To (a) determine the diagnostic performance of 64-section multidetector computed tomography (CT) trajectography for penetrating diaphragmatic injury (PDI), (b) determine the diagnostic performance of ...classic signs of diaphragmatic injury at 64-section multidetector CT, and (c) compare the performance of these signs with that of trajectography.
This HIPAA-compliant retrospective study had institutional review board approval, with a waiver of the informed consent requirement. All patients who had experienced penetrating thoracoabdominal trauma, who had undergone preoperative 64-section multidetector CT of the chest and abdomen, and who had surgical confirmation of findings during a 2.5-year period were included in this study (25 male patients, two female patients; mean age, 32.6 years). After a training session, four trauma radiologists unaware of the surgical outcome independently reviewed all CT studies and scored the probability of PDI on a six-point scale. Collar sign, dependent viscera sign, herniation, contiguous injury on both sides of the diaphragm, discontinuous diaphragm sign, and transdiaphragmatic trajectory were evaluated for sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). Accuracies were determined and receiver operating characteristic curves were analyzed.
Sensitivities for detection of PDI by using 64-section multidetector CT with postprocessing software ranged from 73% to 100%, specificities ranged from 50% to 92%, NPVs ranged from 71% to 100%, PPVs ranged from 68% to 92%, and accuracies ranged from 70% to 89%. Discontinuous diaphragm, herniation, collar, and dependent viscera signs were highly specific (92%-100%) but nonsensitive (0%-60%). Contiguous injury was generally more sensitive (80%-93% vs 73%-100%) but less specific (50%-67% vs 83%-92%) than transdiaphragmatic trajectory when patients with multiple entry wounds were included in the analysis. Transdiaphragmatic trajectory was a much more sensitive sign of PDI than previously reported (73%-100% vs 36%), with NPVs ranging from 71% to 100% and PPVs ranging from 85% to 92%.
Sixty-four-section multidetector CT trajectography facilitates the identification of transdiaphragmatic trajectory, which accurately rules in PDI when identified. Contiguous injury remains a highly sensitive sign, even when patients with multiple injuries are considered, and is useful for excluding PDI.
Purpose
The purpose of this quality improvement initiative was to study the effect of providing scorecards to emergency department providers to assess its effect on changes in utilization.
Methods
CT ...of the abdomen and pelvis, CT angiogram of the chest for pulmonary embolism, and CT of the head were targeted due to ordering variability, cost, and radiation exposure. The utilization rate for each provider was assessed for emergency department providers. Following this, providers were given scorecards regarding their utilization as well as their relative utilization compared with each other. Utilization was then monitored following the intervention to assess the effect of the scorecard on ordering practices.
Results
No significant effect on the utilization of these 3 exams was found after the scorecard intervention.
Conclusion
Providing scorecards to make emergency department providers aware of their relative utilization does not significantly alter ordering behavior. Incentive-based systems may be required in order to lessen overutilization of these 3 commonly ordered radiology procedures in the emergency department.
Blunt pancreatic trauma almost always occurs in the setting of multiple severe injuries, and is usually diagnosed within the context of whole-body trauma CT. Associated injuries may flag the pancreas ...for greater scrutiny. Main duct laceration is the primary determinant of the need for surgical intervention. Characterization is improved with advanced post-processing techniques. We present useful diagnostic pearls, describe key pitfalls, and review advancements in the evaluation of pancreatic trauma at whole-body MDCT.
Abstract
The implantable arterial doppler (IAD) is frequently used to postoperatively monitor free flaps with high accuracy, but there are no guidelines for its use. Bedside exam is used adjunctively ...to determine necessary intervention. This systematic review seeks to discover why the doppler is used adjunctively despite its established record of accuracy. Criteria for inclusion and exclusion were established. In total, 280 articles were found on PubMed and Web of Science, then screened accordingly. Data from 22 articles were analyzed using a bivariate hierarchical random effects model. Twenty‐two studies yielded 2996 total patients undergoing 3127 free flap procedures. The meta‐analysis found a high sensitivity of 0.809 (95% CI = 0.709, 0.880) and specificity of 0.966 (95% CI = 0.947, 0.979). False‐positive rate was found to be 0.034 (95% CI = 0.021, 0.053). Positive and negative predictive values were 0.711 (95% CI = 0.581, 0.817) and 0.979 (95% CI = 0.966, 0.988). Positive and negative likelihood ratios were 24.7 (95% CI = 14.5, 39.5) and 0.20 (95% CI = 0.12, 0.30). The established efficacy of the IAD is supported by this study. Clinical exams may remain as the final adjunct due to the risks of inaccurate IAD signals. Further studies are warranted to optimize its use for future practice guidelines.
Category:
Midfoot/Forefoot; Ankle
Introduction/Purpose:
Venous thromboembolism (VTE) after foot and ankle surgery is a significant concern for patients and surgeons. The absence of guidelines for ...thromboprophylaxis in elective procedures underscores the importance of understanding risk factors. This study aimed to identify key risk factors of VTE in patients who underwent elective foot and ankle surgery, analyzing the rates based on the anatomical location of the surgery and the post-operative period.
Methods:
Data was collected from IBM MarketScan Database (2009-2019) for patients >18y without prior VTE who underwent elective foot/ankle surgery. Patients were divided into three groups based on region of surgery (forefoot, mid/hindfoot, lower leg/ankle), and VTE incidence was recorded 30- and 90-days post-surgery. Risk factors for VTE were identified through multivariate logistical regression analysis.
Results:
Among the 301,256 patients who underwent elective foot and ankle surgeries, the overall incidence of VTE within 90 days was 0.95%. The findings revealed that 31.8% of VTE incidents occurred within the first two weeks after surgery, and 29.2% still occurred after 6 weeks. An analysis of the anatomical region of surgery demonstrated that the lowest rate of VTE was amongst patients undergoing forefoot surgery (0.70%). There was a higher incidence and risk for VTE in patients undergoing midfoot/hindfoot surgery (1.22%, OR = 1.75) and lower leg/ankle surgery (1.76%, OR= 2.53). Additional risk factors for VTE included thrombophilia (OR = 5.06), male sex (OR = 1.43), increasing age (OR > 1.25), and a high Charlson Comorbidity Index (OR < 0.82 for scores < 5).
Conclusion:
This study identifies the incidence and timing for VTE after elective foot and ankle surgery. Furthermore, this study defines the risk factors associated with increased odds of VTE after elective foot and ankle surgeries. These findings are helpful in educating patients about a continued risk for VTE throughout the 90-day postoperative period. These results can also be utilized to stratify patients who need thromboprophylaxis based on the individual risk level.
Category:
Ankle Arthritis; Ankle
Introduction/Purpose:
Total ankle arthroplasty (TAA) utilization is increasing in the United States. As the incidence of this procedure grows, it is important for ...providers to understand the future projections for ankle arthroplasty and more importantly revision total ankle arthroplasty (rTAA).
Methods:
The national inpatient sample (USA) was queried from 2005 to 2017 for all TAA and rTAA. Poisson and linear regression analyses were performed to project annual incidence of TAA and rTAA to 2030, with subgroup analyses on septic rTAA.
Results:
There were 5315 TAAs performed in 2017, a 564% increase when compared to the TAAs performed in 2005. From 2017 to 2030, the incidence of TAAs is projected to increase from 110% to 796%. There were 1170 rTAAs performed in 2017, a 155% increase when compared to rTAAs performed in 2005. There was a 256% increase in the incidence of septic rTAAs from 2005 to 2017 with a projected increase between 22% and 120% by 2030.
Conclusion:
The incidence of both TAAs and rTAAs are projected to significantly increase over the next decade. Given the known risk factors of TAA and rTAA, these findings reinforce the need for thoughtful consideration when selecting patients for TAA.
Preserving optimal mitochondrial function is critical in the heart, which is the most ATP-avid organ in the body. Recently, we showed that global deficiency of the nuclear receptor RORα in the ...“staggerer” mouse exacerbates angiotensin II–induced cardiac hypertrophy and compromises cardiomyocyte mitochondrial function. However, the mechanisms underlying these observations have not been defined previously. Here, we used pharmacological and genetic gain- and loss-of-function tools to demonstrate that RORα regulates cardiomyocyte mitophagy to preserve mitochondrial abundance and function. We found that cardiomyocyte mitochondria in staggerer mice with lack of functional RORα were less numerous and exhibited fewer mitophagy events than those in WT controls. The hearts of our novel cardiomyocyte-specific RORα KO mouse line demonstrated impaired contractile function, enhanced oxidative stress, increased apoptosis, and reduced autophagic flux relative to Cre(-) littermates. We found that cardiomyocyte mitochondria in “staggerer” mice with lack of functional RORα were upregulated by hypoxia, a classical inducer of mitophagy. The loss of RORα blunted mitophagy and broadly compromised mitochondrial function in normoxic and hypoxic conditions in vivo and in vitro. We also show that RORα is a direct transcriptional regulator of the mitophagy mediator caveolin-3 in cardiomyocytes and that enhanced expression of RORα increases caveolin-3 abundance and enhances mitophagy. Finally, knockdown of RORα impairs cardiomyocyte mitophagy, compromises mitochondrial function, and induces apoptosis, but these defects could be rescued by caveolin-3 overexpression. Collectively, these findings reveal a novel role for RORα in regulating mitophagy through caveolin-3 and expand our currently limited understanding of the mechanisms underlying RORα-mediated cardioprotection.
Background: Total ankle arthroplasty (TAA) utilization is increasing in the United States. As the incidence of this procedure grows, it is important for providers to understand the future projections ...for ankle arthroplasty and more importantly revision total ankle arthroplasty (rTAA). Methods: The National Inpatient Sample (USA) was queried from 2005 to 2017 for all TAA and rTAA. Poisson and linear regression analysis was performed to project annual incidence of TAA and rTAA to 2030, with subgroup analyses on septic rTAA. Results: There were 5315 TAAs performed in 2017, a 564% (P < .001) increase when compared with the TAAs performed in 2005. From 2017 to 2030, the incidence of TAAs is projected to increase from 110% to 796% (P < .001). There were 1170 rTAAs performed in 2017, a 155% (P < .001) increase when compared with rTAAs performed in 2005. There was a 256% increase in the incidence of septic rTAAs from 2005 to 2017 with a projected increase between 22% and 120% by 2030. Conclusions: The incidence of both TAAs and rTAAs is projected to significantly increase over the next decade. Given the known risk factors of TAA and rTAA, these findings reinforce the need for thoughtful consideration when selecting patients for TAA.
Background:
Professional athletes are predisposed to fractures of the foot due to large stresses placed on the lower extremity. These players are concerned with efficiently returning to play at a ...high level. Return-to-play rates after operative treatment have been previously reported, yet performance outcomes after such treatment are generally unknown in this population.
Hypothesis:
Overall, professional athletes sustaining a foot fracture would return to play at high rates with little impact on postoperative performance or league participation. However, National Football League (NFL) athletes would have a significantly greater decline in performance due to the high-impact nature of the sport.
Study Design:
Case series.
Level of Evidence:
Level 4.
Methods:
Athletes in the National Basketball League (NBA), NFL, Major League Baseball (MLB), and National Hockey League (NHL) undergoing operative fixation of a foot fracture were identified through a well-established protocol confirmed by multiple sources of the public record. Return-to-play rate and time to return were collected for each sport. League participation and game performance data were collected before and after surgery. Statistical analysis was performed, with significance accepted as P ≤ 0.05.
Results:
A total of 77 players undergoing 84 procedures met the inclusion criteria. Overall, 98.7% (76/77) of players were able to return to play, with a median time to return across all sports of 137 days. Players returned to preoperative performance levels within 1 season of surgery. Six players (7.8%) sustained refracture requiring reoperation, all of whom were in the NBA. Percentage of games started during the season after primary operative treatment was a predictive factor for reinjury (99% vs 40%, P = 0.001).
Conclusion:
Athletes returned to play at a high rate after foot fracture fixation, with excellent postoperative performance levels, regardless of sport and fracture location. NBA athletes sustaining fifth metatarsal and navicular fractures are at greater risk of reinjury compared with other athletes. Returning to high levels of athletic participation soon after surgery may predispose athletes to refracture and subsequent reoperation.
Clinical Relevance:
Players, coaches, and team physicians should be aware of the impact of foot fractures on career performance and longevity to best guide therapy.
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