Continuous Compartment Pressure Monitoring Allows the Early Detection of Compartment Syndrome After Arterial Revascularization.

Compartment syndrome (CS) occurs in several clinical scenarios. Reperfusion injury and tissue swelling are common causes. This can occur after trauma but also is seen post revascularization of extremities. CS is a difficult diagnosis to make in a timely fashion that avoids permanent tissue damage. The treatment for CS is immediate fasciotomy, but fasciotomy is not a complication-free procedure. Previous care pathways usually resulted in fasciotomy being performed in a disproportionate number of normal legs. These false positives and prophylactic releases are costly to the health system because of protracted hospital stays and increased surgery numbers. The desirable tool for surgeons would be one that decreases false positives and negatives while ensuring a diagnosis in a timely fashion with true positives. A new technology that allows continuous pressure monitoring seems to be the best aid to make a diagnosis. We present our experience in decreasing the time to diagnosis in a CS case post revascularization despite the neurological blockade.

Predictors of Episode-of-Care Costs for Ankle Fractures.

Ankle fractures are one of the most resource-consuming traumatic orthopedic injuries. Few studies have successfully evaluated the episode-of-care costs (EOCC) of common traumatic orthopedic injuries. The objective of this study was to determine the EOCC associated with the surgical management of ankle fractures. A retrospective cohort study of 105 consecutive patients who underwent open reduction internal fixation of an isolated ankle fracture at a Canadian Level-1 trauma center was conducted. Episode-of-care costs were generated using an activity-based costing framework. The median global episode-of-care cost for ankle fracture surgeries performed at the studied institution was $3,487 CAD [IQR 880] ($2,685 USD [IQR 616]). Patients aged 60 to 90 years had a significantly higher median EOCC than younger patients (p = .01). Supination-adduction injuries had a significantly higher median EOCC than other injury patterns (p = .01). The median EOCC for patients who underwent surgery within 10 days of their injury ($3,347 CAD [582], $2,577 USD [448]) was significantly lower than the cost for patients who had their surgery delayed 10 days or more after the injury ($3,634 CAD [776], $2,798 USD [598]) (p = .03). Patient sex, anesthesia type, ASA score and surgeon's fellowship training did not affect the EOCC. This study provides valuable data on predictors of EOCC in the surgical management of ankle fractures. Delaying simple ankle fracture cases due to operating time constraints can increase the total cost and burden of these fractures on the healthcare system. In addition, this study provides a framework for future episode-of-care cost analysis studies in orthopedic surgery.

Hospital episode-of-care costs for hip fractures: an activity-based costing analysis.

Background: Despite the large impact of hip fracture care on hospital budgets, accurate episode-of-care costs (EOCC) calculations for this injury remains a challenge. The objective of this article was to assess EOCC for geriatric patients with hip fractures using an activity-based costing methodology and identify intraoperative, perioperative, and patient-specific factors associated with higher EOCC. Material and Methods: This is a retrospective cohort study involving a total of 109 consecutive patients with hip fracture treated surgically at a Canadian level-1 trauma center from April 2018 to February 2019. Clinical and demographic data were extracted through the institution's centralized data warehouse. Data acquisition also included direct and indirect costs per episode of care, adverse events, and precise temporal data. Results: The median total EOCC was $13,113 (interquartile range 6658), excluding physician fees. Out of the total cost, 75% was attributed to direct costs, which represented a median expenditure of $9941. The median indirect cost of the EOCC was $3322. Based on the multivariate analysis, patients not operated within the 48 hours guidelines had an increased length of stay by 5.7 days (P = 0.003), representing an increase in EOCC of close to 5000$. Higher American Society of Anesthesiology (ASA) scores were associated with elevated EOCC. Conclusion: The cost of managing a patient with geriatric hip fracture from arrival in the emergency department to discharge from surgical ward represented $13,113. Main factors influencing the EOCC included adherence to the 48-hour benchmark surgical delay and ASA score. High-quality costing data are vital in assessing health care spending, conducting cost effectiveness analyses, and ultimately in guiding policy decisions. Level of Evidence: Level III (3), retrospective cohort study.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

OBJECTIVE: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

Diagnosis Accuracy for Compartment Syndrome: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate whether published studies support basing the diagnosis of compartment syndrome of the lower leg on clinical findings, intracompartmental pressure (ICP) monitoring, or both. DATA SOURCES: A PubMed/MEDLINE, Web of Science, and Embase search of the English literature from 1966 to February 2022 was performed. This used "lower extremity" or "leg" or "tibia" and "compartment syndrome" and "pressure" as the subjects. A manual search of the bibliographies was performed and cross-referenced with those used to formulate the American Academy of Orthopaedic Surgeons clinical practice guidelines. STUDY SELECTION AND EXTRACTION: Inclusion criteria were traumatic tibia injuries, presence of data to calculate the sensitivity, specificity, positive and negative predictive values of clinical findings and/or pressure monitoring, and the presence or absence of compartment syndrome as the outcome. A total of 2906 full articles were found, of which 63 were deemed relevant for a detailed review. Seven studies met all eligibility criteria. DATA SYNTHESIS: The likelihood ratio form of Bayes theorem was used to assess the discriminatory ability of the clinical findings and ICP monitoring as tests for compartment syndrome. The predictive value for diagnosing acute compartment syndrome was 21% and 29% for the clinical signs and ICP, respectively. When combining both, the probability reached 68%. CONCLUSIONS: The use of ICP monitoring may be helpful when combined with a clinical assessment to increase the sensitivity and specificity of the overall diagnosis. Previously accepted individual inference values should be revisited with new prospective studies to further characterize the statistical value of each clinical finding. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Foot Acute Compartment Syndrome: Big Data analysis.

Acute compartment syndrome (ACS) in the foot is a challenging diagnosis and can lead to significant disabilities to patients. The present study aims to investigate the incidence, risk factors, demographics and association in the analysis of acute compartment syndrome (ACS) of the foot. We performed a retrospective review of the Trauma Quality Programs data from the American College of Surgeons including 70,525 patients who sustained a fracture of the foot from 2015 to 2018 (4 calendar years). Fasciotomies were performed in 0.7% of all foot fractures. Open fractures, crush injuries and multiple foot fractures were the strongest predictors of fasciotomies, with odds ratios of 2.38, 2.38 and 2.33 respectively. Being a male was associated with an increased likelihood of fasciotomies of 64% (p < .0001 O.R. = [1.42-1.90]), while a dislocation in the foot increased likelihood of fasciotomies by 48% (p = .0008 O.R. = [1.18-1.86]). Trauma centre level III had higher rate of fasciotomy than Tertiary Trauma centers. Multiple other factors were addressed while controlling for cofounders. This big data analysis provided information not previously reported on the risk factors, demographics, and clinical association of ACS in the foot.

Porcine Model of Acute Compartment Syndrome.

OBJECTIVES: Acute compartment syndrome is a devastating condition associated with lasting consequences or even death if not treated in a timely fashion. Current preclinical modeling is inadequate. Ideally a model should mimic human disease. There should be a trauma-induced reperfusion or direct muscle event that causes gradual increased pressure and is amenable to release with fasciotomy. We have attempted to reproduce this mechanism and outcome in a porcine model. METHODS: Anterior tibial musculature was injured with vascular occlusion plus exterior tourniquet crush or direct intracompartmental crush through balloon inflation. The injury was maintained for over 5 hours. At that time, the tourniquet or balloon was removed. The injuries were continuously monitored with an intramuscular continuous pressure sensor. Pressure changes were recorded and after 2 hours of postinjury observation, a fasciotomy was performed for the muscle compartment. RESULTS: Pressures were brought to 100 mm Hg during the injury phase. During the two-hour observation period, the balloon catheter technique achieved an average pressure of 25.1 ± SD 8.8 mm Hg with a maximum reading of 38.2 mm Hg and minimum reading of 14.1 mm Hg. During this same period, the ischemia-reperfusion + direct crush technique achieved an average pressure of 33.7 ± SD 7.3 mm Hg, with a maximum reading of 43.5 mm Hg and minimum reading of 23.5 mm Hg. Average pressure postfasciotomy for the balloon catheter technique was 2.4 ± SD 2.5 mm Hg; and for the crush technique, average value postfasciotomy was 4.9 ± SD 3.7 mm Hg-both representing a return to physiologic levels. CONCLUSION: This is the first preclinical model that shows the same response to injury and treatment as is observed in human physiology. Surgical and nonsurgical therapies for compartment syndrome can now be tested reliably.

Zincon-Modified CNTs Electrochemical Tool for Salivary and Urinary Zinc Detection.

Recently, the abnormal level of zinc emerged as a powerful indicator or risk factor for metabolic, endocrine, neurodegenerative and cardiovascular diseases, including cancer. Electrochemical detection has been explored to quantify zinc in a precise, rapid, and non-expensive way; however, most of the current electrochemical systems lack in specificity. In this work we studied a highly selective and sensitive electrochemical method to detect quickly and reliably free zinc ions (Zn2+). The surface of the working electrode was modified with zincon electropolymerized on carbon nanotube (CNT) to enable the binding of zinc in complex body fluids. After being physicochemically characterized, the performances of the zincon-CNT complex was electrochemically assessed. Square Wave Voltammetry (SWV) was used to determine the calibration curve and the linear range of zinc quantification in artificial saliva and urine. This zincon- CNT system could specifically quantify mobile Zn2+ in salivary and urinary matrices with a sensitivity of ~100 ng·mL-1 and a limit of detection (LOD) of ~20 ng·mL-1. Zincon-modified CNT presented as a desirable candidate for the detection and quantification of free zinc in easily body fluids that potentially can become a diagnostic non-invasive testing platform.