Open distal tibial shaft fractures: a retrospective comparison of medial plate versus nail fixation

Purpose

Studies comparing open reduction internal fixation (ORIF) vs. intramedullary nailing (IMN) for distal tibia shaft fractures focus upon closed injuries containing small patient series with open fractures. As such, complication rates for open fractures are unknown. To characterize complications associated with ORIF vs. IMN, we compared complications based on surgical approach in a large patient series of open distal tibia shaft fractures.

Methods

Through retrospective analysis at an urban level I trauma center, 180 IMN and 36 ORIF patients with open distal tibia fractures from 2002 to 2012 were evaluated. Patient charts were reviewed to identify patient demographics, fracture grade (G), patient comorbidities, and postoperative complications including nonunion, malunion, infection, hardware-related pain, and wound dehiscence. Fisher’s exact tests compared complications between ORIF and IMN groups. Multivariate regression identified risk factors with statistical significance for the development of a postoperative complication.

Results

One hundred and eighty IMN (G1 22, G2 79, and G3 79) and 36 ORIF (G1 10, G2 16, and G3 10) patients were included for analysis. ORIF patients had a higher rate of nonunion (25.0 %, n = 9) compared with IMN patients (10.6 %, n = 20, p = 0.03). No additional complication had a significant statistical difference between groups. Multivariable analysis shows only surgical method influenced the development of complications: ORIF patients had 2.52 greater odds of developing complications compared with IMN patients (95 % CI 1.05–6.02; p = 0.04).

Conclusions

ORIF leads to higher rates of nonunion and significantly increases the odds of developing a complication compared with IMN for open distal tibia fractures. This is the first study investigating complication rates based on surgical approach in a large cohort of patients with exclusively open distal tibia fractures.

     

Variation in Frequency of Intraoperative Arterial,Central Venous and Pulmonary Artery Catheter Placement During Kidney Transplantation: An Analysis of Invasive Monitoring Trends

The rapidly increasing number of kidney transplantations warrants assessment of anesthesia care in this patient population. We explored the frequency of arterial catheter (AC), central venous catheter (CVC) and pulmonary artery catheter (PAC) placement during kidney transplantation in the USA using data from the National Anesthesia Clinical Outcomes Registry (NACOR) and assessed the between-facility variation in the frequency of catheter placement. We defined cases of kidney transplantation using Agency for Healthcare Research and Quality Clinical Classification Software. Placement of AC, CVC and PAC was defined by respective Current Procedural Terminology codes. The frequency of vascular catheter placement across facility types was compared using Pearson χ2 test. We identified 10,580 cases of kidney transplantation performed in 100 facilities from January 1, 2010 to December 31, 2014. Placement of an AC was reported in 1700 (16.1%), CVC in 2580 (24.4%) and PAC in 50 (0.5%) of cases. The frequency of placement of specific types of catheters was statistically different across facility types (p?<?0.001). Within individual facilities that reported at least 50 cases of kidney transplantation, the percentages of cases performed with AC, CVC and PAC ranged from 0% to 86%, 0% to 90% and 0% to 3%, respectively. Considerable between-facility variation in the frequency of AC, CVC and PAC placement during kidney transplantation raises concerns about the need for better practice standardization. Excess invasive monitoring may represent a safety risk as well as unnecessary additional cost. If kidney transplantation can be safely performed without an AC, CVC or PAC in most patients, facilities with above-average catheter placement rates may have an opportunity for measurable reduction in catheter-related perioperative complications. Optimizing perioperative monitoring is an important component of ensuring high functioning, high-value medical systems.     

Gunshot Victims at a Major Level I Trauma Center: A Study of 343,866 Emergency Department Visits

Background

Disturbing trends regarding the sex, age, and race of gunshot victims have been reported in previous national studies; however, gunshot trends have not been well documented in individual cities in the southeastern United States.

Objectives

1) Analyze trends in gunshot wounds, particularly the association between gunshot wounds and race, among victims presenting to a Level I Trauma Center in Middle Tennessee; 2) Compare specific characteristics of gunshot victims to the general Emergency Department (ED) population.

Methods

This is a retrospective cohort study of 343,866 ED visits from 2004 to 2009.

Results

Compared to the general ED population, gunshot victims were more predominantly male (87.5% vs. 43.4%), black (57.6% vs. 29.5%), younger (47.8% under age 25 years vs. 31.6%), and demonstrated higher Medicaid enrollment (78.6% vs. 44.7%). The majority of black gunshot victims were aged 18–25 years (47.1%) and victims of assault (65.9%). Non-black gunshot victims suffered more unintentional (40.2% vs. 28.2%) and self-inflicted (9.1% vs. 0.4%) injuries and were more evenly distributed among ages 18–55 years. Black patients were 3.03 (95% confidence interval 2.93–3.14) times more likely to present to this ED for gunshot wounds than non-black patients, after controlling for age, sex, and insurance status (p < 0.001).

Conclusions

Our study demonstrates that black patients between 18 and 25 years of age presenting to this trauma center are more likely to be victims of gun violence than their non-black counterparts. Our study evaluates trends in gun violence in the Southeast, particularly in relation to race, age, and insurance status.     

Social correlates of satisfaction and stress among Israeli nurses within intensive coronary care units (I.C.C.U.s)

This study focuses on job satisfaction and work-related stress of nurses within the Israeli I.C.C.U.--a complex technological environment. The main purpose was to assess the contribution of multiple factors which may be associated with the nurses' level of satisfaction and stress. These factors include personal characteristics and professional attributes of the nurse, as well as some objective and subjective characteristics of their work setting. In general, with the exception of income, nurses are satisfied. Stress presents a big problem in the I.C.C.U. Structure of work was found to be correlated with satisfaction, but only partially with stress. It was deduced that nurses are willing to 'pay the price' of professionalization: to work under stress and yet be autonomous, take responsibility for work decisions, and be highly involved in work, thus gaining satisfaction.     

A new technique for transcrestal sinus floor elevation with press-fit bone cylinders (dowel lift): short communication of the first in vitro results]

The minimally invasive sinus floor elevation as first described by Summers is limited in augmentation volume, whereas a more invasive approach is required for the technique of Tatum for larger bone defects. We developed a new technique for the transcrestal elevation of the sinus floor with bone dowels using a press-fit technique (dowel lift). We present the technique with first in vitro results in a fresh, unpreserved, human cadaver.     

Enzymatic activity of poliovirus RNA polymerase synthesized in Escherichia coli from viral cDNA

Plasmids have been constructed that contain DNA sequences that direct the expression of the poliovirus RNA-dependent RNA polymerase, in the form of recombinant fusion proteins. Inclusion of an additional gene for the poliovirus protease results in cleavage of the fusion protein to yield a 52-kDa, enzymatically active, polymerase protein, apparently identical to the functional enzyme isolated from virus-infected HeLa cells. A large amount of polymerase protein accumulates as particulate or insoluble material in bacteria, and this protein has little or no activity. However, significant amounts of soluble, active enzyme are recovered, such that the resulting specific activity of crude bacterial extracts is greater than that obtained from virus-infected HeLa cells. Purification of the enzyme from Escherichia coli is readily accomplished, and yields a preparation that will copy poliovirion RNA as template, in the presence of oligo(U) primer. The availability of cloned DNA sequences encoding catalytically active RNA polymerase will allow genetic manipulations to initiate structure-function studies of this enzyme.     

Late results following operative repair for celiac artery compression syndrome

The clinical significance of celiac artery compression by the median arcuate ligament of the diaphragm remains unsettled. The controversy stems from an undefined pathophysiologic mechanism and the existence of celiac compression in asymptomatic patients. This study was therefore conducted to evaluate the late results of operative therapy among our patients and possibly to identify parameters that might correlate with sustained symptom relief. Among 51 patients (12 men and 39 women) (mean age 47 years) who underwent operative treatment for symptomatic celiac artery compression, 44 (86%) were available for late follow-up. Their clinical status was determined between 1 and 18 years postoperatively (mean 9.0 years) by patient interview (36) or chart review (7). Operative treatment consisted of celiac axis decompression only (16 patients), celiac decompression and dilatation (17 patients), or celiac decompression and reconstruction by primary reanastomosis or interposition grafting (18 patients). Sustained symptom relief occurred more often with a postprandial pain pattern (81% cure), age between 40 and 60 years (77%), and weight loss of 20 pounds or more (67%). A negative correlation with clinical improvement was demonstrated for an atypical pain pattern with periods of remission (43% cure), a history of psychiatric disorder or alcohol abuse (40%), age greater than 60 years (40%), and weight loss of less than 20 pounds (53%). Eight of 15 patients (53%) treated by celiac decompression alone remained asymptomatic at late follow-up in contrast to 22 of 29 patients (76%) treated by celiac decompression plus some form of celiac revascularization. Late follow-up arteriograms (18 studies) showed a widely patent celiac artery in 70% of asymptomatic patients but a stenosed or occluded celiac axis in 75% of symptomatic patients. These findings suggest that persistent clinical improvement in patients with symptomatic celiac axis compression can be achieved by an operative technique that ensures celiac axis patency. Although some clinical features are identified that correlate with long-term benefit, reliable diagnosis of the symptomatic patient awaits definition of the pathophysiologic mechanisms involved in this syndrome.     

Clinical spectrum of symptomatic external iliac fibromuscular dysplasia

External iliac fibromuscular dysplasia is a rare and usually asymptomatic disorder. We report eight symptomatic patients seen over a 15-year period and review pathophysiologic mechanisms accounting for the three following distinct lower extremity ischemic sequelae: (1) Emboli--episodic focal digital ischemia (blue toe) was seen in three patients. Resection and primary anastomosis of focal iliac ulcerative fibromuscular dysplasia (one patient) or resection and replacement (two patients) removed the embolic source and relieved the symptoms. (2) Chronic ischemia--gradual onset of full leg claudication in four patients was treated by operative graduated intraluminal dilation in three patients and prosthetic bypass in one. Arteriography subsequently showed a remodeled lumen in the three patients who underwent dilation. (3) Dissection--acute onset leg ischemia resulted from presumed dissection of the external iliac segment. After 4 months of conservative management of antiplatelet agents and exercise, symptoms resolved completely, and arteriogram showed spontaneous restoration of a normal lumen in the dissected segment. The clinical presentation of fibromuscular dysplasia may mimic other arterial processes such as atherosclerosis. Diagnosis is made only by arteriography with specific magnification views of the external iliac arteries and careful surveillance of the renal arteries. Appropriate treatment should be tailored to the clinical presenting symptom. For microembolic disease, resection and replacement are required. For chronic ischemia, intraluminal dilation is generally sufficient and durable and has proved to be a simpler and acceptable alternative to replacement or bypass. In acute dissection, surgical intervention may be deferred if the limb is viable to allow spontaneous healing and remodeling. Persistent symptoms may be the only indication for intervention in this ischemic manifestation of external iliac fibromuscular dysplasia.