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Foster JA, Hawk GS, Landy DC, Griffin JT, Bernard AC, Oyler DR, Southall WGS, Muhammad M, Sierra-Arce CR, Mounce SD, Borgida JS, Xiang L, Aneja A. Does Scheduled Low-Dose Short-Term NSAID (Ketorolac) Modulate Cytokine Levels After Orthopaedic Polytrauma? A Secondary Analysis of a Randomized Clinical Trial. J Orthop Trauma 2024; 38:358-365. [PMID: 38506517 DOI: 10.1097/bot.0000000000002807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/11/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES To determine whether scheduled low-dose, short-term ketorolac modulates cytokine concentrations in orthopaedic polytrauma patients. METHODS DESIGN Secondary analysis of a double-blinded, randomized controlled trial. SETTING Single Level I trauma center from August 2018 to October 2022. PATIENT SELECTION CRITERIA Orthopaedic polytrauma patients between 18 and 75 years with a New Injury Severity Score greater than 9 were enrolled. Participants were randomized to receive 15 mg of intravenous ketorolac every 6 hours for up to 5 inpatient days or 2 mL of intravenous saline similarly. OUTCOME MEASURES AND COMPARISONS Daily concentrations of prostaglandin E2 and interleukin (IL)-1a, IL-1b, IL-6, and IL-10. Clinical outcomes included hospital and intensive care unit length of stay, pulmonary complications, and acute kidney injury. RESULTS Seventy orthopaedic polytrauma patients were enrolled, with 35 participants randomized to the ketorolac group and 35 to the placebo group. The overall IL-10 trend over time was significantly different in the ketorolac group ( P = 0.043). IL-6 was 65.8% higher at enrollment compared to day 3 ( P < 0.001) when aggregated over both groups. There was no significant treatment effect for prostaglandin E2, IL-1a, or IL-1b ( P > 0.05). There were no significant differences in clinical outcomes between groups ( P > 0.05). CONCLUSIONS Scheduled low-dose, short-term, intravenous ketorolac was associated with significantly different mean trends in IL-10 concentration in orthopaedic polytrauma patients with no significant differences in prostaglandin E2, IL-1a, IL-1b, or IL-6 levels between groups. The treatment did not have an impact on clinical outcomes of hospital or intensive care unit length of stay, pulmonary complications, or acute kidney injury. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeffrey A Foster
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Gregory S Hawk
- Dr Bing Zhang Department of Statistics, University of Kentucky, Lexington, KY
| | | | - Jarod T Griffin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew C Bernard
- Department of Trauma and Acute Care Surgery, University of Kentucky, Lexington, KY
| | - Douglas R Oyler
- Pharmacy Practice & Science Department, University of Kentucky, Lexington, KY
| | - Wyatt G S Southall
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Maaz Muhammad
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Samuel D Mounce
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Jacob S Borgida
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Lusha Xiang
- US Army Institute of Surgical Research, San Antonio, TX
| | - Arun Aneja
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
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Wong A, Burke CE, Bangura A, O'Hara NN, Mundy L, O'Toole RV, Pensy RA. What Outcomes Are Most Important to Patients Following a Lower Extremity Limb-threatening Injury? Ann Surg 2023; 277:21-27. [PMID: 35797182 DOI: 10.1097/sla.0000000000005470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine what outcomes are most important to patients after a limb-threatening injury, and if those preferences vary based on the patients' treatment (salvage vs amputation), health, demographics, or time since injury. BACKGROUND The preferences that motivate the patients' choice of treatment following a limb-threatening injury are poorly understood. Discrete choice experiments (DCEs) are a robust survey methodology to quantify preferences. METHODS Patients with a history of traumatic limb-threatening injury, January 2010 to December 2020, completed a survey with our DCE and the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. The DCE attributes included recovery time, function, appearance, cost, and time in hospital. We used conditional logit modeling to estimate the relative importance of each attribute on a scale of 0% to 100%, determine willingness to pay for improvements in the included attributes, and assess variation in preferences based on patient characteristics, including PROMIS score. RESULTS A total of 150 patients completed the survey (104 limb salvage, 46 amputation; mean age, 48±16 years; 79% male). Regaining preinjury function [relative importance=41%; 95% confidence interval (CI), 37%-45%] and minimizing costs (24%; 95% CI, 21%-28%) were of greatest importance. Changes in appearance were least important (7%; 95% CI, 5%-9%). The hierarchy of preferences did not vary between those who had limb salvage or amputation, but patient age, physical and mental health, and income were associated with preference variation. CONCLUSIONS Patients with limb-threatening injuries most valued gains in function and reduced out-of-pocket costs.
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Affiliation(s)
- Alison Wong
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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Bhan K, Patel R, Hasan K, Pimplé M, Sharma S, Nandwana V, Basta M. Fracture Nonunions and Delayed Unions Treated With Low-Intensity Pulsed Ultrasound Therapy: A Clinical Series. Cureus 2021; 13:e17067. [PMID: 34522545 PMCID: PMC8428199 DOI: 10.7759/cureus.17067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 12/27/2022] Open
Abstract
The incidence of nonunion of fractures has been steadily rising owing to improved life expectancy following severe injuries along with rising cases of polytrauma. Once a nonunion is established, the chances of spontaneous healing are deemed to be quite low. Fracture nonunion continues to be a challenge in clinical practice with nonunions having a considerable impact on patient’s quality of life causing both functional and psychosocial disability. Low-Intensity Pulsed Ultrasound (LIPUS) therapy is being projected as a viable and non-interventional alternative to surgical management of nonunions and delayed unions. LIPUS therapy is being widely recommended as a standalone treatment option for the treatment of established nonunions and delayed unions as it is believed to promote healing in all phases of fracture healing viz., inflammatory, intramembranous ossification, chondrogenesis, endochondral ossification and remodelling. In the current scenario of varying results and unclear clinical role of LIPUS therapy, we present a prospective case series of fracture nonunions and delayed unions treated with LIPUS therapy at a large District General Hospital.
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Affiliation(s)
- Kavyansh Bhan
- Trauma & Orthopaedics, Barts Health NHS Trust, London, GBR
| | - Ronak Patel
- Trauma & Orthopaedics, Barts Health NHS Trust, London, GBR
| | - Kamrul Hasan
- Trauma & Orthopaedics, Barts Health NHS Trust, London, GBR
| | - Mahesh Pimplé
- Trauma & Orthopaedics, Barts Health NHS Trust, London, GBR
| | - Sucheta Sharma
- Orthopaedic Surgery, Punjab Institute of Medical Sciences, Jalandhar, IND
| | - Varsha Nandwana
- Orthopaedic Surgery, Lady Hardinge Medical College, Delhi, IND
| | - Mhafrin Basta
- Dermatology, James Cook University Hospital, Middlesbrough, GBR
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Braun BJ, Grimm B, Hanflik AM, Marmor MT, Richter PH, Sands AK, Sivananthan S. Finding NEEMO: towards organizing smart digital solutions in orthopaedic trauma surgery. EFORT Open Rev 2020; 5:408-420. [PMID: 32818068 PMCID: PMC7407868 DOI: 10.1302/2058-5241.5.200021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
There are many digital solutions which assist the orthopaedic trauma surgeon. This already broad field is rapidly expanding, making a complete overview of the existing solutions difficult.The AO Foundation has established a task force to address the need for an overview of digital solutions in the field of orthopaedic trauma surgery.Areas of new technology which will help the surgeon gain a greater understanding of these possible solutions are reviewed.We propose a categorization of the current needs in orthopaedic trauma surgery matched with available or potential digital solutions, and provide a narrative overview of this broad topic, including the needs, solutions and basic rules to ensure adequate use in orthopaedic trauma surgery. We seek to make this field more accessible, allowing for technological solutions to be clearly matched to trauma surgeons' needs. Cite this article: EFORT Open Rev 2020;5:408-420. DOI: 10.1302/2058-5241.5.200021.
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Affiliation(s)
- Benedikt J Braun
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Germany
| | | | | | - Meir T Marmor
- Department of Orthopaedic Surgery, University of California, San Francisco, California, USA
| | - Peter H Richter
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Germany
| | - Andrew K Sands
- Weill Cornell Medical College, Foot and Ankle Surgery, Downtown Orthopedic Associates, New York Presbyterian Lower Manhattan Hospital, New York, USA
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Almahmoud K, Abboud A, Namas RA, Zamora R, Sperry J, Peitzman AB, Truitt MS, Gaski GE, McKinley TO, Billiar TR, Vodovotz Y. Computational evidence for an early, amplified systemic inflammation program in polytrauma patients with severe extremity injuries. PLoS One 2019; 14:e0217577. [PMID: 31163056 PMCID: PMC6548366 DOI: 10.1371/journal.pone.0217577] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/14/2019] [Indexed: 12/21/2022] Open
Abstract
Extremity and soft tissue injuries contribute significantly to inflammation and adverse in-hospital outcomes for trauma survivors; accordingly, we examined the complex association between clinical outcomes inflammatory responses in this setting using in silico tools. Two stringently propensity-matched, moderately/severely injured (Injury Severity Score > 16) patient sub-cohorts of ~30 patients each were derived retrospectively from a cohort of 472 blunt trauma survivors and segregated based on their degree of extremity injury severity (above or below 3 on the Abbreviated Injury Scale). Serial blood samples were analyzed for 31 plasma inflammatory mediators. In addition to standard statistical analyses, Dynamic Network Analysis (DyNA) and Principal Component Analysis (PCA) were used to model systemic inflammation following trauma. Patients in the severe extremity injury sub-cohort experienced longer intensive care unit length of stay (LOS), total LOS, and days on a mechanical ventilator, with higher Marshall Multiple Organ Dysfunction (MOD) Scores over the first 7 days post-injury as compared to the mild/moderate extremity injury sub-cohort. The higher severity cohort had statistically significant elevated lactate, base deficit, and creatine phosphokinase on first blood draw, along with significant changes in multiple circulating inflammatory mediators. DyNA pointed to a sustained role for type 17 immunity in both sub-cohorts, along with IFN-γ in the severe extremity injury group. DyNA network complexity increased over 7 days post-injury in the severe injury group, while generally decreasing over this same time period in the mild/moderate injury group. PCA suggested a more robust activation of multiple pathways in the severe extremity injury group as compared to the mild/moderate injury group. These studies thus point to the possibility of self-sustaining inflammation following severe extremity injury vs. resolving inflammation following less severe extremity injury.
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Affiliation(s)
- Khalid Almahmoud
- Department of Surgery, Division of Trauma & Critical Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, United States of America
| | - Andrew Abboud
- Department of Surgery, Division of Trauma & Critical Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Rami A. Namas
- Department of Surgery, Division of Trauma & Critical Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Ruben Zamora
- Department of Surgery, Division of Trauma & Critical Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jason Sperry
- Department of Surgery, Division of Trauma & Critical Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Andrew B. Peitzman
- Department of Surgery, Division of Trauma & Critical Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Michael S. Truitt
- Department of Graduate Medical Education, Department of Surgery, Methodist Dallas Health System, Dallas, TX, United States of America
| | - Greg E. Gaski
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Todd O. McKinley
- Department of Orthopedic Surgery, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Timothy R. Billiar
- Department of Surgery, Division of Trauma & Critical Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Yoram Vodovotz
- Department of Surgery, Division of Trauma & Critical Care Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
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