Audio Distraction for Traction Pin Insertion: A Prospective Randomized Controlled Study.

BACKGROUND: Insertion of a skeletal traction pin in the distal femur or proximal tibia can be a painful and unpleasant experience for patients with a lower-extremity fracture. The purpose of this study was to determine whether providing patients with audio distraction (AD) during traction pin insertion can help to improve the patient-reported and the physician-reported experience and decrease pain and/or anxiety during the procedure. METHODS: A prospective randomized controlled trial was conducted at 2 level-I trauma centers. Patients ≥18 years of age who were conscious and oriented and had a medical need for skeletal traction were included. Patients were randomized to receive AD or not receive AD during the procedure. All other procedure protocols were standardized and were the same for both groups. Surveys were completed by the patient and the physician immediately following the procedure. Patients rated their overall experience, pain, and anxiety during the procedure, and physicians rated the difficulty of the procedure, both on a 1-to-10 Likert scale. RESULTS: A total of 54 patients met the inclusion criteria. Twenty-eight received AD and 26 did not. Femoral fractures were the most common injury (33 of 55, 60.0%). Baseline demographic characteristics did not differ between the 2 groups. The overall patient-reported procedure experience was similar between the AD and no-AD groups (3.9 ± 2.9 [95% confidence interval (CI), 3.1 to 4.7] versus 3.5 ± 2.2 [95% CI, 2.9 to 4.1], respectively; p = 0.55), as was pain (5.3 ± 3.2 [95% CI, 4.4 to 6.2] versus 6.1 ± 2.4 [95% CI, 5.4 to 6.8]; p = 0.28). However, anxiety levels were lower in the AD group (4.8 ± 3.3 [95% CI, 3.9 to 5.7] versus 7.1 ± 2.8 [95% CI, 6.3 to 7.9]; p = 0.007). Physician-reported procedure difficulty was similar between the groups (2.6 ± 2.0 [95% CI, 2.1 to 3.1] versus 2.8 ± 1.7 [95% CI, 2.3 to 3.3]; p = 0.69). CONCLUSIONS: AD is a practical, low-cost intervention that may reduce patient anxiety during lower-extremity skeletal traction pin insertion. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Incidence and Risk Factors of Heterotopic Ossification in the Knee After Reamed Tibial Nailing.

INTRODUCTION: Heterotopic ossification (HO) in the knee after tibial intramedullary nailing (IMN) has yet to be thoroughly investigated. Our aim was to assess frequency and associated factors for HO in the knee after tibial IMN. METHODS: This is a retrospective review at a single level 1 urban trauma center of 213 patients who underwent reamed tibial IMN. Plain radiographs were reviewed postoperatively and on final follow-up (≥6 weeks). Chart review was performed for surgical approach (suprapatellar versus infrapatellar), demographics, injury characteristics, and clinical follow-up. The primary outcome was frequency of HO. RESULTS: HO on final follow-up (mean: 41.43 weeks) was recorded in 15% cases. Postsurgical retroinfrapatellar reaming debris (odds ratio [OR], 4.73), Injury Severity Score (OR, 1.05), intensive care unit admission (OR, 2.89), chest injury (OR, 3.4), and ipsilateral retrograde femoral IMN (OR, 5.08) showed a notable association with HO development. No association was observed in HO formation between surgical approach, knee pain, or range-of-motion deficits. DISCUSSION: Radiographic evidence of HO in the knee after reamed tibial IMN is not uncommon and is associated with retained reaming debris, Injury Severity Score, chest injury, intensive care unit admission, and ipsilateral retrograde femoral nailing. No differences were noted in HO formation between approaches. HO was not associated with knee pain or range-of-motion deficits.

Increases in adolescent firearm injuries were associated with school closures during COVID-19.

BACKGROUND: Mitigation measures, including school closures, were enacted to protect the public during the COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional support.  This study explores the statistical relationships between school closures and adolescent firearm injuries (AFI) during the pandemic. METHODS: Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2 pediatric). Firearm injuries affecting adolescents aged 11-21 years from 1/1/2016 to 6/30/2021 were evaluated. Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage changes. RESULTS: There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the 10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city. CONCLUSION: AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings reinforce the need to consider the direct implications on public health and adolescent safety when implementing public policy.

Traumatic Degloving Wounds Treated With Low Continuous Wall Suction Drainage: A Novel and Effective Technique to Prevent Recurrence.

Soft tissue degloving wounds overlying fractures present a technical surgical challenge and have a high rate of recurrence. Despite several current treatment methods, there remains a need for improved therapies to address this complex issue. The purpose of this study was to introduce a novel technique for managing soft tissue degloving wounds in the setting of fractures requiring operative fixation. Eleven consecutive patients with soft tissue degloving wounds overlying operatively managed fractures were treated with our novel technique for "dead space" elimination in the peri-operative period. The technique entails placing Jackson Pratt drain(s) within the degloving wound during operative debridement and placing them to low continuous wall suction postoperatively. This patient series shows that the application of 40 to 60 mm Hg of negative pressure allows for thorough drainage of the hemolymphatic fluid collection and elimination of dead space, allowing the delaminated tissue layers to heal together and preventing recurrence. [Orthopedics. 2023;46(4):e257-e263.].

Fixation vs Arthroplasty for Femoral Neck Fracture in Patients Aged 40-59 Years: A Propensity-Score-Matched Analysis.

Background: Internal fixation (IF) has historically been favored for the treatment of femoral neck fractures (FNFs) in young, nongeriatric patients. However, recent literature reporting high reoperation rates among those receiving IF, taken in conjunction with favorable survivorship of modern bearing surfaces in total hip arthroplasty (THA), has begun to question this paradigm. Our study sought to compare outcomes between IF and THA for FNFs in patients aged 40-59 years. Methods: Using the Truven MarketScan Database, we performed a retrospective propensity-score-matched cohort study on patients aged 40-59 years who underwent surgical management of an isolated FNF (THA or IF). Patients with pathologic fracture were not included. Analysis was conducted on patients aged 40-49 and 50-59 years separately. A subgroup analysis was performed on those patients with 1 year and 3 years of follow-up. Multivariate analysis, controlling for baseline patient information, was then performed. Results: Seven hundred sevety-eight 40- to 49-year-old patients and 3470 50- to 59-year-old matched patients (IF and THA) were included in this study. A multivariate analysis found that patients aged 40-49 years who underwent IF were at higher odds of both 1-year (odds ratio 2.35, 95% confidence interval 1.22-4.54, P = .011) and 3-year (odds ratio 5.68, 95% confidence interval 2.21-14.60, P < .001) reoperation. Similar results were found in those aged 50-59 years. While complication rates were similar, postoperative anemia and 90-day visits to the emergency room were more common after THA in both age cohorts. Conclusions: While THA is associated with increased postoperative anemia and resource utilization compared with IF, patients aged 40-59 years who undergo IF for FNF are at increased risk of reoperation in the first 3 postoperative years. This information should be used to assist in shared decision-making with patients in this age group.

Tranexamic acid with a pre-operative suspension of anticoagulation decreases operative time and blood transfusion in the treatment of pelvic and acetabulum fractures.

PURPOSE: The purpose was to evaluate the impact of intra-operative administration of tranexamic acid (TXA) and pre-operative discontinuation of prophylactic chemoprophylaxis in patients undergoing internal fixation of pelvic or acetabular fractures on the need for subsequent blood transfusion. Operative time and the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) were also assessed. METHODS: Data from a single level one trauma centre was retrospectively reviewed from January 2014 to December 2017 to identify pelvic ring or acetabular fractures managed operatively. Patients who did not receive their scheduled dose of chemoprophylaxis prior to surgery but who did receive intra-operative TXA were identified as the treatment group. Due to the interaction of VTE prophylaxis and TXA, the variables were analyzed using an interaction effect to account for administration of both individually and concomitantly. RESULTS: One hundred fifty-nine patients were included. The treatment group experienced a 20.7% reduction in blood product transfusion (regression coefficient (RC): - 0.207, p = 0.047, 95%CI: - 0.412 to - 0.003) and an average of 36 minutes (RC): - 36.90, p = 0.045, 95%CI: - 72.943 to - 0.841) reduction in surgical time as compared to controls. The treatment group did not experience differential rates of PE or DVT (RC: 1.302, p = 0.749, 95%CI: 0.259-6.546) or PE (RC: 1.024, p = 0.983, 95%CI: 0.114-9.208). CONCLUSIONS: In the study population, the combination of holding pre-operative chemoprophylaxis and administering intra-operative TXA is a safe and effective combination in reducing operative time and blood product transfusions.

Predictors of chronic groin discomfort after laparoscopic totally extraperitoneal inguinal hernia repair.

BACKGROUND: Chronic groin discomfort is an undesired complication of laparoscopic totally extraperitoneal (TEP) inguinal hernia repairs. We examined whether perioperative factors may be associated with an increased risk of developing this problem and if their recognition could lead to preventive strategies. STUDY DESIGN: We performed a retrospective review of 1 surgeon's experience with 1,479 TEP repairs on 976 patients from 1995 to 2009. A mailed survey, which included a groin discomfort questionnaire (Carolinas Comfort Scale), was distributed to all patients. Symptom severity grading (range 0, none to 5, severe) was used to sort individual responses. Perioperative factors were compared between asymptomatic and symptomatic patients with varying levels of discomfort. RESULTS: There were 691 patients (71%) who provided complete responses to the questionnaire. Median follow-up was 5.7 years (range 0 to 14.4 years). The majority (n = 543, 79%) denied any symptoms of mesh sensation, pain, or movement limitation. In the remaining 148 (21%) patients, symptoms were most often mild (n = 108), followed by mild but bothersome (n = 25), and 15 patients (2%) had moderate or severe symptoms. Symptomatic patients were younger (median age 52 vs 57 years, p = 0.002) and were more likely to have had the TEP repair for recurrent hernias (24% vs 17%, p = 0.035). Operative diagnosis, bilateral exploration, mesh fixation techniques, perioperative complications, American Society of Anesthesiologists grade, and length of hospital stay were not associated with chronic groin discomfort. CONCLUSIONS: The majority of patients are asymptomatic after a laparoscopic TEP inguinal hernia repair. Most of the symptomatic patients do not have any bothersome symptoms. Given that younger age and a repair for recurrent hernia were predictors of chronic groin discomfort, we counsel these patients about their increased risks.

Minimally invasive inguinal lymph node dissection (MILND) for melanoma: experience from two academic centers.

BACKGROUND AND AIM: Regional lymph nodes are the most frequent site of spread of metastatic melanoma. Operative intervention remains the only potential for cure, but the reported morbidity rate associated with inguinal lymphadenectomy is approximately 50%. Minimally invasive lymph node dissection (MILND) is an alternative approach to traditional, open inguinal lymph node dissection (OILND). The aim of this study is to evaluate our early experience with MILND and compare this with our OILND experience. METHODS: We conducted a prospective study of 13 MILND cases performed for melanoma from 2010 to 2012 at two tertiary academic centers. We compared our outcomes with retrospective data collected on 28 OILND cases performed at the same institutions, by the same surgeons, between 2002 and 2011. Patient characteristics, operative outcomes, and 30-day morbidity were evaluated. RESULTS: Patient characteristics were similar in the two cohorts with no statistically significant differences in patient age, gender, body mass index, or smoking status. MILND required longer operative time (245 vs 138 min, p=0.0003). The wound dehiscence rate (0 vs 14%, p=0.07), hospital readmission rate (7 vs 21%, p=0.25), and hospital length of stay (1 vs 2 days, p=0.01) were all lower in the MILND group. The lymph node count was significantly higher (11 vs 8, p=0.03) for MILND compared with OILND. CONCLUSIONS: MILND for melanoma is a novel alternative to OILND, and our preliminary data suggest that MILND provides an equivalent lymphadenectomy while minimizing the severity of postoperative complications. Further research will need to be conducted to determine if the oncologic outcomes are similar.