Acute pain after digital crushing and nicotine intoxication. Cigarettes are always a false friend. A prospective study.

BACKGROUND: Nicotine addiction is a public health problem. Our hypothesis was that the degree of nicotine dependence is positively correlated with the perceived intensity of acute pain. MATERIALS AND METHODS: A single-center prospective comparative observational study was conducted from 2019 to 2021. Patients included presented distal phalanx extra-articular trauma of less than 24hours' progression. We compared a group of smokers with a group of non-smokers. A Digital Pain Scale (DPS) was assessed at time of trauma, at first consultation, and once a day until the fifth day post-trauma. A Fagerström test was performed. The primary endpoints were the correlation between dependence and DPS and the correlation between the amount of tobacco consumed and DPS. The secondary endpoints were analgesic consumption according to Fagerström, DPS and tobacco consumption. RESULTS: Sixty-seven patients were included: 26 smokers, 41 non-smokers. No significant correlation was found between dependence level or amount of tobacco used and DPS. Consumption of level II analgesics was significantly 2-fold higher in the smoking group on the second, third and fifth day: respectively, 2.15 tablets versus 1.22 (p=0.02), 1.27 versus 0.49 (p=0.01), and 0.69 versus 0.20 (p=0.04). CONCLUSION: Patients who smoke are exposed to more frequent and more intense pain and consume more palliative painkillers. LEVEL OF EVIDENCE: IIB; exposed vs. non-exposed cohort.

Fast-track teaching in microsurgery.

INTRODUCTION: In France, microsurgery is taught in University diploma courses, for a mean 100hours (range, 45-120hours) extending over several months. This training, spread over the year, encounters problems of maintaining high-quality supervision and enduring acquisition of skills. These difficulties risk leading to withdrawal of certain courses, already suffering from funding issues and administrative requirements for animal welfare. MATERIAL AND METHOD: We report our experience with a 2-week module comprising nine 4-hour sessions (total, 36hours), with continuous supervision of 5 students in each of 2 groups (10 students), enabling personalized learning. At the end of each session, an assessment questionnaire was filled out by teachers and students. RESULTS: Students' scores increased from a mean 23.9/30 points (range, 20 - 30) at session 3 to 26.9 points (range, 23 - 30) at session 9 (p=0.012). At the end of session 3, students were grouped as good, average or beginners, based on the first assessments: i.e., with differences in level between groups at session 3. At the end of session 9, all 3 groups showed statistically comparable levels. Comparison between student and teacher questionnaire responses showed a significant discrepancy in 7 of the 10 cases in week 1, and no significant discrepancy in 7 of the 10 cases by the end of week 2. DISCUSSION: The efficacy of condensed learning is based on immediate repetition of exercises, following Ebbinghaus: without repetition, memory decays exponentially, whereas if the information is rapidly repeated, the curve flattens and memory is consolidated. The present rapid improvement in the acquisition of the principles of microsurgery stimulated the enthusiasm of both students and teachers for what is reputed to be a demanding type of training. The study showed that acquisition, assessed in terms of vascular suture reliability, was achieved by the end of a 36-hour module, regardless of the student's baseline level.

Fast-track care for pertrochanteric hip fracture: What impact on function and autonomy after discharge?

INTRODUCTION: Fast-track treatment of pertrochanteric fracture is being developed in traumatology. The present study hypothesis was that fast-track treatment of pertrochanteric fracture does not jeopardize patient autonomy. MATERIAL AND METHOD: A single-center prospective comparative observational study, conducted from 2014 to 2016 in the University Hospital of Angers, France, included patients presenting with isolated A1 or A2 pertrochanteric fracture on the AO classification, managed by intramedullary nailing and requiring transfer to Post-acute Recovery (PAR). The fast-track exposure group were transferred directly on postoperative day 1, while the non-exposure group received postoperative care in the surgery department before transfer to PAR. The main endpoint was difference in Parker score between admission and discharge. Secondary endpoints comprised type of walking aid at discharge and destination of discharge from PAR. RESULTS: 109 patients were initially included, with 54 patients (27 pairs) after matching. There was a significant difference in reduction in Parker score in favor of fast-track: -1.27 (95% CI: -2.27; -0.32) (p=0.012). There were no differences in amount or type of aid at discharge or discharge destination, although there was a trend toward greater discharge to the initial place of residence with fast-track. DISCUSSION: Orthopedics is heading to the fast-track. Previous studies reported shorter hospital stay, comparable survival and complications rates, and significant cost-saving. The present study addressed progression: fast-track patients showed significantly less loss of walking autonomy. CONCLUSION: Fast-track management of pertrochanteric fracture significantly reduced loss of walking autonomy, without significant impact on discharge destination or walking aids. LEVEL OF EVIDENCE: IIB, exposure/non-exposure cohort.

Fast track care for pertrochanteric hip fractures: How does it impact length of stay and complications?

INTRODUCTION: The medical and economic impact of treating pertrochanteric hip fractures is growing. We hypothesized that fast track surgery of pertrochanteric fractures would reduce the length of stay (LOS) without compromising the quality of care. MATERIALS AND METHODS: This was a prospective, observational, single-center cohort study conducted between 2014 and 2016 at the Angers Teaching Hospital in France. The enrolled patients had an isolated A1 or A2 proximal femur fracture (AO classification) that was treated surgically by intramedullary nailing and required post-acute rehabilitation (PAR) care. The exposed FT cohort was transferred into the PAR pathway on postoperative day 1. The non-exposed (control) group was provided with postoperative care in the surgery unit before transfer to PAR. The primary outcome was the total LOS (LOS in surgery+LOS in PAR). The secondary objectives were to determine the immediate survival, 1-year survival, postoperative complications and average cost of hospitalization. RESULTS: The study enrolled 109 patients initially, with 54 patients eligible for analysis after matching (27 pairs). The LOS in PAR and total LOS were 45.85±19.24 days and 48.56±19.36 days in the FT group (n=27), and 68.41±48.77 days and 77.85±48.80 days in the control group (n=27). Thus the LOS in PAR and total LOS were significantly lower in the FT group (p=0.022, p=0.003). There was no significant difference in the number of early deaths, complications, and 1-year survival without rehospitalization between cohorts. The mean cost per patient was lower in the FT cohort. DISCUSSION: The FT pathway has already been adopted in orthopedics. For patient who suffer a hip fracture, it contributes to reducing the total LOS without negatively impacting the quality of care. Early health economics studies support this care pathway. CONCLUSION: The FT approach to treating pertrochanteric fractures reduces total LOS without increasing mortality or complication rates. The 1-year survival is comparable. LEVEL OF EVIDENCE: IIB, Exposed/Unexposed cohort.