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1.
Ann R Coll Surg Engl ; 103(4): 302-307, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33682433

RESUMO

INTRODUCTION: The epidemiology of acute paediatric orthopaedic trauma managed surgically across the NHS is poorly described. Compliance against national standards for the management of supracondylar humeral fractures is also unknown at a national level. METHODS: Collaborators in 129 NHS hospitals prospectively collected data on surgically managed acute paediatric orthopaedic trauma cases. Data were collected over a seven-day period and included demographics, injury characteristics, operative details and timing of surgery. A national audit was also undertaken to evaluate compliance with the British Orthopaedic Association Standards for Trauma Guideline 11: Supracondylar Fractures of the Humerus in Children. RESULTS: Data were captured on 770 surgically treated cases. The three most common injuries were forearm fractures of both bones (n = 235), distal radius fractures (n = 194) and supracondylar elbow fractures (n = 89). The mode day of injury was Friday (n = 136) and the mode day of surgery was Saturday (n = 138). 88% of supracondylar fractures received surgery on the day of presentation or the following day. Only 14% of supracondylar fractures were treated surgically after 8pm; 33/89 used 2.0mm Kirschner wires, 38/89 used 1.6mm wires and 2/89 used 1.2mm wires. CONCLUSION: Forearm fractures of both bones, distal radius fractures and supracondylar humeral fractures were the three most common injuries treated surgically. There is wide variation in compliance against national standards in the management of supracondylar humeral fractures with 88% undertaking surgery on the day of or the day following presentation but only 37% using the recommended 2.0mm Kirschner wires.


Assuntos
Fixação de Fratura/métodos , Fidelidade a Diretrizes/estatística & dados numéricos , Fraturas do Úmero/epidemiologia , Fraturas do Úmero/cirurgia , Padrões de Prática Médica/estatística & dados numéricos , Fraturas do Rádio/epidemiologia , Fraturas do Rádio/cirurgia , Adolescente , Criança , Pré-Escolar , Estudos Transversais , Feminino , Fixação de Fratura/estatística & dados numéricos , Humanos , Incidência , Masculino , Auditoria Médica , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Medicina Estatal , Reino Unido/epidemiologia
2.
Bone Joint J ; 103-B(2): 264-270, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33517718

RESUMO

AIMS: Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients. METHODS: This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions. RESULTS: Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75th percentile) proportion of recent surgical admission compared to a low (25th percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4). CONCLUSION: A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264-270.


Assuntos
Fixação de Fratura/estatística & dados numéricos , Recursos em Saúde/provisão & distribução , Fraturas do Quadril/cirurgia , Hospitalização/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Fraturas do Quadril/mortalidade , Humanos , Masculino , Noruega/epidemiologia , Resultado do Tratamento
3.
J Pediatr Orthop ; 40(6): 267-270, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32501905

RESUMO

BACKGROUND: Medial epicondyle fractures represent up to 20% of elbow fractures in children and adolescents. There is a growing body of literature to support surgical fixation for displaced fractures. However, controversy regarding imaging modality for displacement measurement and surgical indications remain controversial. The purpose of this survey was to gauge Latin American surgeons' practices and preferences for the evaluation and treatment of medial epicondyle fractures. METHODS: A web-based survey containing 19 questions was distributed to active members of SLAOTI (Sociedad Latinoamericana de Ortopedia y Traumatología Infantil) in November 2018. The survey elicited information regarding surgeon demographics, evaluation methods, the factors involved in the decision to perform surgery, and their experience in cases of symptomatic nonunion. Categorical variables were summarized using frequencies and proportions. Analysis of associations between surgeon demographics and treatment preferences were carried out. RESULTS: A total of 193 out of 354 completed questionnaires were returned (54% response rate). In total, 74% of the participants (142/193) favored radiographs for the evaluation of the fracture displacement, and 25.4% (49/193) added a computed tomography scan for a more detailed evaluation. The majority of respondents (48.2%) would consider a 5 mm displacement as the cutoff for surgical treatment, 21.8% 2 mm, 20.7% 10 mm, and 9.3% 15 mm. There were no differences between the experience of the participants, academic versus private setting, or training regarding surgical/nonsurgical management. CONCLUSIONS: There are significant differences in opinions between SLAOTI members as to the optimal management of medial epicondyle fractures. Implications of disagreement in evaluation and treatment support the need for multicenter prospective studies to develop evidence-based guidelines for the management of this fracture. LEVEL OF EVIDENCE: Level V-expert opinion. Cross-sectional electronic survey.


Assuntos
Articulação do Cotovelo , Fratura-Luxação , Fixação de Fratura , Radiografia/métodos , Tomografia Computadorizada por Raios X/métodos , Criança , Articulação do Cotovelo/diagnóstico por imagem , Articulação do Cotovelo/lesões , Articulação do Cotovelo/cirurgia , Fratura-Luxação/diagnóstico , Fratura-Luxação/cirurgia , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Humanos , América Latina , Padrões de Prática Médica/estatística & dados numéricos , Inquéritos e Questionários
4.
J Surg Res ; 252: 183-191, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32278973

RESUMO

BACKGROUND: Timing of surgical treatment of facial fractures may vary with the patient age, injury type, and presence of polytrauma. Previous studies using national data sets have suggested that trauma patients with government insurance experience fewer operations, longer length of hospital stay (LOS), and worse outcomes compared with privately insured patients. The objective of this study is to compare treatment of facial fractures in patients with and without Medicaid insurance (excluding Medicare). METHODS: All adults with mandibular, orbital, and midface fractures at a Level 1 Trauma Center between 2009 and 2018 were included. Statistical analyses were performed to assess the differences in the frequency of surgery, time to surgery (TTS), LOS, and mortality based on insurance type. RESULTS: The sample included 1541 patients with facial fractures (mandible, midface, orbital), of whom 78.8% were male, and 13.1% (208) were enrolled in Medicaid. Mechanism of injury was predominantly assault for Medicaid enrollees and falls or motor vehicle accidents for non-Medicaid enrollees (P < 0.001). Patients with mandible and midface fractures underwent similar rates of surgical repair. Medicaid enrollees with orbital fractures underwent less frequent surgery for facial fractures (24.8% versus 34.7%, P = 0.0443) and had higher rates of alcohol and drug intoxication compared with non-Medicaid enrollees (42.8% versus 31.6%, P = 0.008). TTS, LOS, and mortality were similar in both groups with facial fractures. CONCLUSIONS: Overall, the treatment of facial fractures was similar regardless of the insurance type, but Medicaid enrollees with orbital fractures experienced less frequent surgery for facial fractures. Further studies are needed to identify specific socioeconomic and geographic factors contributing to these disparities in care.


Assuntos
Fixação de Fratura/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Fraturas Orbitárias/cirurgia , Centros de Traumatologia/estatística & dados numéricos , Adulto , Intoxicação Alcoólica/epidemiologia , Comorbidade , Feminino , Fixação de Fratura/economia , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Fraturas Orbitárias/economia , Fraturas Orbitárias/mortalidade , Estudos Retrospectivos , Tempo para o Tratamento/economia , Tempo para o Tratamento/estatística & dados numéricos , Centros de Traumatologia/economia , Estados Unidos
5.
Ann R Coll Surg Engl ; 102(5): 348-354, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32233845

RESUMO

INTRODUCTION: Predicting when fracture incidence will rise assists in healthcare planning and delivery of preventative strategies. The aim of this study was to investigate the relationship between temperature and the incidence of hip and wrist fractures. METHODS: Data for adults presenting to our unit with a hip or wrist fracture over a seven and eight-year period respectively were analysed. Incidence rates were calculated and compared with meteorological records. A Poisson regression model was used to quantify the relationship between temperature and fracture rate. RESULTS: During the respective study periods, 8,380 patients presented with wrist fractures and 5,279 patients were admitted with hip fractures. All women (≥50 years: p<0.001; <50 years: p<0.001) and men aged ≥50 years (p=0.046) demonstrated an increased wrist fracture rate with reduced temperature. Men aged <50 years also had an increased wrist fracture rate with increased temperature (p<0.001).The hip fracture rate was highest in women aged ≥50 years but was not associated with temperature (p=0.22). In men aged ≥50 years, there was a significant relationship between reduced temperature and increased fracture rate (p<0.001). CONCLUSIONS: Fragility fracture of the wrist is associated with temperature. Compared with an average summer, an additional 840 procedures are performed for wrist fractures during an average winter in our trust with an additional 798 bed days taken up at a cost of £3.2 million. The winter increase seen in male hip fracture incidence requires approximately 888 surgical procedures, with 18,026 bed days, and costs £7.1 million. Hip fracture incidence in older women is not related to temperature.


Assuntos
Temperatura Baixa/efeitos adversos , Fraturas do Quadril/epidemiologia , Temperatura Alta/efeitos adversos , Fraturas por Osteoporose/epidemiologia , Fraturas do Rádio/epidemiologia , Traumatismos do Punho/epidemiologia , Acidentes por Quedas/prevenção & controle , Acidentes por Quedas/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fixação de Fratura/estatística & dados numéricos , Fraturas do Quadril/cirurgia , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fraturas por Osteoporose/cirurgia , Estudos Prospectivos , Fraturas do Rádio/cirurgia , Fatores de Risco , Estações do Ano , Fatores Sexuais , Traumatismos do Punho/cirurgia , Adulto Jovem
6.
Medicine (Baltimore) ; 99(9): e19328, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32118764

RESUMO

We assessed factors associated with premature physeal closure (PPC) and outcomes after closed reduction of Salter-Harris type II (SH-II) fractures of the distal tibia. We reviewed patients with SH-II fractures of the distal tibia treated at our center from 2010 to 2015 with closed reduction and a non-weightbearing long-leg cast. Patients were categorized by immediate postreduction displacement: minimal, <2 mm; moderate, 2 to 4 mm; or severe, >4 mm. Demographic data, radiographic data, and Lower Extremity Functional Scale (LEFS) scores were recorded.Fifty-nine patients (27 girls, 31 right ankles, 26 concomitant fibula fractures) were included, with a mean (±SD) age at injury of 12.0 ±â€Š2.2 years. Mean maximum fracture displacements were 6.6 ±â€Š6.5 mm initially, 2.7 ±â€Š2.0 mm postreduction, and 0.4 ±â€Š0.7 mm at final follow-up. After reduction, displacement was minimal in 23 patients, moderate in 21, and severe in 15. Fourteen patients developed PPC, with no significant differences between postreduction displacement groups. Patients with high-grade injury mechanisms and/or initial displacement ≥4 mm had 12-fold and 14-fold greater odds, respectively, of PPC. Eighteen patients responded to the LEFS survey (mean 4.0 ±â€Š2.1 years after injury). LEFS scores did not differ significantly between postreduction displacement groups (P = .61).The PPC rate in this series of SH-II distal tibia fractures was 24% and did not differ by postreduction displacement. Initial fracture displacement and high-grade mechanisms of injury were associated with PPC. LEFS scores did not differ significantly by postreduction displacement.Level of Evidence: Level IV, case series.


Assuntos
Fixação de Fratura/normas , Fraturas Salter-Harris/terapia , Adolescente , Criança , Feminino , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Tíbia/anatomia & histologia , Tíbia/lesões , Tíbia/fisiopatologia , Resultado do Tratamento
7.
Bone Joint J ; 102-B(1): 33-41, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31888365

RESUMO

AIMS: The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures. METHODS: A total of 250 patients presenting within three weeks of sustaining a displaced proximal humeral fracture involving the surgical neck were recruited at 32 acute NHS hospitals in the United Kingdom between September 2008 and April 2011. Of the 125 participants, 109 received surgery (fracture fixation or humeral head replacement) as per randomization. Data were included for 101 and 67 participants at six-month and five-year follow-up, respectively. Oxford Shoulder Scores (OSS) collected at six, 12, and 24 months and at three, four, and five years following randomization was plotted against time to surgery. Long-term recovery was explored by plotting six-month scores against five-year scores and agreement was illustrated with a Bland-Altman plot. RESULTS: The mean time from initial trauma to surgery was 10.5 days (1 to 33). Earlier surgical intervention did not improve OSS throughout follow-up, nor when stratified by participant age (< 65 years vs ≥ 65 years) and fracture severity (one- and two-part vs three- and four-part fractures). Participants managed later than reported international averages (three days in the United States and Germany, eight days in the United Kingdom) did not have worse outcomes. At five-year follow-up, 50 participants (76%) had the same or improved OSS compared with six months (six-month mean OSS 35.8 (SD 10.0); five-year mean OSS 40.1 (SD 9.1); r = 0.613). A Bland-Altman plot demonstrated a positive mean difference (3.3 OSS points (SD 7.92)) with wide 95% limits of agreement (-12.2 and 18.8 points). CONCLUSION: Timing of surgery did not affect OSS at any stage of follow-up, irrespective of age or fracture type. Most participants had maximum functional outcome at six months that was maintained at five years. These findings may help guide providers of trauma services on surgical prioritization. Cite this article: Bone Joint J 2020;102-B(1):33-41.


Assuntos
Fraturas do Ombro/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/estatística & dados numéricos , Feminino , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Tempo para o Tratamento
8.
Bone Joint J ; 102-B(1): 26-32, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31888373

RESUMO

AIMS: Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation. METHODS: We collected data on 182 consecutive patients with a type II, IIIA, or IIIB open fracture of the tibia who presented to our hospital between July and December 2016. For the purposes of the study, the patients were jointly treated by experienced consultant orthopaedic and plastic surgeons who determined the type of treatment. Separately, the study team (SP, HS, AD, JD) independently calculated the GHS and prospectively collected data on six outcomes for each patient. These included time to bony union, number of admissions, length of hospital stay, total length of treatment, final functional score, and number of operations. Spearman's correlation was used to compare GHS with each outcome. Forward stepwise linear regression was used to generate predictive models based on components of the GHS. Five-fold cross-validation was used to prevent models from over-fitting. RESULTS: The mean follow-up was 11.4 months (3 to 31). The mean time to union was 9.7 months (3 to 21), the mean number of operations was 2.8 (1 to 11), the mean time in hospital was 17.7 days (5 to 84), the mean length of treatment was 92.7 days (5 to 730), the mean number of admissions was 1.7 (1 to 6), and the mean functional score (Lower Extremity Functional Score (LEFS)) was 60.13 (33 to 80). There was a significant correlation between the GHS and each of the outcome measures. A predictive model was generated from which the GHS could be used to predict the various outcome measures. CONCLUSION: The GHS can be used to predict the outcome of patients who present with an open fracture of the tibia. Our model generates a numerical value for each outcome measure that can be used in clinical practice to inform the treating team and to advise patients. Cite this article: Bone Joint J 2020;102-B(1):26-32.


Assuntos
Fraturas Expostas/cirurgia , Fraturas da Tíbia/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Fixação de Fratura/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
9.
J Surg Res ; 249: 91-98, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31926401

RESUMO

BACKGROUND: Tibia fractures are common after trauma. Prior studies have shown that delays in treatment are associated with poor outcomes. A subpopulation of our patients are transported from Mexico, adding barriers to prompt care. We hypothesized that patients with tibia fractures crossing from Mexico would have delays in treatment and subsequently worse outcomes. METHODS: The trauma registry of an American College of Surgeons-verified level 1 trauma center was retrospectively reviewed for all tibia fractures admitted from 2010 to 2015. Data collection included demographics, country of injury, characterization of injuries, interventions, complications, and outcomes. Patients were subdivided into those injured in the United States and in Mexico, and the two groups were compared. RESULTS: A total of 498 patients were identified, 440 from the United States and 58 from Mexico. Mexico patients were more severely injured overall, with higher injury severity scores and a higher percentage of patients with abbreviated injury scale scores ≥3 for both head and chest regions. Mexico patients had longer times from injury to admission, as well as increased times to both debridement of open fractures and operative fixation after admission. On subgroup analysis of patients with isolated tibia fractures (other system abbreviated injury scale < 3), times from arrival to treatment and injury severity score were no longer statistically different. CONCLUSIONS: Patients crossing the border from Mexico with tibia fractures have delays in time to admission and from admission to operative management, although this is primarily due to other severe injuries. Ongoing systems development is required to minimize delays in care and optimize outcomes.


Assuntos
Fraturas Expostas/cirurgia , Fraturas da Tíbia/cirurgia , Tempo para o Tratamento/estatística & dados numéricos , Transporte de Pacientes/estatística & dados numéricos , Adulto , Desbridamento/estatística & dados numéricos , Feminino , Fixação de Fratura/estatística & dados numéricos , Fraturas Expostas/diagnóstico , Humanos , Escala de Gravidade do Ferimento , Masculino , México , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fraturas da Tíbia/diagnóstico , Centros de Traumatologia/estatística & dados numéricos , Tri-Iodotironina/análogos & derivados , Estados Unidos , Adulto Jovem
10.
J Bone Joint Surg Am ; 102(5): e18, 2020 Mar 04.
Artigo em Inglês | MEDLINE | ID: mdl-31895168

RESUMO

BACKGROUND: There is a new method of transportation that started in our community in late 2017- rideshare electric scooters (e-scooters). These scooters have proven immensely popular and can now be found in many cities around the world. Despite the pervasiveness of e-scooters, their associated injury patterns are poorly understood. The purpose of this study was to describe our department's experience at the epicenter of the e-scooter phenomenon that is sweeping the globe and to characterize operative orthopaedic injuries that are related to e-scooter accidents. METHODS: We performed a retrospective chart review of all of the operative orthopaedic cases and trauma consults at 2 trauma centers (a level-I center and a level-II center) between September 2017 and August 2019. We identified all operative injuries in which the cause of injury was an e-scooter accident. Data that included demographics, mechanism of injury, diagnosis, and treatment were collected. RESULTS: Seventy-five operative injuries were identified in 73 patients during the study period. The mean patient age was 35.4 years (range, 14 to 74 years), and the median age was 32 years. There were 4 pediatric patients (14, 15, 15, and 17 years old). Thirty-two patients (43.8%) sustained upper-extremity injuries, and 42 patients (57.5%) sustained lower-extremity injuries; 1 of these patients had both upper and lower-extremity injuries. Nine patients (12.3%) had open fractures. There were 7 hip fractures in patients with an average age of 42.4 years (range, 28 to 68 years). Seventy-one (97.3%) of 73 patients were e-scooter riders, and 2 (2.7%) were pedestrians who were struck by e-scooter riders. CONCLUSIONS: E-scooters can cause serious injury. Seventy-three patients required operative treatment in just the first 2 years of e-scooter use in our community. Operative injuries occurred throughout the skeletal system, and several were injuries that are typically associated with high-energy trauma. Although, as a rule, e-scooter use is limited to adults and banned in high pedestrian-traffic areas in our city, the inclusion of 4 underage riders and 2 pedestrians in our cohort suggests that these rules are not always followed. As e-scooters continue to increase in popularity, additional steps should be taken to regulate their use and protect riders and the public.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Fontes de Energia Elétrica , Fixação de Fratura/estatística & dados numéricos , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/cirurgia , Motocicletas , Adolescente , Adulto , Idoso , Feminino , Fraturas Ósseas/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
11.
Injury ; 51(2): 317-321, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31917010

RESUMO

BACKGROUND: Patients who experience traumatic spine injuries remain in spinal precautions (SP) to minimize the risk of devastating cord injury while awaiting definitive management. This study examines the incidence of pneumonia (PNA), urinary tract infection (UTI), deep vein thrombosis (DVT), or pulmonary embolism (PE) in this population. STUDY DESIGN: From 2014 to 2016, 344 patients aged 18 and older with spinal column injuries were identified in a prospectively-collected registry at an urban, level 1 trauma center. After exclusion criteria, 330 patients were reviewed and the following were analyzed: demographics, duration of SP, time to intervention, and rates of PNA, UTI, and DVT or PE. Those patients kept in SP for ≤ 72 h ("prolonged") were compared to patients maintained in SP for > 72 h ("early"). RESULTS: Mean age was 54.6 years (SD, 21.7), median Injury Severity Score (ISS) 10 (IQR, 5-17). The median SP was 4.0 (IQR, 3.0-6.0) days. Fifty-eight (17.6%) patients underwent fixation and 170 (51.5%) received a brace. 102 (30.9%) patients initially awaiting a brace were cleared after MRI. 93 (28.2) patients suffered one of the tracked complications; 51 (15.5%) developed PNA, 35 (10.6%) UTI, 23 (7.0%) DVT, and 5 (1.5%) PE. Rate of overall complications between patients with SP ≤ 72 h versus patients with SP > 72 h was statistically significant (20.5% vs 34.6%, p = 0.005) as was the incidence of UTI (14.5 vs 6.0, p = 0.012). CONCLUSION: Prolonged SP (>72 h) is associated with increased rates of immobility-associated morbidities. Focus should be on prompt, definitive care and early mobilization. LEVEL OF EVIDENCE: III Retrospective review of prospectively-collected data.


Assuntos
Restrição Física/efeitos adversos , Traumatismos da Medula Espinal/prevenção & controle , Traumatismos da Coluna Vertebral/complicações , Ferimentos e Lesões/complicações , Adulto , Idoso , Braquetes/estatística & dados numéricos , Estudos de Casos e Controles , Feminino , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Humanos , Doença Iatrogênica/epidemiologia , Incidência , Escala de Gravidade do Ferimento , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Pneumonia/epidemiologia , Embolia Pulmonar/epidemiologia , Restrição Física/estatística & dados numéricos , Estudos Retrospectivos , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tempo para o Tratamento , Infecções Urinárias/epidemiologia , Trombose Venosa/epidemiologia , Ferimentos e Lesões/epidemiologia
12.
J Am Acad Orthop Surg ; 28(18): 743-749, 2020 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-31764201

RESUMO

INTRODUCTION: Among surgical patients, utilization of institutional-based postacute care (PAC) presents a notable financial burden and is associated with increased risk of complications and mortality rates when compared with discharge home. The purpose of this study was to identify predictors of postdischarge disposition to PAC in geriatric patients after surgical fixation of native hip fractures. METHODS: We have done a query of the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained surgical femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to compute risk factors for discharge to and prolonged stay (>30 days) in PAC. RESULTS: Eight thousand one hundred thirty-three geriatric hip fracture patients with sufficient follow-up data were identified. Of these, 6,670 patients (82.0%) were initially discharged to PAC after their hip fracture episode of care, and 2,986 patients (36.7%) remained in PAC for >30 days. Age (odds ratio [OR] 1.06 [1.05 to 1.08], P < 0.001), partial (OR 2.41 [1.57 to 3.71], P < 0.001) or total dependence (OR 3.03 [1.92 to 4.46], P < 0.001) for activities of daily living, dementia (OR 1.62 [1.33 to 1.96], P < 0.001), diabetes (OR 1.46 [1.14 to 1.85], P = 0.002), hypertension (OR 1.32 [1.10 to 1.58], P = 0.002), and total hospital length of stay (OR 1.04 [1.01 to 1.08], P = 0.006) were independent risk factors for discharge to PAC. Age (OR 1.05 [1.04 to 1.06], P < 0.001), partial (OR 2.86 [1.93 to 3.79], P < 0.001) or total dependence (OR 3.12 [1.45 to 4.79], P < 0.001) for activities of daily living, American Society of Anesthesiologist's classification (OR 1.27 [1.13 to 1.43], P < 0.001), dementia (OR 1.49 [1.28 to 1.74], P < 0.001), and total hospital length of stay (OR 1.10 [1.08 to 1.13], P < 0.001) were independent risk factors for prolonged PAC stay >30 days. DISCUSSION: Discharge to PAC is the norm among patients undergoing hip fracture surgery. Provider foreknowledge of risk factors may help improve hip fracture outcomes and decrease healthcare costs.


Assuntos
Fixação de Fratura/estatística & dados numéricos , Fraturas do Quadril/cirurgia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Cuidados Pós-Operatórios/estatística & dados numéricos , Cuidados Semi-Intensivos/estatística & dados numéricos , Atividades Cotidianas , Fatores Etários , Idoso de 80 Anos ou mais , Demência , Feminino , Humanos , Tempo de Internação , Masculino , Alta do Paciente , Fatores de Risco
13.
Injury ; 51(2): 347-351, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31843199

RESUMO

BACKGROUND: Acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Despite advances in operative techniques, there remains a cohort of elderly, extremely frail patients with comminuted fractures who are considered unfit for surgery and are treated conservatively. We aim to assess mortality, mobility and radiological outcomes one-year post injury in this challenging cohort. METHODS: We performed a review of the regional Fracture Outcome and Research Database for patients over 65 with associated type acetabular fractures which were treated conservatively. We collected data on demographics, fracture classification, pre-injury mobility and habitation, and length of acute hospital stay. Mobility status, habitation, radiographic result and mortality were also recorded at one-year post injury. RESULTS: There were 49 patients with a mean age of 80 years. The mean estimated American Society of Anaesthesiologist (ASA) score was 3.1. 92% sustained a low energy injury, and the most common fracture pattern was anterior posterior hemi-transverse (84%). Mean acute hospital stay was 20 days and mortality was 24% at one year. 56% of patients maintained habitation in their own home and 35% returned to their premorbid level of mobility. Of the surviving patients, 30% had an 'excellent/good' reduction on x-ray at one year, 70% had a 'fair/poor' reduction. There was no correlation between fracture reduction and either one year mobility status or maintenance of mobility. CONCLUSIONS: The data confirms that conservatively managed complex acetabular fractures in the elderly, frail patient are associated with a significant reduction in mobility and living independence, a high level of mortality and poor radiological outcomes. IMPLICATIONS: Conservative management of this cohort is associated with poor outcomes and current operative solutions are unsuitable for this frail cohort of patients. Future developments should focus on minimising surgical insult and allowing weight bearing mobilisation to maximise the rehabilitation potential in this frail cohort.


Assuntos
Acetábulo/lesões , Tratamento Conservador/efeitos adversos , Fraturas do Quadril/mortalidade , Pelve/lesões , Suporte de Carga/fisiologia , Acetábulo/patologia , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/métodos , Deambulação Precoce/métodos , Feminino , Fixação de Fratura/estatística & dados numéricos , Fraturas Ósseas/classificação , Idoso Fragilizado , Fraturas do Quadril/diagnóstico por imagem , Fraturas do Quadril/epidemiologia , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Mortalidade/tendências , Pelve/diagnóstico por imagem , Pelve/patologia , Radiografia/métodos , Estudos Retrospectivos
14.
Acta Orthop ; 91(1): 58-62, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31635502

RESUMO

Background and purpose - In Denmark, 44 per 10,000 persons over the age of 50 years suffered a hip fracture (HF) in 2011. We characterized the patients and identified risk factors associated with 30-day, 90-day, and 1-year postoperative mortality in Denmark from 2000 to 2014.Patients and methods - The study builds upon data from the Danish National Patients Register and the National Causes of Death Register including all acute hospitalized HF patients aged 18 years and above. Outcomes were 30-day, 90-day, and 1-year postoperative mortality. Mortality risk was analyzed with a univariable and multivariable Cox regression including predefined variables.Results - 113,721 acute hospitalized HF patients were admitted to Danish hospitals between 2000 and 2014. The 30-day mortality risk was 9.6%, 16% at 90 days, and 27% at 1 year after HF surgery. Mortality risk was similar from 2000 to 2014 while the median lengths of stay declined from 14 (IQR 8-25) to 8 (IQR 5-11) days. Male sex, increasing age, higher Charlson Comorbidity Index, per- and subtrochanteric fracture, and operation type other than total hip arthroplasty were independently associated with postoperative mortality.Interpretation - Short- and long-term mortality was high after hip fracture surgery and did not decline in Denmark from 2000 to 2014.


Assuntos
Artroplastia de Quadril/estatística & dados numéricos , Fraturas do Colo Femoral/cirurgia , Fraturas do Quadril/cirurgia , Mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Dinamarca , Feminino , Fixação de Fratura/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Modelos de Riscos Proporcionais , Sistema de Registros , Fatores Sexuais
15.
Injury ; 51(2): 357-360, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31679832

RESUMO

PURPOSE: This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns. METHODS: We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test. RESULTS: 139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure. CONCLUSION: Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.


Assuntos
Redução Fechada/efeitos adversos , Fraturas do Colo Femoral/cirurgia , Fixação de Fratura/métodos , Reoperação/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Parafusos Ósseos , Estudos de Casos e Controles , Redução Fechada/instrumentação , Coxa Valga/diagnóstico por imagem , Coxa Valga/etiologia , Coxa Vara/diagnóstico por imagem , Coxa Vara/etiologia , Feminino , Fraturas do Colo Femoral/classificação , Fraturas do Colo Femoral/diagnóstico por imagem , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Humanos , Masculino , Radiografia/métodos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Falha de Tratamento
16.
Acta Orthop ; 91(1): 104-108, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31680591

RESUMO

Background and purpose - Fractures of the distal ulna can occur in isolation or in conjunction with a distal radius fracture. They may result in incongruence and instability of the distal radioulnar joint. We investigated the incidence of distal ulna fractures, whether any fracture types were more common, and the methods of treatment used.Patients and methods - Data were collected from patients 18 years or older, treated for a fracture of the distal ulna in Östergötland, Sweden, during 2010-2012. Patients were identified in the patient registry. The fractures were classified according to the AO comprehensive classification of fractures.Results - The incidence of distal ulna fractures was 74/100,000 person-years. The most common fracture type was that of the ulnar styloid Q1 (79%), followed by the ulnar neck Q2 (11%). Rarest was ulna head fracture, type Q4 (1%). Incidental findings were a mean age of 63 years (SD 18), a concomitant distal radius fracture in 92% of the patients and that 79% were caused by falling from standing height. Internal fixation was performed in 30% of the Q2-Q6 fractures. This indicates that most were considered stable without internal fixation or stable after fixation of a concomitant radius fracture.Interpretation - Our results show that fractures of the distal ulna are not very common, and some fracture types are even rare. There seem to be no consensus on treatment.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Fixação Interna de Fraturas/estatística & dados numéricos , Fraturas do Rádio/epidemiologia , Fraturas da Ulna/epidemiologia , Acidentes de Trânsito/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fixação de Fratura/estatística & dados numéricos , Fraturas Múltiplas/epidemiologia , Fraturas Múltiplas/cirurgia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fraturas do Rádio/complicações , Fraturas do Rádio/cirurgia , Suécia/epidemiologia , Fraturas da Ulna/complicações , Fraturas da Ulna/cirurgia , Adulto Jovem
17.
Arch Orthop Trauma Surg ; 140(4): 449-455, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31392407

RESUMO

PURPOSE: To determine the factors that influence radiation exposure during repair of supracondylar humerus fractures. METHODS: Medical records of almost 200 children with supracondylar fractures were retrospectively analyzed for variables correlated with fluoroscopy time and radiation dose as measures of radiation exposure. RESULTS: There was no statistically significant difference in fluoroscopy time (27 vs. 22 s p = 0.345) or direct radiation dose (0.394 vs. 0.318 mSv p = 0.290) between uniplanar and biplanar C-arm use. No statistically significant differences in fluoroscopy time or radiation dose were found for surgical technique, comorbid ipsilateral fractures, preoperative neurovascular compromise, or resident participation. There was a significant 8.3 s increase in fluoroscopy time (p = 0.022) and 0.249 mSv increase in radiation dose (p = 0.020) as the fracture type increased from II to III. An increase in one pin during CRPP resulted in a statistically significant 10.4 s increase in fluoroscopy time and a 0.205 mSv increase in radiation dose. There were significant differences between the physician with the lowest fluoroscopy time and radiation dose compared with the physicians with the two highest values for both fluoroscopy time and radiation dose (p < 0.01). CONCLUSIONS: We found no significant difference in direct radiation exposure or fluoroscopy time when comparing biplanar to uniplanar C-arm use, resident participation, preoperative neurovascular compromise, or for comorbid ipsilateral fractures. Both outcomes increased significantly as fracture type increased from II to III and as the number of pins used during CRPP increased. Both outcomes were significantly different between the surgeons performing CRPP.


Assuntos
Fluoroscopia , Fraturas do Úmero , Exposição à Radiação , Criança , Fluoroscopia/efeitos adversos , Fluoroscopia/estatística & dados numéricos , Fixação de Fratura/efeitos adversos , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Humanos , Fraturas do Úmero/diagnóstico por imagem , Fraturas do Úmero/cirurgia , Úmero/diagnóstico por imagem , Úmero/cirurgia , Exposição à Radiação/normas , Exposição à Radiação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo
18.
J Surg Res ; 246: 123-130, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31569034

RESUMO

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Fixação de Fratura/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Fraturas da Coluna Vertebral/cirurgia , Organizações de Assistência Responsáveis/economia , Idoso , Idoso de 80 Anos ou mais , Grupos de Populações Continentais/estatística & dados numéricos , Redução de Custos/economia , Redução de Custos/estatística & dados numéricos , Grupos Étnicos , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/economia , Gastos em Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/organização & administração , Mortalidade Hospitalar , Humanos , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/estatística & dados numéricos , Fatores Socioeconômicos , Fraturas da Coluna Vertebral/economia , Estados Unidos/epidemiologia
19.
Arch Orthop Trauma Surg ; 140(4): 487-492, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31664575

RESUMO

INTRODUCTION: Geriatricians have been increasingly involved in the pre-operative process in frail elderly patients with a hip fracture which can benefit re-hospitalization, post-operative functional performance, and mortality. The objective of this study was to compare the number of older patients with hip fractures who opted for non-surgical management after the addition of pre-operative comprehensive geriatric assessment (CGA) with shared decision making by a geriatrician to usual care. Secondary objectives were: reasons for non-surgical management, duration of life, and location of death. MATERIALS AND METHODS: A single-center, with a level 2 trauma center, retrospective study comparing care before and after introducing pre-operative CGA with shared decision making in September 2014. Patients ≥ 70 years with a hip fracture, admitted from January 2014 to September 2015, were included. The percentages of patients elected for non-surgical management and palliative care without or with CGA were compared. Differences in secondary objectives (age, sex, medical history, medication use, functional, and social status) were compared descriptively and qualitatively. RESULTS: With pre-operative CGA significantly more patients (or representatives) elected the non-surgical management option after hip fracture (respectively, 9.1% vs 2.7%, p = 0.008). Patient characteristics were comparable. Reported reasons not to undergo surgery include aversion to be more dependent on others, and severe dementia. CONCLUSION: The geriatrician can have an important role in decisions for non-surgical management by shared decision making in the pre-operative period in patients ≥ 70 years with a hip fracture in the emergency room.


Assuntos
Fixação de Fratura/estatística & dados numéricos , Avaliação Geriátrica/estatística & dados numéricos , Fraturas do Quadril , Idoso , Idoso de 80 Anos ou mais , Tratamento Conservador/estatística & dados numéricos , Feminino , Idoso Fragilizado , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/terapia , Humanos , Masculino , Estudos Retrospectivos
20.
Rev. Soc. Esp. Dolor ; 26(6): 324-330, nov.-dic. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-191389

RESUMO

Objetivo: Determinar si existe correlación entre el dolor y el alineamiento aceptable de la fractura de radio distal (FRD) en pacientes mayores de 60 años. Material y método: El presente estudio correlacional fue realizado en el Hospital Clínico San Borja Arriarán. Se reclutaron de forma prospectiva 210 pacientes con FRD extrarticular según la clasificación AO. Para evaluar los resultados de la reducción ortopédica se evaluaron índices radiológicos como la inclinación radial, la angulación dorsal residual y la varianza ulnar. Tras la retirada de la inmovilización y a los 6 meses de seguimiento se evaluó la intensidad del dolor con la escala visual analógica (EVA), la función de la muñeca con el cuestionario de evaluación de la muñeca valorada por el paciente (PRWE) y la fuerza de puño con un dinamómetro. Resultados: Solo 88 pacientes (42 %) presentaron un alineamiento aceptable de la FRD. Tras la retirada de la inmovilización, en el total de pacientes la correlación con la EVA fue de 0,17 (p = 0,546), la puntuación PRWE de 0,09 (p = 0,821) y la fuerza de puño de 0,08 (p = 0,631). Al sexto mes de seguimiento la correlación con la EVA fue de 0,09 (p = 0,668), PRWE de 0,05 (p = 0,882) y la fuerza de puño de 0,04 (p = 0,614). Conclusión: A corto y medio plazo no existe una correlación significativa entre el alineamiento aceptable basado en índices radiológicos y el dolor y la función de pacientes mayores de 60 años con FRD extrarticular tratados de manera conservadora


Objective: To determine whether there is a correlation between pain and acceptable distal radius fracture (DRF) alignment in patients older than 60 years of age. Material and method: This correlational study was carried out at the San Borja Arriarán Clinical Hospital. A total of 210 patients diagnosed with extra-articular DRF, according to the AO classification, were recruited prospectively recruited. Radiological parameters, including radial inclination, residual dorsal angulation and ulnar variance, were evaluated to assess the results of the orthopedic reduction. After the removal of the immobilization and after 6 months of follow-up, the pain intensity was assess with the visual analogue scale (VAS), the wrist function with the PRWE questionnaire and the grip strength with a dynamometer. Results: Only 88 patients (42%) showed acceptable DRF alignment. After cast removal, in the total of patients the correlations between alignment were as follows: VAS 0.17 (p = 0.546), PRWE 0.09 (p = 0.821), and grip strength 0.08 (p = 0.631). At the 6th months of follow-up, the correlation with the VAS was 0.09 (p = 0.668), PRWE 0.05 (p = 0.882) and grip strength 0.04 (p = 0.614). Conclusion: In the short and medium term, there was no significant correlation between acceptable alignment according to radiological parameters and pain and function of patients older than 60 years with extra-articular DRF treated conservatively


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Fraturas do Rádio/diagnóstico por imagem , Dor Aguda/diagnóstico por imagem , Medição da Dor/métodos , Fixação de Fratura/métodos , Fraturas do Rádio/complicações , Manejo da Dor/métodos , Correlação de Dados , Radiografia/métodos , Recuperação de Função Fisiológica , Fixação de Fratura/estatística & dados numéricos , Mau Alinhamento Ósseo/epidemiologia
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