Objective
To demonstrate the application and surgical time savings of the Spider Limb Positioner for subscapular system free flaps in head and neck reconstructive surgery.
Methods
Single institution ...retrospective chart review and analysis of patients between 2011 and 2019 that underwent a subscapular system free flap either with or without use of the Spider Limb Positioner. One hundred five patients in total were reviewed with 53 patients in the Spider group. The surgical times were compared between the two groups. Patient‐specific information regarding average age, laterality of donor site, recipient site, gender, and flap type were reviewed.
Results
Forty‐one patients in both groups underwent a latissimus free flap. Twelve of 53 in the Spider group and 11/52 in the control group underwent a scapula free flap. The average age in the Spider group at the time of surgery was 64 years. The recipient sites for the Spider groups were reviewed. The free flap was ipsilateral to the defect in 81% of cases. The mean surgical time for the 105 patients without the Spider was 568 minutes versus 486 minutes with a Spider P‐value of .003478.
Conclusion
Use of the Spider Limb Positioner allows for a simultaneous two‐team approach during free flap elevation of the subscapular system, which eliminates both dependence on an assistant to support the arm and time consuming positioning changes during flap elevation.
Level of Evidence
3 Laryngoscope, 131:525–528, 2021
Falls from heights represent one of the principal causes of multiple injuries and are usually associated with maxillofacial trauma. The aim of this study was to compare the distribution of injuries ...between patients who have fallen accidentally and those who have jumped from a height, and to reveal the features of the resulting injuries. A total of 494 patients treated in the Department of Emergency and Critical Care Medicine, Fukuoka University Hospital, between June 2009 and May 2019, who were classified as either having fallen (fallers) or who jumped (jumpers) from a height were studied. Fifty-one patients (10.3%) were treated in the Department of Oral and Maxillofacial Surgery, among whom 22 were jumpers and 29 were fallers. Jumpers were younger (mean age, 28.5 vs. 47.0 years), more likely to be female (8 males, 14 females vs. 22 males, 7 females) and sustained significantly more fractures of the jaw (72.7% vs. 31.0%, p=0.043), pelvis (54.5% vs. 13.8%, p=0.002), and lower limbs (77.3% vs. 27.6%, p=0.001). Jumpers tended to land feet-first, resulting in fractures of the lower limbs, pelvis, and jaw. As for treatment, open reduction and internal fixation were conducted in a significantly higher proportion of jumpers than fallers (59.1% vs. 20.7%, p=0.005). In addition, an extraoral surgical approach for the management of mandibular fractures was used in a significantly higher proportion of jumpers than fallers (72.7% vs. 42.9%), reflecting the common injury patterns. The injury patterns identified by this study are expected to facilitate the more rapid assembly of treatment teams.
Background
Bone-patellar tendon-bone (bone-tendon-bone) and four-strand hamstring tendon grafts (hamstring) are the most commonly utilized autografts for primary anterior cruciate ligament (ACL) ...reconstruction. Existing clinical trials, registry studies, and meta-analyses offer conflicting opinions regarding the most favorable graft choice.
Questions/purposes
Which graft type for ACL reconstruction (bone-tendon-bone or hamstring) has a higher risk of (1) graft rupture and/or (2) graft laxity?
Methods
We performed a meta-analysis of randomized controlled trials (RCTs), prospective cohort studies, and high-quality national registry studies to compare the outcomes of primary ACL reconstruction with bone-tendon-bone autograft or hamstring autograft. Studies that compared these graft types were identified through a comprehensive search of electronic databases (PubMed, MEDLINE, EMBASE, and the Cochrane Library). Two independent reviewers utilized the Jadad scale for RCT study quality and the Modified Coleman Methodology Score for prospective comparative and registry study quality. The included studies were analyzed for the primary outcome measure of graft rupture with or without revision ACL surgery. In surviving grafts, secondary outcomes of graft laxity were quantified by KT1000/2000™ testing, a positive pivot shift test, and a positive Lachman test. Meta-analysis was performed with Review Manager. A total of 47,613 ACL reconstructions (39,768 bone-tendon-bone and 7845 hamstring) from 14 RCTs, 10 prospective comparative studies, and one high-quality national registry study were included in this meta-analysis. Mean age was 28 years in both groups. Sixty-three percent of patients in the bone-tendon-bone cohort were men versus 57% of patients in the hamstring cohort. Mean followup was 68 ± 55 months.
Results
Two hundred twelve of 7560 (2.80%) bone-tendon-bone grafts ruptured compared with 1123 of 39,510 (2.84%) in the hamstring group (odds ratio = 0.83, 95% confidence interval, 0.72-0.96; p = 0.01). The number needed to treat analysis found that 235 patients would need to be treated with a bone-tendon-bone graft over a hamstring tendon graft to prevent one graft rupture. Instrumented laxity analysis showed that 22% (318 of 1433) of patients in the bone-tendon-bone group had laxity compared with 18% (869 of 4783) in the hamstring tendon group (odds ratio = 0.86; p = 0.16). Pivot shift analysis showed a positive pivot shift in 19% (291 of 1508) of the bone-tendon-bone group compared with 17% (844 of 5062) in the hamstring group (odds ratio = 0.89; p = 0.51). Lachman testing showed a positive Lachman in 25% (71 of 280) of patients receiving bone-tendon-bone grafts compared with 25% (73 of 288) in the hamstring group (odds ratio = 0.96; p = 0.84).
Conclusions
In this meta-analysis of short- to mid-term followup after primary ACL reconstruction, hamstring autografts failed at a higher rate than bone-tendon-bone autografts. However, failure rates were low in each group, the difference observed was small, and we observed few differences between graft types in terms of laxity. Both graft types remain viable options for primary ACL reconstruction, and the difference in failure rate should be one part of a larger conversation with each individual patient about graft selection that should also include potential differences in donor site morbidity, complication rates, and patient-reported outcome measures. Continued prospective collection of patient data will be important going forward as we attempt to further characterize the potential differences in outcomes attributable to graft selection.
Level of Evidence
Level III, therapeutic study.
We examined the relationship between a multidisciplinary individual team approach (MTA) and the hemodialysis (HD) course and prognosis after HD compared to only a dietitian approach (ODA). Sixty-nine ...diabetic patients with diabetic nephropathy (DN) receiving HD periodically from 2010 to 2016 were examined. The duration from a creatinine value of 2.0 mg/dL to HD induction in MTA was significantly longer than in ODA. The hemoglobin and hematocrit values, cardiothoracic ratio, hospitalization and costs were significantly better for MTA than ODA. MTA patients more frequently underwent 24-h urine collection than did ODA patients. The survival rate from baseline in MTA patients was significantly longer than in ODA patients. The MTA might have beneficial effects on the HD course and prognosis in patients with DN, since various staff members provide multiple and broad information on the present and future clinical condition as well as self-management.
We investigated the efficacy of the Delirium Team Approach program for delirium prevention after cardiovascular surgery.
We retrospectively investigated 256 patients who underwent cardiac or thoracic ...vascular surgery between May 2017 and May 2020. We compared the outcomes before and after implementation of the Delirium Team Approach program in December 2018. The program included the following components: (a) educational sessions for the medical team regarding delirium and its management, (b) review of preprinted physician orders for insomnia and agitation, and (c) routine screening for delirium. We investigated the early outcomes and effects of the Delirium Team Approach program on postoperative delirium.
The incidence of postoperative delirium significantly decreased from 53.3% to 37.0% after implementation of the Delirium Team Approach program (P = .008). Although no intergroup differences were observed in the rates of stroke and reexploration for bleeding, the length of intensive care unit stay and the overall length of postoperative hospital stay were shorter in the postintervention group. Hospital costs, excluding surgery, and the cost during intensive care unit stay were lower in the postintervention group. Multivariable analysis showed that the Delirium Team Approach program was associated with a reduction in postoperative delirium (odds ratio, 0.38; 95% confidence interval, 0.21-0.67; P = .001). Other predictors of delirium included age, dementia, chronic kidney disease, and intubation time. After risk adjustment using propensity score matching, the rate of postoperative delirium was lower in the postintervention group.
Implementation of the Delirium Team Approach program was associated with a lower incidence of postoperative delirium in patients who underwent cardiovascular surgery.
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Purpose: Open extremity fractures require prompt antibiotic medication and initial debridement surgery to reduce the infection rate and restore functional stabilization. We aimed to report the ...effects and positive outcomes of a trauma team approach on the management of open extremity fractures in polytrauma patients.
Methods: This retrospective review included all polytrauma patients with open extremity fractures admitted between March 2009 and December 2019. Patients were divided into two groups according to whether they were treated before or after the implementation of the trauma team approach (March 2014). We analyzed the outcomes in each group with respect to the time interval until the doctor’s arrival, total length of stay in the emergency department, the time interval until initial antibiotic treatment and operation, whether the initial operation was performed within 24 hours, and the rate of deep infections.
Results: A total of 123 patients met the inclusion criteria. There were no statistically significant differences in demographic characteristics. The time interval until the doctor’s arrival (64.12±49.2 minutes vs. 19.82±15.23 minutes; p=0.035) and initial antibiotic treatment (115.47±72.12 minutes vs. 48.78±30.12 minutes; p=0.023) significantly improved after implementing the trauma team approach. The union rate was not significantly different. However, the time interval until initial debridement, opportunity for initial debridement within 24 hours, and the rate of deep infections demonstrated better results.
Conclusions: The reduced time interval until initial antibiotic treatment and debridement could be attributed to the positive effect of the trauma team approach on the management of open extremity fractures in polytrauma patients.
Background
The FIFA 11+ injury prevention program has been shown to decrease the risk of soccer injuries in men and women. The program has also been shown to decrease time loss resulting from injury. ...However, previous studies have not specifically investigated how the program might impact the rate of anterior cruciate ligament (ACL) injury in male soccer players.
Questions/purposes
The purpose of this study was to examine if the FIFA 11+ injury prevention program can (1) reduce the overall number of ACL injuries in men who play competitive college soccer and whether any potential reduction in rate of ACL injuries differed based on (2) game versus practice setting; (3) player position; (4) level of play (Division I or II); or (5) field type.
Methods
This study was a prospective cluster randomized controlled trial, which was conducted in 61 Division I and Division II National Collegiate Athletic Association men’s soccer teams over the course of one competitive soccer season. The FIFA 11+ is a 15- to 20-minute on-the-field dynamic warm-up program used before training and games and was utilized as the intervention throughout the entire competitive season. Sixty-five teams were randomized: 34 to the control group (850 players) and 31 to the intervention group (675 players). Four intervention teams did not complete the study and did not submit their data, noting insufficient time to complete the program, reducing the number for per-protocol analysis to 61. Compliance to the FIFA 11+ program, athletic exposures, specific injuries, ACL injuries, and time loss resulting from injury were collected and recorded using a secure Internet-based system. At the end of the season, the data in the injury surveillance system were crosshatched with each individual institution’s internal database. At that time, the certified athletic trainer signed off on the injury collection data to confirm their accuracy and completeness.
Results
A lower proportion of athletes in the intervention group experienced knee injuries (25% 34 of 136) compared with the control group (75% 102 of 136; relative risk RR, 0.42; 95% confidence interval CI, 0.29-0.61; p < 0.001). When the data were stratified for ACL injury, fewer ACL injuries were reported in the intervention group (16% three of 19) compared with the control group (84% 16 of 19), accounting for a 4.25-fold reduction in the likelihood of incurring ACL injury (RR, 0.236; 95% CI, 0.193–0.93; number needed to treat = 70; p < 0.001). With the numbers available, there was no difference between the ACL injury rate within the FIFA 11+ group and the control group with respect to game and practice sessions (games—intervention: 1.055% three of 15 versus control: 1.80% 12 of 15; RR, 0.31; 95% CI, 0.09–1.11; p = 0.073 and practices—intervention: 0% zero of four versus control: 0.60% four of four; RR, 0.14; 95% CI, 0.01–2.59; p = 0.186). With the data that were available, there were no differences in incidence rate (IR) or injury by player position for forwards (IR control = 0.339 versus IR intervention = 0), midfielders (IR control = 0.54 versus IR intervention = 0.227), defenders (IR control = 0.339 versus IR intervention = 0.085), and goalkeepers (IR control = 0.0 versus IR intervention = 0.0) (p = 0.327). There were no differences in the number of ACL injuries for the Division I intervention group (0.70% two of nine) compared with the control group (1.05% seven of nine; RR, 0.30; CI, 0.06–1.45; p = 0.136). However, there were fewer ACL injuries incurred in the Division II intervention group (0.35% one of 10) compared with the control group (1.35% nine of 10; RR, 0.12; CI, 0.02–0.93; p = 0.042). There was no difference between the number of ACL injuries in the control group versus in the intervention group that occurred on grass versus turf (Wald chi square
1
= 0.473, b = 0.147, SE = 0.21, p = 0.492). However, there were more ACL injuries that occurred on artificial turf identified in the control group (1.35% nine of 10) versus the intervention group (0.35% one of 10; RR, 0.14; 95% CI, 0.02–1.10; p = 0.049).
Conclusions
This program, if implemented correctly, has the potential to decrease the rate of ACL injury in competitive soccer players. In addition, this may also enhance the development and dissemination of injury prevention protocols and may mitigate risk to athletes who utilize the program consistently. Further studies are necessary to analyze the cost-effectiveness of the program implementation and to analyze the efficacy of the FIFA 11+ in the female collegiate soccer cohort.
Level of Evidence
Level I, therapeutic study.
Background Acute myocardial infarction (AMI) infrequently occurs after acute stroke. The Heart-brain team approach has a potential to appropriately manage this poststroke cardiovascular complication. ...However, clinical outcomes of AMI complicating acute stroke (AMI-CAS) with the heart-brain team approach have not been characterized. The current study investigated cardiovascular outcomes in patients with AMI-CAS managed by a heart-brain team. Methods and Results We retrospectively analyzed 2390 patients with AMI at our institute (January 1, 2007-September 30, 2020). AMI-CAS was defined as the occurrence of AMI within 14 days after acute stroke. Major adverse cerebral/cardiovascular events (cardiac-cause death, nonfatal myocardial infarction, and nonfatal stroke) and major bleeding events were compared in subjects with AMI-CAS and those without acute stroke. AMI-CAS was identified in 1.6% of the subjects. Most AMI-CASs (37/39=94.9%) presented ischemic stroke. Median duration of AMI from the onset of acute stroke was 2 days. Patients with AMI-CAS less frequently received primary percutaneous coronary intervention (43.6% versus 84.7%;
<0.001) and dual-antiplatelet therapy (38.5% versus 85.7%;
<0.001), and 33.3% of them did not receive any antithrombotic agents (versus 1.3%;
<0.001). During the observational period (median, 2.4 years interquartile range, 1.1-4.4 years), patients with AMI-CAS exhibited a greater likelihood of experiencing major adverse cerebral/cardiovascular events (hazard ratio HR, 3.47 95% CI, 1.99-6.05;
<0.001) and major bleeding events (HR, 3.30 95% CI, 1.34-8.10;
=0.009). These relationships still existed even after adjusting for clinical characteristics and medication use (major adverse cerebral/cardiovascular event: HR, 1.87 95% CI, 1.02-3.42;
=0.04; major bleeding: HR, 2.67 95% CI, 1.03-6.93;
=0.04). Conclusions Under the heart-brain team approach, AMI-CAS was still a challenging disease, reflected by less adoption of primary percutaneous coronary intervention and antithrombotic therapies, with substantially elevated cardiovascular and major bleeding risks. Our findings underscore the need for a further refined approach to mitigate their ischemic/bleeding risks.
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