Contemporary Review of Traumatic Axillary and Subclavian Artery Injuries at an Urban Level One Trauma Center.

OBJECTIVE: Traumatic axillary and subclavian artery injuries are uncommon. Limited data are available regarding patient and injury characteristics, as well as management strategies and outcomes. METHODS: Retrospective chart review was performed on patients presenting to University of Louisville Hospital, an urban Level One Trauma Center, with traumatic axillary and subclavian artery injuries from 2015-2021. Patients were identified using University of Louisville trauma, radiology, and billing database searches based on ICD9/10 codes for axillary and subclavian artery injuries. Descriptive statistics are expressed as frequencies and percentages. Comparisons were performed using Fisher's Exact and Chi-squared tests. RESULTS: Forty-four patients with traumatic axillary-subclavian arterial injuries were identified for analysis. Blunt and penetrating trauma were equally represented (n = 22 for both). A variety of injury types were seen, including minimal/intimal injury, laceration, pseudoaneurysm, transection, occlusion, and arteriovenous fistula. Management strategies were also variable, including non-operative, endovascular, planned hybrid, open, and endovascular converted to open. In operative patients, revascularization technical success was high (n = 31, 97%) with low likelihood of thrombosis (n = 2, 6%) and no infections. Among all patients, amputation rate was 5% (n = 2) and mortality rate was 9% (n = 3). Regarding arterial involvement, blunt injury was more likely to affect the subclavian (n = 18) than the axillary artery (n = 6) (P = .04). No significant difference was seen in brachial plexus injury based on artery involved (subclavian = 9 vs axillary = 11, P = .14) or mechanism (blunt = 6 vs penetrating = 11, P = .22). Non-operative management was more likely with subclavian artery injury (n = 11) vs axillary artery injury (n = 1) (P = .008). There was no significant difference between decision for non-operative (blunt = 9, penetrating = 3) vs operative (blunt = 13, penetrating = 19) management based on mechanism (P = .09). Transection injury was associated with an open repair strategy (endovascular/hybrid = 1, open/endovascular to open conversion = 11, P = .0003). Of the three patients requiring endovascular to open conversion, two required amputation, which were the only two patients in the study undergoing amputation. CONCLUSIONS: Both open and endovascular/hybrid strategies are useful when treating traumatic axillary and subclavian artery injuries and are associated with high likelihood of revascularization technical success, with low rates of thrombosis or infection, when treated promptly at a trauma center with vascular specialists available. Transection injuries were most often treated with open revascularization. Patients undergoing amputation had blunt transection injuries to the subclavian artery and underwent endovascular to open conversion after failed attempts at endovascular revascularization.

Retrospective Evaluation of Short-Term Outcomes of an Enhanced Recovery Protocol for Patients Undergoing Complex Abdominal Wall Reconstruction.

BACKGROUND: Enhanced recovery protocols (ERPs) have the potential to streamline care and improve short-term outcomes for surgical patients. However, for patients undergoing modern iterations of complex abdominal wall reconstruction (AWR), little literature exists on the effectiveness of these protocols. STUDY DESIGN: In this retrospective study we reviewed our institutional experience with complex AWR throughout a 2-year period with 1 year immediately before and 1 year after implementation of our ERP. Patients undergoing primarily minimally invasive complex AWR who were compliant with 11 elements of our ERP were compared with patients who received surgery before implementation of the protocol or did not meet these criteria. Baseline patient characteristics and patient outcomes including hospital length of stay, narcotic usage, and readmission were compared across groups. Multivariable regression models were used to estimate the associations of our ERP protocol with outcomes adjusting for surgical approach. RESULTS: Median length of stay for the overall cohort (n = 132) was 3 days (interquartile range 1 to 4). Morbidity and mortality rates were 22.6% and 0.7%, respectively. ERP patients were less likely to have a complication (ERP compliant 8.7% [n = 46] vs non-ERP 30.2% [n = 86], p < 0.01), had a shorter median postoperative length of stay (median 1 vs 3 days, p < 0.01), and received fewer morphine equivalents (median 30.8 vs 45 mg, p < 0.01). Readmission rate for ERP patients did not differ significantly vs non-ERP patients (6.5% vs 11.8%, p = 0.34). CONCLUSIONS: Use of ERPs in patients undergoing complex AWR may provide benefits for both patients and hospitals.

Patient Perception of Orthopedic Surgeon Reimbursement.

Significant attention has been directed at evaluating reimbursement rates to orthopedic surgeons for various surgical procedures. To evaluate patients' understanding of the surgeon reimbursement process, studies using patient surveys have been conducted to determine patients' perceptions of orthopedic surgeon compensation. To date, there has been no systematic review to consolidate the data of these studies. This study aimed to synthesize the findings of these individual studies across multiple subspecialties of orthopedic surgery to evaluate the potential discrepancy between how much patients believe orthopedic surgeons are reimbursed and the actual reimbursement rate. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies that report findings of patient perceptions of orthopedic surgeon reimbursement for various procedures. Searches were conducted using MEDLINE through PubMed, Embase, and Scopus. Summary estimates of reimbursement discrepancies across subspecialties and overall were reported as unweighted averages of the individual study results within each group. Twelve studies were identified that met inclusion criteria, constituting 4309 surveys. These survey studies measured patients' perceptions of how much orthopedic surgeons are reimbursed for common procedures, including anterior cruciate ligament reconstruction, arthroscopic meniscectomy, carpal tunnel release, rotator cuff repair, multiple spine procedures and total shoulder, hip, and knee arthroplasty. It was found that patients reported reasonable surgeon's fees to be 11.2 times more than actual Medicare reimbursement. Among individual studies, the largest discrepancies were seen in total hip arthroplasty (26 times), whereas the smallest difference was in anterior cruciate ligament reconstruction (1.6 times). On average, patients estimated Medicare reimbursement rates to be 5.9 times higher than the actual surgeon reimbursement. Patients consistently overestimate how much orthopedic surgeons are reimbursed for common orthopedic procedures. The results of this systematic review suggest that patients may value these procedures more than what Medicare reimburses. Such information may help educate the public, direct policy, and increase transparency between orthopedic surgeons and patients.

Clinical outcomes following conservative and surgical management of floating shoulder injuries: a systematic review.

BACKGROUND: Floating shoulder is an uncommon injury characterized by fractures of the clavicle and ipsilateral scapular neck. No consensus exists on management. The purpose of this study was to analyze the existing literature on treatment and clinical outcomes of floating shoulder injuries to provide a baseline understanding of current treatment strategies of this injury. METHODS: A systematic review was performed to identity published literature on outcomes and management of floating shoulder injuries. Searches were performed using PubMed, Embase, and SCOPUS. RESULTS: Seventeen studies were identified that included data for 371 shoulders. The mean reported age was 39.4 years (range, 16-82) and the mean follow-up was 49.4 months (range, 6-312). The major mechanism of injury was motor vehicle accident (51%) followed by fall from height (16%). Of the 371 shoulders, 215 (58%) were treated surgically, whereas 156 shoulders (42%) were managed nonoperatively. The most commonly reported outcome score was the Constant-Murley score (9 studies), followed by the Herscovici Floating Shoulder Injury score (5 studies). The mean Constant-Murley score was 80% of ideal maximum for both shoulders treated surgically and those treated nonoperatively. CONCLUSION: Satisfactory outcomes can be expected following both surgical fixation and nonoperative management of floating shoulder injuries when appropriately individualized to the patient, as evidenced by clinical outcome scores. Floating shoulder injuries with significant displacement of the scapular neck may benefit from surgical fixation of both the clavicle and scapula fractures. In those with minimal or nondisplaced scapular neck fractures, good outcomes may be achieved when treated nonoperatively or with surgical fixation of the clavicle alone.

Current concepts in vitamin D and orthopaedic surgery.

INTRODUCTION: Vitamin D plays an important role in the musculoskeletal system of the human body. Here, we review the most current literature on vitamin D as it relates to orthopaedic surgery and the musculoskeletal system, focusing largely on non-fracture applications. MATERIALS AND METHODS: A literature review was performed on the basic science of vitamin D metabolism, epidemiology of vitamin D levels, role of vitamin D within the musculoskeletal system, and the correlation of vitamin D with injuries and orthopaedic surgical outcomes. RESULTS: The existing literature suggests vitamin D plays multiple roles in the musculoskeletal system. Recent research has shed light on the importance of vitamin D in the setting of soft tissue healing and recovery in addition to affecting postoperative outcomes after common orthopaedic procedures. CONCLUSIONS: Given the widespread prevalence of vitamin D deficiency, orthopaedic surgeons should be aware of the current evidence regarding clinical implications in patients with musculoskeletal complaints.