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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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Pogorzelski D, McKay P, Weaver MJ, Jaeblon T, Hymes RA, Gaski GE, Fraifogl J, Ahn JS, Bzovsky S, Slobogean G, Sprague S, Slobogean GP, Sprague S, Wells J, Bhandari M, O'Toole RV, D'Alleyrand JC, Eglseder A, Johnson A, Langhammer C, Lebrun C, Nascone J, Pensy R, Pollak A, Sciadini M, Slobogean GP, Degani Y, Demyanovich HK, Howe A, O'Hara NN, Phipps H, Hempen E. The impact of COVID-19 restrictions on participant enrollment in the PREPARE trial. Contemp Clin Trials Commun 2022; 29:100973. [PMID: 35989898 PMCID: PMC9384338 DOI: 10.1016/j.conctc.2022.100973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/13/2022] [Accepted: 08/07/2022] [Indexed: 11/09/2022] Open
Abstract
Background At the initiation of the COVID-19 pandemic, restrictions forced researchers to decide whether to continue their ongoing clinical trials. The PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities) trial is a pragmatic cluster-randomized crossover trial in patients with open and closed fractures. PREPARE was enrolling over 200 participants per month at the initiation of the pandemic. We aim to describe how the COVID-19 research restrictions affected participant enrollment. Methods The PREPARE protocol permitted telephone consent, however, sites were obtaining consent in-person. To continue enrollment after the initiation of the restrictions participating sites obtained ethics approval for telephone consent scripts and the waiver of a signature on the consent form. We recorded the number of sites that switched to telephone consent, paused enrollment, and the length of the pause. We used t-tests to compare the differences in monthly enrollment between July 2019 and November 2020. Results All 19 sites quickly implement telephone consent. Fourteen out of nineteen (73.6%) sites paused enrollment due to COVID-19 restrictions. The median length of enrollment pause was 46.5 days (range, 7–121 days; interquartile range, 61 days). The months immediately following the implementation of restrictions had significantly lower enrollment. Conclusion A pragmatic design allowed sites to quickly adapt their procedures for obtaining informed consent via telephone and allowed for minimal interruptions to enrollment during the pandemic.
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Affiliation(s)
- David Pogorzelski
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Paula McKay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Todd Jaeblon
- Department of Orthopaedics, University of Maryland, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert A Hymes
- Department of Orthopaedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Greg E Gaski
- Department of Orthopaedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Joanne Fraifogl
- Department of Orthopaedics, The MetroHealth System, Cleveland, OH, USA
| | - James S Ahn
- Department of Orthopaedic Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Gerard Slobogean
- Department of Orthopaedics, University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Robert V O'Toole
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Jean-Claude D'Alleyrand
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Andrew Eglseder
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Aaron Johnson
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Christopher Langhammer
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Christopher Lebrun
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Jason Nascone
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Raymond Pensy
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Andrew Pollak
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Marcus Sciadini
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Gerard P Slobogean
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Yasmin Degani
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Haley K Demyanovich
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Andrea Howe
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Nathan N O'Hara
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Heather Phipps
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Eric Hempen
- University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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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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Abstract
Treatment of ulnar diaphyseal fractures can range broadly from nonoperative with immobilization to surgical intervention with a variety of implants or approaches. At a Level 1 trauma center, a series of ulnar shaft fractures have been treated using a percutaneous plating technique that is base beneath the extensor carpi ulnaris. This technique description illustrates relevant anatomy, important patient and injury characteristics, implant considerations, and potential outcomes and complications. The described treatment option provides an effective way of spanning comminuted fracture patterns without disrupting the surrounding biology while providing stable fixation. An associated patient series is included which enumerates associated injuries and describes limited follow-up. In the multiply injured trauma patient, such a fixation method also had potential benefits for their overall care and rehabilitation.
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Affiliation(s)
| | - Joshua K Napora
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma, Baltimore, MD
| | - Andrew Eglseder
- Department of Orthopaedic Surgery, R. Adams Cowley Shock Trauma, Baltimore, MD
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Rodriguez EK, Eglseder A. A technique for low-profile intramedullary fixation of intraarticular proximal ulnar fractures. J Surg Orthop Adv 2008; 17:252-261. [PMID: 19138498] [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: 05/27/2023]
Abstract
A technique for low-profile fixation of intraarticular proximal ulnar fractures using an intramedullary (IM) screw is described. A retrospective study of the early outcome of patients treated with this technique versus patients treated with 3.5-mm LCDP plating is also presented. The authors report on 33 patients managed with IM fixation and 16 managed with plate fixation. Mean follow-up time was 16 months. Injuries managed with IM fixation had decreased flexion contractures and improved pronation (p<.05) compared with injuries treated with plating. Elbow arc of motion and supination did not differ significantly. Hardware removal was required in 56% of injuries treated with plating and in 9% of injuries treated with IM fixation. Release for limited motion was required in about 25% of patients in both groups. Mayo scores did not differ between both groups. Low-profile intramedullary fixation facilitates wound closure and soft tissue management and results in similar short-term outcomes as plating. The authors recommend this technique for cases with significant soft tissue injury where plating may result in a difficult closure or prominent hardware.
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Affiliation(s)
- Edward K Rodriguez
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Shapiro 2, Boston, MA 02215, USA.
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