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PURPOSE: This study aimed to evaluate the incidence of, and factors associated with, reoperation after distal radius nonunion repair. METHODS: We conducted a retrospective cohort study at a multicenter academic institution and identified adult patients who underwent open reduction and internal fixation for distal radius nonunion between January 2005 and August 2021. Thirty-three patients were included in this study. The cohort consisted of 13 males (13/33) and had a median age of 56 years (interquartile ranges: 49-64). Median follow-up was 59 months (interquartile ranges: 23-126). RESULTS: Unplanned reoperations occurred in eight of 33 patients. The most common reasons for reoperation were irrigation and debridement for infection, revision surgery for persistent nonunion, and unplanned hardware removal. In total, 10 complications occurred in nine patients. The most common complications were infection and persistent nonunion; both occurred in three cases. CONCLUSIONS: Complications after distal radius nonunion repair are common. Reoperation after distal radius nonunion repair is required in approximately one of four cases. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.
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BACKGROUND: Patients with malignancy often require urgent surgical consultation for treatment or palliation of disease. The objective of this study is to explore the prognostic determinants affecting care in acute cancer-related surgical presentations and the effect on patient outcomes. MAIN BODY: This is a retrospective review of patients referred to the acute general surgery (ACS) service at a tertiary hospital for management of cancer-related problem from July 2017 to September 2018. Patient demographics, course in hospital, and survival were recorded. Multivariant logistic regression and Kaplan-Meier estimates were performed. One hundred eighty-nine patients were identified (53% female) with a mean age of 65.9 years. Forty-two patients (22%) were newly diagnosed with cancer on presentation, and 94 (50%) patients had metastatic disease. Cancer staging was completed in 84% of patients, and 65% had multidisciplinary team (MDT) assessment during their hospital stay. Surgery was performed on 90 (48%) patients, of which 31.2% was with palliative intent. Overall mortality was 56% with 30- and 60-day mortality of 15% and 22%, respectively. The adjusted odds ratio (OR) for a 60-day mortality was high in patients presenting with new cancer diagnosis (OR 3.18, 95% CI 1.18-9.02, p=0.03), metastatic disease (OR 5.11, 95% CI 2.03-12.85, p=0.001), or systemic therapy on presentation (OR 3.46, 95% CI 1.30-9.22, p=0.013). CONCLUSION: Emergency surgical referral is common in patients with malignancy. Surgical decision making can be challenging due to the heterogeneity of this population and their associated comorbidities. Optimizing prognostic determinants such as goal-directed palliative care, MDT discussions, and bridging to systemic therapy can improve patient outcomes.
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Neoplasias , Derivación y Consulta , Anciano , Femenino , Humanos , Masculino , Neoplasias/cirugía , Cuidados Paliativos , Pronóstico , Estudios RetrospectivosRESUMEN
BACKGROUND: Socioeconomic status (SES) has been shown to influence the outcomes of surgical pathologies in areas with unequal access to health care. The purpose of this study was to measure the effect of SES on the urgency for inguinal hernia repair in an area with purported equitable access to health care in the context of a universal health care system. METHODS: We included all adult patients who underwent surgical management of an inguinal hernia between 2012 and 2016 at 2 urban academic centres. We measured the SES using the Vancouver Area Neighbourhood Deprivation Index (VANDIX) score. RESULTS: We included 2336 patients: 98 emergency surgery and 294 elective surgery cases. We matched patients without replacement on age, sex and American Society of Anesthesiology score, using optimized propensity score matching at a ratio of 1 case to 3 controls. We found no significant correlation between lower SES and emergency surgical management (p = 0.122). Secondary analysis assessed the impact of SES on morbidity and length of stay. We found no significant difference in the rate of complications, length of stay and recurrence by SES category. Patients from lower SES brackets had increased odds for readmission (odds ratio 1.979; 95% confidence interval 1.111-4.318). CONCLUSION: We found no correlation between a low SES and the need for emergency inguinal hernia repair, but found an increased rate of readmission in patients from lower SES brackets. This finding should be further scrutinized through a deeper dive into the barriers to access to nonacute care settings, such as home care.
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Hernia Inguinal , Adulto , Canadá , Procedimientos Quirúrgicos Electivos , Hernia Inguinal/diagnóstico , Hernia Inguinal/cirugía , Hospitales de Enseñanza , Humanos , Clase Social , Estados UnidosRESUMEN
Background: Our objective was to establish a sustainable educational partnership and clinical exchange between the trauma services at Vancouver General Hospital (VGH) and the Mexican Red Cross hospital in Mexico City (Hospital Central de la Cruz Roja [HCCR] Polanco). Methods: In 2017, a general surgery resident in postgraduate year 4 travelled from VGH to HCCR Polanco for the initial exchange, followed by a trauma fellow. The surgical case volumes in a month at VGH and a month at HCCR Polanco were compared. At the end of the exchange, a 36-item Likert style questionnaire was administered to the Mexican surgeons and residents who interacted with the Canadian resident and fellow during the exchange. Results: The most commonly performed procedures on the VGH acute care surgery service were laparoscopic cholecystectomy (35%) and laparoscopic appendectomy (17%). The most commonly performed procedures on the VGH trauma service were chest tube insertions (24%) and tracheostomies (24%). The most commonly performed procedures at HCCR Polanco were surgery for penetrating abdominal trauma (19%) and extremity trauma (13%). The survey results indicated that the costs of travel and accommodation were obstacles to future exchanges. All survey respondents wanted to continue collaborating with Canadians on clinical and research endeavours, felt that hosting Canadian residents was a valuable experience and felt that visiting VGH would also be valuable. Conclusion: Canadian surgical trainees gained valuable exposure to operative trauma during the exchange. The mix of operations performed at VGH and HCCR Polanco was vastly different; therefore, the exchange broadened the trainees' surgical experience. There was a unanimously positive response to the exchange among the Mexican survey respondents. This exchange is part of a long-term collaboration between our surgical centres.
Contexte: Notre objectif était d'établir un partenariat pédagogique et un échange clinique durables entre les services de traumatologie de l'Hôpital général de Vancouver (VGH) et de l'hôpital de la Croix-Rouge mexicaine à Mexico (Hospital Central de la Cruz Roja [HCCR] Polanco). Méthodes: En 2017, un résident R4 en chirurgie générale du VGH s'est rendu au HCCR Polanco pour l'échange inaugural; un fellow en traumatologie l'a suivi peu après. Les volumes de cas de chirurgie par mois dans les 2 hôpitaux ont été comparés. À la fin de l'échange, les chirurgiens et les résidents mexicains qui ont interagi avec le résident et le fellow canadiens ont répondu à un questionnaire en 36 points s'apparentant à l'échelle de Likert. Résultats: Les interventions les plus fréquemment effectuées au service chirurgical d'urgence du VGH étaient la cholécystectomie laparoscopique (35 %) et l'appendicectomie laparoscopique (17 %); au service de traumatologie, les plus fréquentes étaient l'insertion d'un drain thoracique (24 %) et la trachéotomie (24 %). Au HCCR Polanco, les interventions chirurgicales les plus courantes étaient la chirurgie pour un traumatisme abdominal pénétrant (19 %) et un traumatisme aux extrémités (13 %). Les résultats du questionnaire suggèrent que les coûts associés aux déplacements et à l'hébergement seraient un obstacle pour les échanges futurs. Cela dit, tous les répondants ont dit vouloir poursuivre leur collaboration avec les Canadiens dans des projets cliniques et de recherche, considérer que l'accueil de résidents canadiens était une expérience profitable et qu'ils gagneraient à se rendre eux-mêmes au VGH. Conclusion: Durant l'échange, les chirurgiens en formation canadiens ont reçu une exposition précieuse à la chirurgie traumatologique. Puisque la nature et la fréquence relative des opérations effectuées au VGH étaient très différentes de celles observées au HCCR Polanco, l'échange a contribué à diversifier l'expérience chirurgicale des apprenants. Tous les répondants mexicains au questionnaire avaient une expérience positive de l'échange. Le programme fait partie d'une collaboration à long terme entre les 2 centres chirurgicaux.
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Cuidados Críticos , Planificación en Desastres , Cirugía General/educación , Intercambio Educacional Internacional , Internado y Residencia , Heridas y Lesiones , Colombia Británica , Canadá , Humanos , México , Cruz Roja , Universidades , Heridas y Lesiones/terapiaRESUMEN
BACKGROUND: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. METHODS: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. RESULTS: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). CONCLUSION: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.
CONTEXTE: La plupart des études sur les services de chirurgie générale d'urgence (CGU) s'intéressent seulement aux atteintes de l'appendice et de la vésicule biliaire. Pourtant, les chirurgiens du domaine traitent beaucoup d'autres problèmes complexes. L'objectif de l'étude était de décrire le travail chirurgical associé à ces problèmes dans l'ensemble du Canada. MÉTHODES: Notre étude de cohorte rétrospective multicentrique inclut les patients adultes (≥ 18 ans) qui ont subi en 2014 une opération non planifiée pour une atteinte qui ne touchait ni l'appendice ni la vésicule biliaire dans 1 des 7 centres sélectionnés, répartis un peu partout au pays. Nous avons recueilli les données suivantes : renseignements de base des patients, diagnostic, détails de l'intervention, nature des complications et durée d'hospitalisation. Puis nous avons dégagé les facteurs prédictifs de morbidité et de mortalité en appliquant un modèle de régression logistique. RÉSULTATS: L'échantillon totalisait 2595 patients, pour un âge médian de 60 ans (écart interquartile 4673 ans). Les diagnostics principaux les plus courants étaient l'occlusion de l'intestin grêle (16 %), la hernie (15 %), la tumeur maligne (11 %) et les lésions périanales (9 %). Les interventions les plus fréquentes étaient la résection de l'intestin (30 %), la réparation d'une hernie (15 %), le débridement (11 %) et le débridement de tissus mous ou cutanés infectés (10 %). L'opération a eu lieu le soir ou la nuit (entre 17 h et 8 h) dans 47 % des cas. Le taux global de mortalité à l'hôpital était de 8 %. Des complications sont survenues chez 33 % des patients, dont les facteurs prédictifs indépendants étaient l'âge avancé (p = 0,001), un score ASA (de l'American Society of Anesthesiologists) élevé (p = 0,02) et le transfert à partir d'un autre centre (p = 0,001). CONCLUSION: Cette étude dresse le profil épidémiologique des interventions effectuées par les services de CGU du Canada en présence d'atteintes autres que celles de l'appendice et de la vésicule biliaire. Les chirurgiens du pays font beaucoup d'interventions générales urgentes, pour traiter des affections associées à un risque élevé de morbidité et de mortalité. Les résultats de l'étude guideront les prochaines recherches et serviront de points de référence en matière d'amélioration de la qualité.
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Tratamiento de Urgencia/estadística & datos numéricos , Cirugía General/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Pautas de la Práctica en Medicina/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Anciano , Benchmarking , Canadá , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tratamiento de Urgencia/efectos adversos , Femenino , Cirugía General/organización & administración , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Pautas de la Práctica en Medicina/organización & administración , Mejoramiento de la Calidad , Estudios Retrospectivos , Procedimientos Quirúrgicos Operativos/efectos adversos , Resultado del TratamientoRESUMEN
This retrospective cohort study evaluates the concordance between Soong grades classified from radiographs and computed tomography (CT) scans and whether a Soong grade ≥1 is associated with flexor pollicis longus (FPL) injury and reoperation incidence. We included 181 patients with 185 dorsally displaced distal radial fractures treated with anterior locking plates. For the analysis of binary Soong grades, grade 0 was compared with grades 1 and 2. A moderate correlation was found between Soong grades on radiographs and CT scans (MCC 0.66). FPL injury occurred in 3% (6/185) and reoperation in 15% (28/185) of cases. There was no statistically significant difference between Soong grades when correlated with the incidence of FPL injury or reoperation, but no patients with a Soong grade 0 had an FPL injury. Binary Soong grading is non-inferior in predictive value and has a better correlation between radiographs and CT scans. Using the Soong classification as a binary system may be easier than a ternary system in clinical practice.Level of evidence: IV.
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BACKGROUND: This research sought to analyze a cohort of patients with extensor pollicis longus (EPL) ruptures after volar locked plating of a distal radius fracture (DRF) to characterize the incidence of ruptures that are unlikely to be related to dorsal screw prominence. METHODS: This is a retrospective, observational, descriptive cohort study of adults with operative fixation of a closed DRF and an EPL rupture between 2002 and 2022. Eighteen patients with operative fixation using a volar plate of a closed DRF had an EPL rupture. The cohort consisted of 66% women with an average age of 57.5 years. Median follow-up was 14.5 months. RESULTS: The incidence of EPL rupture was 0.4% (18/4768). The average time from DRF and DRF fixation to EPL rupture was 3.7 and 3.4 months, respectively. Based on the operative record, in 2 of the 18 patients (11%), the rupture was directly attributable to prominent hardware; however, in 4 of the 18 patients (22%), the rupture was not related to prominent hardware, and the cause was indeterminate in 12 patients (67%). Radiologic analysis of those in the indeterminate group demonstrated that 5 of the 12 patients had screws that had a high probability of being prominent. CONCLUSIONS: The incidence of EPL rupture after volar plating of DRF is between 0% and 1% and usually occurs about 3 months after fixation. Approximately 50% of EPL ruptures are attributable to prominent dorsal screws. Although screw prominence is an important cause of EPL rupture, it is not the sole cause of rupture.
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BACKGROUND: We assessed factors associated with change in radiographic teardrop angle following volar locking plate (VLP) fixation of volarly displaced intra-articular distal radius fractures with volar ulnar fragments (VUF) within the ICUC database. The primary outcome was change in radiographic alignment on follow-up imaging, defined as a change in teardrop angle from intra-operative fluoroscopy greater than 5°. METHODS: Patients with distal radius fractures treated with a VLP within the ICUC database, an international collaborative and publicly available dataset, were identified. The primary outcome was volar rim loss of reduction on follow-up imaging, defined as a change in radiographic alignment from intra-operative fluoroscopy, teardrop angle less than 50°, or loss of normal radiocarpal alignment. Secondary outcomes were final range of motion (ROM) of the affected extremity. Radiographic Soong classification was used to grade plate position. Descriptive statistics were used to assess variables' distributions. A Random Forest supervised machine learning algorithm was used to classify variable importance for predicting the primary outcome. Traditional descriptive statistics were used to compare patient, fracture, and treatment characteristics with volar rim loss of reduction. Volar rim loss of reduction and final ROM in degrees and as compared with contralateral unaffected limb were also assessed. RESULTS: Fifty patients with volarly displaced, intra-articular distal radius fractures treated with a VLP were identified. Six patients were observed to have a volar rim loss of reduction, but none required reoperation. Volar ulnar fragment size, Soong grade 0, and postfixation axial plate position in relation to the sigmoid notch were significantly associated (P < .05) with volar rim loss of reduction. All cases of volar rim loss of reduction occurred when VUF was 10.8 mm or less. CONCLUSIONS: The size of the VUF was the most important variable for predicting volar rim loss of reduction followed by postfixation plate position in an axial position to the sigmoid notch and the number of volar fragments in the Random Forest machine learning algorithm. There were no significant differences in ROM between patients with volar ulnar escape and those without.
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Purpose: This retrospective study aimed to validate the ACS NSQIP Surgical Risk Calculator (SCR) to predict 30-day postoperative outcomes in patients with one of the following subacute orthopedic trauma diagnoses; multiple rib fractures, pelvic ring/acetabular fracture, or unilateral femoral fracture. Methods: Data of patients with these diagnoses treated between January 1, 2015 and September 19, 2020 were extracted from the patients' medical files. Diagnostic performance, discrimination, calibration, and accuracy of the ACS NSQIP SRC to predict specific outcomes developing within 30 days after surgery was determined. Results: The total cohort of the three diagnoses consisted of 435 patients. ACS NSQIP SRC underestimated the risk for serious complications, especially in patients with multiple rib fractures (8.3% predicted vs 17.2% observed) or pelvic ring/acetabular fracture (6.1% vs 19.8%). Underestimation was more pronounced for the composite outcome 'any complication'. Sensitivity ranged from 16.7% to 100% and specificity from 41.1% to 97.1%. Specificity exceeded sensitivity for pelvic ring/acetabular and femoral fractures. Discrimination was good for predicting death (femoral fracture), fair for readmission (femoral fracture), serious complication (multiple rib fractures), and any complication (multiple rib fractures), but poor in all other outcomes and diagnoses. Calibration and accuracy were adequate for all three diagnoses (p-value for Hosmer-Lemeshow test >0.05 and Brier scores <0.25). Conclusion: Performance of the ACS NSQIP SRC in the studied cohort was variable for all three diagnoses. Although it underestimated the risk of most outcomes, calibration and accuracy seemed generally adequate. For most outcomes, adequate diagnostic performance and discrimination could not be confirmed.
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BACKGROUND: Unstable fractures of the distal radius fractures (DRFs) may result in malunion, usually consisting of subsequent shortening and angular deviations. Ulnar shortening osteotomy (USO) is assumed to be a simpler procedure than radial correction osteotomy, resulting in fewer complications and comparable outcomes. The aim of this study was to identify the best surgical technique to perform USO to restore distal radioulnar joint congruency after DRF malunion. METHODS: A systematic review of the literature is performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in February 2022 to identify studies reporting outcomes and surgical technique for isolated USO. The primary outcome was complication rates. Secondary outcomes included functional, radiologic, and patient-rated outcomes. The methodological index for nonrandomized studies criteria were used to assess the quality of evidence. RESULTS: Included were 12 cohorts (185 participants). Due to substantial heterogeneity, a meta-analysis could not be performed. The overall complication rate was 33% (95% confidence interval, 16% to 51%). The most reported complication was implant irritation (22%), often requiring removal of the implant (13%). Only 3% nonunions were mentioned. Functional and patient-rated outcomes improved in most patients after USO. Quality of evidence of the papers was low to very low. Common methodological flaws were related to retrospective research. CONCLUSION: No evident differences in complication rates and functional outcomes between the surgical techniques were observed. Based on this literature, most complications are related to implant irritation. Nonunion and infection rates were rare. Therefore, a surgical technique with a buried implant might be preferred. This hypothesis requires further investigation.