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Oladipo V, Portney D, Haber J, Baker H, Strelzow J. Lactic acid levels are associated with morbidity, length of stay, and total treatment costs in urban trauma patients with lower extremity long bone fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1963-1970. [PMID: 38480531 DOI: 10.1007/s00590-024-03877-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 02/18/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population. METHODS Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression. RESULTS A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0 years old, with patients remaining hospitalized for 8.8 ± 9.5 days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008). CONCLUSION High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Victoria Oladipo
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, USA
| | - Daniel Portney
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA.
| | - Jordan Haber
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA
- Ohio State University School of Medicine, Columbus, USA
| | - Hayden Baker
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA
| | - Jason Strelzow
- Department of Orthopaedic Surgery, University of Chicago, Chicago, USA
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Yu TP, Chen YT, Ko PY, Wu CH, Yang TH, Hung KS, Wu PT, Wang CJ, Yen YT, Shan YS. Is delayed fixation worthwhile in patients with long bone fracture concomitant with mild traumatic brain injury? A propensity score-matched study. Injury 2023:110804. [PMID: 37225544 DOI: 10.1016/j.injury.2023.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Early definite treatment for orthopedic patients is strongly advocated. However, a consensus has not been reached on the optimal timing of long bone fracture fixation for patients with associated mild traumatic brain injury (TBI). Surgeons lack evidence on the basis on which they should decide on the operation timing. METHODS We retrospectively reviewed the data of patients with mild TBI and lower extremity long bone fractures from 2010 to 2020. The patients receiving internal fixation within and after 24 h were defined as the early- and delayed-fixation groups. We compared the discharge Glasgow Coma Scale (GCS) scores, lengths of stay, and in-hospital complications. Propensity score matching (PSM) with multiple adjusted variables and a 1:1 matching ratio was applied to reduce selection bias. RESULTS In total, 181 patients were enrolled; 78 (43.1%) and 103 (56.9%) patients received early and delayed fracture fixation, respectively. After matching, each group had 61 participants and were statistically identical. The delayed group did not have better discharge GCS scores (early vs. delayed: 15.0 ± 0 vs. 15.0 ± 0.1; p = 0.158). The groups did not differ in their lengths of hospital stay (15.3 ± 10.6 vs. 14.8 ± 7.9; p = 0.789), intensive care unit stay (2.7 ± 4.3 vs. 2.7 ± 3.8; p = 0.947), or incidence of complications (23.0% vs. 16.4%; p = 0.494). CONCLUSIONS Delayed fixation for patients with lower extremity long bone fractures concurrent with mild TBI does not result in fewer complications or improved neurologic outcomes compared with early fixation. Delaying fixation may not be necessary to prevent the second hit phenomenon and has not demonstrated any clear benefits.
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Affiliation(s)
- Tzu-Ping Yu
- School of Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ting Chen
- School of Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Po-Yen Ko
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Hsien Wu
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Tsung-Han Yang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Kuo-Shu Hung
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ting Wu
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Jung Wang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Yi-Ting Yen
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yan-Shen Shan
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Pean C, Weaver MJ, Harris MB, Ly T, von Keudell AG. What Do Orthopedic Trauma Surgeons Want and Expect from Anesthesiologists? Anesthesiol Clin 2022; 40:547-556. [PMID: 36049881 DOI: 10.1016/j.anclin.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
From the orthopedic trauma surgeon's perspective, successful injury management hinges on fracture fixation and restoration of patient mobility in a safe and expeditious manner. Management of critically injured polytrauma patients and shared decisions regarding regional anesthetics presents a myriad of challenges for orthopedic trauma surgeons and anesthesiologists alike. As the populations age, the typical patient sustaining traumatic orthopedic injuries are increasingly frail and elderly. This trend in demographics has mandated that care for orthogeriatric patients is coordinated by multidisciplinary teams working in concert on medically complex cases to a common end. In this article, we highlight opportunities for improved communication and care integration between orthopedic trauma surgeons and anesthesiologists.
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Affiliation(s)
- Christian Pean
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Michael J Weaver
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mitchel B Harris
- Massachusetts General Hospital, 55 Fruit Street #14, Boston, MA 02114, USA
| | - Thuan Ly
- Massachusetts General Hospital, 55 Fruit Street #14, Boston, MA 02114, USA
| | - Arvind G von Keudell
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Bispebjerg Hospital, Universtiy of Copenhagen, Bispebjerg Bakke 23, Copenhagen, KBH 2400, Denmark.
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