Outcomes of simultaneous versus staged intramedullary nailing fixation of multiple long bone lower extremity fractures.

INTRODUCTION: Repair of multiple lower extremity long bone fractures with intramedullary nail (IMN) fixation is associated with significant cardiopulmonary burden and may result in mortality. These patients are at an increased risk for fat embolism syndrome, pulmonary embolism, Acute Respiratory Distress Syndrome (ARDS), and pneumonia. No standardized guidelines exist to guide treatment of these patients. Further, there is a paucity of data regarding the risk of simultaneous versus staged fixation of multiple long bone fractures that includes both tibial and femoral injuries, as patients with multiple concomitant fractures are often excluded from relevant analyses. Our level one trauma center aimed to identify whether simultaneous fixation, defined by definitive fixation of multiple lower extremity long bone fractures during one operative event, led to increased cardiopulmonary complications as compared to a staged approach, defined as multiple operations to reach definitive fixation. PATIENTS AND METHODS: The Michigan Trauma Quality Improvement Program (MTQIP) database from 35 Level I and II trauma centers was queried to identify patients from January 2016 - December 2019. The primary outcome was incidence of cardiopulmonary complications for staged and simultaneous IMN fixation. RESULTS: We identified 11,427 patients with tibial and/or femoral fractures during the study period. 146 patients met the inclusion criteria of two or more fractures treated with IMN fixation. 118 patients underwent simultaneous IMN fixation, and 28 patients received staged IMN fixation. There were no significant differences in injury severity score (ISS), demographics, pre-existing conditions, and cardiopulmonary complications between the two groups. There was a statistically significant difference in hospital length of stay (LOS) (p = 0.0012). The median hospital LOS for simultaneous fixation was 8.3 days versus 15.8 days for the staged cohort, a difference of 7.5 days. CONCLUSION: This is the largest retrospective study to date examining simultaneous versus staged IMN fixation in patients with multiple long bone lower extremity fractures. In contrast to previous studies, we found no difference in cardiopulmonary complications. Given these findings, patients with multiple long bone lower extremity fractures should be considered for simultaneous IMN, an approach which may decrease hospital LOS.

Comparison of Robotic, Laparoscopic, and Open Unilateral Repair of Non-recurrent Inguinal Hernia.

BACKGROUND: There is a paucity of data comparing open, robotic, and laparoscopic approaches on unilateral, non-recurrent inguinal hernias. Our study presents a large, retrospective triple-arm outcome analysis between robotic, laparoscopic, and open unilateral, non-recurrent inguinal hernia repairs at a single institution. METHODS: 706 patients who underwent elective, non-recurrent inguinal hernia repair performed by 8 general surgeons at a single institution from 2016 to 2019 were reviewed retrospectively. Patient baseline characteristics, operative times, resident involvement, and postoperative outcomes were analyzed for all repair types. A cost analysis of the different procedures was performed. RESULTS: There were 305 laparoscopic repairs, 207 robotic repairs, and 194 open repairs. Open and laparoscopic repairs were performed on patients who were older (p =< .001) and with a higher Charlson Comorbidity Index (p =< .001). Patient BMI was higher in minimally invasive repair than open repair (P = .021). There were no significant differences in complication rates on pairwise analysis. Robotic and open repairs had significantly longer operative times than laparoscopic repairs (P < .001). There was less resident involvement in robotic repair than with the other approaches (P < .001). Resident involvement was associated with shorter OR times (P = .001) and no significant difference in postoperative complications. There was a trend over the study period toward faster operative times and more robotic repair. Robotic repair is the most expensive repair, followed by laparoscopic and open repairs. CONCLUSION: All 3 repair techniques can be performed without significant differences in outcomes. The technique utilized should be based on surgeon preference and patient characteristics.

Metastatic breast cancer in a transgender female with history of mantle field radiation and free silicone breast injections: case report.

Background: In today's world, the concept of gender has been scrutinized and an appreciation for those who experience dysphoria with their birth sex and gender classification is becoming more commonplace. Keeping in mind the patients gender orientation in addition to their birth sex is necessary when assessing health conditions more prevalent in one sex, such as breast cancer. Case Description: In this report, we present a 51-year-old African American transgender female with history of chemotherapy and mantle-field radiation treatment for sub-clavicular and mediastinal Hodgkin's lymphoma 24 years prior to presentation of a new left neck mass. The enlarged lymph node was removed revealing metastatic salivary adenocarcinoma with features corresponding to metastatic breast carcinoma. Computed tomography (CT) of the chest, abdomen, and pelvis detected metastasis to the pelvis and a few lucent bone lesions in the lumbar spine. Of note, the patient underwent free silicone injections into both breasts to emphasize her desired gender three years after treatment for Hodgkin's lymphoma. Based on her history of metastatic disease and history of mantle radiation, it was determined that her previous cancer diagnoses were likely due to metastatic breast cancer that was obscured by silicone injections. Bilateral skin-sparing mastectomy was performed, patient recovered well, and continued with palliative care at follow up. Conclusions: Even though there is significant data regarding the incidence of breast cancer in the separate female and male populations, review of the literature shows minimal information regarding incidence in the transgender population. Our hope is that this report will contribute to the current base of knowledge present in the literature while also bringing attention to the need for further investigation of sex-specific diseases in transgender individuals.