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1.
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
2.
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
3.
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
4.
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
5.
Rev Esp Salud Publica ; 932019 Oct 18.
Artigo em Espanhol | MEDLINE | ID: mdl-31625534

RESUMO

OBJECTIVE: The Spanish National Hip Fracture Registry (Registro Nacional de Fracturas de Cadera or RNFC) is a Spanish, prospective, multi- centric registry, commenced in 2017. The goal of this paper is to present the data from the first annual report and to compare them with autonomic registries and recent prospective multi-centric studies performed in Spain. METHODS: We included persons 75 years or older treated for fragility hip fractures in any of the centers participating in the RNFC between January and October 2017. The descriptive statistics of each variable used the mean (and standard deviation) or the median (and interquartile ranges) for the ordinal variables and the percentage for the categoric variables. A descriptive analysis of the casemix was performed and compared with available data from the aforementioned studies. RESULTS: The RNFC included 7.208 patients from 54 hospitals, with a mean age of 86.7 (SD 5.6) years; 75.4% were women, and 36.4% showed cognitive decline. Mean surgical delay was 75.7 (SD 63.6) hours, and length of stay averaged 10.9 (SD 6.7) days. Of the patients who lived at home (75.4%), less than half (37.0%) returned home at discharge. One-month mortality was 7.1%. Comparison with other studies showed important differences, especially regarding patients newly sent to nursing homes (7.7-29.4%) and with antiosteoporotic treatment at discharge (14.5-36.7%). CONCLUSIONS: The RNFC is the largest prospective database to date that offers data regarding the characteristics of patients hospitalized for hip fractures in Spain. Comparison with recent studies showed some important differences.


Assuntos
Fraturas do Quadril , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Idoso Fragilizado , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/reabilitação , Fraturas do Quadril/cirurgia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Estudos Prospectivos , Sistema de Registros , Espanha , Tempo para o Tratamento/estatística & dados numéricos
6.
BMC Musculoskelet Disord ; 20(1): 419, 2019 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-31506075

RESUMO

BACKGROUND: Proximal humeral fractures can be treated non-operatively or operatively with open reduction and internal fixation (ORIF) and arthroplasty. Our objective was to assess practice patterns for operative and non-operative treatment of proximal humeral fractures. We also report on complications, readmissions, in-hospital mortality, and need for surgery after initial treatment of proximal humeral fractures in California, Florida, and New York. METHODS: The State Inpatient Databases and State Emergency Department Databases from the Healthcare Cost and Utilization Project, sponsored by the Agency for Healthcare Research and Quality, were used for the states of California (2005-2011), Florida (2005-2014), and New York (2008-2014). Data on patients with proximal humeral fractures was extracted. Patients underwent non-operative or operative (ORIF or arthroplasty) treatment at baseline and were followed for at least 4 years from the index presentation. If the patient needed subsequent surgery, time to event was calculated in days, and Kaplan-Meier survival curves were plotted. RESULTS: At the index visit, 90.3% of patients with proximal humeral fractures had non-operative treatment, 6.7% had ORIF, and 3.0% had arthroplasty. 7.6% of patients initially treated non-operatively, 6.6% initially treated with ORIF, and 7.2% initially treated with arthroplasty needed surgery during follow-up. Device complications were the primary reason for readmission in 5.3% of ORIF patients and 6.7% of arthroplasty patients (p < 0.0001). All-cause in-hospital mortality was 9.8% for patients managed non-operatively, 8.8% for ORIF, and 10.0% for arthroplasty (p = 0.003). CONCLUSIONS: A majority of patients with proximal humeral fractures underwent non-operative treatment. There was a relatively high all-cause in-hospital mortality irrespective of treatment. Given the recent debate on operative versus non-operative treatment for proximal humeral fractures, our study provides valuable information on the need for revision surgery after initial treatment. The differences in rates of revision surgery between patients treated non-operatively, with ORIF, and with arthroplasty were small in magnitude. At nine years of follow-up, ORIF had the lowest probability of needing follow-up surgery, and arthroplasty had the highest.


Assuntos
Artroplastia/efeitos adversos , Fixação de Fratura/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Fraturas do Ombro/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia/métodos , Artroplastia/estatística & dados numéricos , California/epidemiologia , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Florida/epidemiologia , Seguimentos , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Úmero/lesões , Úmero/cirurgia , Estimativa de Kaplan-Meier , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Padrões de Prática Médica/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Fraturas do Ombro/mortalidade , Resultado do Tratamento
7.
Bull Hosp Jt Dis (2013) ; 77(3): 200-205, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31487486

RESUMO

BACKGROUND: Workers Compensation claims have been previously associated with inferior clinical outcomes. However, variation in inpatient stays for orthopedic trauma injuries according to insurance type has not been previously examined. METHODS: We investigated the differences according to insurance for tibial shaft fractures in regard to length of stay and disposition. Using the New York SPARCS database, we identified 1,856 adult non-elderly patients with an isolated tibial shaft fracture who underwent surgery. Patients were stratified by insurance type, including private, Medicaid, Workers Compensation, and no-fault, which covers medical expenses related to automobile or pedestrian accidents. RESULTS: Compared to private insurance (mean: 2.7 days), length of stay was longer for no-fault (mean: 3.9 days; adjusted difference +33%, p < 0.001) and Medicaid (mean: 3.5 days; adjusted difference +22%, p < 0.001), but not significantly different for Workers Compensation (mean: 3.5 days; adjusted difference +4%, p = 0.474). Compared to private insurance (rate: 3.5%), disposition to a facility was significantly higher for no-fault (rate: 10.1%; adjusted odds ratio [OR] = 3.3, p < 0.001) and Medicaid (rate: 7.6%; OR = 2.2, p = 0.003), but was not significantly different for Workers Compensation (rate: 6.3%; OR = 1.8, p = 0.129). CONCLUSIONS: Patients with no-fault insurance, but not Workers Compensation, are subject to longer hospital stays and are more likely to be discharged to a facility following operative fixation of an isolated tibial shaft fracture. These findings suggest that financial, social, and legal factors influence medical care for patients involved in automobile accidents with no-fault insurance.


Assuntos
Acidentes de Trânsito/economia , Fixação de Fratura , Seguro de Responsabilidade Civil/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Fraturas da Tíbia , Indenização aos Trabalhadores/estatística & dados numéricos , Adulto , Feminino , Fixação de Fratura/economia , Fixação de Fratura/reabilitação , Fixação de Fratura/estatística & dados numéricos , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Masculino , Fraturas da Tíbia/economia , Fraturas da Tíbia/etiologia , Fraturas da Tíbia/cirurgia , Estados Unidos
8.
Bull Hosp Jt Dis (2013) ; 77(3): 211-215, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31487488

RESUMO

INTRODUCTION: Spinal cord injured patients have an estimated 25% to 34% lifetime incidence of sustaining an extremity fracture. The objective of this study is to describe the outcomes of femur fractures treated in patients with pre-existing spinal cord injury (SCI) and lower extremity paraplegia. MATERIALS AND METHODS: An IRB approved retrospective review of patients 18 years of age and older who sustained a femur fracture a minimum of 2 years following spinal cord injury and received treatment at a regional academic level 1 trauma center over a 10-year period was performed. Patients were divided into two groups based on whether they received operative or nonoperative management of the femoral shaft fracture. The primary outcome assessed was re-operation. Additional outcomes including union, infection, implant failure, and mortality were recorded. RESULTS: Twenty-one patients sustaining a total of 25 femur fractures were identified. The most common mechanism of injury was fall during transfer. Sixteen fractures were treated non-operatively and nine were treated operatively. At a mean of 4.1 years of follow-up (range: 1.1 to 12.1 years) six out of nine (66.7%) patients in the operative group required an unplanned secondary surgery compared to two patients (12.5%) in the non-operative group (p = 0.006). Overall, the rate of fracture union was 48%, and there was no difference seen between treatment groups (56.3% in nonoperative group versus 33.3% in operative group, p = 0.28). Six operative patients (66.7%) developed an infection as compared to one patient (6.3%) in the non-operative group (p = 0.002). Three operative patients (33.3%) had failure of fixation with implant cutout. One patient died within 2 years of fracture in the non-operative group (6.3%) as did one patient in the operative group (11.1%), (p = 1.0). CONCLUSIONS: Surgical treatment of femur fractures in patients with a pre-existing SCI and lower extremity paraplegia had a higher rate of complications than nonoperative management in our series. Based on our experience, we recommend non-operative treatment of femur fractures in patients with pre-existing spinal cord injury and lower extremity paraplegia.


Assuntos
Tratamento Conservador , Fraturas do Fêmur , Fixação de Fratura , Paraplegia , Traumatismos da Medula Espinal , Adulto , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Feminino , Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/etiologia , Fraturas do Fêmur/cirurgia , Fixação de Fratura/efeitos adversos , Fixação de Fratura/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Paraplegia/complicações , Paraplegia/epidemiologia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/epidemiologia
9.
J Pediatr Orthop ; 39(8): 394-399, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31393292

RESUMO

BACKGROUND: To determine if the AAOS clinical practice guidelines (CPG) for the treatment of pediatric femoral shaft fractures (2009) changed treatment, we analyzed pediatric femoral shaft fractures at 4 high-volume, geographically separated, level-1 pediatric trauma centers over a 10-year period (2004 to 2013). METHODS: Consecutive series of pediatric femoral shaft fractures (ages, birth to 18 y) treated at the 4 centers were reviewed. Treatment methods were analyzed by age and treatment method for each center and in aggregate. RESULTS: Of 2646 fractures, 1476 (55.8%) were treated nonoperatively and 1170 fractures operatively. Of the operative group, flexible intramedullary nails (IMN) were used for 568 patients (21.5%), locked intramedullary nails (LIMNs) for 309 (11.7%), and plating for 188 (7.1%). In total, 105 fractures were treated with external fixation or skeletal traction. Analysis before and after the CPG publication revealed a significant increase in the use of interlocked IMNs in patients younger than 11 years (0.5% before, 3.8% after; P<0.001). Over the same time period there was an increase in surgical management, regardless of technique, for patients younger than 5 years (6.4% before, 8.4% after; P=0.206). There were considerable differences in treatment among centers: 74% of fractures treated with plating were from a single center (center A), which also contributed 68% of patients younger than 5 years treated with plating; center B had the highest rate (41%) of flexible IMN in children younger than 5 years; center C had the highest rate (63%) of LIMN in children younger than 11 years; and center D treated the fewest patients outside the CPG guidelines. CONCLUSIONS: Following publication of the AAOS CPG, there was a significant increase in the use of LIMNs in patients younger than 11 years old and a trend toward surgical treatment in patients younger than 5 years. The considerable variability among centers in treatment methods and adherence to the CPG highlights the need for further outcome studies to better define optimal treatment methods and perhaps update the AAOS CPG guidelines. LEVEL OF EVIDENCE: Level III-therapeutic.


Assuntos
Tratamento Conservador , Fraturas do Fêmur/cirurgia , Fixação de Fratura , Guias de Prática Clínica como Assunto , Pinos Ortopédicos/estatística & dados numéricos , Criança , Pré-Escolar , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Feminino , Fixação de Fratura/instrumentação , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Masculino , Estudos Retrospectivos
10.
Bone Joint J ; 101-B(8): 1015-1023, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31362544

RESUMO

AIMS: Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. MATERIALS AND METHODS: We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay. RESULTS: There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay. CONCLUSION: This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England. Cite this article: Bone Joint J 2019;101-B:1015-1023.


Assuntos
Fixação de Fratura/economia , Fraturas do Quadril/economia , Melhoria de Qualidade/economia , Reembolso de Incentivo , Idoso , Idoso de 80 Anos ou mais , Inglaterra , Feminino , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Humanos , Análise de Séries Temporais Interrompida , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Melhoria de Qualidade/estatística & dados numéricos , Escócia , Tempo para o Tratamento/economia , Resultado do Tratamento
11.
J Surg Res ; 244: 205-211, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31299437

RESUMO

BACKGROUND: Rib fractures are a common consequence of traumatic injury and can result in significant debilitation. Rib fixation offers fracture stabilization, resulting in improved outcomes and decreased pulmonary complications, especially in high-risk groups such as those with flail segments. However, commercial rib fixation has only recently become clinically prevalent, and we hypothesize that significant variability exists in its utilization based on injury pattern and trauma center. METHODS: The Pennsylvania Trauma System Foundation database was queried for all multiple rib fracture patients occurring statewide in 2016 and 2017. Demographics including the presence of flail and the occurrence of rib fixation was abstracted. Outcomes were compared between the fixation group and all other rib fracture patients. Deidentified treating trauma center was used to elicit center-level disparities. RESULTS: During the study period, there were 12,910 patients with multiple rib fractures, of which 135 had flail segments. 57 patients underwent rib fixation, and 10 of which had a flail segment. Compared with the nonoperative cohort, those who underwent rib fixation were younger (52.5 versus 61.5, P = 0.0009), similar in gender (68% versus 62% male, P = 0.373), and race (80% versus 86% White, P = 0.239). The rib fixation group had higher Injury Severity Scores (19.4 versus 15.4 P = 0.0011). The timing of rib fixation was most frequent within 1 wk of injury but extended out through 3 wk; the occurrence of pulmonary complications had a similar distribution. The frequency of rib fixation rates within trauma centers was not associated with rib fracture patient volume, and 37.1% of multiple rib fracture patients were cared for at centers that did not perform rib fixation. CONCLUSIONS: Rib fixation is infrequently used at trauma centers in Pennsylvania. It is used more frequently in nonflail injuries, and its use may be associated with the occurrence of pulmonary complications. Significant center-level variation exists in rib fixation rates among multiple fractured patients. A significant number of patients are cared for at centers that do not perform rib fixation. Further research is needed to illicit better-defined indications for operative fixation, and opportunities exist to further the penetrance of this practice to all trauma centers.


Assuntos
Tórax Fundido/cirurgia , Fixação de Fratura/estatística & dados numéricos , Fraturas Múltiplas/cirurgia , Padrões de Prática Médica/estatística & dados numéricos , Fraturas das Costelas/cirurgia , Adulto , Idoso , Feminino , Tórax Fundido/etiologia , Fraturas Múltiplas/complicações , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Fraturas das Costelas/complicações , Centros de Traumatologia/estatística & dados numéricos
12.
Rev. andal. med. deporte ; 12(2): 117-120, jun. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-184510

RESUMO

Objetivo: Describir las características clínico-epidemiológicas de los pacientes rescatados que presentaban luxación de hombro, así como el abordaje terapéutico. Método: Estudio descriptivo retrospectivo de los pacientes atendidos durante el periodo julio 2010-diciembre 2016 que presentaban una luxación de hombro. Resultados: Se analizan 57 pacientes. Las luxaciones de hombro suponen un 42.5% de las lesiones en extremidades superiores y un 2.7% del total de rescates. La edad media es 40.7±11.9 años; 96.4% varones. El senderismo, barranquismo y esquí de montaña son las actividades con más luxaciones. El 98.2% eran tipo glenohumeral anterior. La reducción fue exitosa en 80.9%, siendo la maniobra de Kocher la más empleada. El tiempo medio hasta el primer intento de reducción cuando maniobra fue exitosa fue de 87 minutos y 142 minutos cuando fracasa. Conclusiones: Se observa un aumento en las luxaciones de hombro, siendo la mayoría reducidas en el lugar del accidente, sin existir una maniobra de elección, y mayor éxito cuanto menor tiempo hasta maniobra. Reducir sin radiografía es seguro y eficaz


Objective: To describe the clinical-epidemiological characteristics of the rescued patients with shoulder dislocation, as well as the therapeutic approach. Method: A retrospective descriptive study of the patients treated during the period July 2010-December 2016, who presented with a shoulder dislocation. Results: A total of 57 patients were analysed. Shoulder dislocations account for 42.5% of upper extremity injuries and 2.7% of total rescues. The mean age being 40.7±11.9 years; 96.4% were male. Hiking, canyoning and mountain skiing are the activities in which most of the dislocations occur. 98.2% of the dislocations were anterior glenohumeral type. The reduction was successful in 80.9%, with the Kocher manoeuvre being the most used. The mean time until the first reduction attempt was successful was 87 minutes and 142 minutes when the manoeuvre failed. Conclusions: An increase in the number of shoulder dislocation was observed, most of them reduced at the accident site, there is no evidence of a single most successful manoeuvre over another. The quicker the reduction is attempted the more success is achieved. A reduction without performing an X-ray is safe and efficient


Objetivo: Descrever as características clínico-epidemiológicas e abordagem terapêutica em pacientes resgatados com luxação do ombro. Método: Estudo descritivo retrospectivo dos pacientes que apresentaram luxação de ombro, atendidos no período de julho de 2010 a dezembro de 2016. Resultados: Um total de 57 pacientes foram analisados. Luxações do ombro representam 42.5% das lesões da extremidade superior e 2.7% do total de resgates. A médiade idade foi de 40.7 ± 11.9 anos; 96.4% eram do sexo masculino. Caminhadas, canyoning e esqui de montanha são as atividades nas quais a mayoría das luxações ocorre. 98.2% das luxações foram do tipo glenoumeral anterior. A redução foi bem sucedida em 80.9%, sendo a manobra de Kocher a mais utilizada. O tempo médio até a primeira tentativa de redução foi de 87 minutos e 142 minutos quando a manobra falhou. Conclusões: Um aumento no número de luxações do ombro foi observado e a maioria delas reduzidas no local do acidente. Não há evidência de uma única manobra de maior sucesso em detrimento de outra. Quanto mais rápidaa redução é realizada, maior é o sucesso alcançado. Uma redução sem a realização de um raio X é segura e eficiente


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Assistência Pré-Hospitalar/métodos , Montanhismo/estatística & dados numéricos , Traumatismos em Atletas/epidemiologia , Luxação do Ombro/epidemiologia , Fixação de Fratura/estatística & dados numéricos , Tratamento de Emergência/métodos , Estudos Retrospectivos
13.
Injury ; 50(6): 1159-1165, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31047683

RESUMO

Rib fractures are common injuries associated with significant morbidity and mortality, largely due to pulmonary complications. Despite equivocal effectiveness data, incentive spirometers are widely utilized to reduce pulmonary complications in the postoperative setting. Few studies have evaluated the effectiveness of incentive spirometry after rib fracture. Multiple investigations have demonstrated incentive spirometry to be an important screening tool to identify high-risk rib fracture patients who could benefit from aggressive, multidisciplinary pulmonary complication prevention strategies. This review evaluates the epidemiology of rib fractures, their associated pulmonary complications, along with the evidence for optimizing their clinical management through the use of incentive spirometry, multimodal analgesia, and surgical fixation.


Assuntos
Fixação de Fratura/estatística & dados numéricos , Insuficiência Respiratória/diagnóstico por imagem , Fraturas das Costelas/complicações , Traumatismos Torácicos/complicações , Humanos , Escala de Gravidade do Ferimento , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologia , Fraturas das Costelas/fisiopatologia , Fraturas das Costelas/terapia , Espirometria , Traumatismos Torácicos/fisiopatologia , Traumatismos Torácicos/terapia , Estados Unidos/epidemiologia
14.
Orthop Clin North Am ; 50(2): 223-231, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30850080

RESUMO

Proximal humerus fractures in the setting of osteoporosis can be technically challenging. Intraoperative challenges include comminution, thin cortical bone, and crushed cancellous bone that lead to difficulties in obtaining and maintaining a reduction and hardware fixation. Loss of fixation and varus collapse continue to be problems despite the utilization of modern locking plate fixation. A clearer understanding of predictors of fixation failure and the encouraging early results of reverse total shoulder arthroplasty (RTSA) have resulted in increased utilization of RTSA for the primary treatment of proximal humerus fractures.


Assuntos
Fixação de Fratura/instrumentação , Osteoporose/complicações , Fraturas por Osteoporose/cirurgia , Fraturas do Ombro/cirurgia , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Ombro/métodos , Artroplastia do Ombro/estatística & dados numéricos , Placas Ósseas/normas , Feminino , Fixação de Fratura/estatística & dados numéricos , Fraturas Cominutivas/complicações , Humanos , Úmero , Ílio/transplante , Masculino , Fraturas do Ombro/diagnóstico por imagem , Resultado do Tratamento
15.
Arch Orthop Trauma Surg ; 139(9): 1179-1185, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30864089

RESUMO

PURPOSE: This study looks to compare patient outcomes in those with pilon fractures fixed with the anterolateral approach versus those with the posterolateral approach. METHODS: 135 patient charts of those with surgically treated pilon fractures over a 7-year period were retrospectively reviewed, recording demographic information, fracture description, surgical intervention timeline, operative outcomes, patient outcomes, and complication rates. RESULTS: Of the 44 included patients (32 anterolateral and 12 posterolateral), most were older than 40 years of age (65.9%) and male (63.6%). There was no difference seen between anterolateral approach and posterolateral approach tourniquet times (p = 0.80), operating room time (p = 0.40), or estimated blood loss (p = 0.73). There was also no reported difference in decrease in Numerical Rating Scale pain scores (p = 0.38), FOTO (Focus on Therapeutic Outcomes) percent increase (p = 0.13), active flexion-extension axis range of motion (p = 0.35), or inversion-eversion axis (p = 0.25) range of motion after an anterolateral approach versus a posterolateral approach. Finally, statistically similar complication rates (p = 0.75) were seen between anterolateral and posterolateral approaches, but patients who underwent a posterolateral approach surgical fixation were trending towards significantly using more post-operative outpatient opioid medications for pain control compared to those who underwent surgical fixation with an anterolateral approach (p = 0.09). CONCLUSIONS: Pilon injuries that lend themselves to anterolateral fixation have similar outcomes peri-operatively and post-operatively compared to injuries lending to posterolateral fixation. Both approaches can be used as dictated by the injury not fearing poorer outcomes or increased complication rates. However, surgeons must be wary of high complication rates associated with all pilon injury patterns. LEVEL OF EVIDENCE: Therapeutic Level IV.


Assuntos
Fixação de Fratura , Fraturas da Tíbia/cirurgia , Adulto , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Humanos , Masculino , Estudos Retrospectivos , Resultado do Tratamento
16.
N Z Med J ; 132(1490): 17-25, 2019 02 22.
Artigo em Inglês | MEDLINE | ID: mdl-30789885

RESUMO

AIM: Mortality rates of up to 38% at one year have been reported following surgery for neck of femur fractures. The aim of this review is to evaluate the post-operative mortality rates and trends over time for patients with fractured neck of femur at Waitemata District Health Board. METHOD: A retrospective cohort study of all patients who received surgery following a neck of femur fracture at Waitemata District Health Board between 2009 and 2016. Inpatient data was retrieved from electronic hospital records and mortality rates from the Ministry of Health, New Zealand. Analyses included crude mortality rates and trends over time, and time-to-theatre from presentation with neck of femur fracture. RESULTS: A total of 2,822 patients were included in the study; mean age 81.9 years, 70.4% female and 29.6% male. Overall post-operative crude rates for inpatient, 30-day and one-year mortality were 3.7%, 7.2% and 23.8% respectively. Adjusted analyses showed a statistically significant decrease in mortality rates between 2009 and 2016 at inpatient (p=0.001), 30 days (p=<0.001) and one year (p=<0.001) time periods. There was also a significant association between time-to-theatre and mortality at inpatient (p=0.002), 30 days (p=0.0001), and one year (p=0.0002) time periods. CONCLUSION: Mortality rates following surgery for fractured NOF have significantly improved over recent years at Waitemata District Health Board. Reduced time-to-theatre is associated with decreased inpatient, 30-day and one-year mortality.


Assuntos
Fraturas do Colo Femoral , Fixação de Fratura , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Efeitos Psicossociais da Doença , Feminino , Fraturas do Colo Femoral/economia , Fraturas do Colo Femoral/epidemiologia , Fraturas do Colo Femoral/mortalidade , Fraturas do Colo Femoral/cirurgia , Fixação de Fratura/métodos , Fixação de Fratura/reabilitação , Fixação de Fratura/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Mortalidade , Nova Zelândia/epidemiologia , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco
17.
Clin Pediatr (Phila) ; 58(6): 618-626, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30773927

RESUMO

Childhood non-accidental trauma (NAT) is the second most common cause of death in children. Despite its prevalence, NAT is frequently unreported due to provider misdiagnosis or unawareness. The purpose of this study was to determine current risk factors and injury patterns associated with NAT. A retrospective review of the Kids' Inpatient Database was performed for the years 2009 and 2012. Univariate and multivariate analyses were used to determine the statistically significant risk factors for NAT. In 2009 and 2012, 174 442 children were hospitalized for fractures. Of these, 2.07% (3614) were due to NAT. Lower extremity (femur, tibia/fibula, foot), hand/carpus, clavicle, pelvis, and spine fractures were more likely to result from NAT; tibia/fibula fractures were most predictive of NAT. Children with anxiety, attention-deficit, conduct, developmental, and mood disorders were more likely to experience NAT. Those with cerebral palsy and autism were not at an increased risk for NAT.


Assuntos
Maus-Tratos Infantis/estatística & dados numéricos , Fraturas Ósseas/epidemiologia , Traumatismos da Perna/epidemiologia , Análise de Variância , Criança , Maus-Tratos Infantis/prevenção & controle , Pré-Escolar , Bases de Dados Factuais , Feminino , Traumatismos do Pé/diagnóstico por imagem , Traumatismos do Pé/epidemiologia , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Fraturas Ósseas/diagnóstico por imagem , Hospitalização/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Traumatismos da Perna/diagnóstico por imagem , Masculino , Análise Multivariada , Prevalência , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia
18.
Osteoporos Int ; 30(4): 907-916, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30715561

RESUMO

Treatment of older adults with hip fracture is a healthcare challenge. Orthogeriatric comanagement that is an integrated model of care with shared responsibility improves time to surgery and reduces the length of hospital stay and mortality compared with orthopedic care with geriatric consultation service and usual orthopedic care, respectively. INTRODUCTION: Treatment of fractures in older adults is a clinical challenge due partly to the presence of comorbidity and polypharmacy. The goal of orthogeriatric models of care is to improve clinical outcomes among older people with hip fractures. We compare clinical outcomes of persons with hip fracture cared according to orthogeriatric comanagement (OGC), orthopedic team with the support of a geriatric consultant service (GCS), and usual orthopedic care (UOC). METHODS: This is a single-center, pre-post intervention observational study with two parallel arms, OGC and GCS, and a retrospective control arm. Hip fracture patients admitted to the trauma ward were assigned by the orthopedic surgeon to the OGC (n = 112) or GCS (n = 108) group. The intervention groups were compared each with others and both with the retrospective control group (n = 210) of older adults with hip fracture. Several clinical indicators are considered, including time to surgery, length of stay, in-hospital, and 1-year mortality. RESULTS: Patients in the OGC (OR 2.62; CI 95% 1.40-4.91) but not those in the GCS (OR 0.74; CI 95% 0.38-1.47) showed a higher probability of undergoing surgery within 48 h compared with those in the UOC. Moreover, the OGC (ß, - 1.08; SE, 0.54, p = 0.045) but not the GCS (ß, - 0.79; SE, 0.53, p = 0.148) was inversely associated with LOS. Ultimately, patients in the OGC (OR 0.31; CI 95 % 0.10-0.96) but not those in the GCS (OR 0.37; CI 95% 0.10-1.38) experienced a significantly lower 1-year mortality rate compared with those in the UOC. All analyses were independent of several confounders. CONCLUSIONS: Older adults with hip fracture taken in care by the OGC showed better clinical indicators, including time to surgery, length of stay and mortality, than those managed by geriatric consultant service or usual orthopedic care.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Serviços de Saúde para Idosos/organização & administração , Fraturas do Quadril/terapia , Fraturas por Osteoporose/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Fixação de Fratura/métodos , Fixação de Fratura/estatística & dados numéricos , Avaliação Geriátrica/métodos , Fraturas do Quadril/complicações , Humanos , Itália , Tempo de Internação/estatística & dados numéricos , Masculino , Modelos Organizacionais , Fraturas por Osteoporose/complicações , Equipe de Assistência ao Paciente/organização & administração , Centros de Traumatologia/organização & administração , Resultado do Tratamento
19.
J Am Acad Orthop Surg ; 27(16): 607-612, 2019 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-30601371

RESUMO

INTRODUCTION: Increased overlap in the scope of practice between orthopaedic surgeons and podiatrists has led to increased podiatric treatment of foot and ankle injuries. However, a paucity of studies exists in the literature comparing orthopaedic and podiatric outcomes following ankle fracture fixation. METHODS: Using an insurance claims database, 11,745 patients who underwent ankle fracture fixation between 2007 and 2015 were retrospectively evaluated. Patient data were analyzed based on the provider type. Complications were identified by the International Classification of Diseases, Ninth Revision, codes, and revision surgeries were identified by the Current Procedural Terminology codes. Complications analyzed included malunion/nonunion, infection, deep vein thrombosis, and rates of irrigation and débridement. Risk factors for complications were compared using the Charlson Comorbidity Index. RESULTS: Overall, 11,115 patients were treated by orthopaedic surgeons and 630 patients were treated by podiatrists. From 2007 to 2015, the percentage of ankle fractures surgically treated by podiatrists had increased, whereas that treated by orthopaedic surgeons had decreased. Surgical treatment by podiatrists was associated with higher malunion/nonunion rates among all types of ankle fractures. No differences in complications were observed in patients with unimalleolar fractures. In patients with bimalleolar or trimalleolar fractures, treatment by a podiatrist was associated with higher malunion/nonunion rates. Patients treated by orthopaedic surgeons versus podiatrists had similar comorbidity profiles. DISCUSSION: Surgical treatment of ankle fractures by orthopaedic surgeons was associated with lower rates of malunion/nonunion when compared with that by podiatrists. The reasons for these differences are likely multifactorial but warrants further investigation. Our findings have important implications in patients who must choose a surgeon to surgically manage their ankle fracture, as well as policymakers who determine the scope of practice. LEVEL OF EVIDENCE: Level III-retrospective cohort study.


Assuntos
Fraturas do Tornozelo/cirurgia , Fixação de Fratura/estatística & dados numéricos , Ortopedia/estatística & dados numéricos , Podiatria/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Demandas Administrativas em Assistência à Saúde , Bases de Dados Factuais , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/tendências , Fraturas Mal-Unidas/epidemiologia , Fraturas não Consolidadas/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Estados Unidos/epidemiologia
20.
Eur J Trauma Emerg Surg ; 45(3): 445-453, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29396757

RESUMO

BACKGROUND: Open tibia fractures usually occur in high-energy mechanisms and are commonly associated with multiple traumas. The purposes of this study were to define the epidemiology of open tibia fractures in severely injured patients and to evaluate risk factors for major complications. METHODS: A cohort from a nationwide population-based prospective database was analyzed (TraumaRegister DGU®). Inclusion criteria were: (1) open or closed tibia fracture, (2) Injury Severity Score (ISS) ≥ 16 points, (3) age ≥ 16 years, and (4) survival until primary admission. According to the soft tissue status, patients were divided either in the closed (CTF) or into the open fracture (OTF) group. The OTF group was subdivided according to the Gustilo/Anderson classification. Demographic data, injury mechanisms, injury severity, surgical fracture management, hospital and ICU length of stay and systemic complications (e.g., multiple organ failure (MOF), sepsis, mortality) were collected and analyzed by SPSS (Version 23, IBM Inc., NY, USA). RESULTS: Out of 148.498 registered patients between 1/2002 and 12/2013; a total of 4.940 met the inclusion criteria (mean age 46.2 ± 19.4 years, ISS 30.4 ± 12.6 points). The CTF group included 2000 patients (40.5%), whereas 2940 patients (59.5%) sustained open tibia fractures (I°: 49.3%, II°: 27.5%, III°: 23.2%). High-energy trauma was the leading mechanism in case of open fractures. Despite comparable ISS and NISS values in patients with closed and open tibia fractures, open fractures were significantly associated with higher volume resuscitation (p < 0.001), more blood (p < 0.001), and mass transfusions (p = 0.006). While the rate of external fixation increased with the severity of soft tissue injury (37.6 to 76.5%), no major effect on mortality and other major complications was observed. CONCLUSION: Open tibia fractures are common in multiple trauma patients and are therefore associated with increased resuscitation requirements, more surgical procedures and increased in-hospital length of stay. However, increased systemic complications are not observed if a soft tissue adapted surgical protocol is applied.


Assuntos
Acidentes de Trânsito/estatística & dados numéricos , Fraturas Fechadas/epidemiologia , Fraturas Expostas/epidemiologia , Traumatismo Múltiplo/epidemiologia , Choque Hemorrágico/epidemiologia , Fraturas da Tíbia/epidemiologia , Acidentes por Quedas/estatística & dados numéricos , Adolescente , Adulto , Idoso , Ciclismo/lesões , Transfusão de Sangue/estatística & dados numéricos , Feminino , Hidratação/estatística & dados numéricos , Fixação de Fratura/estatística & dados numéricos , Fraturas Expostas/terapia , Alemanha/epidemiologia , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/terapia , Pedestres/estatística & dados numéricos , Fatores de Risco , Choque Hemorrágico/terapia , Fraturas da Tíbia/terapia , Adulto Jovem
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