Journal of Orthopaedic Trauma最新文献

Objectives: This study aimed to determine if outpatient upper extremity fracture surgery was associated with increased post-operative ED visits and identify related risk factors.

Methods: Design: Retrospective cohort.

Setting: This multi-center study was conducted within a single academic institution, encompassing two level 1, two level 2, and one level 3 trauma center.

Patient selection criteria: All patients >18 years of age that underwent upper extremity fracture surgery from 2015-2021 were included.

Outcome measures and comparisons: Risk factors for postoperative ED visit that were investigated included age, sex, tobacco use, alcohol abuse, psychiatric diagnosis, Elixhauser comorbidity score, race, location of upper extremity fracture, surgical setting (inpatient vs. outpatient), upper extremity block, surgical specialty, and Area Deprivation Index. Variables with a p<0.1 in bivariate analysis were included in a multivariable logistic regression to determine factors associated with a postoperative ED visit at 30 and 90-days.

Results: A total of 6,315 patients with an average age of 51±19 years were identified of which 52% were female and 65% had outpatient surgery. Post-operatively, 188 patients (3.0%) presented to the ED within 30 days and 304 (4.8%) presented within 90 days. Thirty-seven percent of ED visits were directly related to the procedure, most commonly for pain (20%), cast issues (4.3%), and swelling (3.9%). At 30 days postoperatively, 2.8% of patients who underwent surgery in an outpatient setting and 3.4% of those who underwent inpatient surgery returned to the ED, with these rates increasing to 4.4% and 5.6%, respectively, by 90 days. In multivariable analysis, outpatient surgery (OR:1.5, p=0.030), tobacco use (OR:2.1, p<0.001), higher Elixhauser Comorbidity scores (OR:1.2, p<0.001), non-White race (OR:1.9, p<0.001) elbow fractures (OR:1.8, p=0.016), and hand fractures (OR: 1.6, p=0.046) were associated with 30-day ED visits.

Conclusions: Outpatient surgery was associated with increased rate of 30-day ED visits. Patients that smoke, had increased number of comorbidities or were non-White presented to the ED more frequently.

Level of evidence: III.

Objectives: Individuals with pelvic and acetabular fractures are at high risk of venous thromboembolism (VTE). The purpose of this study was to determine whether serum markers for thrombophilia and rapid thromboelastography (r-TEG) values correlate with increased VTE risk among patients with pelvic and acetabular fractures.

Methods: .

Design: Prospective observational study.

Setting: Two urban academic level 1 trauma centers.

Patient selection criteria: Adult patients with isolated pelvis and/or acetabulum fractures (OTA/AO 61 and 62) treated surgically placed on a standardized VTE chemoprophylaxis regimen with enoxaparin over a 5-year period were included.

Outcome measures and comparisons: Serum r-TEG, coagulation laboratory values, and markers for heritable thrombophilia were drawn postoperatively and after completion of a 6-week course of enoxaparin. The primary outcome was VTE event (either deep venous thrombosis or pulmonary embolism) diagnosed using a Duplex ultrasound, chest computed tomography angiogram, or lung ventilation-perfusion ordered based on clinical suspicion of a VTE event. Laboratory markers and values were then compared between patients who went on to have a VTE event and those who did not and patients with and without markers of thrombophilia.

Results: One hundred thirty-three adult patients with isolated operative pelvic and/or acetabular fractures were enrolled in this study. The average age of patients at time of injury was 48.3 years (range 18-91). Sixty-seven percent of patients in the study were (n = 90) males. Sixty-three percent of patients (n = 84) completed both clinical and laboratory follow-up. Forty-one percent of patients (n = 54) had 1 or more markers of heritable thrombophilia. Twelve percent (n = 10) of patients who completed follow-up were diagnosed with VTE. Age, sex, and smoking status were not associated with VTE. Patients who developed VTE had a higher body mass index (P = 0.04). Having more than 1 marker of heritable thrombophilia (P = 0.004) and an r-TEG mean amplitude greater than 72 mm postoperatively was positively associated with VTE (P = 0.02).

Conclusions: Among patients treated surgically for isolated pelvic and acetabular fractures who received enoxaparin prophylaxis, the presence of more than 1 marker of heritable thrombophilia or r-TEG mean amplitude value greater than 72 mm postoperatively was associated with an increased risk of VTE.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective: To determine how fracture clinic patients perceive the dangers of distracted driving.

Methods:

Design: Analysis of patient perception subset data from the original DRIVSAFE study; a large, multicenter cross-sectional study, surveying fracture clinic patients about distracted driving.

Setting: Four Level 1 Canadian trauma center fracture clinics.

Patient selection criteria: English-speaking patients with a valid Canadian driver's license and a traumatic musculoskeletal injury sustained in the past 6 months.

Outcome measures and comparisons: Primary outcome was patients' safety ratings of driving distractions. As per the original DRIVSAFE study, patients were categorized as distraction-prone or distraction-averse using their questionnaire responses and published crash-risk odds ratios (ORs). A regression analysis was performed to identify associations with unsafe driving perceptions.

Results: The study included 1378 patients, 749 (54.3%) male and 614 (44.6%) female. The average age was 45.8 ± 17.0 years (range 16-87). Sending electronic messages was perceived as unsafe by 92.9% (1242/1337) of patients, while reading them was seen as unsafe by 81.2% (1086/1337). Approximately three-quarters of patients viewed making (78.9%, 1061/1344) and accepting (74.8%, 998/1335) calls on handheld mobile phones as unsafe. However, 31.0% (421/1356) of patients believed that they had no differences in their driving ability when talking on the phone while 13.1% (175/1340) reported no driving differences when texting. Younger age (OR, 0.93 [95% confidence interval (CI) 0.90-0.96], P < 0.001), driving experience (OR, 1.06 [95% CI 1.02-1.09], P < 0.001), and distraction-prone drivers (OR, 3.79 [95% CI 2.91-4.94], P < 0.001) were associated with unsafe driving perceptions.

Conclusions: There is a clear association between being prone to distractions and unsafe driving perceptions, with distraction-prone drivers being 3.8 times more likely to perceive driving distractions as safe. This information could potentially influence the appropriate delivery and content of future educational efforts to change the perception of driving distractions and thereby reduce distracted driving.

Level of evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: This study aimed to profile modified Radiographic Union Scale for Tibia (mRUST) scores over time in distal femur fractures treated with intramedullary nails and identify predictors of radiographic union timing and delayed progression.

Methods: Design: Multicenter retrospective cohort study.

Setting: Ten Level I Trauma Centers.

Patient selection criteria: The inclusion criteria were patients with distal femur fractures (OTA/AO 33A and 33C) treated with intramedullary nails, with a minimum follow-up of one year or until radiographic union or reoperation. The exclusion criteria were fractures treated with combination nail-plate constructs, pathologic fractures, and patients under 18 years old.Outcome Measures and Comparisons: The primary outcome was the mRUST score at 3, 6, and 12 months post-operatively. Receiver operating characteristic (ROC) curve analysis identified the optimal 3-month mRUST score predicting reoperation. Multivariable models were used to identify predictors of radiographic union timing and delayed progression.

Results: The study included 155 fractures in 152 patients, with a mean patient age of 51 and a mean follow-up of 17 months. A 3-month mRUST score of ≤8 predicted reoperation with a PPV of 25%, and a NPV of 99%. The timing of radiographic union was associated with tobacco use (1.2 months later; p = 0.04), open fracture (1.4 months later; p = 0.04), and the use of topical antibiotics (2.1 months longer; 95% CI: 0.33 - 3.84; p = 0.02), however topical antibiotics was at high risk of being confounded by injury severity. Delayed progression to fracture healing, wherein the most rapid radiographic healing occurs more than 3 months post-operatively, was predicted by chronic kidney disease (p < 0.01).

Conclusions: A 3-month mRUST score >8 suggests a very high likelihood of avoiding reoperation for nonunion.Tobacco use and open fractures were associated with a longer time to radiographic union. Chronic kidney disease is associated with a delayed radiographic progression, suggesting a need for adjusted expectations and management strategies in these patients.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To assess patients' opioid prescription usage and pain management satisfaction after fracture surgery.

Methods: Design : An IRB-approved prospective prognostic cohort study for postoperative fracture patients was conducted. Patients were evaluated by an independent observer at two weeks, six weeks, three months, and six months postoperatively where they were given Detroit Interventional Pain Assessment (DIPA) questionnaires regarding their postoperative pain and opioid usage. Opioid prescriptions were verified by Michigan Automated Prescription System. All patients were divided into major fractures (tibia, femur, acetabulum, pelvis, calcaneus, talus, and polytrauma) and minor fractures (scapula, clavicle, humerus, radius, ulna, scaphoid, carpal/metacarpal, patella, fibula, ankle, and metarsal) and were followed for two years.

Setting: Single-Center Level One Trauma Center.

Patient selection criteria: Patients presenting to clinic over a six month period were invited to participate in this study. Patients who did not consent were excluded.

Outcome measures and comparisons: Outcome measures were the amount of prescribed opioids in daily Milligram Morphine equivalents (MMEs), opioid usage, DIPA pain scores, pain management efficiency (percentage of patients reporting no pain or tolerable pain with their regimen). Prescribed MMEs, pain management efficiency scores, and the percentage of patients using opioids were compared across all postoperative periods.

Results: For 201 fracture patients, the average age was 47.8 ± 16.3 SD (18-87 years) and there were 116 males (57.8%) and 85 females (42.2%). The percentage of patients using opioids and their daily prescribed MMEs significantly decreased from two weeks (48.2%, 21.6 MMEs) to six months (10.3%, 8.13 MMEs) (P < 0.001). Fifty-one percent of patients were off opioids at two weeks, 64.5% at six weeks, 84.2% at three months, and 89.7% at six months. All opioid prescriptions at six months and two years were prescribed to polytrauma patients who underwent sequential surgeries and these prescriptions originated from outside prescribers. Pain management efficiency scores were worst at two weeks (67.2%) but improved at three months (82.6%).

Conclusions: As patients transitioned further from their surgical date, there was a decrease in opioid prescriptions and patient reported opioid usage. Despite the opioid tapering practices by surgeons, polytrauma patients still received prescriptions from outside prescribers for orthopaedic aftercare after three months, signaling the necessity for patients to see outside prescribers for their pain management after this time.

Level of evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.