Outcomes of isolated medial tibial plateau fractures by fracture morphology.

PURPOSE: To identify a cohort of isolated medial tibial plateau fractures treated with surgical fixation and to categorize them by Moore and Wahlquist classifications in order to determine the rate of complications with each fracture morphology and the predictive value of each classification system. We hypothesized there would be high rates of neurovascular injury, compartment syndrome, and complications overall with a higher incidence of neurovascular injury in Moore type III rim avulsion fractures and Wahlquist type C fractures that enter the plateau lateral to the tibial spines. METHODS: Patients who presented to six Level I trauma centers between 2010 and 2021 who underwent surgical fixation for isolated medial tibial plateau fractures were retrospectively reviewed. Data including demographics, radiographs, complications, and functional outcomes were collected. RESULTS: One hundred and fifty isolated medial tibial plateau fractures were included. All patients were classified by the Wahlquist classification of medial tibial plateau fractures, and 139 patients were classifiable by the Moore classification of tibial plateau fracture-dislocations. Nine percent of fractures presented with neurovascular injury: 5 % with isolated vascular injury and 6 % with isolated nerve injury. There were no significant differences in neurovascular injury by fracture type (Wahlquist p = 0.16, Moore p = 0.33). Compartment syndrome developed in two patients (1.3 %). The average final range of motion was 0.8-122° with no difference by Wahlquist or Moore classifications (p = 0.11, p = 0.52). The overall complication rate was 32 % without differences by fracture morphology. The overall rate of return to the operating room (OR) was 25 %. CONCLUSIONS: Isolated medial tibial plateau fractures often represent fracture-dislocations of the knee and should receive a meticulous neurovascular exam on presentation with a high suspicion for neurovascular injury. No specific fracture pattern was found to be predictive of neurovascular injuries, complications, or final knee range of motion. Patients should be counseled pre-operatively regarding high rates of return to the OR after the index surgery.

Anterior internal versus external fixation of unstable pelvis fractures was not associated with discharge destination, critical care, length of stay, or hospital charges.

PURPOSE: Determine if anterior internal versus supra-acetabular external fixation of unstable pelvic fractures is associated with care needs or discharge. METHODS: A retrospective cohort study was performed at two tertiary trauma referral centers. Adults with unstable pelvis fractures (AO/OTA 61B/61C) who received operative fixation of the anterior and posterior pelvic ring by two orthopedic trauma surgeons from October 2020 to November 2022 were included. The primary outcome was discharge destination. Secondary outcomes included intensive care unit (ICU) or ventilator days, length of stay, and hospital charges. RESULTS: Eighty-three eligible patients were 38.6% female, with a mean age of 47.2 ± 20.3 years and BMI 28.1 ± 6.4 kg/m2. Fifty-nine patients (71.1%) received anterior pelvis internal fixation and 24 (28.9%) received external fixation. External fixation was associated with weight-bearing restrictions (91.7% versus 49.2%, p = 0.01). No differences in demographic, functional status, insurance type, fracture classification, or injury severity measures were observed by treatment. Internal versus external anterior pelvic fixation was not associated with discharge to home (49.2% versus 29.2%, p = 0.10), median ICU days (3.0 [interquartile range (IQR) 7.8 versus 5.5 [IQR 4.3], p = 0.14, ventilator days (0 [IQR 6.0] versus 0 [IQR 2.8], p = 0.51), length of stay (13.0 [IQR 13.0] versus 17.5 (IQR 20.5), p = 0.38), or total hospital charges (US dollars 180,311 [IQR 219,061.75] versus 243,622 [IQR 187,111], p = 0.14). CONCLUSIONS: Anterior internal versus supra-acetabular external fixation of unstable pelvis fractures was not significantly associated with discharge destination, critical care, hospital length of stay, or hospital charges. This sample may be underpowered to detect differences between groups. LEVEL OF EVIDENCE: Therapeutic Level IV.

True "outpatient discharge" following single-stage bilateral unicompartmental knee arthroplasty may be unrealistic for most.

BACKGROUND: Single-stage bilateral unicompartmental knee arthroplasty (BUKA) has shown post-operative function and cost benefits over staged bilateral procedures, without increased complications. A rapid discharge protocol at the current study site has reported outpatient discharge for the unilateral procedure exceeding 97%. However, the feasibility of outpatient discharge following BUKA remains unclear. Therefore, the purpose of this study was to determine the success of achieving outpatient (< 24 h) discharge following BUKA, and identify patient variables associated with failure. METHODS: A retrospective chart review was completed for 104 BUKA patients. All patients with bilateral, symptomatic unicompartmental knee arthritis were offered the single-stage procedure. Data collection included patient demographics, discharge status, and disposition location. Independent t tests (continuous) and Chi-squared tests (categorical) determined differences between discharge (outpatient/inpatient) and disposition (home/other) groups. Variables associated with discharge status and location were assessed with multivariable regression. RESULTS: While 96 (92.3%) patients discharged within 24 h, only 63.5% were able to discharge directly home. Patients requiring a longer hospital stay (> 24 h) were more likely to require a pre-operative assistive device (62.5% and 25.0%, p = 0.037) and live alone (37.5 vs 8.3%, p = 0.033). For those discharged within 24 h, living alone significantly increased the risk (odds ratio: 5.800, p = 0.038) of requiring an acute inpatient facility prior to transition home. CONCLUSION: Achieving "true" outpatient discharge is only modestly successful for most BUKA patients, as many required an acute inpatient or short-term rehabilitation facility prior to returning home. BUKA should be differentiated from the unilateral procedure regarding outpatient discharge expectations. LEVEL OF EVIDENCE: III, Case-control study; Retrospective comparative study.

Medical student medium-term skill retention following cardiac point-of-care ultrasound training based on the American Society of Echocardiography curriculum framework.

BACKGROUND: No studies have demonstrated medium- or long-term skill retention of cardiac point-of-care ultrasound (POCUS) curriculum for medical student. Based on the American Society of Echocardiography (ASE) curriculum framework, we developed a blended-learning cardiac POCUS curriculum with competency evaluation. The objective of this study was to investigate the curriculum impact on image acquisition skill retention 8 weeks after initial training. METHODS: This study was a prospective, pre-post education intervention study for first- and second-year medical students, with blinded outcome assessment. The curriculum included a pre-training ASE online module and healthy volunteer hands-on training to obtain 5 views: parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical 4-chamber (A4C), subcostal 4-chamber (S4C), and subcostal inferior vena cava (SIVC) views. Students took 5-view image acquisition skill tests at pre-, immediate post-, and 8-week post-training, using a healthy volunteer. Three blinded assessors rated the image quality using a validated 10-point maximum scoring system. Students used a hand-held ultrasound probe (Butterfly iQ). RESULTS: Fifty-four students completed hands-on training, and pre- and immediate post-training skill tests. Twenty-seven students completed 8-week post-training skill tests. Skill test score improvement between pre- and 8-week post-training was 2.11 points (95% CI, 1.22-3.00; effect size, 1.13). CONCLUSION: The cardiac POCUS curriculum demonstrated medium-term skill retention. The curriculum was sufficient for S4C and SIVC skill retention, but inadequate for PLAX, PSAX, and A4C. Therefore, instructional design modifications or re-training for PLAX, PSAX, and A4C are needed to make the curriculum more effective for clinically relevant skill retention.

Pre-clinical medical student cardiac point-of-care ultrasound curriculum based on the American Society of Echocardiography recommendations: a pilot and feasibility study.

BACKGROUND: Cardiac point-of-care ultrasound (POCUS) training has been integrated into medical school curricula. However, there is no standardized cardiac POCUS training method for medical students. To address this issue, the American Society of Echocardiography (ASE) proposed a framework for medical student cardiac POCUS training. The objective of this pilot study was to develop a medical student cardiac POCUS curriculum with test scoring systems and test the curriculum feasibility for a future definitive study. METHODS: Based on the ASE-recommended framework, we developed a cardiac POCUS curriculum consisting of a pre-training online module and hands-on training with a hand-held ultrasound (Butterfly iQ, Butterfly Network Inc., Guilford, CT, USA). The curriculum learning effects were assessed with a 10-point maximum skill test and a 40-point maximum knowledge test at pre-, immediate post-, and 8-week post-training. To determine the curriculum feasibility, we planned to recruit 6 pre-clinical medical students. We semi-quantitatively evaluated the curriculum feasibility in terms of recruitment rate, follow-up rate 8 weeks after training, instructional design of the curriculum, the effect size (ES) of the test score improvements, and participant satisfaction. To gather validity evidence of the skill test, interrater and test-retest reliability of 3 blinded raters were assessed. RESULTS: Six pre-clinical medical students participated in the curriculum. The recruitment rate was 100% (6/6 students) and the follow-up rate 8 weeks after training was 100% (6/6). ESs of skill and knowledge test score differences between pre- and immediate post-, and between pre- and 8-week post-training were large. The students reported high satisfaction with the curriculum. Both interrater and test-retest reliability of the skill test were excellent. CONCLUSIONS: This pilot study confirmed the curriculum design as feasible with instructional design modifications including the hands-on training group size, content of the cardiac POCUS lecture, hands-on teaching instructions, and hand-held ultrasound usage. Based on the pilot study findings, we plan to conduct the definitive study with the primary outcome of long-term skill retention 8 weeks after initial training. The definitive study has been registered in ClinicalTrials.gov (Identifier: NCT04083924).

Comparison of early post-operative complications following unilateral or single-stage bilateral unicompartmental knee arthroplasty.

BACKGROUND: Unicompartmental knee arthroplasty (UKA) demonstrates excellent functional outcomes and patient satisfaction with low complication rates for single compartment knee arthritis. For patients with bilateral symptoms, single-stage bilateral UKA (SSBUKA) provides an alternative to staged procedures but may risk increased blood loss and systemic complications. Therefore, the purpose of this study is to compare 90-day postoperative complications between unilateral UKA and SSBUKA without exclusion for comorbidities. METHODS: A retrospective review was completed for 555 consecutive patients having undergone UKA (317 unilateral and 238 bilateral). Data collection included patient demographics and 90-day complications. Independent t-tests (continuous) and Fishers' Exact tests (nominal) were performed to determine differences between unilateral UKA and SSBUKA patients. RESULTS: The SSBUKA group had more male patients than the unilateral group (51.3% and 43.8%, respectively). There was no difference in age, body mass index or comorbidity classification. More SSBUKA patients experienced nausea than unilateral patients (17.6% and 11.0%), however, no significant differences were observed in the overall incidence of wound or systemic complications, and no transfusions were required. Significantly more unilateral patients (96.2%) were discharged home compared to SSBUKA (63.0%) (p < 0.001). Two SSBUKA (1.7%) and two unilateral UKA (0.6%) patients required readmission within 90-days with systemic complications. CONCLUSIONS: SSBUKA did not increase the risk of early postoperative systemic or wound complications, when performed in all patients with symptomatic disease without exclusion criteria as compared to patients undergoing unilateral UKA. Therefore, SSBUKA can safely be performed on the majority of patients who present to experienced high volume community hospitals.