group. CONCLUSION If osseous fixation pathways are present, U-type sacral fractures can be successfully treated with percutaneous sacral screws. LPF may be indicated in more displaced fractures with loss of spinopelvic alignment. Both techniques for U-type sacral fractures result in reliable fixation and healing without reoperations.
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Affiliation(s)
- Augustine M Saiz
- Department of Orthopaedic Surgery, The University of California Davis, Sacramento, CA, USA.
| | - Patrick J Kellam
- Department of Orthopedic Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Adeet Amin
- Department of Orthopedic Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Zachary Arambula
- Department of Orthopedic Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Abhi Rashiwala
- Department of Orthopedic Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Joshua L Gary
- Keck School of Medicine, Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA, USA
| | - Stephen J Warner
- Department of Orthopedic Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Milton Routt
- Department of Orthopedic Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jonathan G Eastman
- Department of Orthopedic Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA
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O'Hara NN, Castillo RC, Carlini AR, Joshi M, Murray CK, Allen LE, Huang Y, Gary JL, Bosse MJ, Obremskey WT, McKinley TO, Schmidt AH, O'Toole RV. Application of Bayesian Methods to Help Interpret the VANCO Trial Results. J Orthop Trauma 2023; 37:1-7. [PMID: 35830572 DOI: 10.1097/bot.0000000000002458] [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: 07/11/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether a Bayesian analysis changes the results of the VANCO trial. DESIGN A secondary analysis of a randomized clinical trial using Bayesian methods. SETTING Thirty-six US trauma centers. PATIENTS Patients ages 18-80 years with a tibial plateau or pilon fracture deemed high risk of infection and definitively treated with plate and screw fixation. INTERVENTION Patients were randomly allocated to receive 1000 mg of intrawound vancomycin powder at their definitive fixation or to a control group that received no topical antibiotics. MAIN OUTCOME MEASUREMENTS A deep surgical site infection requiring operative treatment within 6 months of definitive fixation. Secondary outcomes included gram-positive and gram-negative-only deep surgical site infections. RESULTS Of the 980 patients randomized, 874 (89%) had at least 140 days of follow-up and were included in this Bayesian analysis. The estimated probability that intrawound vancomycin powder reduces the risk of a deep surgical site infection is >98% [relative risk (RR), 0.66; 95% credible interval (CrI), 0.46-0.98]. There is a >99% chance intrawound vancomycin powder reduces gram-positive infections and an 80% chance the magnitude of this risk reduction exceeds 35% (RR, 0.52; 95% CrI, 0.33-0.84) exists. It is unlikely (44%) that intrawound vancomycin powder prevents gram-negative surgical site infections (RR, 1.06; 95% CrI, 0.48-2.45). CONCLUSIONS There is a high probability (>98%) that intrawound vancomycin powder reduces deep surgical site infections in patients with tibial plateau or pilon fractures at high risk of infection and even more likely it reduces deep infections with gram-positive pathogens (>99%). LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Renan C Castillo
- METRC Coordinating Center at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Anthony R Carlini
- METRC Coordinating Center at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Manjari Joshi
- Department of Infectious Diseases, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Clinton K Murray
- Department of Orthopaedic Surgery, Infectious Disease Service, Brooke Army Medical Center, San Antonio, TX
| | - Lauren E Allen
- METRC Coordinating Center at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yanjie Huang
- METRC Coordinating Center at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Joshua L Gary
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Michael J Bosse
- Atrium Health Musculoskeletal Institute-Carolinas Medical Center, Charlotte, NC
| | - William T Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Todd O McKinley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN; and
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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12
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Patterson JT, Wier J, Gary JL. Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization: Management of Refractory Hypotension in Closed Pelvic Ring Injury. J Bone Joint Surg Am 2022; 104:1821-1829. [PMID: 35939780 DOI: 10.2106/jbjs.22.00252] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury. METHODS Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay. RESULTS In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching. CONCLUSIONS PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Julian Wier
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
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Slobogean GP, Sprague S, Wells JL, Bhandari M, Harris AD, Mullins CD, Thabane L, Wood A, Della Rocca GJ, Hebden JN, Jeray KJ, Marchand LS, O'Hara LM, Zura RD, Lee C, Patterson JT, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt G, Heels-Ansdell D, Marvel D, Palmer JE, Friedrich J, O'Hara NN, Grissom F, Gitajn IL, Morshed S, O'Toole RV, Petrisor B, Mossuto F, Joshi MG, D'Alleyrand JCG, Fowler J, Rivera JC, Talbot M, Pogorzelski D, Dodds S, Li S, Del Fabbro G, Szasz OP, Bzovsky S, McKay P, Minea A, Murphy K, Howe AL, Demyanovich HK, Hoskins W, Medeiros M, Polk G, Kettering E, Mahal N, Eglseder A, Johnson A, Langhammer C, Lebrun C, Nascone J, Pensy R, Pollak A, Sciadini M, Degani Y, Phipps H, Hempen E, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Gallant JL, Pusztai K, MacRae S, Renaud S, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich Jr RW, Lazarus DE, Millon SJ, Moody MC, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill Jr LE, Garitty MJ, Poole AS, Sims ML, Walker CM, Carlisle R, Hofer EA, Huggins B, Hunter M, Marshall W, Ray SB, Smith C, Altman KM, Pichiotino ER, Quirion JC, Loeffler MF, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Bray E, Sykes JW, Yoder K, Conner K, Abbott H, Natoli RM, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Mullis BH, Jang Y, Lopas LA, Hill LC, Fentz CL, Diaz MM, Brown K, Garst KM, Denari EW, Osborn P, Pierrie SN, Kessler B, Herrera M, Miclau T, Marmor MT, Matityahu A, McClellan RT, Shearer D, Toogood P, Ding A, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Pokhvashchev D, Obremskey WT, Jahangir AA, Sethi M, Boyce R, Stinner DJ, Mitchell PP, Trochez K, Rodriguez E, Pritchett C, Hogan N, Fidel Moreno A, Hagen JE, Patrick M, Vlasak R, Krupko T, Talerico M, Horodyski M, Pazik M, Lossada-Soto E, Gary JL, Warner SJ, Munz JW, Choo AM, Achor TS, Routt ML“C, Kutzler M, Boutte S, Warth RJ, Prayson MJ, Venkatarayappa I, Horne B, Jerele J, Clark L, Boulton C, Lowe J, Ruth JT, Askam B, Seach A, Cruz A, Featherston B, Carlson R, Romero I, Zarif I, Dehghan N, McKee M, Jones CB, Sietsema DL, Williams A, Dykes T, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Porcel-Vazquez JA, Andres-Peiro JV, Esteban-Feliu I, Vidal-Tarrason N, Serracanta J, Nuñez-Camarena J, del Mar Villar-Casares M, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Marcano-Fernández F, Martínez-Carreres L, Martí-Garín D, Serrano-Sanz J, Sánchez-Fernández J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Cámara-Cabrera J, Caparros-García A, Fillat-Gomà F, Fuentes-López R, Garcia-Rodriguez R, Gimeno-Calavia N, Martínez-Álvarez M, Martínez-Grau P, Pellejero-García R, Ràfols-Perramon O, Peñalver JM, Salomó Domènech M, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Cueva-Sevieri HE, Garcia-Gimenez S, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Spicer E, Payne K, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Gaski GE, Wills J, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Williams W, Hill T, Brotherton A, Romeo NM, Vallier HA, Vergon A, Higgins TF, Haller JM, Rothberg DL, Olsen ZM, McGowan AV, Hill S, Dauk MK, Bergin PF, Russell GV, Graves ML, Morellato J, McGee SL, Bhanat EL, Yener U, Khanna R, Nehete P, Potter D, VanDemark III R, Seabold K, Staudenmier N, Coe M, Dwyer K, Mullin DS, Chockbengboun TA, DePalo Sr. PA, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Bauer B, Meredith S, Talwar S, Domes CM, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Mehta S, Donegan D, Horan A, Dooley M, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial. Lancet 2022; 400:1334-1344. [PMID: 36244384 DOI: 10.1016/s0140-6736(22)01652-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture. METHODS We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304. FINDINGS Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4). INTERPRETATION For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds. FUNDING US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.
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Gitajn IL, Natoli RM, Spitler CA, Firoozabadi R, Tatman LM, Gary JL, Githens MF, Thompson RE, DeLuca A, Reider L, Wysocki E, Obremskey W. Radiographic Assessment of Ankle Fracture Displacement: A Validation Study. Foot Ankle Int 2022; 43:1269-1276. [PMID: 35837716 DOI: 10.1177/10711007221106471] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ankle fracture displacement is an important outcome in clinical research examining the effectiveness of surgical and rehabilitation interventions. However, the assessment of displacement remains subjective without well-described or validated measurement methods. The aim of this study was to assess inter- and intrarater reliability of ankle fracture displacement radiographic measures and select measurement thresholds that differentiate displaced and acceptably reduced fractures. METHODS Eight fellowship-trained orthopaedic surgeons evaluated a set of 26 postoperative ankle fracture radiographs on 2 occasions. Surgeons followed standardized instructions for making 5 measurements: coronal displacement (3) talar tilt (1), and sagittal displacement (1). Inter- and intraobserver interclass correlations were determined by random effects regression models. Logistic regression was used to determine the optimal sensitivity and specificity for the measurements with the highest correlation. RESULTS Three of the 5 measures had excellent interobserver reliability (correlation coefficient > 0.75): (1) coronal plane distance between the lateral border of tibia and lateral border of talus, (2) coronal plane talar tilt, and (3) sagittal plane displacement. The threshold that best discriminated displaced from well-aligned fractures was 2 mm for coronal plane distance (sensitivity 82.1%, specificity 85.4%), 3 degrees for talar tilt (sensitivity 80.4%, specificity 82.2%), and 5 mm for sagittal plane distance (sensitivity 83.9%, specificity 84.9%). CONCLUSION This study identified 3 reliable measures of ankle fracture displacement and determined optimal thresholds for discriminating between displaced and acceptably reduced fractures. These measurement criteria can be used for the design and conduct of clinical research studying the impact of surgical treatment and rehabilitation interventions.
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Affiliation(s)
| | - Roman M Natoli
- Indiana University Methodist Hospital, Indianapolis, IN, USA
| | - Clay A Spitler
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Reza Firoozabadi
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Joshua L Gary
- McGovern Medical School, UTHealth Houston, Houston, TX, USA
| | - Michael F Githens
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Richard E Thompson
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrea DeLuca
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa Reider
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth Wysocki
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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15
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Levy JF, Reider L, Scharfstein DO, Pollak AN, Morshed S, Firoozabadi R, Archer KR, Gary JL, O'Toole RV, Castillo RC, Quinnan SM, Kempton LB, Jones CB, Bosse MJ, MacKenzie EJ. The 1-Year Economic Impact of Work Productivity Loss Following Severe Lower Extremity Trauma. J Bone Joint Surg Am 2022; 104:586-593. [PMID: 35089905 DOI: 10.2106/jbjs.21.00632] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism). METHODS This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups. RESULTS Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures). CONCLUSIONS Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.
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Affiliation(s)
- Joseph F Levy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel O Scharfstein
- Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, Utah
| | - Andrew N Pollak
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Saam Morshed
- Departments of Orthopaedic Surgery, Epidemiology, and Biostatistics, University of California San Francisco, San Francisco, California
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research and Department of Physical Medicine and Rehabilitation and Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stephen M Quinnan
- The Paley Orthopedic & Spine Institute at St. Mary's Medical Center, West Palm Beach, Florida
| | - Laurence B Kempton
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Clifford B Jones
- Dignity Health Medical Group, St. Joseph's Hospital Medical Center & Creighton University School of Medicine, Phoenix, Arizona
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Ellen J MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Chandra Vemulapalli K, Pechero GR, Warner SJ, Achor TS, Gary JL, Munz JW, Choo AM, Prasarn ML, Chip Routt ML. Is retrograde nailing superior to lateral locked plating for complete articular distal femur fractures? Injury 2022; 53:640-644. [PMID: 34863509 DOI: 10.1016/j.injury.2021.11.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 10/26/2021] [Accepted: 11/14/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Nonunion rates for distal femur fractures treated with lateral locked plating (LLP) remains as high as 18-22% despite significant advances with implant design and construct modulation. However, whether treatment of distal femur fractures with rIMN has improved outcomes compared to LLP has not been well characterized. The purpose of this study was to compare outcomes of complete articular distal femur fractures (AO/OTA 33-C) treated with either LLP or rIMN. METHODS 106 distal femur fractures in 106 patients between January 2014 and January 2018 were identified. Medical records were reviewed to collect patient age, gender, body mass index, sagittal and coronal plane alignment on immediate postoperative radiographs, time to union, incidence of nonunion, and incidence of secondary operative procedures for repair of a nonunion. RESULTS Of 106 patients, 50 underwent rIMN and 56 underwent LLP. The mean age at the time of injury was 51 years (21 to 86 years) and there were 55 males. Average coronal alignment of 83.7° of anatomic lateral distal femoral angle (aLDFA) and sagittal alignment of <1° of apex anterior angulation in the rIMN group. In the LLP group there was an average of 87.9° of aLDFA and 1.9° of apex anterior angulation (p = .005 and p = .36). Average time to union in the rIMN group was 6 months and 6.6 months in the LLP group (p = .52). Incidence of nonunion in the rIMN group was 11.8% and 27.5% in the LLP group (p = .008). There were 8 secondary procedures for nonunion in the rIMN group and 18 in the LLP group (p = .43). CONCLUSIONS Our results demonstrated a higher nonunion rate and coronal plane malalignment with LLP compared to rIMN. While prospective data is required, rIMN does appear to be an appropriate treatment for complete articular distal femur fractures with a potentially decreased rate of nonunion .
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Affiliation(s)
- K Chandra Vemulapalli
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA USA.
| | - Guillermo R Pechero
- Department of Orthopaedic Surgery, UTHealth McGovern Medical School, Houston, TX USA
| | - Stephen J Warner
- Department of Orthopaedic Surgery, UTHealth McGovern Medical School, Houston, TX USA
| | - Timothy S Achor
- Department of Orthopaedic Surgery, UTHealth McGovern Medical School, Houston, TX USA
| | - Joshua L Gary
- Department of Orthopaedic Surgery, UTHealth McGovern Medical School, Houston, TX USA
| | - John W Munz
- Department of Orthopaedic Surgery, UTHealth McGovern Medical School, Houston, TX USA
| | - Andrew M Choo
- Department of Orthopaedic Surgery, UTHealth McGovern Medical School, Houston, TX USA
| | - Mark L Prasarn
- Department of Orthopaedic Surgery, UTHealth McGovern Medical School, Houston, TX USA
| | - Milton L Chip Routt
- Department of Orthopaedic Surgery, UTHealth McGovern Medical School, Houston, TX USA
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17
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Gary JL. Commentary on: "Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamically Unstable Patients With Pelvic Ring Injuries". J Orthop Trauma 2022; 36:74. [PMID: 34407036 DOI: 10.1097/bot.0000000000002243] [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: 02/02/2023]
Affiliation(s)
- Joshua L Gary
- McGovern Medical School at UTHealth Houston, Houston, TX
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18
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Bangura A, Shannon C, Enobun B, O’Hara NN, Gary JL, Floccare D, Chizmar T, Pollak AN, Slobogean GP. Are Pelvic Binders an Effective Prehospital Intervention? PREHOSP EMERG CARE 2022; 27:24-30. [PMID: 34874811 PMCID: PMC9309190 DOI: 10.1080/10903127.2021.2015024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 06/22/2021] [Revised: 11/17/2021] [Accepted: 11/30/2021] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Widespread adoption of prehospital pelvic circumferential compression devices (PCCDs) by emergency medical services (EMS) systems has been slow and variable across the United States. We sought to determine the frequency of prehospital PCCD use by EMS providers. Secondarily, we hypothesized that prehospital PCCD use would improve early hemorrhagic shock outcomes. METHODS We conducted a single-center retrospective cohort study of 162 unstable pelvic ring injuries transported directly to our center by EMS from 2011 to 2020. Included patients received a PCCD during their resuscitation (prehospital or emergency department). Prehospital treatment details were obtained from the EMS medical record. The primary outcome was the proportion of patients who received a PCCD by EMS before hospital arrival. Secondarily, we explored factors associated with receiving a prehospital PCCD, and its association with changes in vital signs, blood transfusion, and mortality. RESULTS EMS providers documented suspicion of a pelvic ring fracture in 85 (52.8%) patients and 52 patients in the cohort (32.2%) received a prehospital PCCD. Wide variation in prehospital PCCD use was observed based on patient characteristics, geographic location, and EMS provider level. Helicopter flight paramedics applied a prehospital PCCD in 46% of the patients they transported (38/83); in contrast, the EMS organizations geographically closest to our hospital applied a PCCD in ≤5% of cases (2/47). Other predictors associated with receiving a prehospital PCCD included lower body mass index (p = 0.005), longer prehospital duration (p = 0.001) and lower Injury Severity Score (p < 0.05). We were unable to identify any improvements in clinical outcomes associated with prehospital PCCD, including early vital signs, number of blood transfusions within 24 hours, or mortality during admission (p > 0.05). CONCLUSION Our results demonstrate wide practice variation in the application of prehospital PCCDs. Although disparate PCCD application across the state is likely explained by differences across EMS organizations and provider levels, our study was unable to identify any clinical benefits to the prehospital use of PCCDs. It is possible that the benefits of a prehospital PCCD can only be observed in the most displaced fracture patterns with the greatest early hemodynamic instability.
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Affiliation(s)
- Abdulai Bangura
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Cynthia Shannon
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Blessing Enobun
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Nathan N. O’Hara
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Joshua L. Gary
- Keck School of Medicine of the University of Southern California, Los Angeles, California, United States
| | - Doug Floccare
- Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland, United States
| | - Timothy Chizmar
- Maryland Institute for Emergency Medical Services Systems, Baltimore, Maryland, United States
| | - Andrew N. Pollak
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
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19
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Stinner DJ, Rivera JC, Smith CS, Weiss DB, Hymes RA, Matuszewski PE, Gary JL, Morshed S, Schmidt AH, Wilken JM, Archer KR, Bailey L, Kleihege J, McLaughlin KH, Thompson RE, Chung S, Remenapp C, MacKenzie EJ, Reider L. Early Advanced Weight-Bearing After Periarticular Fractures: A Randomized Trial Comparing Antigravity Treadmill Therapy Versus Standard of Care. J Orthop Trauma 2022; 36:S8-S13. [PMID: 34924513 DOI: 10.1097/bot.0000000000002285] [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: 10/07/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY In current clinical practice, weight-bearing is typically restricted for up to 12 weeks after definitive fixation of lower extremity periarticular fractures. However, muscle atrophy resulting from restricting weight-bearing has a deleterious effect on bone healing and overall limb function. Antigravity treadmill therapy may improve recovery by allowing patients to safely load the limb during therapy, thereby reducing the negative consequences of prolonged non-weight-bearing while avoiding complications associated with premature return to full weight-bearing. This article describes a multicenter randomized controlled trial comparing outcomes after a 10-week antigravity treadmill therapy program versus standard of care in adult patients with periarticular fractures of the knee and distal tibia. The primary hypothesis is that, compared with patients receiving standard of care, patients receiving antigravity treadmill therapy will report better function 6 months after definitive treatment.
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Affiliation(s)
- Daniel J Stinner
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica C Rivera
- U.S. Army Institute for Surgical Research, Brooke Army Medical Center, San Antonio, TX. Dr. Rivera is now with the Department of Orthopaedic Surgery, Louisiana State University Medical Center, New Orleans, LA
| | - Christopher S Smith
- Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, VA
| | - David B Weiss
- Department of Orthopaedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Robert A Hymes
- Department of Orthopaedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | - Paul E Matuszewski
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Joshua L Gary
- Department of Orthopaedic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX (now at the Department of Orthopaedic Surgery, at the Keck School of Medicine, University of Southern California, Los Angeles, CA)
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Jason M Wilken
- Department of Physical Therapy and Rehabilitation Sciences, University of Iowa, Iowa City, IA
| | - Kristin R Archer
- Department of Orthopaedic Surgery, Center for Musculoskeletal Research and Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lane Bailey
- Memorial Hermann IRONMAN Sports Medicine Institute, Houston, TX
| | | | - Kevin H McLaughlin
- Department of Physical Medicine and Rehabilitation, John Hopkins University, Baltimore, MD
| | - Richard E Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and
| | - Suna Chung
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Craig Remenapp
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ellen J MacKenzie
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Lisa Reider
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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20
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McKinley TO, Gaski GE, Billiar TR, Vodovotz Y, Brown KM, Elster EA, Constantine GM, Schobel SA, Robertson HT, Meagher AD, Firoozabadi R, Gary JL, O'Toole RV, Aneja A, Trochez KM, Kempton LB, Steenburg SD, Collins SC, Frey KP, Castillo RC. Patient-Specific Precision Injury Signatures to Optimize Orthopaedic Interventions in Multiply Injured Patients (PRECISE STUDY). J Orthop Trauma 2022; 36:S14-S20. [PMID: 34924514 DOI: 10.1097/bot.0000000000002289] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions.
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Affiliation(s)
- Todd O McKinley
- Department of Orthopedic Surgery, Indiana University Health Methodist Hospital, Indianapolis, IN
| | - Greg E Gaski
- Department of Orthopedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA
| | | | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Krista M Brown
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Greg M Constantine
- Department of Mathematics and Statistics, University of Pittsburgh, Pittsburgh, PA
| | - Seth A Schobel
- Department of Surgery, Uniformed Services University of the Health Sciences, Surgical Critical Care Initiative, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Henry T Robertson
- Department of Surgery, Uniformed Services University of the Health Sciences, Surgical Critical Care Initiative, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Ashley D Meagher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Reza Firoozabadi
- Department of Orthopaedics and Sports Medicine, University of Washington Harborview Medical Center, Seattle, WA
| | - Joshua L Gary
- Department of Orthopedic Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX (now at Keck School of Medicine of University of Southern California, Los Angeles, CA)
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY
| | - Karen M Trochez
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Laurence B Kempton
- Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Scott D Steenburg
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine and Indiana University Health Methodist Hospital, Indianapolis, IN; and
| | - Susan C Collins
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Katherine P Frey
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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21
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Gitajn IL, Werth PM, Sprague S, O’Hara N, Della Rocca G, Zura R, Marmor M, Domes CM, Hill LC, Churchill C, Townsend C, Van C, Hogan N, Girardi C, Slobogean GP, Slobogean GP, Sprague S, Wells J, Bhandari M, D'Alleyrand JC, Harris AD, Mullins DC, Thabane L, Wood A, Della Rocca GJ, Hebden J, Jeray KJ, Marchand L, O'Hara LM, Zura R, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt GH, Heels-Ansdell D, Marvel D, Palmer J, Friedrich J, O'Hara NN, Grissom F, Gitajn IL, Morshed S, O'Toole RV, Petrisor BA, Camara M, Mossuto F, Joshi MG, Fowler J, Rivera J, Talbot M, Dodds S, Garibaldi A, Li S, Nguyen U, Pogorzelski D, Rojas A, Scott T, Del Fabbro G, Szasz OP, McKay P, Howe A, Rudnicki J, Demyanovich H, Little K, Boissonneault A, Medeiros M, Polk G, Kettering E, Hale D, Mahal N, Eglseder A, Johnson A, Langhammer C, Lebrun C, Manson T, Nascone J, Paryavi E, Pensy R, Pollak A, Sciadini M, Degano Y, Demyanovich HK, Joseph K, Phipps H, Hempen E, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Leonard J, Marcano-Fernández FA, Gallant J, Persico F, Gjorgjievski M, George A, McGaugh SM, Pusztai K, Piekarski S, Lyons M, Gennaccaro J, Natoli RN, Gaski GE, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Baele JR, Mullis BH, Jang Y, Hill LC, Hudgins A, Fentz CL, Diaz MM, Garst KM, Denari EW, Osborn P, Pierrie S, Martinez E, Kimmel J, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich RW, Lazarus DE, Millon SJ, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill LE, Garitty MJ, Poole AS, Sims ML, Carlisle RM, Adams-Hofer E, Huggins BS, Hunter MD, Marshall WA, Bielby Ray S, Smith CD, Altman KM, Bedard JC, Loeffler MF, Pichiotino ER, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Moody MC, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Skyes JW, Kandemir U, Marmor M, Matityahu A, McClellan RT, Meinberg E, Miclau T, Shearer D, Toogood P, Ding A, Donohue E, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Paul A, Garg K, Pokhvashchev D, Gary JL, Warner SJ, Munz JW, Choo AM, Schor TS, Routt ML"C, Rao M, Pechero G, Miller A, Kutzler M, Hagen JE, Patrick M, Vlasak R, Krupko T, Sadasivan K, Talerico M, Horodyski M, Koenig C, Bailey D, Wentworth D, Van C, Schwartz J, Pazik M, Dehghan N, Jones CB, Watson JT, McKee M, Karim A, Sietsema DL, Williams A, Dykes T, Obremsky WT, Jahangir AA, Sethi M, Boyce R, Mitchell P, Stinner DJ, Trochez K, Rodriguez A, Gajari V, Rodriguez E, Pritchett C, Hogan N, Moreno AF, Boulton C, Lowe J, Wild J, Ruth JT, Taylor M, Askam B, Seach A, Saeed S, Culbert H, Cruz A, Knapp T, Hurkett C, Lowney M, Featherston B, Prayson M, Venkatarayappa I, Horne B, Jerele J, Clark L, Marcano-Fernández F, Jornet-Gibert M, Martinez-Carreres L, Marti-Garin D, Serrano-Sanz J, Sanchez-Fernandez J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Camara-Cabrera J, Caparros-Garcia A, Fillat-Goma F, Fuentes-Lopez R, Garcia-Rodriguez R, Gimeno-Calavia N, Graells-Alonso G, Martinez-Alvarez M, Martinez-Grau P, Pellejero-Garcia R, Rafols-Perramon O, Penalver JM, Domenech MS, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Enrique Cueva-Sevieri H, Garcia-Gimenez S, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Antonio Porcel-Vasquez J, Vicente Andres-Peiro J, Minguell-Monyart J, Nuñez-Camarena J, del Mar Villar-Casares M, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Romeo NM, Vallier HA, Breslin MA, Fraifogl J, Wilson ES, Wadenpfuhl LK, Halliday PG, Heimke I, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Zomar M, Spicer E, Fan C"B, Payne K, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Bartel C, Mayberry RM, Brownrigg M, Girardi C, Mayfield A, Sweeney J, Pollock H, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Wills J, Ramsey L, Ahn JS, Panjshiri F, Das S, English AD, Haaser SM, Cuff JAN, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Bullard D, Williams W, Hill T, Brotherton A, Higgins TF, Haller JM, Rothberg DL, Marchand LS, Neese A, Russell M, Olsen ZM, McGowan AV, Hill S, Coe M, Dwyer K, Mullin D, Reilly CA, DePalo P, Hall AE, Dabrowski RE, Chockbengboun TA, Heng M, Harris MB, Smith RM, Lhowe DW, Esposito JG, Bansal M, McTague M, Alnasser A, Bergin PF, Russell GV, Graves ML, Morellato J, Champion HK, Johnson LN, McGee SL, Bhanat EL, Thimothee J, Serrano J, Mehta S, Donehan D, Ahn J, Horan A, Dooley M, Kuczinski A, Iwu A, Potter D, VanDemark R, Pfaff B, Hollinsworth T, Atkins K, Weaver MJ, von Keudell AG, Allen EM, Sagona AE, Jaeblon T, Beer R, Bauer B, Meredith S, Stone A, Gage MJ, Reilly RM, Sparrow C, Paniagua A. Association of COVID-19 With Achieving Time-to-Surgery Benchmarks in Patients With Musculoskeletal Trauma. JAMA Health Forum 2021; 2:e213460. [PMID: 35977160 PMCID: PMC8727030 DOI: 10.1001/jamahealthforum.2021.3460] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/31/2021] [Indexed: 11/14/2022] Open
Abstract
Question Were resource constraints due to the COVID-19 pandemic associated with a delay in urgent fracture surgery beyond national time-to-surgery benchmarks? Findings In this cohort pre-post study that included 3589 patients, there was no association between time to surgery and COVID-19 in either open fracture or closed femur/hip fracture cohorts. Meaning Despite concerns that the unprecedented challenges associated with the COVID-19 pandemic would delay acute management of urgent surgery, many hospital systems within the US were able to implement strategies in keeping with time-to-surgery standards for orthopedic trauma. Importance In response to the COVID-19 pandemic, many hospital systems were forced to reduce operating room capacity and reallocate resources. The outcomes of these policies on the care of injured patients and the maintenance of emergency services have not been adequately reported. Objective To evaluate whether the COVID-19 pandemic was associated with delays in urgent fracture surgery beyond national time-to-surgery benchmarks. Design, Setting, and Participants This retrospective cohort study used data collected in the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma among at 20 sites throughout the US and Canada and included patients who sustained open fractures or closed femur or hip fractures. Exposure COVID-19–era operating room restrictions were compared with pre–COVID-19 data. Main Outcomes and Measures Surgery within 24 hours after injury. Results A total of 3589 patients (mean [SD] age, 55 [25.4] years; 1913 [53.3%] male) were included in this study, 2175 pre–COVID-19 and 1414 during COVID-19. A total of 54 patients (3.1%) in the open fracture cohort and 407 patients (21.8%) in the closed hip/femur fracture cohort did not meet 24-hour time-to-surgery benchmarks. We were unable to detect any association between time to operating room and COVID-19 era in either open fracture (odds ratio [OR], 1.40; 95% CI, 0.77-2.55; P = .28) or closed femur/hip fracture (OR, 1.01; 95% CI, 0.74-1.37; P = .97) cohorts. In the closed femur/hip fracture cohort, there was no association between time to operating room and regional COVID-19 prevalence (OR, 1.07; 95% CI, 0.70-1.64; P = .76). Conclusions and Relevance In this cohort study, there was no association between meeting time-to-surgery benchmarks in either open fracture or closed femur/hip fracture during the COVID-19 pandemic compared with before the pandemic. This is counter to concerns that the unprecedented challenges associated with managing the COVID-19 pandemic would be associated with clinically significant delays in acute management of urgent surgical cases and suggests that many hospital systems within the US were able to effectively implement policies consistent with time-to-surgery standards for orthopedic trauma in the context of COVID-19–related resource constraints.
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Affiliation(s)
| | - Paul M. Werth
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Nathan O’Hara
- University of Maryland School of Medicine, Baltimore
| | | | - Robert Zura
- Louisiana State University Medical Center, New Orleans
| | | | | | | | - Christine Churchill
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | - Chi Van
- University of Florida, Gainesville
| | | | - Cara Girardi
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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- for the PREP-IT Investigators
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Rogers NB, Karam WN, Kumaravel M, Warner SJ, Gary JL. Dual-Energy CT to Diagnose Occult Femoral Neck Fracture in MRI-Contraindicated Patient: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00013. [PMID: 34648465 DOI: 10.2106/jbjs.cc.21.00404] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 79-year-old woman presented after a ground level fall with the inability to bear weight on her right hip. Radiographs and computed tomography (CT) imaging were negative for a femoral neck fracture. Her medical comorbidities precluded magnetic resonance imaging (MRI), so dual-energy CT with focused evaluation for bone edema was performed, identifying a femoral neck fracture that was stabilized surgically. CONCLUSION Dual-energy CT with processing for edema can successfully identify nondisplaced femoral neck fractures in MRI-contraindicated patients. This imaging modality could be useful for diagnosing femoral neck stress fractures and ipsilateral femoral neck fractures in patients sustaining high-energy femoral shaft fractures.
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Affiliation(s)
- Nathan B Rogers
- Orthopaedic Surgery Resident, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Wade N Karam
- Orthopaedic Surgery Resident, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Manickam Kumaravel
- Department of Radiology, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Stephen J Warner
- Orthopaedic Trauma Service, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joshua L Gary
- Orthopaedic Trauma Service, Keck Medical Center of University of Southern California, Los Angeles, California
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23
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Rogers NB, Achor TS, Kumaravel M, Gary JL, Munz JW, Choo AM, Routt ML, Warner SJ. Implementation of a novel MRI protocol for diagnosing femoral neck fractures in high energy femoral shaft fractures: One year results. Injury 2021; 52:2390-2394. [PMID: 34053775 DOI: 10.1016/j.injury.2021.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 01/13/2021] [Revised: 04/15/2021] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Preliminary results using a novel rapid-sequence MRI to diagnose ipsilateral femoral neck fractures in patients sustaining high-energy femoral shaft fractures have been favorable compared to radiographic and CT imaging alone. To evaluate and optimize this new institutional imaging protocol further, we reviewed our results one year after implementation. METHODS Rapid-sequence MRI was added to the imaging evaluation of patients with high-energy femoral shaft fractures without femoral neck fractures identified on radiographs or CT imaging. Data was retrospectively reviewed from a consecutive series of patients who met inclusion criteria. RESULTS From September 2018 through September 2019, 114 patients sustained 121 high-energy femoral shaft fractures. The average patient age was 29.9 years, 73.7% (84/114) of patients were male, and 16.5% (20/121) were open fractures. Of patients indicated for a rapid-sequence MRI, 86% (92/107) underwent MR imaging. 5% (6/121) of patients had an ipsilateral femoral neck fracture identified on radiographs alone. Three additional femoral neck fractures were identified with CT imaging for an initial incidence of 7.4% (9/121). MRI identified 10 additional non-displaced femoral neck fractures, three complete and seven incomplete fractures, for an incidence of 15.7% (19/121). All identified femoral neck fractures were stabilized. DISCUSSION/CONCLUSION The addition of rapid-sequence MRI of the pelvis in patients with high-energy femoral shaft fractures reliably increases the diagnosis of ipsilateral femoral neck fractures not identified with standard imaging. There were no cases of missed/delayed femoral neck fractures in patients with a negative MRI. This new imaging protocol effectively and safely improves the diagnosis of this injury pattern.
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Affiliation(s)
- Nathan B Rogers
- Orthopaedic Surgery Resident, McGovern Medical School at UTHealth Houston, Houston, TX.
| | - Timothy S Achor
- Orthopaedic Trauma Service, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Manickam Kumaravel
- Department of Radiology, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Joshua L Gary
- Orthopaedic Trauma Service, McGovern Medical School at UTHealth Houston, Houston, TX
| | - John W Munz
- Orthopaedic Trauma Service, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Andrew M Choo
- Orthopaedic Trauma Service, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Milton L Routt
- Orthopaedic Trauma Service, McGovern Medical School at UTHealth Houston, Houston, TX
| | - Stephen J Warner
- Orthopaedic Trauma Service, McGovern Medical School at UTHealth Houston, Houston, TX
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24
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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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25
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Abstract
Principles of care in the polytraumatized patient have continued to evolve with advancements in technology. Although hemorrhage has remained a primary cause of morbidity and mortality in acute trauma, emerging strategies that can be applied pre-medical facility as well as in-hospital have continued to improve care. Exo-vascular modalities, including the use of devices to address torso hemorrhage and areas not amenable to traditional tourniquets, have revolutionized prehospital treatment. Endovascular advancements including the resuscitative endovascular balloon occlusion of the aorta (REBOA), have led to dramatic improvements in systolic blood pressure, although not without their own unique complications. Although novel treatment options have continued to emerge, so too have concepts regarding optimal time frames for intervention. Though prior care has focused on Injury Severity Score (ISS) as a marker to determine timing of intervention, current consensus contends that unnecessary delays in fracture care should be avoided, while respecting the complex physiology of certain patient groups that may remain at increased risk for complications. Thromboelastography (TEG) has been one technique that focuses on the unique pathophysiology of each patient, providing guidance for resuscitation in addition to providing information in recognizing the at-risk patient for venous thromboembolism. Negative pressure wound therapy (NPWT) has emerged as a therapeutic adjuvant for select trauma patients with significant soft tissue defects and open wounds. With significant advancements in medical technology and improved understanding of patient physiology, the optimal approach to the polytrauma patient continues to evolve.
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Affiliation(s)
- Christopher Lee
- Department of Orthopaedic Surgery, University of California - Los Angeles, Los Angeles, CA
| | - Todd E Rasmussen
- Department of General Surgery, F. Edward Hebert School of Medicine at the Uniformed Services University, Bethesda, MD
| | | | - Joshua L Gary
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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O'Toole RV, Stein DM, Frey KP, O'Hara NN, Scharfstein DO, Slobogean GP, Taylor TJ, Haac BE, Carlini AR, Manson TT, Sudini K, Mullins CD, Wegener ST, Firoozabadi R, Haut ER, Bosse MJ, Seymour RB, Holden MB, Gitajn IL, Goldhaber SZ, Eastman AL, Jurkovich GJ, Vallier HA, Gary JL, Kleweno CP, Cuschieri J, Marvel D, Castillo RC. PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT): a randomised pragmatic trial protocol comparing aspirin versus low-molecular-weight heparin for blood clot prevention in orthopaedic trauma patients. BMJ Open 2021; 11:e041845. [PMID: 33762229 PMCID: PMC7993181 DOI: 10.1136/bmjopen-2020-041845] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 01/27/2021] [Accepted: 02/25/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. METHODS AND ANALYSIS PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. ETHICS AND DISSEMINATION The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. TRIAL REGISTRATION NUMBER NCT02984384.
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Affiliation(s)
- Robert V O'Toole
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Deborah M Stein
- Department of Surgery, University of California in San Francisco, San Francisco, California, USA
| | - Katherine P Frey
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Daniel O Scharfstein
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Tara J Taylor
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bryce E Haac
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anthony R Carlini
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Theodore T Manson
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Kuladeep Sudini
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - C Daniel Mullins
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Reza Firoozabadi
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, North Carolina, USA
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, North Carolina, USA
| | - Martha B Holden
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Ida Leah Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexander L Eastman
- Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Gregory J Jurkovich
- Department of Surgery, University of California Davis, Davis, California, USA
| | - Heather A Vallier
- Department of Orthopaedics, MetroHealth System, Cleveland, Ohio, USA
| | - Joshua L Gary
- Department of Orthopedic Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Conor P Kleweno
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Debra Marvel
- PREVENT CLOT Stakeholder Committee, Baltimore, Maryland, USA
| | - Renan C Castillo
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Cunningham BA, Warner S, Berkes M, Achor T, Choo A, Munz J, Chip Routt ML, Gary JL. Effect of Intraoperative Multidimensional Fluoroscopy Versus Conventional Fluoroscopy on Syndesmotic Reduction. Foot Ankle Int 2021; 42:132-136. [PMID: 32945190 DOI: 10.1177/1071100720959025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite multiple techniques to improve syndesmotic reduction accuracy, syndesmotic malreduction in unstable ankle fractures remains prevalent. We performed a prospective, observational study to assess the ability of intraoperative multidimensional fluoroscopy to lead a surgeon to change the syndesmotic reduction obtained by conventional fluoroscopic techniques with the goal of achieving an accurate reduction. METHODS Thirty patients with unilateral malleolar ankle fractures and syndesmotic instability were enrolled. Following fixation of the malleollar fractures, the syndesmosis was provisionally reduced. Once the surgeon believed acceptable reduction was obtained by comparison with the contralateral, uninjured ankle mortise and lateral fluoroscopic images, provisional fixation was used to maintain reduction. Intraoperative, multidimensional fluoroscopy was used to generate cross-sectional images to assess the reduction. The surgeon then decided if a change in the reduction was needed, and fixation proceeded per surgeon preference. Postoperative bilateral computed tomography (CT) scans of the ankles were used to assess the reduction. RESULTS The main outcome recorded was syndesmotic reduction change by the attending surgeon following 3-dimensional (3D) fluoroscopic imaging. The secondary outcome was syndesmotic reduction accuracy on postoperative CT scan. Fourteen of 30 patients had intraoperative reduction change following 3D fluoroscopic imaging. Three of 30 patients had residual malreduction compared with the contralateral ankle on bilateral postoperative CT scan. CONCLUSION Intraoperative 3D fluoroscopy frequently led the surgeon to change the syndesmotic reduction obtained by conventional techniques and provided additional information not available with 2-dimensional fluoroscopy. A 10% syndesmotic malreduction rate was obtained with this technique. LEVEL OF EVIDENCE Diagnostic level II, prospective comparative study.
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Affiliation(s)
- Bryce A Cunningham
- Department of Orthopaedic Surgery, University of Tennessee College of Medicine Chattanooga, Erlanger Hospital, Chattanooga, TN, USA
| | - Stephen Warner
- Department of Orthopedic Surgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Marschall Berkes
- Department of Orthopedic Surgery, Washington University Center for Advanced Medicine, Barnes-Jewish Hospital, St. Louis MO, USA
| | - Timothy Achor
- Department of Orthopedic Surgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Andrew Choo
- Department of Orthopedic Surgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - John Munz
- Department of Orthopedic Surgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Milton L Chip Routt
- Department of Orthopedic Surgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Joshua L Gary
- Department of Orthopedic Surgery, McGovern Medical School at UTHealth, Houston, TX, USA
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Alamarat ZI, Babic J, Tran TT, Wootton SH, Dinh AQ, Miller WR, Hanson B, Wanger A, Gary JL, Arias CA, Pérez N. Long-Term Compassionate Use of Cefiderocol To Treat Chronic Osteomyelitis Caused by Extensively Drug-Resistant Pseudomonas aeruginosa and Extended-Spectrum-β-Lactamase-Producing Klebsiella pneumoniae in a Pediatric Patient. Antimicrob Agents Chemother 2020; 64:e01872-19. [PMID: 31871075 PMCID: PMC7179260 DOI: 10.1128/aac.01872-19] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [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: 09/16/2019] [Accepted: 12/02/2019] [Indexed: 11/20/2022] Open
Abstract
We report a 15 year-old Nigerian adolescent male with chronic osteomyelitis caused by an extensively drug-resistant (XDR) Pseudomonas aeruginosa strain of sequence type 773 (ST773) carrying blaNDM-1 and an extended spectrum β-lactamase (ESBL)-producing Klebsiella pneumoniae strain. The patient developed neurological side effects in the form of circumoral paresthesia with polymyxin B and asymptomatic elevation of transaminases with aztreonam (used in combination with ceftazidime-avibactam). Cefiderocol treatment for 14 weeks plus bone implantation resulted in apparent cure and avoided amputation.
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Affiliation(s)
- Zain I Alamarat
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Jessica Babic
- Department of Pharmacy, Memorial Hermann Texas Medical Center, Houston, Texas, USA
| | - Truc T Tran
- Division of Infectious Diseases, UT Health, McGovern Medical School, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics (CARMiG), UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Susan H Wootton
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UTHealth, McGovern Medical School, Houston, Texas, USA
| | - An Q Dinh
- Division of Infectious Diseases, UT Health, McGovern Medical School, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics (CARMiG), UTHealth, McGovern Medical School, Houston, Texas, USA
| | - William R Miller
- Division of Infectious Diseases, UT Health, McGovern Medical School, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics (CARMiG), UTHealth, McGovern Medical School, Houston, Texas, USA
- Center for Infectious Diseases, UTHealth, School of Public Health, Houston, Texas, USA
| | - Blake Hanson
- Division of Infectious Diseases, UT Health, McGovern Medical School, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics (CARMiG), UTHealth, McGovern Medical School, Houston, Texas, USA
- Center for Infectious Diseases, UTHealth, School of Public Health, Houston, Texas, USA
| | - Audrey Wanger
- Department of Pathology and Laboratory Medicine, UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Joshua L Gary
- Department of Orthopaedic Surgery, UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Cesar A Arias
- Division of Infectious Diseases, UT Health, McGovern Medical School, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics (CARMiG), UTHealth, McGovern Medical School, Houston, Texas, USA
- Center for Infectious Diseases, UTHealth, School of Public Health, Houston, Texas, USA
- Molecular Genetics and Antimicrobial Resistance Unit, Universidad El Bosque, Bogota, Colombia
- International Center for Microbial Genomics, Universidad El Bosque, Bogota, Colombia
| | - Norma Pérez
- Department of Pediatrics, Division of Pediatric Infectious Diseases, UTHealth, McGovern Medical School, Houston, Texas, USA
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Rogers NB, Hartline BE, Achor TS, Kumaravel M, Gary JL, Choo AM, Routt ML, Munz JW, Warner SJ. Improving the Diagnosis of Ipsilateral Femoral Neck and Shaft Fractures: A New Imaging Protocol. J Bone Joint Surg Am 2020; 102:309-314. [PMID: 31725122 DOI: 10.2106/jbjs.19.00568] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite increased awareness of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures and advanced imaging with thin-cut high-resolution computed tomography (CT), failure of diagnosis remains problematic. The purpose of the present study was to determine if the preoperative diagnosis of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures can be improved with magnetic resonance imaging (MRI) compared with radiographic and CT imaging. METHODS In response to delayed diagnoses of femoral neck fractures despite thin-cut high-resolution CT, our institutional imaging protocol for acute, high-energy femoral shaft fractures was altered to include rapid limited-sequence MRI to evaluate for occult femoral neck fractures. All patients received standard radiographic imaging as well as thin-cut high-resolution pelvic CT imaging upon presentation. Rapid limited-sequence MRI of the pelvis was obtained to evaluate for an occult femoral neck fracture. RESULTS Thirty-seven consecutive patients with 39 acute, high-energy femoral shaft fractures resulting from blunt trauma were included. The average age of the patients was 29.1 years (range, 14 to 82 years). Ten (25.6%) of the 39 femoral shaft fractures were open. Two femoral shaft fractures (5.1%) were associated with ipsilateral femoral neck fractures that were detected on radiographs, and no MRI was performed. None of the remaining 37 femoral shaft fractures were associated with a femoral neck fracture that was identified on CT imaging. Thirty-three (89.2%) of 37 patients underwent pelvic MRI to evaluate the ipsilateral femoral neck. Four (12.1%) of those 33 patients were diagnosed with a femoral neck fracture (2 complete, 2 incomplete) that was not identified on thin-cut high-resolution CT or radiographic imaging. CONCLUSIONS Rapid limited-sequence MRI of the pelvis for patients with femoral shaft fractures identified femoral neck fractures that were not diagnosed on thin-cut high-resolution CT in 12% of our patients. Our results suggest that the frequency of femoral neck fractures may be underrepresented on CT imaging; rapid limited-sequence MRI was feasible without delaying definitive treatment even in polytraumatized patients. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nathan B Rogers
- Orthopaedic Trauma Service (T.S.A., J.L.G., A.M.C., M.L.R., J.W.M., and S.J.W.) and Department of Radiology (M.K.), McGovern Medical School at UTHealth Houston (N.B.R. and B.E.H.), Houston, Texas
| | - Braden E Hartline
- Orthopaedic Trauma Service (T.S.A., J.L.G., A.M.C., M.L.R., J.W.M., and S.J.W.) and Department of Radiology (M.K.), McGovern Medical School at UTHealth Houston (N.B.R. and B.E.H.), Houston, Texas
| | - Timothy S Achor
- Orthopaedic Trauma Service (T.S.A., J.L.G., A.M.C., M.L.R., J.W.M., and S.J.W.) and Department of Radiology (M.K.), McGovern Medical School at UTHealth Houston (N.B.R. and B.E.H.), Houston, Texas
| | - Manickam Kumaravel
- Orthopaedic Trauma Service (T.S.A., J.L.G., A.M.C., M.L.R., J.W.M., and S.J.W.) and Department of Radiology (M.K.), McGovern Medical School at UTHealth Houston (N.B.R. and B.E.H.), Houston, Texas
| | - Joshua L Gary
- Orthopaedic Trauma Service (T.S.A., J.L.G., A.M.C., M.L.R., J.W.M., and S.J.W.) and Department of Radiology (M.K.), McGovern Medical School at UTHealth Houston (N.B.R. and B.E.H.), Houston, Texas
| | - Andrew M Choo
- Orthopaedic Trauma Service (T.S.A., J.L.G., A.M.C., M.L.R., J.W.M., and S.J.W.) and Department of Radiology (M.K.), McGovern Medical School at UTHealth Houston (N.B.R. and B.E.H.), Houston, Texas
| | - Milton L Routt
- Orthopaedic Trauma Service (T.S.A., J.L.G., A.M.C., M.L.R., J.W.M., and S.J.W.) and Department of Radiology (M.K.), McGovern Medical School at UTHealth Houston (N.B.R. and B.E.H.), Houston, Texas
| | - John W Munz
- Orthopaedic Trauma Service (T.S.A., J.L.G., A.M.C., M.L.R., J.W.M., and S.J.W.) and Department of Radiology (M.K.), McGovern Medical School at UTHealth Houston (N.B.R. and B.E.H.), Houston, Texas
| | - Stephen J Warner
- Orthopaedic Trauma Service (T.S.A., J.L.G., A.M.C., M.L.R., J.W.M., and S.J.W.) and Department of Radiology (M.K.), McGovern Medical School at UTHealth Houston (N.B.R. and B.E.H.), Houston, Texas
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Gary JL. A Potential Step Forward in Classifying Acetabular Fractures If Surgeons Are Open to Change: Commentary on an article by Ruipeng Zhang, MD, et al.: "Three-Column Classification for Acetabular Fractures. Introduction and Reproducibility Assessment". J Bone Joint Surg Am 2019; 101:e124. [PMID: 31764376 DOI: 10.2106/jbjs.19.00966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Joshua L Gary
- Department of Orthopedic Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
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Castillo RC, Huang Y, Scharfstein D, Frey K, Bosse MJ, Pollak AN, Vallier HA, Archer KR, Hymes RA, Newcomb AB, MacKenzie EJ, Wegener S, Hsu JR, Karunakar MA, Seymour RB, Sims SH, Flores E, Churchill C, Hak DJ, Henderson CE, Mir HR, Chan DS, Shah AR, Steverson B, Westberg J, Gary JL, Achor TS, Choo A, Munz JW, Porrey M, Hendrickson S, Breslin MA, McKinley TO, Gaski GE, Kempton LB, Sorkin AT, Virkus WW, Hill LC, Jones CB, Sietsema DL, O'Toole RV, Ordonio K, Howe AL, Zerhusen TJ, Obremskey W, Boyce RH, Jahangir AA, Molina CS, Sethi MK, Vanston SW, Carroll EA, Drye DY, Holden MB, Collins SC, Wysocki E. Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma. JAMA Surg 2019; 154:e184824. [PMID: 30566192 DOI: 10.1001/jamasurg.2018.4824] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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
Importance Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population. Objectives To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes. Design, Setting, and Participants A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018. Main Outcomes and Measures At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months. Results Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups. Conclusions and Relevance This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.
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Affiliation(s)
- Renan C Castillo
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Yanjie Huang
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel Scharfstein
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Katherine Frey
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Andrew N Pollak
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore
| | | | | | | | | | - Ellen J MacKenzie
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stephen Wegener
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Joseph R Hsu
- Carolinas Medical Center, Charlotte, North Carolina
| | | | | | | | | | | | - David J Hak
- Denver Health and Hospital Authority, Denver, Colorado
| | | | - Hassan R Mir
- Florida Orthopedic Institute/Tampa General Hospital, Tampa
| | - Daniel S Chan
- Florida Orthopedic Institute/Tampa General Hospital, Tampa
| | - Anjan R Shah
- Florida Orthopedic Institute/Tampa General Hospital, Tampa
| | | | - Jerald Westberg
- Hennepin County Medical Center/Regions Hospital, Minneapolis, Minnesota
| | - Joshua L Gary
- University of Texas Health Science Center at Houston
| | | | - Andrew Choo
- University of Texas Health Science Center at Houston
| | - John W Munz
- University of Texas Health Science Center at Houston
| | | | | | | | | | | | | | | | | | | | | | | | - Robert V O'Toole
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore
| | - Katherine Ordonio
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore
| | - Andrea L Howe
- University of Maryland R Adams Cowley Shock Trauma Center, Baltimore
| | | | | | - Robert H Boyce
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Cesar S Molina
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Manish K Sethi
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Eben A Carroll
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | | | - Martha B Holden
- Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina
| | - Susan C Collins
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth Wysocki
- METRC Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Kamath AF, Kleweno CP, Gary JL, Tannoury C. The 2018 American Orthopaedic Association-Japanese Orthopaedic Association (AOA-JOA) Traveling Fellowship. J Bone Joint Surg Am 2018; 100:e126. [PMID: 30278003 DOI: 10.2106/jbjs.18.00718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Atul F Kamath
- Department of Orthopaedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Conor P Kleweno
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Joshua L Gary
- Department of Orthopaedic Surgery, McGovern Medical School at University of Texas Health, Houston, Texas
| | - Chadi Tannoury
- Department of Orthopaedic Surgery, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
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Abstract
Tibial plateau fractures are common in the elderly population following a low-energy mechanism. Initial evaluation includes an assessment of the soft tissues and surrounding ligaments. Most fractures involve articular depression leading to joint incongruity. Treatment of these fractures may be complicated by osteoporosis, osteoarthritis, and medical comorbidities. Optimal reconstruction should restore the mechanical axis, provide a stable construct for mobilization, and reestablish articular congruity. This is accomplished through a variety of internal or external fixation techniques or with acute arthroplasty. Regardless of the treatment modality, particular focus on preservation and maintenance of the soft tissue envelope is paramount.
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Affiliation(s)
- Joshua C Rozell
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Krishna C Vemulapalli
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Joshua L Gary
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Derek J Donegan
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Heydemann J, Hartline B, Gibson ME, Ambrose CG, Munz JW, Galpin M, Achor TS, Gary JL. Do Transsacral-transiliac Screws Across Uninjured Sacroiliac Joints Affect Pain and Functional Outcomes in Trauma Patients? Clin Orthop Relat Res 2016; 474:1417-21. [PMID: 26472585 PMCID: PMC4868165 DOI: 10.1007/s11999-015-4596-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with pelvic ring displacement and instability can benefit from surgical reduction and instrumentation to stabilize the pelvis and improve functional outcomes. Current treatments include iliosacral screw or transsacral-transiliac screw, which provides greater biomechanical stability. However, controversy exists regarding the effects of placement of a screw across an uninjured sacroiliac joint for pelvis stabilization after trauma. QUESTIONS/PURPOSES Does transsacral-transiliac screw fixation of an uninjured sacroiliac joint increase pain and worsen functional outcomes at minimum 1-year followup compared with patients undergoing standard iliosacral screw fixation across the injured sacroiliac joint in patients who have sustained pelvic trauma? METHODS All patients between ages 18 and 84 years who sustained injuries to the pelvic ring (AO/OTA 61 A, B, C) who were surgically treated between 2011 and 2013 at an academic Level I trauma center were identified for selection. We included patients with unilateral sacroiliac disruption or sacral fractures treated with standard iliosacral screws across an injured hemipelvis and/or transsacral-transiliac screws placed in the posterior ring. Transsacral-transiliac screws were generally more likely to be used in patients with vertically unstable sacral injuries of the posterior ring as a result of previous reports of failures or in osteopenic patients. We excluded patients with bilateral posterior pelvic ring injuries, fixation with a device other than a screw, previous pelvic or acetabular fractures, associated acetabular fractures, and ankylosing spondylitis. Of the 110 patients who met study criteria, 53 (44%) were available for followup at least 12 months postinjury. Sixty patients were unable to be contacted by phone or mail and seven declined to participate in the study. Outcomes were obtained by members of the research team using the visual analog scale (VAS) pain score for both posterior sacroiliac joints, Short Musculoskeletal Functional Assessment (SMFA), and Majeed scores. Patients completed the forms by themselves when able to return to the clinic. A phone interview was performed for others after they received the outcome forms by mail or email. RESULTS There were no differences between iliosacral and transsacral-transiliac in terms of VAS injured (2.9 ± 2.9 versus 3.0 ± 2.8, mean difference = 0.1 [95% confidence interval, -1.6 to 1.7], p = 0.91), VAS uninjured (1.8 ± 2.4 versus 2.0 ± 2.6, mean difference = 0.2 [-1.3 to 1.6], p = 0.82), Majeed (80.3 ± 19.9, 79.3 ± 17.5, mean difference = 1.0 [-11.6 to 9.6], p = 0.92), SMFA Function (22.8 ± 22.2, 21.0 ± 17.6, mean difference = 1.8 [-13.2 to 9.6], p = 0.29, and SMFA Bother (24.3 ± 23.8, 29.7 ± 23.4, mean difference = 5.4 [-7.8 to 18.6], p = 0.42). CONCLUSIONS Placement of fixation across a contralateral, uninjured sacroiliac joint resulted in no differences in pain and function when compared with standard iliosacral screw placement across an injured hemipelvis at least 1 year after instrumentation. When needed for biomechanical stability, transsacral-transiliac fixation across an uninjured sacroiliac joint can be used without expectation of positive or negative effects on pain or functional outcomes at minimum 1-year followup. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- John Heydemann
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Braden Hartline
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Mary Elizabeth Gibson
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Catherine G. Ambrose
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - John W. Munz
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Matthew Galpin
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Timothy S. Achor
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Joshua L. Gary
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA ,grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, 6400 Fannin Street, Suite 1700, Houston, TX 77030 USA
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Davis JA, Roper B, Munz JW, Achor TS, Galpin M, Choo AM, Gary JL. Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture? Clin Orthop Relat Res 2016; 474:1430-5. [PMID: 26497882 PMCID: PMC4868158 DOI: 10.1007/s11999-015-4609-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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] [Indexed: 01/31/2023]
Abstract
BACKGROUND Controversy regarding heterotopic ossification (HO) prophylaxis exists after Kocher-Langenbeck for treatment of acetabular fracture. Prophylaxis options include antiinflammatory oral medications, single-dose radiation therapy, and débridement of gluteus minimus muscle. Prior literature has suggested single-dose radiation therapy as the best prophylaxis to prevent HO formation. However, recent reports have emerged of radiation-induced sarcoma after radiotherapy for HO prophylaxis, which has led many surgeons to reconsider the risks and benefits of single-dose radiation therapy. We set out to determine if radiotherapy, in addition to standard débridement of gluteus minimus muscle, affected postoperative HO formation after a Kocher-Langenbeck approach for acetabular fracture. QUESTIONS/PURPOSES (1) After the Kocher-Langenbeck approach and gluteus minimus débridement, is single-dose radiotherapy associated with a decreased risk of HO? (2) Does addition of single-dose radiotherapy prolong length of stay after a Kocher-Langenbeck approach and gluteus minimus débridement as compared with patients without radiotherapy? METHODS After institutional review board approval, all adult patients treated for acetabular fracture by a single surgeon with a Kocher-Langenbeck approach between August 2011 and October 2014 were identified (n = 60). Débridement of gluteus minimus muscle caudal to the superior gluteal bundle was standard in all patients. Radiotherapy was given with a single dose of 700 cGy within 72 hours of surgery from August 2011 until April 2013. Patients treated subsequently did not receive radiotherapy. Patients treated with indomethacin (n = 1) and with fewer than 10 weeks followup were excluded (n = 12) because several studies suggest that most HO that develops is visible by that point in time. Our study group totaled 46 patients with 24 in the radiotherapy and débridement group and 22 in the débridement group. Charts were reviewed to determine length of stay. Attending orthopaedic trauma surgeons who were blinded to the patient's treatment group graded all followup radiographs according to the Brooker system, and Classes III and IV HO were considered clinically important Fisher's exact test was used to analyze clinically significant differences HO between the two groups. Length of stay was compared using a t-test. RESULTS Single-dose radiotherapy is associated with a decreased risk of clinically important (Brooker III-IV) HO after a Kocher-Langenbeck approach and gluteus minimus débridement (radiotherapy: one of 24 [4%], no radiotherapy: seven of 22 [32%], relative risk: 0.131 [95% confidence interval {CI}, 0.018-0.981], p = 0.020). Addition of single-dose radiotherapy did not result in increased length of stay (radiotherapy: 12 ± 7.0 days; no radiotherapy: 11 ± 7.2 days; mean difference: 1.0 [95% CI, -3.2 to 5.2] days, p = 0.635). CONCLUSIONS Single-dose radiation in combination with gluteus minimus débridement decreases the risk of clinically important HO compared with gluteus minimus débridement alone after a Kocher-Langenbeck approach for acetabular fracture. No differences in length of stay were seen. Surgeons who chose not to use radiotherapy as a result of concern for future sarcoma may see higher rates of clinically significant HO after a Kocher-Langenbeck approach for acetabular fracture fixation. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Jason A. Davis
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Brennan Roper
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - John W. Munz
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Timothy S. Achor
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Matthew Galpin
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Andrew M. Choo
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA
| | - Joshua L. Gary
- grid.267308.80000000092062401Department of Orthopaedic Surgery, University of Texas Medical School at Houston, Houston, TX USA ,grid.267308.80000000092062401University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 1700, Houston, TX 77030 USA
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Eagan M, Kim H, Manson TT, Gary JL, Russell JP, Hsieh AH, O'Toole RV, Boulton CL. Internal anterior fixators for pelvic ring injuries: Do monaxial pedicle screws provide more stiffness than polyaxial pedicle screws? Injury 2015; 46:996-1000. [PMID: 25697857 DOI: 10.1016/j.injury.2015.01.040] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [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: 12/08/2014] [Accepted: 01/23/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Little is known about the mechanical properties of internal anterior fixators (known as INFIX), which have been proposed as subcutaneous alternatives to traditional anterior external fixators for pelvic ring disruptions. We hypothesised that INFIX has superior biomechanical performance compared with traditional external fixators because the distance from the bar to the bone is reduced. METHODS Using a commercially available synthetic bone model, 15 unstable pelvic ring injuries were simulated by excising the pubic bone through the bilateral superior and inferior rami anteriorly and the sacrum through the bilateral sacral foramen posteriorly. Three test groups were established: (1) traditional supra-acetabular external fixation, (2) INFIX with polyaxial screws, (3) INFIX with monaxial screws. Load was applied, simulating lateral compression force. Outcome measure was construct stiffness. RESULTS The traditional external fixator constructs had an average stiffness of 6.21 N/mm ± 0.40 standard deviation (SD). INFIX with monaxial screws was 23% stiffer than the traditional external fixator (mean stiffness, 7.66 N/mm ± 0.86 SD; p = .01). INFIX with polyaxial screws was 26% less stiff than INFIX with monaxial screws (mean stiffness, 5.69 N/mm ± 1.24 SD; p = .05). No significant difference was noted between polyaxial INFIX and external fixators (mean stiffness, 6.21 N/mm ± 0.40 SD; p=.65). CONCLUSIONS The performance of INFIX depends on the type of screw used, with monaxial screws providing significantly more stiffness than polyaxial screws. Despite the mechanical advantage of being closer to the bone, polyaxial INFIX was not stiffer than traditional external fixation.
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Affiliation(s)
- Michael Eagan
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Hyunchul Kim
- Fischell Department of Bioengineering, University of Maryland Orthopaedic Mechanobiology Laboratory, College Park, MD, United States
| | - Theodore T Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Joshua L Gary
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, Houston, TX, United States
| | - Joseph P Russell
- Fischell Department of Bioengineering, University of Maryland Orthopaedic Mechanobiology Laboratory, College Park, MD, United States
| | - Adam H Hsieh
- Fischell Department of Bioengineering, University of Maryland Orthopaedic Mechanobiology Laboratory, College Park, MD, United States
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Christina L Boulton
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, United States.
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Gary JL, Munz JW, Burgess AR. "Push-past" reaming as a reduction aid with intramedullary nailing of metadiaphyseal and diaphyseal femoral shaft fractures. Orthopedics 2014; 37:393-6. [PMID: 24972428 DOI: 10.3928/01477447-20140528-05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/20/2013] [Indexed: 02/03/2023]
Abstract
Eccentric reaming of cortical bone near a fracture site can introduce malalignment when an intramedullary nail is placed. The authors describe a technique of reaming metadiaphyseal and diaphyseal femur fractures in which maintaining reduction at the fracture site is not necessary to obtain an excellent alignment of long bone fractures after intramedullary nailing. They have found that central reaming proximal and distal to, but not at, the fracture site allows for excellent reduction of long bone fractures when the intramedullary nail is passed. The reamer is stopped just before the fracture site and then "pushed" across the fracture prior to resumption of reaming. The authors present "push-past" reaming as a technical trick to facilitate reduction of femoral fractures treated with intramedullary nails and a consecutive series of 18 cases in which excellent postoperative alignment was achieved.
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Gary JL, Kumaravel M, Gates K, Burgess AR, Routt ML, Welch T, Podbielski JM, Beeler AM, Holcomb JB. Imaging comparison of pelvic ring disruption and injury reduction with use of the junctional emergency treatment tool for preinjury and postinjury pelvic dimensions: a cadaveric study with computed tomography. J Spec Oper Med 2014; 14:30-34. [PMID: 25399365 DOI: 10.55460/wdi0-7q18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Complex dismounted blast injuries from (improvised) explosive devices have caused amputations of the lower extremities associated with open injuries to the pelvic ring, resulting in life-threatening hemorrhage from disruption of blood vessels near the pelvic ring. Provisional stabilization of the skeletal pelvis by circumferential pelvic compression provides stability for intrapelvic clots and reduces the volume of the pelvis, thereby limiting the amount of hemorrhage. The Junctional Emergency Treatment Tool (JETTtm; North American Rescue Products, http://www.narescue.com) is a junctional hemorrhage control device developed to treat pelvic and lower extremity injuries sustained in high-energy trauma on the battlefield and in the civilian environment. Our purpose was to evaluate the compressive function of the JETT in the reduction of pelvic ring injuries in a cadaveric model. METHODS Radiographic comparison of pre (intact) and post pelvic ring disruption and injury was compared with radiographic measurements post reduction with the JETT device in two cadavers. The device's ability to reduce pelvic disruption and injury in a human cadaver model was assessed through measurements of the anteroposterior (AP) and transverse diameters obtained at the inlet and outlet of the pelvis. RESULTS Computed tomography (CT) scans demonstrated that JETT application effectively induced circumferential soft tissue compression that was evoked near anatomic reduction of the sacroiliac joint and symphysis pubis. CONCLUSIONS The JETT is capable of effectively reducing an AP compression type III injury (APC III) pelvic ring disruption and injury by approximating the inlet and outlet dimensions toward predisruption measurements. Such a degree of reduction suggests that the JETT device may be suitable in the acute setting for provisional pelvic stabilization.
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Abstract
Minimally invasive osteosynthesis of proximal tibial fractures has grown in popularity in recent years. This article describes a patient with a Schatzker type VI proximal tibial fracture (AO/OTA type 41.C3) and previous compartment syndrome treated with definitive fixation 8 weeks after initial injury with a precontoured proximal tibial plate and a distal targeting device. Brisk bleeding occurred during percutaneous insertion of a cortical screw at the midshaft of the tibia. Surgical exploration revealed sidewall tearing of the anterior tibial artery and vein, which were clipped at the screw insertion site. After the bleeding was controlled, the patient had a strong palpable posterior tibial pulse with no palpable dorsalis pedis pulse, and the foot remained well perfused. Function of the deep peroneal nerve was normal postoperatively. Previous concerns regarding the percutaneous treatment of proximal tibial fractures have focused on the risks of damage to the superficial peroneal nerve from distal screws. Based on cadaveric studies, percutaneously and laterally based screw placement in the distal tibial metaphysis threatens injury to the anterior tibial system. However, with alterations to the normal anatomy caused by severe trauma, previously described safe zones may be changed and neurovascular structures may be exposed to risk in locations that were previously thought safe.
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Affiliation(s)
- Joshua L Gary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene St, Room T3R, Baltimore, MD 21201, USA
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Gary JL, Lefaivre KA, Gerold F, Hay MT, Reinert CM, Starr AJ. Survivorship of the native hip joint after percutaneous repair of acetabular fractures in the elderly. Injury 2011; 42:1144-51. [PMID: 20850738 DOI: 10.1016/j.injury.2010.08.035] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [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: 07/28/2010] [Revised: 08/19/2010] [Accepted: 08/20/2010] [Indexed: 02/02/2023]
Abstract
Our purpose was to examine survivorship of the native hip joint in patients ages 60 and over who underwent percutaneous reduction and fixation of acetabular fractures. A retrospective review at a University Level I Trauma Center was performed. Our institutional trauma database was reviewed. Patients aged 60 or older treated with percutaneous reduction and fixation of acetabular fractures between 1994 and 2007 were selected. 79 consecutive patients with 80 fractures were identified. Rate of conversion to total hip arthroplasty were used to construct a Kaplan-Meier curve showing survivorship of the native hip joint after treatment. 75 fractures had adequate clinical follow-up with a mean of 3.9 years (range 0.5-11.9 years). Average blood loss was 69 cc and there were no postoperative infections. 19/75 (25%) were converted to total hip arthroplasty at a mean time of 1.4 years after the index procedure. Survivorship analysis demonstrated a cumulative survival of 65% at 11.9 years of follow-up. There were no conversions to arthroplasty beyond 4.7 years postoperatively. There were no statistically significant associations between conversion to arthroplasty and age, sex, closed vs. limited open reduction, and simple vs. complex fracture pattern. Percutaneous fixation is a viable treatment option for patients age 60 or greater with acetabular fractures. Rates of conversion to total hip arthroplasty are comparable to open treatment methods and if conversion is required, soft tissues are preserved for future surgery.
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Affiliation(s)
- Joshua L Gary
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical School, Dallas, TX, USA.
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Gary JL, Taksali S, Reinert CM, Starr AJ. Ipsilateral femoral shaft and neck fractures: are cephalomedullary nails appropriate? J Surg Orthop Adv 2011; 20:122-125. [PMID: 21838074] [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: 05/31/2023]
Abstract
A retrospective review was conducted to examine rates of malreduction and nonunion in ipsilateral femoral neck and shaft fractures using different fixation strategies. Twenty-two consecutive patients with 23 fractures were identified. Participants were treated with various fixation strategies for ipsilateral femoral neck and shaft fractures. Cephalomedullary devices were used in 13 cases, while cannulated screws and a retrograde femoral nail were used in nine cases. One patient was treated with cannulated screws and external fixation of the femoral shaft. Radiographic assessment of the quality of reduction and union of both fractures was evaluated. Clinical and radiographic follow-up was available in 20 fractures (87%) with a mean of 12 months (range 3-50). Two femoral neck nonunions occurred; both had fair reductions of the fractures obtained by closed maneuvers, and two-device fixation was used in each. One femoral shaft nonunion occurred in a fracture treated with a cephalomedullary nail. All three united after revision surgery. No cases of osteonecrosis or conversion to hip arthroplasty were noted. A combination of retrograde femoral nailing and screw fixation of the femoral neck or placement of a cephalomedullary nail can provide excellent reduction and rate of union in the treatment of this injury pattern. Excellent reduction of the femoral neck fracture is key to preventing femoral neck nonunion.
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Affiliation(s)
- Joshua L Gary
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390-8883, USA.
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