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Dunbar RP, Egol KA, Jones CB, Ostrum RF, Mullis BH, Humphrey CA, Ricci WM, Phieffer LS, Teague DC, Sagi HC, Pollak AN, Schmidt AH, Sems A, Pape HC, Morshed S, Perez EA, Tornetta P. Locked Plating versus Nailing for Proximal Tibia Fractures: A Multicenter RCT. J Orthop Trauma 2023; 37:155-160. [PMID: 36729919 DOI: 10.1097/bot.0000000000002537] [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: 11/28/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The main 2 forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing (IMN) and locked lateral plating (LLP). The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN Multicenter, randomized controlled trial. SETTING 16 academic trauma centers. PATIENTS/PARTICIPANTS 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to IMN, and 47 patients were randomized to LLP. INTERVENTION IMN or lateral locked plating. MAIN OUTCOME MEASUREMENTS Functional scoring including Short Musculoskeletal Functional Assessment, Bother Index, EQ-5Dindex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number, and complications. RESULTS Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months postinjury. Similarly, there was no difference in time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support, or complications. CONCLUSIONS Both IMN and LLP provide for similar outcomes after these fractures. Patients continue to improve over the course of the year after injury but remain impaired even 1 year later. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Robert P Dunbar
- Harborview Medical Center/University of Washington, Seattle, WA
| | | | | | | | - Brian H Mullis
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
| | | | | | | | - David C Teague
- University of Oklahoma Medical Center, Oklahoma City, OK
| | - H Claude Sagi
- University of Cincinnati Medical Center, Cincinnati, OH
| | - Andrew N Pollak
- R. Adams Cowley Shock Trauma Center/University of Maryland, Baltimore, MD
| | | | - Andrew Sems
- Mayo Clinic Hospital, St. Mary's Campus, Rochester, MN
| | | | - Saam Morshed
- University of California San Francisco, San Francisco, CA
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Slobogean GP, Bzovsky S, O'Hara NN, Marchand LS, Hannan ZD, Demyanovich HK, Connelly DW, Adachi JD, Thabane L, Sprague S, Sprague S, Adachi JD, Bhandari M, Thabane L, Holick MF, Bzovsky S, Simunovic N, Madden K, Scott T, Duong A, Heels‐Ansdell D, Hannan ZD, Connelly DW, Rudnicki J, Pollak AN, O'Toole RV, LeBrun C, Nascone JW, Sciadini MF, Degani Y, Pensy R, Manson T, Eglseder WA, Langhammer CG, Johnson AJ, O'Hara NN, Demyanovich H, Howe A, Marinos D, Mascarenhas D, Reahl G, Ordonio K, Isaac M, Udogwu U, Baker M, Mulliken A, Atchison J, Schloss MG, Zaidi SMR, McKegg PC, DeLeon GA, Ghulam QM, Camara M, Marchand LS. Effect of Vitamin D 3 Supplementation on Acute Fracture Healing: A Phase II Screening Randomized Double-Blind Controlled Trial. JBMR Plus 2022; 7:e10705. [PMID: 36699638 PMCID: PMC9850434 DOI: 10.1002/jbm4.10705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 11/20/2022] Open
Abstract
Nearly half of adult fracture patients are vitamin D deficient (serum 25-hydroxyvitamin D [25(OH)D] levels <20 ng/mL). Many surgeons advocate prescribing vitamin D supplements to improve fracture healing outcomes; however, data supporting the effectiveness of vitamin D3 supplements to improve acute fracture healing are lacking. We tested the effectiveness of vitamin D3 supplementation for improving tibia and femur fracture healing. We conducted a single-center, double-blinded phase II screening randomized controlled trial with a 12-month follow-up. Patients aged 18-50 years receiving an intramedullary nail for a tibia or femoral shaft fracture were randomized 1:1:1:1 to receive (i) 150,000 IU loading dose vitamin D3 at injury and 6 weeks (n = 27); (ii) 4000 IU vitamin D3 daily (n = 24); (iii) 600 IU vitamin D3 daily (n = 24); or (iv) placebo (n = 27). Primary outcomes were clinical fracture healing (Function IndeX for Trauma [FIX-IT]) and radiographic fracture healing (Radiographic Union Score for Tibial fractures [RUST]) at 3 months. One hundred two patients with a mean age of 29 years (standard deviation 8) were randomized. The majority were male (69%), and 56% were vitamin D3 deficient at baseline. Ninety-nine patients completed the 3-month follow-up. In our prespecified comparisons, no clinically important or statistically significant differences were detected in RUST or FIX-IT scores between groups when measured at 3 months and over 12 months. However, in a post hoc comparison, high doses of vitamin D3 were associated with improved clinical fracture healing relative to placebo at 3 months (mean difference [MD] 0.90, 80% confidence interval [CI], 0.08 to 1.79; p = 0.16) and within 12 months (MD 0.89, 80% CI, 0.05 to 1.74; p = 0.18). The study was designed to identify potential evidence to support the effectiveness of vitamin D3 supplementation in improving acute fracture healing. Vitamin D3 supplementation, particularly high doses, might modestly improve acute tibia or femoral shaft fracture healing in healthy adults, but confirmatory studies are required. The Vita-Shock trial was awarded the Orthopaedic Trauma Association's (OTA) Bovill Award in 2020. This award is presented annually to the authors of the most outstanding OTA Annual Meeting scientific paper. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Sofia Bzovsky
- Division of Orthopaedic Surgery, Department of SurgeryMcMaster UniversityHamiltonCanada
| | - Nathan N. O'Hara
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | | | - Zachary D. Hannan
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Haley K. Demyanovich
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | - Daniel W. Connelly
- R Adams Cowley Shock Trauma Center, Department of OrthopaedicsUniversity of Maryland School of MedicineBaltimoreMDUSA
| | | | - Lehana Thabane
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonCanada
| | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of SurgeryMcMaster UniversityHamiltonCanada,Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonCanada
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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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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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Wilkie WA, Mohamed NS, Remily EA, Bonier J, McDermott S, Pastore M, Wells Z, Pollak AN, Nace J, Delanois RE. Access to Total Knee Arthroplasty Among Patients With Low Incomes Has Not Increased Under Global Budget Revenue. Orthopedics 2022; 45:e11-e16. [PMID: 34846240 DOI: 10.3928/01477447-20211124-03] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Indexed: 02/03/2023]
Abstract
In 2014, Maryland implemented an experimental reimbursement model, Global Budget Revenue (GBR). This model provided hospitals with a capitated annual budget each fiscal year to use toward all services, regardless of payer. Goals of GBR include reductions in cost, improvements in care quality, and increased access for patients to high-volume procedures, such as total knee arthroplasty (TKA). We assessed demographics and outcomes among patients with low incomes and patients of racial minority groups in Maryland who underwent TKA before and after GBR implementation. Patients undergoing TKAs from 2011 to 2016 were queried from the Maryland State Inpatient Database, resulting in 71,066 patients. There were 13,722 patients with low incomes and 19,846 patients of racial minority groups. The chi-square test was used for sex, income, insurance, Charlson Comorbidity Index, and morbid obesity, with the Student's t test being reserved for age before and after GBR. The proportion of patients with low incomes decreased the year before GBR but increased with GBR and maintained (P<.001). The proportion of patients of racial minority groups increased the year before GBR implementation, decreased slightly, and then maintained (P<.001). Mean cost decreased for both cohorts of patients (both P<.001). Discharges to home increased for both cohorts (P<.001), while length of stay decreased (both P<.001). Global Budget Revenue decreased cost while improving outcomes for TKA patients post-GBR. Patients with low incomes have not increased their use of TKA, contrary to patients of racial minority groups. This suggests that barriers remain. Further follow-up of GBR performance in subsequent years will increase understanding of the sustainability of this trend and the degree to which any increase in access is dependent on the implementation of the Affordable Care Act. [Orthopedics. 2022;45(1):e11-e16.].
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Delanois RE, Wilkie WA, Mohamed NS, Remily EA, Pollak AN, Mont MA. Maryland's Global Budget Revenue Model: How Do Costs and Readmission Rates Fare for Patients Undergoing Total Knee Arthroplasty? J Knee Surg 2021; 34:1421-1428. [PMID: 32369838 DOI: 10.1055/s-0040-1709677] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In 2014, Maryland implemented the Global Budget Revenue (GBR) model for cost reduction and quality improvement. This study evaluated GBR's effect on demographics and outcomes for patients who underwent primary total knee arthroplasty (TKA) by comparing Maryland to the United States (U.S.). We identified primary TKA patients in Maryland's State Inpatient Database (n = 71,022) and the National Inpatient Sample (n = 4,045,245) between 2011 and 2016 utilizing International Classification of Disease (ICD)-9 and ICD-10 diagnosis codes. Multiple regression was used for difference-in-difference (DID) analyses to compare the intervention cohort (Maryland) to the nonintervention cohort (U.S.) between the pre-GBR (2011-2013) and post-GBR (2014-2016) periods. After GBR implementation, there were proportionally less white, obese, morbidly obese, Medicare, and Medicaid patients with proportionally more routine discharge patients in Maryland and the U.S. (all p < 0.001). There were proportionally less home health care (HHC) patients in Maryland, but more in the U.S. (both p < 0.001). The mean lengths of stay (LOS), costs, and complications decreased for both cohorts, while charges increased for the U.S. (all p < 0.001). The DID analysis suggested Maryland saw more Asian and Medicaid patients and less obese and morbidly obese patients under GBR. The DID assessments also found decreased LOS, costs, and charges (p < 0.001 for all) for patients under GBR. As other states such as Pennsylvania and Vermont explore hospital budgets, Maryland may provide a more viable model for future health care policies that incorporate global budgets.
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Affiliation(s)
- Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Wayne A Wilkie
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha S Mohamed
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ethan A Remily
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Andrew N Pollak
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York City, New York
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So JY, O'Hara NN, Kenaa B, Williams JG, deBorja CL, Slejko JF, Zafari Z, Sokolow M, Zimand P, Deming M, Marx J, Pollak AN, Reed RM. Population Decline in COPD Admissions During the COVID-19 Pandemic Associated with Lower Burden of Community Respiratory Viral Infections. Am J Med 2021; 134:1252-1259.e3. [PMID: 34126098 PMCID: PMC8196237 DOI: 10.1016/j.amjmed.2021.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/27/2021] [Accepted: 05/17/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Coronavirus disease 2019 (COVID-19) pandemic has led to widespread implementation of public health measures, such as stay-at-home orders, social distancing, and masking mandates. In addition to decreasing spread of severe acute respiratory syndrome coronavirus 2, these measures also impact the transmission of seasonal viral pathogens, which are common triggers of chronic obstructive pulmonary disease (COPD) exacerbations. Whether reduced viral prevalence mediates reduction in COPD exacerbation rates is unknown. METHODS We performed retrospective analysis of data from a large, multicenter health care system to assess admission trends associated with community viral prevalence and with initiation of COVID-19 pandemic control measures. We applied difference-in-differences analysis to compare season-matched weekly frequency of hospital admissions for COPD prior to and after implementation of public health measures for COVID-19. Community viral prevalence was estimated using regional Centers for Disease Control and Prevention test positivity data and correlated to COPD admissions. RESULTS Data involving 4422 COPD admissions demonstrated a season-matched 53% decline in COPD admissions during the COVID-19 pandemic, which correlated to community viral burden (r = 0.73; 95% confidence interval, 0.67-0.78) and represented a 36% greater decline over admission frequencies observed in other medical conditions less affected by respiratory viral infections (incidence rate ratio 0.64; 95% confidence interval, 0.57-0.71, P < .001). The post-COVID-19 decline in COPD admissions was most pronounced in patients with fewer comorbidities and without recurrent admissions. CONCLUSION The implementation of public health measures during the COVID-19 pandemic was associated with decreased COPD admissions. These changes are plausibly explained by reduced prevalence of seasonal respiratory viruses.
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Affiliation(s)
- Jennifer Y So
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore
| | - Blaine Kenaa
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore
| | - John G Williams
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore
| | - Christopher L deBorja
- Department of Medicine, University of Maryland Baltimore Washington Medical Center, Glen Burnie, Md
| | - Julia F Slejko
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
| | - Zafar Zafari
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
| | - Michael Sokolow
- Quality Management Department, University of Maryland Medical System, Baltimore
| | - Paul Zimand
- Quality Management Department, University of Maryland Medical System, Baltimore
| | - Meagan Deming
- Division of Infectious Disease, University of Maryland School of Medicine, Baltimore
| | - Jason Marx
- Department of Medicine, University of Maryland St. Joseph's Medical Center, Towson
| | - Andrew N Pollak
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore
| | - Robert M Reed
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore.
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Lee C, O'Hara NN, Conti B, Hyder M, Sepehri A, Rudnicki J, Hannan Z, Connelly D, Baker M, Pollak AN, O'Toole RV. Quantitative Evaluation of Embolic Load in Femoral and Tibial Shaft Fractures Treated With Reamed Intramedullary Fixation. J Orthop Trauma 2021; 35:e283-e288. [PMID: 33252443 DOI: 10.1097/bot.0000000000002025] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the volume of embolic load during intramedullary fixation of femoral and tibial shaft fractures. Our hypothesis was that tibial intramedullary nails (IMNs) would be associated with less volume of intravasation of marrow than IM nailing of femur fractures. DESIGN Prospective observational study. SETTING Urban Level I trauma center. PATIENTS/PARTICIPANTS Twenty-three patients consented for the study: 14 with femoral shaft fractures and 9 with tibial shaft fractures. INTERVENTION All patients underwent continuous transesophageal echocardiography, and volume of embolic load was evaluated during 5 distinct stages: postinduction, initial guide wire, reaming (REAM), nail insertion, and postoperative. MAIN OUTCOME MEASUREMENTS Volume of embolic load was measured based on previously described luminosity scores. The embolic load based on fracture location and procedure stage was evaluated using a mixed effects model. RESULTS The IMN procedure increased the embolic load by 215% (-12% to 442%, P = 0.07) in femur patients relative to tibia patients after adjusting for baseline levels. Of the 5 steps measured, REAM was associated with the greatest increase in embolic load relative to the guide wire placement and controlling for fracture location (421%, 95% confidence interval: 169%-673%, P < 0.01). CONCLUSIONS Femoral shaft IMN fixation was associated with a 215% increase in embolic load in comparison with tibial shaft IMN fixation, with the greatest quantitative load during the REAM stage; however, both procedures produce embolic load. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA; and
| | - Nathan N O'Hara
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
| | - Bianca Conti
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
| | - Mary Hyder
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
| | - Aresh Sepehri
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
| | - Joshua Rudnicki
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
| | - Zachary Hannan
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
| | - Daniel Connelly
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
| | - Mitchell Baker
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
| | - Andrew N Pollak
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
| | - Robert V O'Toole
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MA
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Joseph K, Udogwu UN, Manson TT, Ludwig SC, Banagan KE, Baker M, Yousaf IS, Yousaf O, Demyanovich H, Pollak AN, O'Toole RV, O'Hara NN. Patient Satisfaction After Discharge Is Discordant With Reported Inpatient Experience. Orthopedics 2021; 44:e427-e433. [PMID: 34039209 DOI: 10.3928/01477447-20210415-01] [Citation(s) in RCA: 3] [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] [Indexed: 02/03/2023]
Abstract
Patient satisfaction measures are commonly used to evaluate clinical performance. However, research on the correlation between patient satisfaction scores and actual patient experience is limited. This study aimed to determine the concordance between patient satisfaction reported as an inpatient and patient satisfaction reported after discharge. The study enrolled 231 adult orthopedic patients at least 48 hours after admission to an academic hospital. Study participants rated their overall inpatient experience on a scale of 0 to 10, followed by open-ended questions on their hospital experience. Participants were then randomized to a second survey by either phone or mail at 4 to 6 weeks after discharge. Statistical and qualitative techniques were used to assess concordance in satisfaction scores and the agreement and association between patient experiences and patient satisfaction scores. The median overall patient satisfaction scores were 9.5 as inpatients (interquartile range [IQR], 8-10) and 10 at follow-up (IQR, 8-10), with a poor concordance between the inpatient and follow-up satisfaction scores (ρc=0.28). This study raises concerns regarding the validity of patient satisfaction measures to accurately quantify inpatient experience and the limitations related to its modes of administration. The authors observed poor agreement between the reported experience as an inpatient and the recollection of the inpatient experience after discharge. [Orthopedics. 2021;44(3):e427-e433.].
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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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Morellato J, O'Hara NN, Baker M, O'Toole RV, Pollak AN. What Is the Long-Term Impact of an Implant Stewardship Program on Orthopaedic Trauma Implant Pricing? J Orthop Trauma 2021; 35:e153-e157. [PMID: 32956204 DOI: 10.1097/bot.0000000000001967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyze the effectiveness of an implant stewardship program on implant cost containment and to estimate surgeons' responsiveness to implant price changes. DESIGN Interrupted time series. SETTING Level I trauma center. PATIENTS/PARTICIPANTS Monitored usage of 5 trauma constructs by 10 surgeons over a 5-year period. INTERVENTION Red-Yellow-Green (RYG) implant pricing comparison chart. MAIN OUTCOME MEASUREMENTS Primary outcomes were changes in the mean price, minimum price, and the number of price changes. The secondary outcome was surgeons' responsiveness to RYG/cost changes. RESULTS The study consisted of 2468 procedures. A mean construct price decrease of $66 per year [95% confidence interval (CI), $-170 to $-151], with distal femoral plates demonstrating the largest mean annual price decline ($486; 95% CI, $-540 to $-432). The minimum construct price decreased by $131 per year (95% CI, $-155 to $-111), with the largest reductions observed for distal femoral plates (-$436 per year; 95% CI, $-516 to $-354) and external fixators (-$122 per year; 95% CI, $-258 to $-136). The median price decrease was $407 (range: $6 to $2491) or 12.5% of the previous price. Positive changes in RYG levels increased surgeons' usage of tibial nails by 115%, femoral nails by 106%, and external fixators by 104%. Surgeons' implant selection was insensitive to RYG changes for distal femoral plates [RYG elasticity (ERYG): -0.74] and proximal tibia plates (ERYG: -0.21). CONCLUSIONS The implant stewardship program was associated with substantial implant price reductions. Surgeons' implant selection was especially sensitive to price changes for intramedullary nails and external fixators.
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Affiliation(s)
- John Morellato
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS; and
| | - Nathan N O'Hara
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Mitchell Baker
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Robert V O'Toole
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Andrew N Pollak
- Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
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Delanois RE, Wilkie WA, Mohamed NS, Remily EA, Pollak AN, Mont MA. The Affordable Care Act and Global Budget Revenue: The Impact on Total Hip Arthroplasties. J Arthroplasty 2020; 35:2791-2797. [PMID: 32561265 DOI: 10.1016/j.arth.2020.05.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 05/14/2020] [Accepted: 05/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Maryland possesses a unique, population-based alternative payment model named Global Budget Revenue (GBR). This study evaluated the effects of GBR on demographics and outcomes for patients who underwent primary total hip arthroplasty (THA) by comparing Maryland to the United States (U.S.). METHODS We identified primary THA patients in the Maryland State Inpatient Database (n = 35,925) and the National Inpatient Sample (n = 2,155,703) between 2011 and 2016 utilizing International Classification of Diseases 9 and 10 diagnosis codes. Qualitative analysis was used to report trends. Multiple regressions were used for difference-in-difference (DID) analyses to compare Maryland to the U.S. between pre-GBR (2011-2013) and post-GBR (2014-2016) periods. RESULTS After GBR implementation, there were proportionally more patients who were obese (Maryland: +5.1% vs U.S.: +3.0%), used Medicare (+1.6% vs +0.7%), used Medicaid (+2.4% vs +1.3%) while less used private insurance (-4.2% vs -1.8%) (all P < .001). There were proportionally less home health care patients in Maryland, but more in the U.S. (-3.5% vs +1.6%; both P < .001). The mean costs decreased for both cohorts (-$1780.80 vs -$209.40; both P < .001). The DID found Maryland saw more Medicaid and less private insurance patients under GBR (both P ≤ .001). Maryland saw more obese patients than would be expected (P = .001). The DID also found decreased costs for patients under GBR (P < .001 for both). CONCLUSION Maryland has benefitted from GBR with decreased cost and an increase in Medicaid patients. Maryland may provide a viable model for future healthcare policies that incorporate global budgets.
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Affiliation(s)
- Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD
| | - Wayne A Wilkie
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD
| | - Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD
| | - Ethan A Remily
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD
| | - Andrew N Pollak
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Michael A Mont
- Department of Orthopaedics, Lenox Hill Hospital, New York City, NY
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13
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Dávila Castrodad IM, Mohamed NS, Wilkie WA, Remily EA, Pollak AN, Mont MA, Delanois RE. Maryland's Global Budget Revenue model associated with lower inpatient costs and 30-day readmissions in patients undergoing total hip arthroplasty. Arthroplast Today 2020; 6:88-93. [PMID: 32211482 PMCID: PMC7083717 DOI: 10.1016/j.artd.2019.12.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/22/2019] [Accepted: 12/02/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Maryland implemented the Global Budget Revenue (GBR) to reduce hospital costs, improve quality, and decrease readmissions. Studies assessing its impact on inpatient total hip arthroplasty (THA) procedures are lacking. This study compared before and after GBR changes in 1) patient characteristics; 2) discharge dispositions and lengths of stay (LOS); 3) costs and charges of inpatient stays; and 4) 30-day readmission rates (RR) for THA recipients. METHODS The Maryland State Inpatient Database was queried for patients who underwent THA between 2010 and 2016 utilizing the ICD-9 and ICD-10 procedure codes (n = 43,251). Pre- and post-GBR periods were grouped as 2010 to 2013 and 2014 to 2016, respectively. Chi-square analyses were used to analyze patient characteristics. Student's t-tests were utilized to compare ages, LOS, costs, charges, and RR. RESULTS There were no differences in the proportion of minorities undergoing THA between the pre- and post-GBR periods (18.3% vs 19.4% African American, 1.2% vs 1.3% Hispanic; P = .056). The number of THA patients with Medicaid insurances increased during post-GBR (4.0% vs 6.7%; P < .001). There was an increased rate of home discharges during post-GBR (33.1% vs 40.9%; P < .001). We found lower LOS (-0.50 days; 95% CI: -0.458 to -0.533; P < .001), mean inpatient costs (-$1417.44; 95% CI -$1143.76 to -$1150.32; P < .001), and mean inpatient charges (-$2196.50; 95% CI: -$1980.10 to -$2412.90; P < .001) during the post-GBR period. There were lower 30-day RR during the post-GBR period (-0.9%; P < .001). CONCLUSIONS Our findings suggest favorable preliminary results for patients undergoing THA under the GBR model.
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Affiliation(s)
- Iciar M Dávila Castrodad
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Nequesha S Mohamed
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Wayne A Wilkie
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Ethan A Remily
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Andrew N Pollak
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York City, NY, USA
| | - Ronald E Delanois
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, MD, USA
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Howie W, Scott-Herring M, Pollak AN, Galvagno SM. Advanced Prehospital Trauma Resuscitation With a Physician and Certified Registered Nurse Anesthetist: The Shock Trauma "Go-Team". Air Med J 2019; 39:51-55. [PMID: 32044070 DOI: 10.1016/j.amj.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/02/2019] [Accepted: 09/03/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The R Adams Cowley Shock Trauma Center (STC) is Maryland's primary adult resource center for trauma care. The Shock Trauma "Go-Team" is a specialized component of Maryland's emergency medical system and is composed of a physician and certified registered nurse anesthetist. They are dispatched when advanced prehospital resuscitation is required. The purpose of this study is to describe the capabilities and historic epidemiology outcomes of the Go-Team. METHODS A retrospective case series review of recoverable Go-Team records was performed from 2011 to 2018. Go-Team call logs/records were identified from multiple sources. Medical records were reviewed for patient demographics, mechanisms of injury, and treatments in the field. There was a total of 61 activations, with 22 deployments to the scene of injury. RESULTS The majority of deployments were via helicopter (73%) and lasted 2 hours. The most common indications for deployment were motor vehicle entrapment (41%), trench collapse (14%), and building collapse (9%). Of the 22 patients treated by the Go-Team, 50% received at least 1 blood transfusion in the field, and 23% required an advanced airway. No field amputations were required. CONCLUSION The STC Go-Team is a unique multidisciplinary specialized component of a statewide emergency medical system.
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Affiliation(s)
- William Howie
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Mary Scott-Herring
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD.
| | - Andrew N Pollak
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Samuel M Galvagno
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD; Department of Anesthesiology and Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
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Delanois RE, Etcheson JI, Dávila Castrodad IM, Mohamed NS, Pollak AN, Mont MA. Influence of the Maryland All-Payer Model on Primary Total Knee Arthroplasties. JB JS Open Access 2019; 4:e0041. [PMID: 32043062 PMCID: PMC6959916 DOI: 10.2106/jbjs.oa.19.00041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In 2014, Maryland received a waiver for the Global Budget Revenue (GBR) program. We evaluated GBR's impact on patient and hospital trends for total knee arthroplasty (TKA) in Maryland compared with the U.S. Specifically, we examined (1) patient characteristics, (2) inpatient course, and (3) costs and charges associated with TKAs from 2014 through 2016. METHODS A comparative analysis of TKA-treated patients in the Maryland State Inpatient Database (n = 36,985) versus those in the National Inpatient Sample (n = 2,117,191) was performed. Patient characteristics included race, Charlson Comorbidity Index (CCI), morbid obesity, patient income status, and primary payer. Inpatient course included length of hospital stay (LOS), discharge disposition, and complications. RESULTS In the Maryland TKA cohort, the proportion of minorities increased from 2014 to 2016 while the proportion of whites decreased (p = 0.001). The proportion of patients with a CCI of ≥3 decreased (p = 0.014), that of low-income patients increased (p < 0.001), and that of patients covered by Medicare or Medicaid increased (p < 0.001). In the U.S. TKA cohort, the proportion of blacks increased (p < 0.001), that of patients with a CCI score of ≥3 decreased (p < 0.001), and the proportions of low-income patients (p < 0.001) and those covered by Medicare or Medicaid increased (p < 0.001). In both Maryland and the U.S., the LOS (p < 0.001) and complication rate (p < 0.001) decreased while home-routine discharges increased (p < 0.001). Costs and charges decreased in Maryland (p < 0.001 for both) whereas charges in the U.S. increased (p < 0.001) and costs decreased (p < 0.001). CONCLUSIONS While the U.S. health reform and GBR achieved similar patient and hospital-specific outcomes and broader inclusion of minority patients, Maryland experienced decreased hospital charges while hospital charges increased in the U.S. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jennifer I Etcheson
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Iciar M Dávila Castrodad
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Nequesha S Mohamed
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Andrew N Pollak
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
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Stockton DJ, Dua K, O'Brien PJ, Pollak AN, Hoshino CM, Slobogean GP. Failure Patterns of Femoral Neck Fracture Fixation in Young Patients. Orthopedics 2019; 42:e376-e380. [PMID: 30913299 DOI: 10.3928/01477447-20190321-03] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 05/15/2018] [Accepted: 10/03/2018] [Indexed: 02/03/2023]
Abstract
The primary purpose of this study was to describe the failure patterns of femoral neck fracture fixation in young patients. The secondary purpose was to determine if pattern of failure varies by type of implant. Adult patients (age range, 18-55 years) who experienced a "fixation failure" following internal fixation of a femoral neck fracture were identified from 5 level 1 trauma centers. Failure was defined by screw cutout, implant breakage, varus collapse (<120° neck-shaft angle), or severe fracture shortening (≥1 cm). When multiple complications were identified, mechanical failures were preferentially noted for the analysis. Failure patterns were compared between patients who received multiple cancellous screws and patients who received a sliding hip screw plus a derotation screw. Severe fracture shortening was the most common complication identified (61%). No differences in the incidence of severe shortening (P=.750) or implant breakage (P=1.000) were detected between the fixation groups. However, among the failures with a sliding hip screw plus a derotation screw construct, a greater portion were related to screw cutout (38% for a sliding hip screw plus a derotation screw vs 7% for screws, P=.019). Failures with multiple screws were associated with varus collapse (25% for screws vs 0% for a sliding hip screw plus a derotation screw, P=.037). Severe shortening was the most common fixation failure. Sliding hip screw plus derotation screw implants were associated with screw cutout. Multiple cancellous screw implants failed by varus collapse. Selecting a surgical implant based on its likely failure pattern may allow surgeons to minimize the severity of failure or the need for secondary conversion to hip arthroplasty. [Orthopedics. 2019; 42(4):e376-e380.].
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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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Kwok AK, O’Hara NN, Pollak AN, O’Hara LM, Herman A, Welsh CJ, Slobogean GP. Are injured workers with higher rehabilitation service utilization less likely to be persistent opioid users? A cross-sectional study. BMC Health Serv Res 2019; 19:32. [PMID: 30642319 PMCID: PMC6332665 DOI: 10.1186/s12913-019-3879-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 01/04/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Given its role in treating musculoskeletal conditions, rehabilitation medicine may be an important factor in decreasing the use of opioids among injured workers. The primary objective was to determine if increased utilization of rehabilitation services was associated with decreased persistent opioid use among workers' compensation claimants. The secondary objective was to determine the combined association of rehabilitation service utilization and persistent opioid use with days of work lost due to injury. METHODS Using Chesapeake Employers' Insurance Company claims data from 2008 to 2016, claimants with at least one filled opioid prescription within 90 days of injury were eligible for inclusion. The primary outcome was persistent opioid use, defined as at least one filled opioid prescription more than 90 days from injury. The secondary outcome was days lost due to injury. The primary variable of interest, rehabilitation service utilization, was quantified based on the number of rehabilitation service claims and grouped into five levels (no utilization, and four quartiles - low, medium, high, very high). RESULTS Of the 9596 claimants included, 29% were persistent opioid users. Compared to claimants that did not utilize rehabilitation services, patients with very high rehabilitation utilization were nearly three times more likely (OR: 2.71, 95% CI: 2.28-3.23, p < 0.001) to be persistent opioid users and claimants with low and medium levels of rehabilitation utilization were less likely to be persistent opioid users (low OR: 0.20, 95%: 0.14-0.27, p < 0.001) (medium OR: 0.26, 95% CI: 0.21-0.32, p < 0.001). Compared to claimants that did not utilize rehabilitation services, very high rehabilitation utilization was associated with a 27% increase in days lost due to the injury (95% CI: 21.9-32.3, p < 0.001), while low (- 16.4, 95% CI: -21.3 - -11.5, p < 0.001) and medium (- 11.5, 95% CI: -21.6 - -13.8, p < 0.001) levels of rehabilitation utilization were associated with a decrease in days lost due to injury, adjusting for persistent opioid use. CONCLUSION Our analysis of insurance claims data revealed that low to moderate levels of rehabilitation was associated with reduced persistent opioid use and days lost to injury. Very high rehabilitation utilization was associated with increased persistent opioid use and increased time from work.
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O’Hara NN, Pollak AN, Welsh CJ, O’Hara LM, Kwok AK, Herman A, Slobogean GP. Factors Associated With Persistent Opioid Use Among Injured Workers' Compensation Claimants. JAMA Netw Open 2018; 1:e184050. [PMID: 30646268 PMCID: PMC6324441 DOI: 10.1001/jamanetworkopen.2018.4050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 08/30/2018] [Indexed: 11/23/2022] Open
Abstract
Importance There is a paucity of data on persistent opioid use and factors associated with persistent opioid use among workers' compensation claimants. Objective To determine the proportion of injured workers who filled an opioid prescription beyond 90 days from injury and the factors associated with persistent opioid use among workers' compensation claimants. Design, Setting, Participants This retrospective cohort study collected workers' compensation claims data from January 1, 2008, to December 31, 2016, from the Chesapeake Employers' Insurance Company in Maryland. All workers' compensation claimants injured during the study years and with at least 1 filled opioid prescription were eligible for inclusion. For patients who had unique injury claims in multiple years of the study, only the first claimed injury was included in our analysis. Patients who died as a result of the claimed injury were excluded. The analysis was performed between October 2017 and August 2018. Main Outcomes and Measures The primary outcome was persistent opioid use, defined as an opioid prescription fulfillment beyond 90 days from the date of injury. Multivariable regression was used to determine prognostic factors of persistent opioid use. Results Of the 9596 study participants (mean [SD] age, 43 [12.3] years; 6218 [65.1%] male), 2741 (28.6%) filled an opioid prescription more than 90 days from their date of injury. Participants aged 60 years or older (odds ratio [OR], 1.92; 95% CI, 1.56-2.36), crush injuries (OR, 1.55; 95% CI, 1.28-1.89), strain and sprain injuries (OR, 1.54; 95% CI, 1.36-1.75), annual income more than $60 000 (OR, 1.31; 95% CI, 1.07-1.61), and concomitant diagnoses for chronic joint pain (OR, 1.98; 95% CI, 1.79-2.20) were significantly associated with persistent opioid use. Compared with workers with claims designated as permanent partial disability, workers with medical-only claims were significantly less likely to have persistent opioid use at 90 days postinjury (OR, 0.17; 95% CI, 0.15-0.20). Conclusions and Relevance A high proportion of persistent opioid use was observed in this workers' compensation cohort. Interventions to lower persistent opioid use in this population should target patients with the characteristics identified in this study.
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Affiliation(s)
| | | | | | | | - Alyson K. Kwok
- Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
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Abstract
BACKGROUND Orthopaedic procedures are expensive, and devices account for a large proportion of the overall costs. Hospitals have employed a variety of strategies to decrease implant costs, but many center on restricting surgeon choice. At our institution, we developed an implant selection tool that guides surgeons toward more cost-effective implants, while minimally restricting choice. The purpose of this study was to assess the effect of this tool on preferred implant usage rates, vendor attitudes toward pricing structure, and hospital implant expenditures. METHODS For 6 commonly used orthopaedic trauma devices, similar constructs were created for the 4 vendors used at our hospital, and the costs were determined. On the basis of these costs, the available options for each device type were categorized as "green" (preferred vendor), "yellow" (midrange), or "red" (used for patient-specific requirements). The "Red-Yellow-Green" chart was posted on the wall of each orthopaedic trauma operating room. To assess the effect of the tool, we compared implant usage patterns before and after implementation of the implant selection tool. We also assessed changes in vendor contract prices, as well as overall savings to our institution. RESULTS Implant usage changed significantly from 30% "red," 56% "yellow," and 14% "green" prior to the intervention, to 9% "red," 21% "yellow," and 70% "green" after the intervention (p < 0.0001). As a result of price renegotiation with vendors following implementation, we observed average price decreases that ranged from 1.1% to 22.4%. Average expenditures on these 6 implants decreased 20% during the study period, which represented a savings of $216,495 per year. CONCLUSIONS At our institution, we designed and implemented "Red-Yellow-Green," a simple tool that guides surgeons toward the selection of lower-cost implants without violating vendor confidentiality clauses, limiting the implants from which surgeons can choose, or requiring surgeons to discern the prices of complex constructs. Following implementation, hospital implant expenditures decreased as a result of a combination of increased preferred vendor usage by surgeons, as well as increased competition among vendors, which resulted in lower overall prices.
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Affiliation(s)
- Kanu Okike
- 1Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland 2Case Western Reserve University, Cleveland, Ohio
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21
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Okike K, O'Toole RV, Pollak AN, Bishop JA, McAndrew CM, Mehta S, Cross WW, Garrigues GE, Harris MB, Lebrun CT. Survey finds few orthopedic surgeons know the costs of the devices they implant. Health Aff (Millwood) 2015; 33:103-9. [PMID: 24395941 DOI: 10.1377/hlthaff.2013.0453] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Orthopedic procedures represent a large expense to the Medicare program, and costs of implantable medical devices account for a large proportion of those procedures' costs. Physicians have been encouraged to consider cost in the selection of devices, but several factors make acquiring cost information difficult. To assess physicians' levels of knowledge about costs, we asked orthopedic attending physicians and residents at seven academic medical centers to estimate the costs of thirteen commonly used orthopedic devices between December 2012 and March 2013. The actual cost of each device was determined at each institution; estimates within 20 percent of the actual cost were considered correct. Among the 503 physicians who completed our survey, attending physicians correctly estimated the cost of the device 21 percent of the time, and residents did so 17 percent of the time. Thirty-six percent of physicians and 75 percent of residents rated their knowledge of device costs "below average" or "poor." However, more than 80 percent of all respondents indicated that cost should be "moderately," "very," or "extremely" important in the device selection process. Surgeons need increased access to information on the relative prices of devices and should be incentivized to participate in cost containment efforts.
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Abstract
Ipsilateral fractures of the femoral neck and shaft are rare, high-energy injuries that typically occur in young polytrauma patients. The associated fracture of the neck is often vertical in nature and is more frequently non-displaced than in isolated femoral neck fractures. Historically the diagnosis of an associated femoral neck fracture was delayed or missed in approximately one third of cases. Studies have shown that detection can be significantly improved with the implementation of a protocolized approach to hip imaging in all patients with femoral shaft fractures. Prompt recognition of an associated femoral neck fracture allows for timely stabilization and may decrease the risks of non-union and avascular necrosis. In contrast, failure to recognize a non-displaced or minimally displaced associated neck fracture prior to fixation of the shaft can lead to displacement, a decrease in neck fixation options, a technically challenging secondary procedure and increased risk of long-term sequelae. A vast array of treatment strategies have been described for this combined injury. Published options range from spica casting to open reduction and internal fixation of both fractures and include almost all conceivable combinations in between. While timely surgical stabilization is now universally recommended for both shaft and neck, no consensus exists as to the most appropriate method of fixation for either fracture. Most authors recommend prompt, but not emergent, surgery with priority given to anatomic reduction and stabilization of the neck fracture by either closed or open methods. Fixation of the shaft fracture follows as patient condition allows. The rare nature of this injury makes it very challenging to study and most published series' are retrospective with very small sample sizes. In short, no scientificallycompelling study is available to definitively support any one implant choice or method of stabilzation over another for the treatment of associated fractures of the femoral neck and shaft.
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Affiliation(s)
- Christina L Boulton
- Department of Orthopaedics, Division of Orthopaedic Traumatology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 South Greene Street, Baltimore, MD 21201, United States
| | - Andrew N Pollak
- Department of Orthopaedics, Division of Orthopaedic Traumatology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 South Greene Street, Baltimore, MD 21201, United States.
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Scalea TM, Carco D, Reece M, Fouche YL, Pollak AN, Nagarkatti SS. Effect of a Novel Financial Incentive Program on Operating Room Efficiency. JAMA Surg 2014; 149:920-4. [DOI: 10.1001/jamasurg.2014.1233] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Thomas M. Scalea
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Darlene Carco
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Melissa Reece
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Yvette L. Fouche
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Andrew N. Pollak
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
| | - Sushruta S. Nagarkatti
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore
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Wegener ST, Castillo RC, Heins SE, Bradford AN, Newell MZ, Pollak AN, MacKenzie EJ. The development and validation of the readiness to engage in self-management after acute traumatic injury questionnaire. Rehabil Psychol 2014; 59:203-10. [PMID: 24611921 DOI: 10.1037/a0035693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Although the management of acute traumatic injury has improved, long-term functional outcomes remain poor. Data suggest major improvements in outcome will require comprehensive, self-management (SM) interventions. However, little is known about trauma survivors' willingness to participate in such interventions. The goal of this study was to create and validate an instrument based on the stages of change (SOC) framework to assess readiness to engage in SM programs following acute traumatic injury. METHOD The Readiness to Engage in Self-Management after Acute Traumatic Injury (RESMATI) was developed based on SOC theory. Participants (N = 150) were admitted to a Level I trauma center for treatment of severe trauma and completed the RESMATI 3 to 12 months postinjury. A random sample (n = 60) completed a reassessment 1 month later to determine item stability. A principal components analysis and an exploratory factor analysis were conducted. RESULTS The analyses of the 34 RESMATI items yielded a 5-factor model, collapsed into 3 domains based on SOC theory. Two factors were classified as "precontemplation," 2 factors were classified as "contemplation," and 1 factor was classified as "action/maintenance." All 3 domains had good internal consistency reliability (.71 to .92) and moderate test-retest reliability (.56 and .73). CONCLUSIONS The exploratory factor analysis yielded 3 domains that were consistent with the SOC model. Two notable exceptions were the lack of a "preparation" domain and lack of distinction between the action and maintenance stages. The RESMATI is a reliable instrument that requires further testing to establish validity and utility in identifying individuals' readiness to engage in SM following acute traumatic injury.
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Jacobs JJ, King TR, Klippel JH, Berven SH, Burr DB, Caskey PM, Elderkin AL, Esposito PW, Gall EP, Goldring SR, Pollak AN, Sandborg CI, Templeton KJ. Beyond the decade: strategic priorities to reduce the burden of musculoskeletal disease. J Bone Joint Surg Am 2013; 95:e1251-6. [PMID: 24005209 PMCID: PMC3748998 DOI: 10.2106/jbjs.l.01370] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [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 J. Jacobs
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612
| | - Toby R.W. King
- U.S. Bone and Joint Initiative, 6300 North River Road, Rosemont, IL 60018
| | - John H. Klippel
- Arthritis Foundation, 1330 West Peachtree Street, Suite 100, Atlanta, GA 30309
| | - Sigurd H. Berven
- Department of Orthopaedic Surgery, University of California San Francisco, 500 Parnassus Avenue MU-320W, San Francisco, CA 94143-0728
| | - David B. Burr
- Department of Anatomy and Cell Biology, Indiana University School of Medicine, MS 5035, 635 Barnhill Drive, Indianapolis, IN 46202
| | - Paul M. Caskey
- Shriners Hospitals for Children Spokane, 911 West 5th Ave, Spokane, WA 99204-2901
| | - Ann L. Elderkin
- American Society for Bone and Mineral Research, 2025 M Street N.W., Suite 800, Washington, DC 20036-3309
| | - Paul W. Esposito
- Children’s Hospital & Medical Center, 8200 Dodge Street–Pavilion 4th Floor, Omaha, NE 68114
| | - Eric P. Gall
- Arizona Arthritis Center, University of Arizona, 1501 North Campbell Avenue, Tucson, AZ 85724
| | | | - Andrew N. Pollak
- Orthopaedic Surgery–Shock Trauma Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201-1595
| | - Christy I. Sandborg
- Pediatric Rheumatology, Stanford University School of Medicine, Lucile Salter Packard Children’s Hospital, 300 Pasteur Drive, A085 A MC 5208, Stanford, CA 94305
| | - Kimberly J. Templeton
- Musculoskeletal Oncology, University of Kansas Medical Center, 3901 Rainbow Boulevard, SM 3017, Kansas City, KS 66160
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Carlson LC, Hirshon JM, Calvello EJB, Pollak AN. Operative care after the Haiti 2010 earthquake: implications for post-disaster definitive care. Am J Emerg Med 2012. [PMID: 23199560 DOI: 10.1016/j.ajem.2012.10.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Carlson LC, Slobogean GP, Pollak AN. Orthopaedic trauma care in Haiti: a cost-effectiveness analysis of an innovative surgical residency program. Value Health 2012; 15:887-893. [PMID: 22999139 DOI: 10.1016/j.jval.2012.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/06/2012] [Accepted: 06/10/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE In an effort to sustainably strengthen orthopaedic trauma care in Haiti, a 2-year Orthopaedic Trauma Care Specialist (OTCS) program for Haitian physicians has been developed. The program will provide focused training in orthopaedic trauma surgery and fracture care utilizing a train-the-trainer approach. The purpose of this analysis was to calculate the cost-effectiveness of the program relative to its potential to decrease disability in the Haitian population. METHODS Using established methodology originally outlined in the World Health Organization's Global Burden of Disease project, a cost-effectiveness analysis was performed for the OTCS program in Haiti. Costs and disability-adjusted life-years (DALYs) averted were estimated per fellow trained in the OTCS program by using a 20-year career time horizon. Probabilistic sensitivity analysis was used to simultaneously test the joint uncertainty of the cost and averted DALY estimates. A willingness-to-pay threshold of $1200 per DALY averted, equal to the gross domestic product per capita in Haiti, was selected on the basis of World Health Organization's definition of highly cost-effective health interventions. RESULTS The OTCS program results in an incremental cost of $1,542,544 ± $109,134 and 12,213 ± 2,983 DALYs averted per fellow trained. The cost-effectiveness ratio of $133.97 ± $34.71 per DALY averted is well below the threshold of $1200 per DALY averted. Furthermore, sensitivity analysis suggests that implementing the OTCS program is the economically preferred strategy with more than 95% probability at a willingness-to-pay threshold of $200 per DALY averted and across the entire range of potential variable inputs. CONCLUSIONS The current economic analysis suggests the OTCS program to be a highly cost-effective intervention. Probabilistic sensitivity analysis demonstrates that the conclusions remain stable even when considering the joint uncertainty of the cost and DALY estimates.
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Affiliation(s)
- Lucas C Carlson
- University of Maryland School of Medicine, R. Adams Cowley Shock Trauma Center, Baltimore, MD 21201, USA
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Born CT, Monchik KO, Hayda RA, Bosse MJ, Pollak AN. Essentials of disaster management: the role of the orthopaedic surgeon. Instr Course Lect 2011; 60:3-14. [PMID: 21553757] [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: 05/30/2023]
Abstract
Disaster preparedness and management education is essential for allowing orthopaedic surgeons to play a valuable, constructive role in responding to disasters. The National Incident Management System, as part of the National Response Framework, provides coordination between all levels of government and uses the Incident Command System as its unified command structure. An "all-hazards" approach to disasters, whether natural, man-made, intentional, or unintentional, is fundamental to disaster planning. To respond to any disaster, command and control must be established, and emergency management must be integrated with public health and medical care. In the face of increasing acts of terrorism, an understanding of blast injury pathophysiology allows for improved diagnostic and treatment strategies. A practical understanding of potential biologic, chemical, and nuclear agents and their attendant clinical symptoms is also prerequisite. Credentialing and coordination between designated organizations and the federal government are essential to allow civilian orthopaedic surgeons to access systems capable of disaster response.
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Affiliation(s)
- Christopher T Born
- Department of Orthopaedics, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
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Pollak AN, Jones AL, Castillo RC, Bosse MJ, MacKenzie EJ. The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. J Bone Joint Surg Am 2010; 92:7-15. [PMID: 20048090 PMCID: PMC2799040 DOI: 10.2106/jbjs.h.00984] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [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 Urgent débridement of open fractures has been considered to be of paramount importance for the prevention of infection. The purpose of the present study was to evaluate the relationship between the timing of the initial treatment of open fractures and the development of subsequent infection as well as to assess contributing factors. METHODS Three hundred and fifteen patients with severe high-energy lower extremity injuries were evaluated at eight level-I trauma centers. Treatment included aggressive débridement, antibiotic administration, fracture stabilization, and timely soft-tissue coverage. The times from injury to admission and operative débridement as well as a wide range of other patient, injury, and treatment-related characteristics that have been postulated to affect the risk of infection within the first three months after injury were studied, and differences between groups were calculated. In addition, multivariate logistic regression models were used to control for the effects of potentially confounding patient, injury, and treatment-related variables. RESULTS Eighty-four patients (27%) had development of an infection within the first three months after the injury. No significant differences were found between patients who had development of an infection and those who did not when the groups were compared with regard to the time from the injury to the first débridement, the time from admission to the first débridement, or the time from the first débridement to soft-tissue coverage. The time between the injury and admission to the definitive trauma treatment center was an independent predictor of the likelihood of infection. CONCLUSIONS The time from the injury to operative débridement is not a significant independent predictor of the risk of infection. Timely admission to a definitive trauma treatment center has a significant beneficial influence on the incidence of infection after open high-energy lower extremity trauma.
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Affiliation(s)
- Andrew N. Pollak
- University of Maryland School of Medicine, 22 South Greene Street, Suite T3R54, Baltimore, MD 21201. E-mail address:
| | - Alan L. Jones
- Orthopedic Trauma Associates of North Texas, Sammons Tower, 3409 Worth Street, Suite 320, Dallas, TX 75246
| | - Renan C. Castillo
- Center for Injury Prevention and Research, Johns Hopkins University Bloomberg School of Public Health, 624 North Broadway Street, Room 482, Baltimore, MD 21205
| | - Michael J. Bosse
- Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232
| | - Ellen J. MacKenzie
- Center for Injury Prevention and Research, Johns Hopkins University Bloomberg School of Public Health, 624 North Broadway Street, Room 482, Baltimore, MD 21205
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Pollak AN, Powell ET, Fang R, Cooper EO, Ficke JR, Flaherty SF. Use of negative pressure wound therapy during aeromedical evacuation of patients with combat-related blast injuries. J Surg Orthop Adv 2010; 19:44-48. [PMID: 20371006] [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: 05/29/2023]
Abstract
The purpose of the study was to evaluate safety and feasibility of negative pressure wound therapy (NPWT) during aeromedical evacuation from a combat zone to a regional treatment center. A retrospective review of patients who received NPWT during aeromedical evacuation from Iraq or Afghanistan to Landstuhl Regional Medical Center (LRMC) was performed. Data were collected describing mechanism of injury; anatomic site of NPWT application; number of sites per patient; date and time of NPWT application; date, time, and wound condition on arrival and inspection at LRMC; and complications encountered during aeromedical evacuation. Broad definitions of complications were employed. Any reported malfunction of NPWT devices or need to reinforce NPWT dressings was abstracted. Presence of tissue under the dressing requiring debridement was defined as a minor complication. Major complications were defined as wound sepsis with systemic manifestations. A total of 218 patients who had received NPWT for 298 wounds (1.37 per patient) during aeromedical evacuation were identified. Most wounds were due to high-energy blast or ballistic mechanisms. Average time from NPWT application to removal was 53 hours (range, 18-133 +/- 22 hours). Complications occurred at 14% of NPWT sites and in 19% of patients receiving NPWT. Most recorded complications were minor (95%). Two patients who arrived at LRMC with fever and evidence of wound sepsis improved rapidly after additional operative debridement. In no case was failure of the NPWT device in flight specifically implicated in the genesis of a recorded complication. In-flight device problems were identified in seven cases. Four of these could not be repaired in flight and were clamped. Complications were not increased in this cohort. Use of NPWT during aeromedical evacuation appears safe and feasible in a large cohort of patients with high-energy injuries. Complications were consistent with severity of injury and not related to failure of NPWT.
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Affiliation(s)
- Andrew N Pollak
- Division of Orthopaedic Trauma, University of Maryland School of Medicine, 22 South Greene Street, Suite T3R54, Baltimore, MD 21201, USA.
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D'Alleyrand JCG, Dutton RP, Pollak AN. Extrapolation of battlefield resuscitative care to the civilian setting. J Surg Orthop Adv 2010; 19:62-69. [PMID: 20371009] [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: 05/29/2023]
Abstract
Experiences in treating wartime casualties in Iraq and Afghanistan have already led to changes in civilian trauma care practices. While advances in the care of civilian musculoskeletal injuries are likely as a result of ongoing military basic and clinical research, major advances in resuscitative care have already been realized. Early liberal use of tourniquets to control bleeding from combat-associated extremity trauma has led to decreased mortality. Military experience has demonstrated that use of temporary intravascular shunts is effective for mitigating ischemic injury from vascular trauma until definitive repair can be accomplished. Hemostatic dressings have improved the surgeon's hemorrhage control armamentarium. Clinical experience with hypotensive resuscitation has led to refinement and improvement in the technique. Use of recombinant factor VIIa has improved hemorrhage control in the context of brain injury and coagulopathy and increasing the ratio of plasma to red cells during early shock resuscitation has improved survival.
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Affiliation(s)
- Jean-Claude G D'Alleyrand
- Division of Orthopaedic Traumatology, Department of Orthopaedics, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 S. Greene Street, Baltimore, MD 21201, USA
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Anglen JO, Bosse MJ, Bray TJ, Pollak AN, Templeman DC, Tornetta P, Watson JT. The Institute of Medicine report on resident duty hours. Part I: The Orthopaedic Trauma Association response to the report. J Bone Joint Surg Am 2009; 91:720-2. [PMID: 19255236 DOI: 10.2106/jbjs.i.00070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [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)
- Jeffrey O Anglen
- Department of Orthopaedics, Indiana University, 541 Clinical Drive, Suite 600, Indianapolis, IN 46201-5111, USA.
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Abstract
BACKGROUND In health care, increased emphasis has been placed on patient-centered care, but to our knowledge little work has been conducted to understand the influences on patient satisfaction after surgery for the treatment of severe lower-extremity injury. Our purpose was to analyze how the patient's satisfaction with the outcome correlates with other measures of outcome (clinical, functional, physical impairment, psychological impairment, and pain) and with the sociodemographic characteristics of the patient, the nature of the injury, and the treatment decisions. METHODS Four hundred and sixty-three patients treated for limb-threatening lower-extremity injuries at eight level-I trauma centers were followed prospectively. Multivariate regression techniques were used to identify factors correlating with variation in patient self-reported satisfaction at two years after the injury. The outcomes that were tested in the model were pain, range of motion, muscle strength, self-selected walking speed, depression, anxiety, the physical and psychosocial scores of the Sickness Impact Profile (SIP), return to work, and the number of major complications. The patient characteristics that were tested in the model were age, sex, education, poverty status, insurance status, occupation, race, personality profile, and medical comorbidities. Injury severity was tested in the model with use of both the Injury Severity Score and a score reflecting the probability of amputation. The treatment decisions that were tested were amputation versus reconstruction and time to treatment. RESULTS No patient demographic, treatment, or injury characteristics were found to correlate with patient satisfaction. Only measures of physical function, psychological distress, clinical recovery, and return to work correlated with patient satisfaction at two years. Five of these outcome measures accounted for >35% of the overall variation in patient satisfaction; these were return to work (p < 0.05), depression (p < 0.05), the physical functioning component of the SIP (p < 0.01), self-selected walking speed (p < 0.001), and pain intensity (p < 0.001). The absence of major complications and less anxiety were marginally significant (p < 0.1). CONCLUSIONS Patient satisfaction after surgical treatment of lower-extremity injury is predicted more by function, pain, and the presence of depression at two years than by any underlying characteristic of the patient, injury, or treatment.
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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, 22 South Greene Street, T3R62, Baltimore, MD 21201. E-mail address for R.V. O'Toole:
| | - Renan C. Castillo
- Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205
| | - Andrew N. Pollak
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, T3R62, Baltimore, MD 21201. E-mail address for R.V. O'Toole:
| | - Ellen J. MacKenzie
- Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205
| | - Michael J. Bosse
- Carolinas Medical Center, 100 Blythe Boulevard, Charlotte, NC 28203
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MacKenzie EJ, Jones AS, Bosse MJ, Castillo RC, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson BM, Burgess AR. Health-care costs associated with amputation or reconstruction of a limb-threatening injury. J Bone Joint Surg Am 2007; 89:1685-92. [PMID: 17671005 DOI: 10.2106/jbjs.f.01350] [Citation(s) in RCA: 150] [Impact Index Per Article: 8.8] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways. METHODS Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpatient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price Index. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of prosthetic devices. RESULTS When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and $91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction ($509,275 and $163,282, respectively). CONCLUSIONS These estimates add support to previous conclusions that efforts to improve the rate of successful reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results in lower lifetime costs.
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Affiliation(s)
- Ellen J MacKenzie
- Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 482, Baltimore, MD 21205, USA.
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Abstract
Trauma centre accreditation originated as a North American initiative in the 1970's with the aim of standardising and improving care for injured patients. This system of grading a hospital's ability to receive serious trauma has subsequently spread, most notably to Australasia. Many studies have focussed on determing whether this accreditation results in improved patient outcomes. We review the evidence to date, which suggests significant mortality reductions albeit from mainly Class III studies and reflect on the future sustainability of this initiative given mounting financial pressures.
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Affiliation(s)
- James N DeBritz
- Division of Orthopaedic Trauma, University of Maryland School of Medicine, R Adams Cowley Shock-Trauma Centre, 22 South Greene St., Baltimore, MD 21201, United States
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MacKenzie EJ, Bosse MJ, Kellam JF, Pollak AN, Webb LX, Swiontkowski MF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson BM, Burgess AR, Travison T, Castillo RC. Early predictors of long-term work disability after major limb trauma. ACTA ACUST UNITED AC 2006; 61:688-94. [PMID: 16967009 DOI: 10.1097/01.ta.0000195985.56153.68] [Citation(s) in RCA: 188] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A better understanding of the factors influencing return to work (RTW) after major limb trauma is essential in reducing the high costs associated with these injuries. METHODS Patients (n = 423) who underwent amputation or reconstruction after limb threatening lower extremity trauma and who were working before the injury were prospectively evaluated at 3, 6, 12, 24, and 84 months. Time to first RTW was assessed. For individuals working at 84 months, the percentage of time limited in performance at work was estimated using the Work Limitations Questionnaire. RESULTS Estimates of the cumulative proportion returning to work at 3, 6, 12, 24, and 84 months were 0.12, 0.28, 0.42, 0.51, and 0.58. Patients working at 84 months were, on average, limited in their ability to perform the demands of their job 20 to 25% of the time. In the context of a Cox proportional hazards model, differences in RTW outcomes by treatment (amputation versus reconstruction) were not statistically significant. Factors that were significantly associated (p < 0.05) with higher rates of RTW include younger age, being White, higher education, being a nonsmoker, average to high self efficacy, preinjury job tenure, higher job involvement, and no litigation. Early (3 month) assessments of pain and physical functioning were significant predictors of RTW. CONCLUSIONS Return to work after severe lower extremity trauma remains a challenge. Although the causal pathway from injury to impairment and work disability is complex, this study points to several factors that influence RTW that suggest strategies for intervention.
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Affiliation(s)
- Ellen J MacKenzie
- Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA.
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Pollak AN, Andersen RC. Moderators' summary: wound management (session I). J Am Acad Orthop Surg 2006; 14:S43-4. [PMID: 17003205 DOI: 10.5435/00124635-200600001-00009] [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: 02/01/2023] Open
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Abstract
Although débridement within 6 to 8 hours of injury seems nearly universally accepted, the data supporting this recommendation are lacking. Most studies indicate that, in the context of modern antibiotic treatment, early débridement is not an independent predictor of decreased risk of infection. Achieving early débridement may pose unjustified risks to patient safety. Given the numerous factors that influence timing of surgical débridement in trauma centers, a prospective randomized trial of emergent versus urgent débridement is not feasible. However, a prospective longitudinal study could yield valuable data.
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Affiliation(s)
- Andrew N Pollak
- Orthopaedics, University of Maryland, School of Medicine, Maryland, USA
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Abstract
Although several studies have been done on the timing of débridement of open fracture, none has specifically examined the effect of timing of soft-tissue coverage on outcome in the types of lower extremity injury being encountered in Iraq and Afghanistan, namely, injuries associated with the detonation of improvised explosive devices. Complex limb salvage requiring free tissue transfer or rotational flap coverage for soft-tissue defects has been commonly performed during the recent military conflicts in Iraq and Afghanistan. Current treatment protocols favor the inclusion of timely and stable axial limb fixation, radical débridement of all compromised soft tissues and osseous structures, and early wound closure with healthy, well-vascularized autologous tissue. In an attempt to minimize overall morbidity, a comprehensive plan must be made to sequentially reconstruct the involved extremity in order to achieve the highest level of function possible, with a durable construct, in the shortest period of time. Prospective studies are necessary to evaluate the effect of timing of coverage on outcome and on limb salvage.
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Affiliation(s)
- Randy Sherman
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of South California, Los Angeles, CA, USA
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Jones AL, Bucholz RW, Bosse MJ, Mirza SK, Lyon TR, Webb LX, Pollak AN, Golden JD, Valentin-Opran A. Recombinant human BMP-2 and allograft compared with autogenous bone graft for reconstruction of diaphyseal tibial fractures with cortical defects. A randomized, controlled trial. J Bone Joint Surg Am 2006. [PMID: 16818967 DOI: 10.2106/00004623-200607000-00002] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [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: 12/18/2022]
Abstract
BACKGROUND Currently, the treatment of diaphyseal tibial fractures associated with substantial bone loss often involves autogenous bone-grafting as part of a staged reconstruction. Although this technique results in high healing rates, the donor-site morbidity and potentially limited supply of suitable autogenous bone in some patients are commonly recognized drawbacks. The purpose of the present study was to investigate the benefit and safety of the osteoinductive protein recombinant human bone morphogenetic protein-2 (rhBMP-2) when implanted on an absorbable collagen sponge in combination with freeze-dried cancellous allograft. METHODS Adult patients with a tibial diaphyseal fracture and a residual cortical defect were randomly assigned to receive either autogenous bone graft or allograft (cancellous bone chips) for staged reconstruction of the tibial defect. Patients in the allograft group also received an onlay application of rhBMP-2 on an absorbable collagen sponge. The clinical evaluation of fracture-healing included an assessment of pain with full weight-bearing and fracture-site tenderness. The Short Musculoskeletal Function Assessment (SMFA) was administered before and after treatment. Radiographs were used to document union, the presence of extracortical bridging callus, and incorporation of the bone-graft material. RESULTS Fifteen patients were enrolled in each group. The mean length of the defect was 4 cm (range, 1 to 7 cm). Ten patients in the autograft group and thirteen patients in the rhBMP-2/allograft group had healing without further intervention. The mean estimated blood loss was significantly less in the rhBMP-2/allograft group. Improvement in the SMFA scores was comparable between the groups. No patient in the rhBMP-2/allograft group had development of antibodies to BMP-2; one patient had development of transient antibodies to bovine type-I collagen. CONCLUSIONS The present study suggests that rhBMP-2/allograft is safe and as effective as traditional autogenous bone-grafting for the treatment of tibial fractures associated with extensive traumatic diaphyseal bone loss. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alan L Jones
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Jones AL, Bucholz RW, Bosse MJ, Mirza SK, Lyon TR, Webb LX, Pollak AN, Golden JD, Valentin-Opran A. Recombinant human BMP-2 and allograft compared with autogenous bone graft for reconstruction of diaphyseal tibial fractures with cortical defects. A randomized, controlled trial. J Bone Joint Surg Am 2006; 88:1431-41. [PMID: 16818967 DOI: 10.2106/jbjs.e.00381] [Citation(s) in RCA: 271] [Impact Index Per Article: 15.1] [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: 02/01/2023]
Abstract
BACKGROUND Currently, the treatment of diaphyseal tibial fractures associated with substantial bone loss often involves autogenous bone-grafting as part of a staged reconstruction. Although this technique results in high healing rates, the donor-site morbidity and potentially limited supply of suitable autogenous bone in some patients are commonly recognized drawbacks. The purpose of the present study was to investigate the benefit and safety of the osteoinductive protein recombinant human bone morphogenetic protein-2 (rhBMP-2) when implanted on an absorbable collagen sponge in combination with freeze-dried cancellous allograft. METHODS Adult patients with a tibial diaphyseal fracture and a residual cortical defect were randomly assigned to receive either autogenous bone graft or allograft (cancellous bone chips) for staged reconstruction of the tibial defect. Patients in the allograft group also received an onlay application of rhBMP-2 on an absorbable collagen sponge. The clinical evaluation of fracture-healing included an assessment of pain with full weight-bearing and fracture-site tenderness. The Short Musculoskeletal Function Assessment (SMFA) was administered before and after treatment. Radiographs were used to document union, the presence of extracortical bridging callus, and incorporation of the bone-graft material. RESULTS Fifteen patients were enrolled in each group. The mean length of the defect was 4 cm (range, 1 to 7 cm). Ten patients in the autograft group and thirteen patients in the rhBMP-2/allograft group had healing without further intervention. The mean estimated blood loss was significantly less in the rhBMP-2/allograft group. Improvement in the SMFA scores was comparable between the groups. No patient in the rhBMP-2/allograft group had development of antibodies to BMP-2; one patient had development of transient antibodies to bovine type-I collagen. CONCLUSIONS The present study suggests that rhBMP-2/allograft is safe and as effective as traditional autogenous bone-grafting for the treatment of tibial fractures associated with extensive traumatic diaphyseal bone loss. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alan L Jones
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson BM, Burgess AR, Castillo RC. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am 2005; 87:1801-9. [PMID: 16085622 DOI: 10.2106/jbjs.e.00032] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.7] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND A recent study demonstrated that patients treated with amputation and those treated with reconstruction had comparable functional outcomes at two years following limb-threatening trauma. The present study was designed to determine whether those outcomes improved after two years, and whether differences according to the type of treatment emerged. METHODS Three hundred and ninety-seven patients who had undergone amputation or reconstruction of the lower extremity were interviewed by telephone at an average of eighty-four months after the injury. Functional outcomes were assessed with use of the physical and psychosocial subscores of the Sickness Impact Profile (SIP) and were compared with similar scores obtained at twenty-four months. RESULTS On the average, physical and psychosocial functioning deteriorated between twenty-four and eighty-four months after the injury. At eighty-four months, one-half of the patients had a physical SIP subscore of > or = 10 points, which is indicative of substantial disability, and only 34.5% had a score typical of a general population of similar age and gender. There were few significant differences in the outcomes according to the type of treatment, with two exceptions. Compared with patients treated with reconstruction for a tibial shaft fracture, those with only a severe soft-tissue injury of the leg were 3.1 times more likely to have a physical SIP subscore of 5 points (p < 0.05) and those treated with a through-the-knee amputation were 11.5 times more likely to have a physical subscore of 5 points (p < 0.05). There were no significant differences in the psychosocial outcomes according to treatment group. Patient characteristics that were significantly associated with poorer outcomes included older age, female gender, nonwhite race, lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at twenty-four and eighty-four months after the injury. CONCLUSIONS The results confirm previous conclusions that reconstruction for the treatment of injuries below the distal part of the femur typically results in functional outcomes equivalent to those of amputation. Regardless of the treatment option, however, long-term functional outcomes are poor. Priority should be given to efforts to improve post-acute-care services that address secondary conditions that compromise optimal recovery.
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Affiliation(s)
- Ellen J MacKenzie
- Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 554, Baltimore, MD 21205, USA.
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Abstract
BACKGROUND Although a number of investigators have documented clinical outcomes and complications associated with tibial plafond, or pilon, fractures, very few have examined functional and general health outcomes associated with these fractures. Our purpose was to assess midterm health, function, and impairment after pilon fractures and to examine patient, injury, and treatment characteristics that influence outcome. METHODS A retrospective cohort analysis of pilon fractures treated at two centers between 1994 and 1995 was conducted. Patient, injury, and treatment characteristics were recorded from patient interviews and medical record abstraction. Study participants returned to the initial treatment centers for a comprehensive evaluation of their health status. The primary outcomes that were measured included general health, walking ability, limitation of range of motion, pain, and stair-climbing ability. A secondary outcome measure was employment status. RESULTS Eighty (78%) of 103 eligible patients were evaluated at a mean of 3.2 years after injury. General health, as measured with the Short Form-36 (SF-36), was significantly poorer than age and gender-matched norms. Thirty-five percent of the patients reported substantial ankle stiffness; 29%, persistent swelling; and 33%, ongoing pain. Of sixty-five participants who had been employed before the injury, twenty-eight (43%) were not employed at the time of follow-up; nineteen (68%) of the twenty-eight reported that the pilon fracture prevented them from working. Multivariate analyses revealed that presence of two or more comorbidities, being married, having an annual personal income of less than 25,000 US dollars, not having attained a high-school diploma, and having been treated with external fixation with or without limited internal fixation were significantly related to poorer results as reflected by at least two of the five primary outcome measures. CONCLUSIONS At more than three years after the injury, pilon fractures can have persistent and devastating consequences on patients' health and well-being. Certain social, demographic, and treatment variables seem to contribute to these poor outcomes.
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Affiliation(s)
- Andrew N Pollak
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore 21201, USA.
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Abstract
BACKGROUND The purpose of this study was to describe differences in demographics, injury pattern, transfusion needs, and outcome of pelvic fractures in older versus younger patients. METHODS This was a retrospective registry review of all patients with pelvic fractures admitted directly from the scene between January 1998 and December 1999. RESULTS We cared for 234 patients with pelvic fractures during the study period. Mean age was 37.2 years, 51% were men, and mean Injury Severity Score (ISS) was 19. Overall mortality was 9%. Eighty-three percent were under the age of 55 years and 17% were older than 55 years. Severe pelvic fractures (AP3, LC3) were more common in young patients (p < 0.05). Admitting systolic blood pressure was lower and heart rate higher, although ISS was not different between the two age groups. Older patients were 2.8 times as likely to undergo transfusion (p < 0.005), and those undergoing transfusion required more blood (median, 7.5 units vs. 5 units). Older patients underwent angiography more frequently and were significantly more likely to die in the hospital even after adjusting for ISS (p < 0.005). This was most marked with ISS 15 to 25. Lateral compression (LC) fractures occurred 4.6 times more frequently in older patients than anteroposterior (AP) compression, and 8.2 times more frequently in those older patients undergoing transfusion as compared with AP compression. Ninety-eight percent of LC fractures in older patients were minor (LC1,2). However, older patients with LC fractures were nearly four times as likely to require blood compared with younger patients. CONCLUSION In older patients, pelvic fractures are more likely to produce hemorrhage and require angiography. Fracture patterns differ in older patients, with LC fractures occurring more frequently, and commonly causing significant blood loss. The outcome of older patients with pelvic fractures is significantly worse than younger patients, particularly with higher injury severity. Recognition of these differences should help clinicians to identify patients at high risk for bleeding and death early, and to refine diagnostic and resuscitation strategies.
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Affiliation(s)
- Sharon M Henry
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Kleiner DM, Pollak AN, McAdam C. Helmet hazards. Do's & don'ts of football helmet removal. JEMS 2001; 26:36-44, 46-8. [PMID: 11450105] [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] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
EMS providers must use extreme caution when evaluating and treating an unconscious football player, especially when the extent of the injury remains unknown. Suspect any unconscious football player has an accompanying spinal injury until proven otherwise. If the football player isn't breathing or the possibility of respiratory arrest exists, it's essential that certified athletic trainers and EMS providers work quickly and effectively to remove the face mask and administer care. In most situations, the helmet doesn't need to be removed in the field. Proper management of head and neck injuries includes leaving the helmet in place whenever possible, removing only the face mask from the helmet and developing a plan to manage head- and neck-injured football players using well-trained sports medicine and EMS providers. EMS agencies should work with their local high school or college athletic trainers to practice these removal techniques prior to the start of the football season.
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Affiliation(s)
- D M Kleiner
- University of North Florida, Jacksonville, Fla., USA
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Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J Bone Joint Surg Am 2000; 82:1681-91. [PMID: 11130641] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of the present study was to compare the rate of short-term wound complications associated with rotational flaps and that associated with free flaps for coverage of traumatic soft-tissue defects about the tibia. METHODS Of 601 patients prospectively enrolled in a multicenter study of high-energy trauma of the lower extremity, 190 patients (195 limbs) required flap coverage and had six months of follow-up. The injury data included the ASIF/OTA classification of the tibial fracture and the soft-tissue injury and the functional status of the neurovascular and muscular structures of the soft-tissue compartments at the time of soft-tissue coverage. The treatment data consisted of the type of flap, the timing of the flap coverage, and the type of fixation. The patient characteristics that were recorded included the age, gender, presence of comorbidities, and smoking status at the time of the injury. Short-term complications included wound infection, wound necrosis, and loss of the flap within the first six months after the injury. RESULTS Eighty-eight limbs were treated with a rotational flap, and 107 limbs were treated with a free flap. Overall, complications occurred after fifty-three (27 percent) of the 195 flap procedures; forty-six (87 percent) of the fifty-three required operative treatment. The two treatment groups were similar with respect to age, gender, comorbidities, preinjury smoking status, ASIF/OTA classification of the fracture, and prevalence of vascular injury requiring repair (p>0.05). There were two important differences between the two groups. First, three of the four leg compartments--that is, the anterior, lateral, and deep posterior compartments--were more likely to be functionally compromised in the free-flap group than in the rotational flap group (p<0.05), suggesting that patients in the free-flap group had sustained more severe soft-tissue injuries. Second, the Injury Severity Score was significantly higher (p = 0.001) in the rotational flap group (mean, 14 points) than in the free-flap group (mean, 11 points), suggesting that patients in the former group had sustained more substantial total body trauma. Overall, there were no significant differences between the two groups with respect to the complication rates. However, among those with the most severe grade of underlying osseous injury (an ASIF/OTA type-C injury), 44 percent of the limbs that were treated with a rotational flap had a wound complication compared with 23 percent of the limbs that were treated with a free flap (p = 0.10). To control for any differences between the two groups with respect to the severity of the injury, the treatment methods, or the patient characteristics, multivariate regression modeling was performed. An interaction effect between the type of flap and the severity of the underlying osseous injury demonstrated significance (p<0.05) after controlling for other factors. Of the limbs that sustained an ASIF/OTA type-C osseous injury, those that were treated with a rotational flap were 4.3 times more likely to have a wound complication requiring operative intervention than were those treated with a free flap. No significant difference in the rate of complications was detected with respect to the type of flap used for the limbs that had lower-grade osseous injuries. CONCLUSIONS We found that use of a free flap to treat limbs with a severe underlying osseous injury was significantly less likely to lead to a wound complication requiring operative intervention than was use of a rotational flap.
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Affiliation(s)
- A N Pollak
- Division of Orthopaedic Traumatology, The R Adams Cowley Shock Trauma Center, The University of Maryland Medical System, Baltimore 21201-1595, USA.
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Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma 2000; 48:613-21; discussion 621-3. [PMID: 10780592 DOI: 10.1097/00005373-200004000-00006] [Citation(s) in RCA: 286] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. We report on the use of EF as a temporary fracture fixation in a group of patients with multiple injuries and with femoral shaft fractures. METHODS Retrospective review of charts and registry data of patients admitted to our Level 1 trauma center July of 1995 to June of 1998. Forty-three patients initially treated with EF of the femur were compared to 284 patients treated with primary IMN of the femur. RESULTS Patients treated with EF had more severe injuries with significantly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treated with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe enough to require intracranial pressure monitoring. All 12 required therapy for intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindication to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time for EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes with an estimated blood loss of 400 mL. One patient died before IMN. One other patient with a mangled extremity was treated with amputation after EF. There was one complication of EF, i.e., bleeding around a pin site, which was self-limited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF followed by IMN had bone infection and another had acute hardware failure. CONCLUSION EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed by IMN when the patient is stabilized. There were minimal orthopedic complications.
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Affiliation(s)
- T M Scalea
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Program in Trauma, University of Maryland School of Medicine, Baltimore 21201-1595, USA
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Abstract
Limb reperfusion after tourniquet ischemia causes pulmonary microvascular injury. Similarly, microembolization, like that associated with reamed femoral nailing, can induce pulmonary microvascular injury. Both processes result in increased pulmonary capillary membrane permeability and edema. However, the association between femoral nailing followed by tourniquet ischemia and clinical lung injury has not been described. The authors reviewed 72 patients with femoral shaft fractures and tibial or ankle fractures requiring internal fixation between 1987 and 1993. All femoral shaft fractures were treated with reamed intramedullary nails. Patients were divided into groups, based on whether the tibial or ankle injury was managed surgically with (Group T, 34 patients) or without (Group NT, 38 patients) a tourniquet. Group T was subdivided based on tourniquet time: T1, less than or equal to 90 minutes; T2, greater than 90 minutes. Groups were matched for injury severity. Group NT had fewer ventilator dependent days and intensive care days than Group T (NT: ventilator dependent days, 2.5 +/- 5.2; intensive care days, 3.9 +/- 6.5; T: 5.1 +/- 6.4; intensive care days, 6.7 +/- 6.6). Ventilator dependent days and intensive care days increased with increasing tourniquet time (T1: ventilator dependent days, 3.2 +/- 3.6; intensive care days, 5.4 +/- 4.6; T2: ventilator dependent days, 7.5 +/- 8.5; intensive care days, 8.5 +/- 8.5), suggesting that in patients with multitrauma, combining reamed femoral nailing with fracture fixation under tourniquet control increases pulmonary morbidity. Further investigation to measure pulmonary injury associated with ischemia reperfusion and intramedullary nailing in patients with multitrauma is warranted.
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Affiliation(s)
- A N Pollak
- Department of Orthopedic Surgery, University of California, Davis Medical Center, Sacramento, USA
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