•Distal femur fractures have increased risk for in-patient mortality compared with hip fractures.•Distal femur fractures have longer length of stay and required ventilation use compared to hip ...fractures.•Secondary fracture patterns vary among patients with distal femur and hip fractures.
The comparison of mortality and morbidity between distal femur (DF) and hip fracture in the old age is rarely reported in the literature. We aim to analyze a nationwide database among the elderly to compare the outcomes between hip fractures and distal femur fractures in the United States.
A retrospective analysis of the National Trauma Data Bank was queried between 2007-2014 to identify distal femur (DF) and hip fracture patients greater than 65 years of age. Outcomes analyzed included in-hospital mortality, total hospital length of stay(LOS), intensive care unit length of stay(ICU-LOS), length of ventilation use and hospital discharge disposition. Multivariable regression models were performed to adjust for potential confounders. Statistical significance was established at p < 0.001.
26,325 (10.1%) and 233,213 (89.9%) patients reported a diagnosis of DF and hip fracture, respectively. The inpatient mortality rate was significantly higher in the distal femur fracture group (8.3% vs. 6.7%), with significantly longer LOS (7.87 vs. 6.65), ICU-LOS (1.50 vs. 0.73), and required ventilation days (0.74 vs. 0.27). Multivariable analyses demonstrated that hip fracture patients had a lower mortality (adjusted odds ratio aOR, 0.80; 95% CI 0.76, -0.85; p < 0.001), shorter LOS (aOR, -0.31; 95% CI -0.39, -0.23; P < 0.001), and more likely to be discharged home (aOR, 0.88; 95% CI, 0.85, 0.91; P < 0.001, compared to DF fracture patients.
After adjusting for potential factors, DF fracture patients have a significantly higher mortality, longer LOS, and less likely to be discharged home compared to hip fractures among the elderly. These results may suggest clinicians and caregivers for closely monitoring of clinical conditions for these patients.
III.
Previous US-based studies have shown that a trauma center designation of level 1 is associated with improved patient outcomes. However, most studies are cross-sectional, focus on volume-related ...issues and are direct comparisons between levels. This study investigates the change in patient characteristics when individual trauma centers transition from level 2 to level 1 and whether the patients have similar outcomes during the initial period of the transition.
We performed a retrospective cohort study that analyzed hospital and patient records included in the National Trauma Data Bank from 2007 to 2016. Patient characteristics were compared before and after their hospitals transitioned their trauma level. Mortality; complications including acute kidney injury, acute respiratory distress syndrome, cardiac arrest with CPR, deep surgical site infection, deep vein thrombosis, extremity compartment syndrome, surgical site infection, osteomyelitis, pulmonary embolism, and so on; ICU admission; ventilation use; unplanned returns to the OR; unplanned ICU transfers; unplanned intubations; and lengths of stay were obtained following propensity score matching, comparing posttransition years with the last pretransition year.
Sixteen trauma centers transitioned from level 2 to level 1 between 2007 and 2016. One was excluded due to missing data. After transition, patient characteristics showed differences in the distribution of race, comorbidities, insurance status, injury severity scores, injury mechanisms, and injury type. After propensity score matching, patients treated in a trauma center after transition from level 2 to 1 required significantly fewer ICU admissions and had lower complication rates. However, significantly more unplanned intubations, unplanned returns to the OR, unplanned ICU transfers, ventilation use, surgical site infections, pneumonia, and urinary tract infections and higher mortality were reported after the transition.
Trauma centers that transitioned from level 2 to level 1 had lower overall complications, with fewer patients requiring ICU admission. However, higher mortality and more surgical site infections, pneumonia, urinary tract infections, unplanned intubations, and unplanned ICU transfers were reported after the transition. These findings may have significant implications in the planning of trauma systems for administrators and healthcare leaders.
Introduction: Fat embolism syndrome (FES) is a rare life-threatening condition that can develop after traumatic orthopedic injuries. Controversy remains concerning the epidemiology in the elderly ...population. Therefore, this study aims to report FES related to inhospital mortality stratified by age. Methods: A retrospective trauma cohort study was conducted using data from the National Trauma Data Bank (NTDB) from 2007 to 2014. All FES cases were included in the study with the diagnosis of FES (ICD9 958.1). Death on arrival cases were excluded. Patients were stratified by age cohort: less than 40 (G1), 40-64 (G2), and greater than 65 (G3) years of age. The primary outcome evaluated was in-hospital mortality. Multivariable regression models were performed to adjust for potential confounders. Results: Between 2007 and 2014, 451 people from a total of 5,836,499 trauma patients in the NTDB met the inclusion criteria. The incidence rate was 8 out of 100,000. The inpatient mortality rate was 11.8% for all subjects with the highest mortality rate of 17.6% in patients over 65. Multivariable analyses demonstrated that age greater than 65 years was an independent predictor of mortality (aOR 24.16, 95% CI 3.73, 156.59, p=0.001), despite higher incidence and injury severity of FES among patients less than 40. No significant association with length of hospital stay, length of intensive unit care, or length of ventilation use was found between the groups. Subgroup analysis of the elderly population also showed a higher mortality rate for FES in femoral neck fracture patients (18%) than other femoral fractures (14%). Conclusion: In this retrospective cohort analysis, old age (> 65 years) was found to be an independent risk factor for in-hospital mortality among fat embolism syndrome patients. Elderly patients specifically with femoral neck fractures should be monitored for the development of FES. Keywords: fat embolism, trauma, database, mortality, age
Delayed wound closure is often used after open reduction and internal fixation (ORIF) of both-bone forearm fractures to reduce the risk of skin necrosis and subsequent infection caused by excessive ...swelling. However, no studies we are aware of have evaluated factors associated with the use of delayed wound closure after ORIF.
(1) What proportion of patients undergo delayed wound closure after ORIF of adult both-bone forearm fractures? (2) What factors are associated with delayed wound closure?
The medical records of all patients who underwent ORIF with plate fixation for both-bone fractures by the adult orthopaedic trauma service at our institution were considered potentially eligible for analysis. Between January 2010 and April 2022, we treated 74 patients with ORIF for both-bone forearm fractures. Patients were excluded if they had fractures that were fixed more than 2 weeks from injury (six patients), if their fracture was treated with an intramedullary nail (one patient), or if the patient experienced compartment syndrome preoperatively (one patient). No patients with Gustilo-Anderson Type IIIB and C open fractures were included. Based on these criteria, 89% (66 of 74) of the patients were eligible. No further patients were excluded for loss of follow-up because the primary endpoint was the use of delayed wound closure, which was performed at the time of ORIF. However, one further patient was excluded for having bilateral forearm fractures to ensure that each patient had a single fracture for statistical analysis. Thus, 88% (65 of 74) of patients were included in the analysis. These patients were captured by an electronic medical record search of CPT code 25575. The mean ± SD age was 34 ± 15 years and mean BMI was 28 ± 7 kg/m 2 . The mean follow-up duration was 4 ± 5 months. The primary endpoint was the use of delayed wound closure, which was determined at the time of definitive fixation if tension-free closure could not be achieved. All surgeons used a volar Henry or modified Henry approach and a dorsal subcutaneous approach to the ulna for ORIF. Univariate logistic regression was used to identify which factors might be associated with delayed wound closure. A multivariable logistic regression analysis was then performed for male gender, open fractures, age, and BMI.
Twenty percent (13 of 65) of patients underwent delayed wound closure, 18% (12 of 65) of which occurred in patients who had high-energy injuries and 14% (nine of 65) in patients who had open fractures. Being a man (adjusted odds ratio 9.9 95% confidence interval 1 to 87; p = 0.04) was independently associated with delayed wound closure, after adjusting for open fractures, age, and BMI.
One of five patients had delayed wound closure after ORIF of both-bone forearm fractures. Being a man was independently associated with greater odds of delayed wound closure. Surgeons should counsel all patients with these fractures about the possibility of delayed wound closure, with particular attention to men with high-energy and open fractures. Future larger-scale studies are necessary to confirm which factors are associated with the use of delayed wound closure in ORIF of both-bone fractures and its effects on fracture healing.
Level III, therapeutic study.
Objective
To evaluate the influence of weight-bearing (WB) load in standard axial ankle syndesmotic measurements using cone beam CT (CBCT) examination of asymptomatic uninjured ankles.
Materials and ...methods
In this IRB approved, prospective study, patients with previous unilateral ankle fractures were recruited. We simultaneously scanned the injured ankles and asymptomatic contralateral ankles of 27 patients in both WB and NWB modes. For this study, only asymptomatic contralateral ankles with normal plain radiographs were included. Twelve standardized syndesmosis measurements at two axial planes (10 mm above the tibial plafond and 5 mm below the talar dome) were obtained by two expert readers using a custom CBCT viewer with the capability for geometric measurements between user-identified anatomical landmarks. Inter-reader reliability between two readers was obtained using the intra-class correlation coefficient (ICC). We compared the WB and NWB measurements using paired
t
test.
Results
Significant agreement was observed between two readers for both WB and NWB measurements (
p
<0.05). ICC values for WB and NWB measurements had a range of 50–95 and 31–71 respectively. Mean values of the medial clear space on WB images (1.75, 95% confidence interval 95% CI: 1.6, 1.9) were significantly lower than on NWB images (2.05, 95% CI: 1.8, 2.2) measurements (
p
<0.001). There was no significant difference between the remaining WB and NWB measurements.
Conclusion
Measurements obtained from WB images are reliable. Except for the medial clear space, no significant difference in syndesmotic measurements were observed during the WB mode of CBCT acquisition, implying that the tibio-fibular relationship remains unchanged when the physiological axial weight-bearing load is applied.
Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist.
To examine the effect of ...intrawound vancomycin powder in reducing deep surgical site infections.
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.
A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder.
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.
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.
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.
ClinicalTrials.gov Identifier: NCT02227446.
A number of clinical studies in the spine literature suggest that the use of local vancomycin powder may substantially reduce surgical site infections (SSIs). These studies are primarily ...retrospective and observational and few focus on orthopaedic trauma patients. This study is a phase III, prospective, randomized, clinical trial to assess the efficacy of locally administered vancomycin powder in the prevention of SSI after fracture surgery. The primary goal of the VANCO Study is to compare the proportion of deep SSI 6 months after fracture fixation surgery. A secondary objective is to compare species and antibacterial susceptibilities among study patients who develop SSI. An additional objective is to build and validate a risk prediction model for the development of SSI. The study population consists of patients aged 18-80 years with tibial plateau or pilon (tibial plafond) fractures, at higher risk of infection, and definitively treated with plate and screw fixation. Participants are block randomized (within center) in a 1:1 ratio to either treatment group (local vancomycin powder up to a maximum dose of 1000 mg, placed immediately before wound closure) or control group (standard of care) for each study injury location, and return to the clinic for evaluations at 2 weeks, 3 months, and 6 months after fixation. The targeted sample size for the study is 500 fractures per study arm. This study should provide important information regarding the use of local vancomycin powder during the definitive treatment of lower extremity fractures and has the potential to significantly reduce the incidence of infection after orthopaedic trauma.
Purpose
Teamwork in surgery depends on a shared mental model of success, i.e., a common understanding of objectives in the operating room. A shared model leads to increased engagement among team ...members and is associated with fewer complications and overall better outcomes for patients. However, clinical training typically focuses on role-specific skills, leaving individuals to acquire a shared model indirectly through on-the-job experience.
Methods
We investigate whether virtual reality (VR) cross-training,
i.e
let@tokeneonedotexposure to other roles, can enhance a shared mental model for non-surgeons more directly. Our study focuses on X-ray guided pelvic trauma surgery, a procedure where successful communication depends on the shared model between the surgeon and a C-arm technologist. We present a VR environment supporting both roles and evaluate a cross-training curriculum in which non-surgeons swap roles with the surgeon.
Results
Exposure to the surgical task resulted in higher engagement with the C-arm technologist role in VR, as measured by the mental demand and effort expended by participants (
p
<
0.001
). It also has a significant effect on non-surgeon’s mental model of the overall task; novice participants’ estimation of the mental demand and effort required for the surgeon’s task increases after training, while their perception of overall performance decreases (
p
<
0.05
), indicating a gap in understanding based solely on observation. This phenomenon was also present for a professional C-arm technologist.
Conclusion
Until now, VR applications for clinical training have focused on virtualizing existing curricula. We demonstrate how novel approaches which are not possible outside of a virtual environment, such as role swapping, may enhance the shared mental model of surgical teams by contextualizing each individual’s role within the overall task in a time- and cost-efficient manner. As workflows grow increasingly sophisticated, we see VR curricula as being able to directly foster a shared model for success, ultimately benefiting patient outcomes through more effective teamwork in surgery.
Purpose: A method for fluoroscopic guidance of a robotic assistant is presented for instrument placement in pelvic trauma surgery. The solution uses fluoroscopic images acquired in standard clinical ...workflow and helps avoid repeat fluoroscopy commonly performed during implant guidance.
Approach: Images acquired from a mobile C-arm are used to perform 3D–2D registration of both the patient (via patient CT) and the robot (via CAD model of a surgical instrument attached to its end effector, e.g; a drill guide), guiding the robot to target trajectories defined in the patient CT. The proposed approach avoids C-arm gantry motion, instead manipulating the robot to acquire disparate views of the instrument. Phantom and cadaver studies were performed to determine operating parameters and assess the accuracy of the proposed approach in aligning a standard drill guide instrument.
Results: The proposed approach achieved average drill guide tip placement accuracy of 1.57 ± 0.47 mm and angular alignment of 0.35 ± 0.32 deg in phantom studies. The errors remained within 2 mm and 1 deg in cadaver experiments, comparable to the margins of errors provided by surgical trackers (but operating without the need for external tracking).
Conclusions: By operating at a fixed fluoroscopic perspective and eliminating the need for encoded C-arm gantry movement, the proposed approach simplifies and expedites the registration of image-guided robotic assistants and can be used with simple, non-calibrated, non-encoded, and non-isocentric C-arm systems to accurately guide a robotic device in a manner that is compatible with the surgical workflow.
PDF
