Publications by authors named "Anjan Shah"

45 Publications

Inferior alveolar nerve dysfunction in mandibular fractures: a prospective cohort study.

J Korean Assoc Oral Maxillofac Surg 2021 Jun;47(3):183-189

Department of Oral and Maxillofacial Surgery, Rajarajeshwari Dental College, Bangalore, India.

Objectives: To assess the prevalence and recovery of inferior alveolar nerve dysfunction (IAND) in mandibular fractures.

Materials And Methods: : This was a prospective cohort study. Clinical neurosensory testing was done preoperatively and the IAND was categorized as mild, moderate or severe. Postoperatively, neurosensory testing was repeated at 1 day, 1 week, 1 month, 3 months and every 3 months thereafter.

Results: : A total of 257 patients with 420 fractures were included in the study with a mean age of 31.7 years. Body fractures (95.9%) had the highest incidence of IAND, followed by the angle fractures (90.1%) and symphysis fractures (27.6%). The condyle and coronoid fractures did not have any IAND and hence were excluded from further study. After eliminating those cases, 232 patients remained in the study with 293 fractures. The overall prevalence of IAND in fractures occurring distal to the mandibular foramen was 56.3%. The changes until 1 week were minimal. From 1 month to 6 months, there was a significant reduction in the severity of IAND. A significant number of cases (60.0%) were lost to follow-up between 6 and 9 months. At 6 months, 23.9% of cases still had some form of IAND and 95.0% of the symphysis, 59.0% of the angle and 34.8% of the body fractures with IAND had become normal.

Conclusion: This study documents the reduction in the degree of severity of IAND in the first six months and provides the basis for future studies with longer periods of follow-up.
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http://dx.doi.org/10.5125/jkaoms.2021.47.3.183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8249188PMC
June 2021

Partial superficial parotidectomy for pleomorphic adenoma of the parotid gland.

BMJ Case Rep 2021 Jun 14;14(6). Epub 2021 Jun 14.

Department of Conservative Dentistry and Endodontics, Melaka Manipal Medical College, Bukit Baru, Melaka, Malaysia.

Pleomorphic adenoma, otherwise called as benign mixed tumour, is the most common salivary gland tumour which accounts for 60% of all benign salivary gland tumours. The clinical, radiological and histopathological presentations are varied. The tumour occurs in diverse anatomical sites and can consist of epithelial and mesenchymal components. In this case report, the patient reported with an asymptomatic swelling on the face. CT scan with contrast was advised. The clinical, roentgenographic findings and Fine Needle Aspiration Cytology were indicative of pleomorphic adenoma of the parotid gland. Treatment included partial superficial parotidectomy under general anaesthesia using the modified Blair's incision. The facial nerve was not involved. Part of the gland along with the tumour was resected completely superficial to the facial nerve with a margin of normal tissue all around. Histopathologic examination of tissue specimen confirmed the lesion as pleomorphic adenoma. The patient was asymptomatic at 6-month follow-up.
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http://dx.doi.org/10.1136/bcr-2020-238759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8204181PMC
June 2021

Quality of life assessment in patients with long-term neurosensory dysfunction after mandibular fractures.

Minerva Dent Oral Sci 2021 Apr 30. Epub 2021 Apr 30.

Department of Oral and Maxillofacial Surgery, JSS Dental College, JSS Academy of Higher Education and Research, Mysore, India.

Background: Long-term neurosensory dysfunction after mandibular fractures can have a significant impact on daily performances and quality of life (QoL) of the patient. The daily activities such as eating, speaking, shaving, kissing, and other social interactions can be affected due to the impaired sensation in the face and lip region.

Methods: A cross-sectional QoL assessment was done for the patients with inferior alveolar nerve dysfunction (IAND) from mandibular fractures at the 6-month follow-up visit. An interviewer-administered Oral Impacts on Daily Performances (OIDP) questionnaire was used. The OIDP scores were compared against the age and the severity of IAND.

Results: A total of 232 patients with mandibular fractures were initially examined, out of which 145 patients had IAND. At the end of 6 months, 52 patients still had some form of IAND and were included in this study. In our study, most affected activities were eating food (96.2%) and speaking clearly (98.1%) whereas the least affected were relaxing (9.6%) and doing major work (9.6%). Smiling (p<0.001), emotional state (p<0.001), and contact of other (p=0.02) were affected significantly more in younger patients than in older patients. Patients who had severe IAND at 6 months had problems with activities like cleaning teeth (p=0.04), doing light physical activity (p=0.007), going out (p=0.003), sleeping (p=0.012), and relaxing (p=0.03).

Conclusions: Long-term IAND causes a significant impact on daily activities. This impact on QoL is particularly high and more frequent in the younger age group and patients with more severe IAND.
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http://dx.doi.org/10.23736/S2724-6329.21.04462-9DOI Listing
April 2021

Barrier Devices, Intubation, and Aerosol Mitigation Strategies: Personal Protective Equipment in the Time of Coronavirus Disease 2019.

Anesth Analg 2021 01 15;132(1):38-45. Epub 2020 Sep 15.

From the Department of Anesthesiology, Perioperative & Pain Medicine.

Background: Numerous barrier devices have recently been developed and rapidly deployed worldwide in an effort to protect health care workers (HCWs) from exposure to coronavirus disease 2019 (COVID-19) during high-risk procedures. However, only a few studies have examined their impact on the dispersion of droplets and aerosols, which are both thought to be significant contributors to the spread of COVID-19.

Methods: Two commonly used barrier devices, an intubation box and a clear plastic intubation sheet, were evaluated using a physiologically accurate cough simulator. Aerosols were modeled using a commercially available fog machine, and droplets were modeled with fluorescein dye. Both particles were propelled by the cough simulator in a simulated intubation environment. Data were captured by high-speed flash photography, and aerosol and droplet dispersion were assessed qualitatively with and without a barrier in place.

Results: Droplet contamination after a simulated cough was seemingly contained by both barrier devices. Simulated aerosol escaped the barriers and flowed toward the head of the bed. During barrier removal, simulated aerosol trapped underneath was released and propelled toward the HCW at the head of the bed. Usage of the intubation sheet concentrated droplets onto a smaller area. If no barrier was used, positioning the patient in slight reverse Trendelenburg directed aerosols away from the HCW located at the head of the bed.

Conclusions: Our observations imply that intubation boxes and sheets may reduce HCW exposure to droplets, but they both may merely redirect aerosolized particles, potentially resulting in increased exposure to aerosols in certain circumstances. Aerosols may remain within the barrier device after a cough, and manipulation of the box may release them. Patients should be positioned to facilitate intubation, but slight reverse Trendelenburg may direct infectious aerosols away from the HCW. Novel barrier devices should be used with caution, and further validation studies are necessary.
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http://dx.doi.org/10.1213/ANE.0000000000005249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523478PMC
January 2021

Using Simulation to Develop Solutions for Ventilator Shortages From the Epicenter.

Simul Healthc 2021 Feb;16(1):78-79

From the Department of Anesthesiology, Perioperative & Pain Medicine (G.W.B., A.S., E.A.F., C.Y.L., M.L.), Icahn School of Medicine at Mount Sinai; and Department of Anesthesiology & Critical Care Medicine (R.S.), Memorial Sloan Kettering Cancer Center, New York, NY.

Summary Statement: The COVID-19 pandemic threatened to overwhelm the medical system of New York City, and the threat of ventilator shortages was real. Using high-fidelity simulation, a variety of solutions were tested to solve the problem of ventilator shortages including innovative designs for safely splitting ventilators, converting noninvasive ventilators to invasive ventilators, and testing and improving of ventilators created by outside companies. Simulation provides a safe environment for testing of devices and protocols before use on patients and should be vital in the preparation for emergencies such as the COVID-19 pandemic.
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http://dx.doi.org/10.1097/SIH.0000000000000523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853722PMC
February 2021

"Unstable" Pediatric Femoral Shaft Fractures Treated With Flexible Elastic Nails Have Few Complications.

J Orthop Trauma 2021 02;35(2):e56-e60

Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and.

Objectives: To determine our complication rate in pediatric femoral shaft fractures treated with flexible elastic nailing and to determine fracture characteristics that may predict complications.

Design: Retrospective cohort study.

Setting: One Level 1 and One Level 2 academic trauma centers.

Patients/participants: One hundred one pediatric femoral shaft fractures treated from 2006 to 2018.

Main Outcome Measurement: Major and minor complications.

Results: One hundred one femurs met inclusion criteria. The average age was 7 years (range 3-12 years). The average weight was 29.0 kg (range 16-55 kg). The average follow-up was 11 months (6-36 months). Ninety-three patients underwent elective implant removal at our institution. Fifty-one of the 101 (50%) fractures were "unstable" patterns. Ninety-three percent had implants that filled >80% of the canal (69 titanium and 32 stainless steel). Seventeen percent (18) had cast immobilization. All fractures went on to union. No patient required revision surgery for malunion as follows: 6 had coronal/sagittal malalignment >10 degrees, 3 had malrotation >15 degrees, and none had a leg length inequality >1 cm. Three patients had an unplanned surgery as follows: 2 for prominent implants and 1 for refracture after a second injury. There were no patient, fracture, or treatment characteristics that were predictive of complications or unplanned surgery, including "unstable" fractures (P = 0.78).

Conclusion: Our study demonstrates that flexible elastic nailing can be safely used in most pediatric femoral shaft fractures, including those previously described as "unstable."

Level Of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001886DOI Listing
February 2021

Quality of Reduction of Displaced Intra-articular Calcaneal Fractures Using a Sinus Tarsi Versus Extensile Lateral Approach.

J Orthop Trauma 2021 06;35(6):285-288

Florida Orthopaedic Institute, Tampa, FL.

Objective: To evaluate the difference in the quality of fracture reduction between the sinus tarsi approach (STA) and extensile lateral approach (ELA) using postoperative Computed Tomography (CT) scans in displaced intra-articular calcaneal fractures (DIACFs).

Design: Retrospective.

Setting: Level 1 and level 2 academic centers.

Patients: Consecutive patients undergoing operative fixation of DIACFs with postoperative CT scans and standard radiographs.

Methods: Patients were identified based on Current Procedural Terminology code and chart review. All operative calcaneal fractures treated between 2012 and 2018 by fellowship-trained orthopaedic trauma surgeons were evaluated. Those with both postoperative CT scans and radiographs were included. Exclusion criteria included extra-articular fractures, malunions, percutaneous fixation, ORIF and primary fusion, and those patients without a postoperative CT scan. The Sanders classification was used. Cases were divided into 2 groups based on ELA versus STA. Bohler angle and Gissane angle were evaluated on plain radiographs. CT reduction quality grading included articular step off/gap within the posterior facet, and varus angulation of the tuberosity: CT reduction grading included: excellent (E): no gap, no step, and no angulation; good (G): <1 mm step, <5 mm gap, and/or <5° of angulation, fair (F): 1-3 mm step, 5-10 mm gap, and/or 5-15° angulation; and poor (P): >3 mm step, >10 mm gap, and/or >15° angulation.

Results: Seventy-seven patients with 83 fractures were included. Average age was 42 years (range, 18-74 years), with 57 men. Four fractures were open. There were 37 Sanders II and 46 Sanders III fractures; 36 fractures were fixed using the STA, whereas 47 used the ELA. Average days to surgery were 5 for STA and 14 for ELA (P < 0.001). A normal Bohler angle was achieved more often with the ELA (91.5%) than with STA (77.8%) (P < 0.001). There was no difference by approach for Gissane angle (P = 0.5). ELA had better overall reduction quality (P = 0.02). For Sanders II, there was no difference in reduction quality with STA versus ELA (P = 0.51). For Sanders III, ELA trended toward better reduction quality (P = 0.06).

Conclusions: The ELA had a better overall reduction of Bohler angle on plain radiographs and of the posterior facet and tuberosity on postoperative CT scans. For Sanders type II DIACFs, there was no difference between STA and ELA. Importantly, for Sanders III DIACFs, ELA trended toward better reduction quality. In addition to fracture reduction, surgeon learning curve, early wound complications, and long-term outcomes must be considered in future studies comparing the ELA and STA.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001971DOI Listing
June 2021

Guidelines for the Responsible Use of Deception in Simulation: Ethical and Educational Considerations.

Simul Healthc 2020 Aug;15(4):282-288

From the Department of Pediatrics (A.C.), University of Louisville School of Medicine, Louisville, KY; Department of Anesthesia (M.P.-S.), Harvard Medical School, Boston, MA; Department of Anesthesia (A.S., A.L., S.D., A.G.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Anesthesia (D.G.), Stanford University School of Medicine, Stanford, CA; and Department of Psychiatry and Center for Bioethics (E.M.), Harvard Medical School, Boston, MA.

Statement: Many techniques and modifications commonly used by the simulation community have been identified as deceptive. Deception is an important issue addressed by both the newly adopted Healthcare Simulationist Code of Ethics and the American Psychological Association Code of Conduct. Some view these approaches as essential whereas others question their necessity as well as their untoward psychological effects. In an attempt to offer guidance to simulation-based healthcare educators, we explore educational practices commonly identified as deceptive along with their potential benefits and detriments. We then address important decision points and high-risk situations that should be avoided to uphold ethical boundaries and psychological safety among learners. These are subsequently analyzed in light of the Code of Ethics and used to formulate guidelines for educators that are intended to ensure that deception, when necessary, is implemented in as psychologically safe a manner as possible.
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http://dx.doi.org/10.1097/SIH.0000000000000440DOI Listing
August 2020

Differential Ventilation Using Flow Control Valves as a Potential Bridge to Full Ventilatory Support during the COVID-19 Crisis.

Anesthesiology 2020 10;133(4):892-904

Background: During the COVID-19 pandemic, ventilator sharing was suggested to increase availability of mechanical ventilation. The safety and feasibility of ventilator sharing is unknown.

Methods: A single ventilator in pressure control mode was used with flow control valves to simultaneously ventilate two patients with different lung compliances. The system was first evaluated using high-fidelity human patient simulator mannequins and then tested for 1 h in two pairs of COVID-19 patients with acute respiratory failure. Patients were matched on positive end-expiratory pressure, fractional inspired oxygen tension, and respiratory rate. Tidal volume and peak airway pressure (PMAX) were recorded from each patient using separate independent spirometers and arterial blood gas samples drawn at 0, 30, and 60 min. The authors assessed acid-base status, oxygenation, tidal volume, and PMAX for each patient. Stability was assessed by calculating the coefficient of variation.

Results: The valves performed as expected in simulation, providing a stable tidal volume of 400 ml each to two mannequins with compliance ratios varying from 20:20 to 20:90 ml/cm H2O. The system was then tested in two pairs of patients. Pair 1 was a 49-yr-old woman, ideal body weight 46 kg, and a 55-yr-old man, ideal body weight 64 kg, with lung compliance 27 ml/cm H2O versus 35 ml/cm H2O. The coefficient of variation for tidal volume was 0.2 to 1.7%, and for PMAX 0 to 1.1%. Pair 2 was a 32-yr-old man, ideal body weight 62 kg, and a 56-yr-old woman, ideal body weight 46 kg, with lung compliance 12 ml/cm H2O versus 21 ml/cm H2O. The coefficient of variation for tidal volume was 0.4 to 5.6%, and for PMAX 0 to 2.1%.

Conclusions: Differential ventilation using a single ventilator is feasible. Flow control valves enable delivery of stable tidal volume and PMAX similar to those provided by individual ventilators.

Editor’s Perspective:
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http://dx.doi.org/10.1097/ALN.0000000000003473DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359901PMC
October 2020

Management of Ameloblastoma with Free Tissue Flap in Comparison with Other Reconstructive Options Available.

J Maxillofac Oral Surg 2020 Jun 23;19(2):283-288. Epub 2019 Apr 23.

Department of Oral and Maxillofacial Surgery, Bhagwan Mahaveer Jain Hospital, 17, Millers Road, Kaverappa Layout, Vasanthnagar, Bengaluru, Karnataka 560052 India.

Aim: To review the management and reconstruction of ameloblastoma of mandible in different age groups over a period of 11 years.

Methodology: This retrospective study includes 51 cases operated in the Maxillofacial Unit, Bhagwan Mahaveer Jain Hospital, Bangalore, from the year 2007 to 2017. The data of these patients were collected to record demographic data such as age, gender with site of tumour and type of reconstruction after resection, follow-up period and incidence of complications. This study evaluated the outcome in terms of aesthetics, function and choice of reconstruction in different age groups.

Results: Most patients were of 21-40 age group. 37 (72.5%) were found to be unicystic ameloblastoma. 41 (80.3%) patients underwent reconstruction following the resection. There was a change in trend seen over a period of time with free grafts and reconstruction plate being historical, except in special situations like old age and unfit patients. According to one-way ANOVA and Tukey's post hoc analysis, free flaps were known to take a longer duration (mean = 503 min) compared to other modes of reconstruction. However, free grafts and free flaps were demonstrated to have a good facial contour and speech with most cases dentally rehabilitated with implants. Among the complications, 1 (16%) case with reconstruction plate showed screw loosening, 2 (28%) cases with free grafts showed graft exposure, and 1 (3.5%) case with free flap had venous congestion, making free flaps the most reliable option.

Conclusion: Free fibula is the gold standard of mandible reconstruction, but depending on age, medical condition, economic status and size of the defect other modes of reconstruction can be chosen with the acceptance of suboptimal results.
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http://dx.doi.org/10.1007/s12663-019-01203-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7176769PMC
June 2020

Utilization of a Voice-Based Virtual Reality Advanced Cardiac Life Support Team Leader Refresher: Prospective Observational Study.

J Med Internet Res 2020 03 12;22(3):e17425. Epub 2020 Mar 12.

Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States.

Background: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison.

Objective: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS.

Methods: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed.

Results: A total of 23 of 25 participants were included in the scoring analysis. Fewer participants were familiar with VR compared with HFS (9/25, 36% vs 25/25, 100%; P<.001). Self-reported satisfaction and utilization scores were similar; however, significantly more participants felt HFS provided better feedback: 99 (IQR 89-100) vs 79 (IQR 71-88); P<.001. Technical scores were higher in the HFS group; however, nontechnical scores for decision making and communication were not significantly different between modalities. VR sessions were 21 (IQR 19-24) min shorter than HFS sessions, the National Aeronautics and Space Administration task load index scores for proctors were lower in each category, and VR sessions were estimated to be US $103.68 less expensive in a single-learner, single-session model.

Conclusions: Utilization of a VR-based team leader refresher for ACLS skills is comparable with HFS in several areas, including learner satisfaction. The VR module was more cost-effective and was easier to proctor; however, HFS was better at delivering feedback to participants. Optimal education strategies likely contain elements of both modalities. Further studies are needed to examine the utility of VR-based environments at scale.
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http://dx.doi.org/10.2196/17425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7099400PMC
March 2020

Locking Screws With a Threaded Degradable Polymer Collar Reduce Construct Stiffness Over Time.

J Orthop Trauma 2020 Mar;34(3):151-157

Stabiliz Orthopaedics, Exton, PA.

Objectives: The stiffness of locking plates provide increased stability for early fracture healing but may limit late interfragmentary motion (IFM) necessary for secondary bone healing. An ideal plating construct would provide early rigidity and late flexibility to optimize bone healing. A novel screw plate construct utilizing locking screws with a degradable polymer locking mechanism is a dynamic option.

Methods: Conventional locked plating constructs (group A) were compared with locking screws with a threaded degradable polymer collar before (group B) and after polymer dissolution (group C). Monotonic axial compression, monotonic torsion, cyclic axial load to failure, and IFM at the near and far cortices were tested on synthetic bone models.

Results: One-way analysis of variance and post hoc Tukey-Kramer testing demonstrated similar axial stiffness in group A (873 ± 146 N/mm) and B (694 ± 314 N/mm) but significantly less stiffness in group C (379 ± 59 N/mm; F(2,15) = 9.12, P = 0.003). Groups A and B also had similar IFM, but group C had significantly increased IFM at both the near (F(2, 15) = 48.66, P = 2.76E-07) and far (F(2, 15) = 11.78, P = 0.0008) cortices. In cyclic axial load to failure, group A (1593 ± 233 N) and B (1277 ± 141 N) were again similar, but group C was significantly less (912 ± 256 N; F(2, 15) = 15.00, P = 0.0003). All failures were above the 500-N threshold seen in typical weight-bearing restrictions for fracture care. Torsional stiffness demonstrated significant differences between all groups (F(2, 15) = 106.64, P = 1.4E-09).

Conclusions: Use of locking plates with a degradable polymer collar show potential for in vitro construct dynamization. Future in vivo studies are warranted to assess performance under combined loading and the effects of decreasing construct stiffness during the course of bony healing.
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http://dx.doi.org/10.1097/BOT.0000000000001664DOI Listing
March 2020

Modern Results of Functional Bracing of Humeral Shaft Fractures: A Multicenter Retrospective Analysis.

J Orthop Trauma 2020 04;34(4):206-209

Orthopaedic Trauma Service, Florida Orthopaedic Institute and University of South Florida, Tampa, FL.

Objectives: To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention.

Design: Multicenter, retrospective analysis.

Setting: Nine Level 1 trauma centers across the United States.

Patients: A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions.

Intervention: Functional brace.

Main Outcome Measurements: Conversion to surgery.

Results: A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion.

Conclusions: This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001666DOI Listing
April 2020

Iatrogenic Nerve Palsy Occurs With Anterior and Posterior Approaches for Humeral Shaft Fixation.

J Orthop Trauma 2020 Mar;34(3):163-168

Orthopaedic Trauma Service, Florida Orthopaedic Institute, University of South Florida, Tampa, FL; and.

Objective: To determine if surgical approach impacts the rate of nerve palsy after plate fixation of humerus shaft fractures and whether or not iatrogenic nerve palsy recovers in similar ways to preoperative palsy.

Design: Retrospective.

Setting: Two trauma centers.

Patients: Patients 18+ years of age with nonpathologic, extra-articular humerus shaft fractures (OTA/AO 12A/B/C and 13A2-3) treated with plate fixation.

Intervention: Plate fixation of humerus shaft fractures, from 2008 to 2016.

Main Outcome Measurement: Rate of iatrogenic nerve palsy by a surgical approach and injury characteristics.

Results: Two hundred sixty-one humeral shaft fractures were included. The rate of preoperative palsy was 19%. Radial nerve palsy (RNP) was present in 18%. Iatrogenic RNP occurred in 12.2% and iatrogenic ulnar palsy in 1.2%. Iatrogenic palsy occurred in 15.6% of middle and 15% of distal fractures, with fracture location significantly different in those developing RNP (P = 0.009). Iatrogenic RNP occurred in 7.1% of anterolateral, 11.7% of posterior triceps-splitting, and 17.9% of posterior triceps-sparing approaches (P = 0.11). Follow-up data were available for 139 patients at an average of 12 months. Preoperative RNP resolved less often than iatrogenic RNP, in 74% versus 95% (P = 0.06). Time to resolution was longer for preoperative RNP, at 5.5 versus 4.1 months (P = 0.91). Twenty-two percent with preoperative RNP underwent tendon transfer or wrist fusion, versus 0% after iatrogenic RNP (P = 0.006).

Conclusion: Iatrogenic RNP is not uncommon with humeral fracture fixation and occurs at similar rates in anterior and posterior approaches and with midshaft and distal fractures. Iatrogenic RNP had a high rate of recovery. Preoperative RNP more often requires surgery for unresolved palsy.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001658DOI Listing
March 2020

Survey of regional anesthesiology fellowship directors in the USA on the use of simulation in regional anesthesiology training.

Reg Anesth Pain Med 2019 Sep 16. Epub 2019 Sep 16.

Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA.

Background: Despite a growing interest in simulated learning, little is known about its use within regional anesthesia training programs. In this study, we aimed to characterise the simulation modalities and limitations of simulation use for US-based resident and fellow training in regional anesthesiology.

Methods: An 18-question survey was distributed to regional anesthesiology fellowship program directors in the USA. The survey aimed to describe residency and fellowship program demographics, modalities of simulation used, use of simulation for assessment, and limitations to simulation use.

Results: Forty-two of 77 (54.5%) fellowship directors responded to the survey. Eighty per cent of respondents with residency training programs utilized simulation for regional anesthesiology education, while simulation was used for 66.7% of fellowship programs. The most common modalities of simulation were gel phantom models (residency: 80.0%, fellowship: 52.4%) and live model scanning (residency: 50.0%, fellowship: 42.9%). Only 12.5% of residency programs and 7.1% of fellowship programs utilized simulation for assessment of skills. The most common greatest limitation to simulation use was simulator availability (28.6%) and funding (21.4%).

Conclusions: Simulation use for education is common within regional anesthesiology training programs, but rarely used for assessment. Funding and simulator availability are the most common limitations to simulation use.
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http://dx.doi.org/10.1136/rapm-2019-100719DOI Listing
September 2019

Simulation-Based Education and Team Training.

Otolaryngol Clin North Am 2019 Dec 13;52(6):995-1003. Epub 2019 Sep 13.

Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Klingenstein Clinical Center 8th Floor, PO Box 1010, New York, NY 10029, USA.

Simulation-based education (SBE) has become pervasive in health care training and medical education, and is even more important in subspecialty training whereby providers such as otolaryngologists and anesthesiologists share overlapping patient concerns because of the proximity of the surgical airway. Both these subspecialties work in a fast-paced environment involving high-stakes situations and life-changing events that necessitate critical thinking and timely action, and have an exceedingly small bandwidth for error. Team training in the form of interprofessional education and learning involving surgeons, anesthesiologists, and nursing is critical for patient safety in the operating room in general, but more so in otolaryngology surgery.
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http://dx.doi.org/10.1016/j.otc.2019.08.002DOI Listing
December 2019

Effect of Nail Size, Insertion, and Δ Canal-Nail on the Development of a Nonunion After Intramedullary Nailing of Femoral Shaft Fractures.

J Orthop Trauma 2019 Nov;33(11):559-563

Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, Florida.

Objective: To determine whether intramedullary nail (IMN) diameter, antegrade versus retrograde insertion, or the difference between the canal and IMN diameter affect femoral shaft fracture healing.

Design: Retrospective analysis of a prospective database.

Setting: Level One Regional Trauma Center.

Patients/participants: Seven hundred thirty-three femoral shaft fractures (OTA/AO 32) treated with an IMN between 1999 and 2017. After exclusion criteria, 484 fractures remained in the final analysis.

Intervention: Closed section, cannulated, interlocked, titanium alloy IMN using a reamed insertion technique.

Main Outcome Measurements: Nonunion, IMN size (10, 11.5, and 13 mm), antegrade versus retrograde insertion, Δ canal-nail diameter (ΔD) after reaming (<1, 1-2, or >2 mm).

Results: IMN diameters used were as follows: 314/10 mm (64%), 137/11.5 mm (28%), and 33/13 mm (8%). Forty-five percent were placed in antegrade versus 55% retrograde. Four hundred fifty-six fractures (94.2%) healed uneventfully. There were no IMN failures. 10/484 IMNs (2%) had broken interlocking screws; only 4 were associated with a NU. Average time to union was 23 weeks (12-119). Twenty-eight (5.8%) developed NU. There was no statistical correlation between (1) the NU rate and IMN diameter: 10 mm, 6.3%; 11.5 mm, 5.1%; 13 mm, 3% (P = 0.8, power = 0.85), (2) the NU rate and ΔD: 7.1% <1 mm, 5.6% 1-2 mm, 20% >2 mm (P = 0.36), (3) the NU rate and fracture location: Prox = 11%, Mid = 5%, Dist = 3% (P = 0.13), or (4) the NU rate and antegrade (7.2%) versus retrograde (4.2%) insertion (P = 0.24).

Conclusion: Similar healing rates occurred regardless of IMN diameter, Δ canal-nail diameter after reaming, or insertion site. This indicates that a closed section, cannulated, interlocked, titanium alloy IMN with a diameter of 10 mm can be considered the standard diameter for the treatment of acute femoral shaft fractures, regardless of entry point. This should be associated with less reaming and therefore shorter operative times, and possibly less hospital implant inventories as well. Larger diameter IMN should be reserved for revision surgery.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001585DOI Listing
November 2019

Multidose prophylactic IV antibiotics do not lower the risk of surgical site infection for isolated closed ankle fractures.

OTA Int 2019 Dec 2;2(4):e035. Epub 2019 Aug 2.

Florida Orthopaedic Institute, Tampa, FL.

Objectives: To compare the surgical site infection (SSI) rates in ankle fracture patients receiving either single preoperative intravenous (IV) dose (SD) or multidose 24 hours IV postoperative (MD) perioperative IV antibiotic prophylaxis.

Design: Retrospective case-control study.

Setting: Level I Trauma Center.

Patients/participants: Three hundred fourteen patients with isolated ankle fractures, OTA classifications 44A1-3, 44B1-3, and 44C1-3, who presented to our institution between January 2012 and June 2016.

Intervention: Operative fracture fixation with either the administration of SD or MD perioperative IV antibiotic prophylaxis.

Main Outcome Measurements: SSI.

Results: Three hundred fourteen patients met all study criteria. There were 99 patients in the SD group with a mean age of 44.2 years and 215 patients in the MD group with a mean age of 47.7 years. The overall SSI rate was 5.1% in the SD group versus 2.8% in the MD group ( = .312). The superficial SSI rate was 2.0% in the SD group versus 1.4% in the MD group not significant (NS). The deep SSI rate was 3.0% in the SD group versus 1.4% in the MD group (NS).

Conclusion: The SSI rates in isolated closed ankle fractures receiving either SD or MD perioperative IV antibiotic prophylaxis were similar. Further studies should be considered to help guide the standard of care for perioperative IV antibiotic prophylaxis.

Level Of Evidence: Therapeutic Level III retrospective case-control study.
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http://dx.doi.org/10.1097/OI9.0000000000000035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7997112PMC
December 2019

Reducing the Syndesmosis Under Direct Vision: Where Should I Look?

J Orthop Trauma 2019 Sep;33(9):450-454

Florida Orthopaedic Institute, Tampa, FL.

Objectives: To compare the quality of syndesmotic reduction obtained using the incisura versus the ankle articular surface as the visual cue. Secondarily, we evaluated the difference in the anterior to posterior depth of the fibula to the tibia at the joint level and the fibula to the incisura 1 cm above the joint.

Methods: Seven surgeons reduced disrupted syndesmoses of 10 cadaveric ankles using either the anterolateral articular surface of the distal tibia to the anteromedial fibular articular surface or the location of the fibula within the incisura as a visual reference. Malreductions in translation were measured in millimeter from the anatomical position of the fibula. The anterior to posterior distances of the tibia and fibula were also measured at both levels to determine the differences in their depths.

Results: The translational reduction was within 2 mm in 93% (0.7 ± 0.7 mm) of reductions using the articular surface as a reference compared with 80% (1.2 ± 1.0 mm) using the incisura as a reference (P = 0.0001). All surgeons' reductions were better using the joint articular surface as the visual reference. The difference in the fibular and the tibial depth was smaller at the level of the articular surface versus the incisura (2.1 mm vs. 5.9 mm; P = 0.0002).

Conclusions: The articular surface is a significantly more accurate visual landmark for translational reduction of the syndesmosis. This is potentially explained by the larger differences in the fibula and tibial depth at the incisura versus the articular surface.
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September 2019

Symptomatic Iliosacral Screw Removal After Pelvic Trauma-Incidence and Clinical Impact.

J Orthop Trauma 2019 Jul;33(7):351-353

Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL.

Objective: To calculate the incidence of symptomatic iliosacral (SI) screw removal following pelvic trauma and to determine the clinical impact of the secondary intervention.

Design: Retrospective chart review.

Setting: Level 1 and Level 2 trauma centers.

Patients: Four hundred seventy-one consecutive patients undergoing percutaneous posterior pelvic fixation over 10 years, with 7 excluded for spinopelvic fixation,and 7 excluded due to age <16 year old.

Intervention: Implant removal.

Main Outcome Measurement: Secondary intervention.

Results: A total of 25/457 patients underwent screw removal (5.4%). Two patients were lost to follow-up, leaving 23 for analysis. There were 13 male patients and 10 female patients. There were 13 SI and 10 trans-sacral screws removed. Four screws were loose before removal (17%). Average time to screw removal was 10.7 months (4-26 minutes). Fifteen (83.3%) patients had subjective improvement, and 3 (16.7%) had no notable improvement.

Conclusion: The incidence of symptomatic SI screws necessitating removal is low (5.4%). When removed, there is a high likelihood (83%) that the secondary intervention will result in subjective symptomatic improvement. Routine screw removal is unnecessary because most patients tolerate the implants without symptoms necessitating subsequent surgery.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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July 2019

Efficacy and Usability of a Novel Barrier Device for Preventing Injection Port Contamination: A Pilot Simulation Study.

Anesth Analg 2020 03;130(3):e45-e48

From the Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.

Contamination of intravenous (IV) ports and stopcocks has been associated with postoperative infections. We tested the usability and efficacy of a novel passive shielding device to prevent such contamination even in the absence of hand hygiene or port disinfection. In a desktop setting with deliberately contaminated hands, qualitative port contamination was detected after 5/60 (8.3%; 95% confidence interval [CI], 2.8-18.4) control port injections versus 0/60 (0%; 95% CI, 0-6.0) shielded injections (P = .025). In clinical simulations with a quantitative bioburden assay (measured in relative light units [RLUs]), median (interquartile range [IQR]) postsimulation bioburden was 46 (32-53) vs 27 (21-42) RLU for the control versus intervention groups (P = .036), yielding a median shift of -13 RLU (95% CI, -2 to -26) in favor of the shielding. Usability of the device was acceptable to practitioners.
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http://dx.doi.org/10.1213/ANE.0000000000004235DOI Listing
March 2020

Feasibility of a Modified Strategy for 2-Rescuer Cardiopulmonary Resuscitation.

J Emerg Med 2019 Jul 3;57(1):51-58. Epub 2019 May 3.

Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.

Background: Cardiopulmonary resuscitation (CPR) requires effective chest compressions and ventilations to circulate and oxygenate blood. It has been established that a 2-handed mask seal is superior when providing bag-valve-mask (BVM) ventilations. However a 1-handed technique remains the standard with which health care providers are trained to perform 2-rescuer CPR.

Objectives: We sought to determine if a modified 2-rescuer CPR technique that incorporates a 2-handed mask seal during ventilations can be accomplished without compromising chest compression quality during a simulated cardiac arrest.

Methods: Medical student volunteers were divided into an "intervention" arm, with 1 rescuer creating a 2-handed mask seal and the second rescuer performing chest compressions followed by that second rescuer squeezing the BVM bag to deliver ventilations during compression pauses, and a "control" arm, in which standard 2-rescuer CPR was performed. Both arms received a brief CPR refresher following a standard script. The 2 rescuer teams then performed 2 rounds of CPR on a manikin while being video recorded. Data were collected from real-time evaluation and post hoc video analysis.

Results: Forty-seven pairs of students enrolled in the study. There were no statistically significant differences between the intervention and control arms for median (interquartile range [IQR]) compression fraction (72% [69.5-75.7%] vs. 73.2% [69.1-76.1%]; p = 1.0), median time to complete 2 rounds of CPR (207.8 s [198.5-222.9 s] vs. 214.7 s [201.3-219.5 s]; p = 0.625), median hands-off time (49.8 s [46.2-63.0 s] vs. 55.4 s [50.4-65.2 s]; p = 0.278), or median time for 30 compressions (15.2 s [14.3-15.9 s] vs. 15.4 s [14.6-16.3 s]; p = 0.452).

Conclusion: Two-rescuer CPR incorporating a 2-handed face mask seal can be performed effectively without impacting chest compression quality during simulated cardiac arrest.
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http://dx.doi.org/10.1016/j.jemermed.2019.03.009DOI Listing
July 2019

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma.

JAMA Surg 2019 02 20;154(2):e184824. Epub 2019 Feb 20.

University of Texas Health Science Center at Houston.

Importance: Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population.

Objectives: To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes.

Design, Setting, And Participants: A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018.

Main Outcomes And Measures: At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months.

Results: Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups.

Conclusions And Relevance: This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.
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http://dx.doi.org/10.1001/jamasurg.2018.4824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439663PMC
February 2019

Orthopaedic Watercraft Injuries: Characterization of Mechanisms, Fractures, and Complications in 216 Injuries.

J Orthop Trauma 2018 04;32(4):e134-e138

Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL.

Objective: To review the orthopaedic injuries from watercraft treated surgically at our institution and report the mechanisms, fractures, and complications encountered.

Design: Retrospective case series.

Setting: Level I trauma center.

Patients/participants: There were 216 fractures from watercraft in 146 patients. Average age was 33 years (range 4-78 years), there were 68% males (99/146), and 16% of the injuries occurred in children.

Intervention: Operative fracture fixation.

Main Outcome Measurements: After IRB approval, data were collected from January 1, 1998, to December 31, 2015, for patients including demographics, watercraft type, mechanism of injury, fracture pattern, infection, organisms, union, and amputation. Descriptive statistics were used.

Results: There were 130 closed fractures (60%) and 86 open fractures (40%). There were 146 (67%) lower extremity injuries, 49 (23%) upper extremity injuries, and 21 (10%) pelvic injuries. The overall postoperative infection rate was 9% (20/216) and was commonly polymicrobial in nature. The postoperative infection rate in closed fractures was 4% (5/130) and the postoperative infection rate in open fractures was 17% (15/86). Open fractures also had a high proportion of nonunion (8%) and amputation (16%).

Conclusions: This is the largest reported series of orthopaedic injuries from watercraft. These injuries can be devastating in nature and difficult to manage, particularly when they are open (40%). There is a high rate of postoperative infection (17%), nonunion (8%), and amputation (16%) associated with open orthopaedic watercraft fractures.

Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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April 2018

Predictors of electrocardiographic screening failure for the subcutaneous implantable cardioverter-defibrillator in children: A prospective multicenter study.

Heart Rhythm 2018 05 5;15(5):703-707. Epub 2018 Jan 5.

Oregon Health and Science University, Portland, Oregon.

Background: Subcutaneous implantable cardioverter-defibrillator (SICD) shows promise for select patients at risk of sudden cardiac death. However, patients need to pass an electrocardiographic (ECG) screening (ECG-S) test before they can receive an SICD. Predictors of ECG-S failure in children are unclear.

Objective: The purpose of this study was to identify the incidence and predictive factors for failure of ECG-S in children.

Methods: Patients 18 years and younger with a preexisting ICD underwent ECG-S for SICD. ECG and demographic data were analyzed for factors predictive of failure.

Results: Seventy-three patients (mean age 14.2 ± 3.3 years; range 5-18 years) with hypertrophic cardiomyopathy (n = 24, 33%), long QT syndrome (n =18, 25%), other inherited arrhythmia syndromes (n = 20, 27%), congenital heart disease (n = 9, 12%), and miscellaneous conditions (n = 2) with an existing transvenous ICD underwent prospective ECG-S. Nineteen (26%) failed ECG-S. Failed patients had a longer corrected QT (QTc) interval (457 ms vs 425 ms; P = .03), a longer QRS duration (120 ms vs 98 ms; P = .04), and a lower ratio of R-wave to T-wave amplitudes (R:T ratio) in lead aVF (4 vs 5; P = .001). Multivariable logistic regression identified QTc interval (odds ratio [OR] 4.31; P = .04), QRS duration (OR 4.93; P = .03), R:T ratio in lead aVF (OR 3.13; P = .08) as predictors of failure. A risk score with 1 point each for QTc interval >440 ms, QRS duration >120 ms, and R:T ratio <6.5 in lead aVF was associated with probability of failure of 15.4% (1 point), 47.4% (2 points), and 88.6% (3 points), respectively.

Conclusion: ECG-S failure for SICD occurred in 26% of children, which is higher than the reported incidence in adults. Factors predicting ECG-S failure included longer QTc interval, longer QRS duration, and lower R:T ratio in lead aVF.
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http://dx.doi.org/10.1016/j.hrthm.2018.01.004DOI Listing
May 2018

Cephalomedullary Nail Fixation of Intertrochanteric Femur Fractures: Are Two Proximal Screws Better Than One?

J Orthop Trauma 2017 11;31(11):577-582

*Department of Orthopaedics, University of South Florida, Tampa, FL; †Department of Orthopaedics and Rehabilitation, William Beaumont Army Medical Center, El Paso, TX; ‡Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and §Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Objectives: To analyze radiographic changes in intertrochanteric (IT) fracture alignment after treatment with either a single sliding lag screw or an integrated compressed and locked, dual screw, cephalomedullary nail construct.

Design: Retrospective comparative study.

Setting: Level 1 regional trauma center.

Patients: 1004 OTA/AO 31A, 31B2.1 fractures treated with either a single screw cephalomedullary nail (Gamma 3) or an integrated dual screw cephalomedullary nail (InterTAN) between February 1, 2005, and June 30, 2013. Four hundred thirteen remained after exclusion criteria; 130 were treated with a single screw device (79 stable and 51 unstable), and 283 with an integrated dual screw device (155 stable and 128 unstable).

Intervention: Cephalomedullary nail insertion.

Outcome Measures: Radiographic analysis included fracture pattern, fracture reduction, neck-shaft angle (NSA), and femoral neck shortening (FNS) differences at 3, 6, and 12 months. Measurements were normalized using known lag screw dimensions, digitally corrected for magnification. Rotation between x-rays was controlled using a ratio of known to measured dimensions. The Mann-Whitney U test was used for statistical analysis.

Results: The single screw device resulted in 2.5 times more varus collapse (NSA) and 2 times more FNS over 1 year, as compared to the locked, integrated dual screw device, regardless of stability (P < 0.001). NSA and FNS changes were greater for both devices in unstable fracture patterns, but significantly less movement occurred with the dual screw device (P < 0.001).

Conclusions: A cephalomedullary nail with 2 integrated proximal screws that can be compressed and then locked seems to maintain initial IT fracture reduction and subsequent position over time, with less varus collapse and less shortening than a single screw device.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000967DOI Listing
November 2017

OTA/AO Classification Is Highly Predictive of Acute Compartment Syndrome After Tibia Fracture: A Cohort of 2885 Fractures.

J Orthop Trauma 2017 Nov;31(11):600-605

*Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, Memphis, TN; †Hughston Trauma at Orange Park Medical Center, Orange Park, FL; ‡Division of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, AL; §Department of Orthopaedic Surgery, University of South Florida, Tampa, FL; and ‖Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL.

Objective: To determine the correlation between the OTA/AO classification of tibia fractures and the development of acute compartment syndrome (ACS).

Design: Retrospective review of prospectively collected database.

Setting: Single Level 1 academic trauma center.

Patients: All patients with a tibia fracture from 2006 to 2016 were reviewed for this study. Three thousand six hundred six fractures were initially identified. Skeletally mature patients with plate or intramedullary fixation managed from initial injury through definitive fixation at our institution were included, leaving 2885 fractures in 2778 patients.

Methods: After database and chart review, univariate analyses were conducted using independent t tests for continuous data and χ tests of independence for categorical data. A simultaneous multivariate binary logistic regression was developed to identify variables significantly associated with ACS.

Results: ACS occurred in 136 limbs (4.7%). The average age was 36.2 years versus 43.3 years in those without (P < 0.001). Men were 1.7 times more likely to progress to ACS than women (P = 0.012). Patients who underwent external fixation were 1.9 times more likely to develop ACS (P = 0.003). OTA/AO 43 injuries were at least 4.0 times less likely to foster ACS versus OTA/AO 41 or 42 injuries (P < 0.007). OTA/AO 41-C injuries were 5.5 times more likely to advance to ACS compared with OTA/AO 41-A (P = 0.03). There was a significantly higher rate of ACS in OTA/AO 42-B (P = 0.005) and OTA/AO 42-C (P = 0.002) fractures when compared with OTA/AO 42-A fractures. In the distal segment, fracture type did not predict the risk of ACS (P > 0.15). Group 1 fractures had a lower rate of ACS compared with group 2 (P = 0.03) and group 3 (P = 0.003) fractures in the middle segment only. Bilateral tibia fractures had a 2.7 times lower rate of ACS (P = 0.04). Open injury, multiple segment injury, fixation type, and concurrent pelvic or femoral fractures did not predict ACS.

Conclusions: In this large cohort of tibia fractures, we found that the age, sex, and OTA/AO classification were highly predictive for the development of ACS.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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November 2017

Anterior-Inferior Plating Results in Fewer Secondary Interventions Compared to Superior Plating for Acute Displaced Midshaft Clavicle Fractures.

J Orthop Trauma 2017 Sep;31(9):468-471

*Department of Orthopedic Surgery, University of South Florida, Tampa, FL; †Geisinger Medical Center, Orthopaedic Institute, Danville, PA; ‡Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; §Shoulder and Elbow Surgery Service, Florida Orthopaedic Institute, Tampa, FL; and ‖Department of Orthopaedics, Harborview Medical Center, Seattle, WA.

Objectives: To determine whether a difference in plate position for fixation of acute, displaced, midshaft clavicle fractures would affect the rate of secondary intervention.

Design: Retrospective Comparative Study.

Setting: Two academic Level 1 Regional Trauma Centers.

Patients: Five hundred ten patients treated surgically for an acutely displaced midshaft clavicle fracture between 2000 and 2013 were identified and reviewed retrospectively at a minimum of 24 months follow-up (F/U). Fractures were divided into 2 cohorts, according to plate position: Anterior-Inferior (AI) or Superior (S). Exclusion criteria included age <16 years, incomplete data records, and loss to F/U. Group analysis included demographics (age, sex, body mass index), fracture characteristics (mechanism of injury, open or closed), hand dominance, ipsilateral injuries, time between injury to surgery, time to radiographic union, length of F/U, and frequency of secondary procedures.

Intervention: Patients were treated either with AI or S clavicle plating at the treating surgeon's discretion.

Main Outcome Measures: Rate and reason for secondary intervention.

Statistical Analysis: Fisher exact test, t test. and odds ratio were used for statistical analysis.

Results: Final analysis included 252 fractures/251 patients. One hundred eighteen (47%) were in group AI; 134 (53%) were in group S. No differences in demographics, fracture characteristics, time to surgery, time to union, or length of F/U existed between groups. Seven patients/7 fractures (5.9%) in Group AI underwent a secondary surgery whereas 30 patients/30 fractures (22.3%) in group S required a secondary surgery. An additional intervention secondary to superior plate placement was highly statistically significant (P < 0.001). Furthermore, because 80% of these subsequent interventions were a result of plate irritation with patient discomfort, the odds ratio for a second procedure was 5 times greater in those fractures treated with a superior plate.

Conclusions: This comparative analysis indicates that AI plating of midshaft clavicle fractures seems to lessen clinical irritation and results in significantly fewer secondary interventions. Considering patient satisfaction and a reduced financial burden to the health care system, we recommend routine AI plate application when open reduction internal fixation of the clavicle is indicated.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000856DOI Listing
September 2017

Versatility of Fibula Free Flap in Reconstruction of Facial Defects: A Center Study.

J Maxillofac Oral Surg 2017 Mar 9;16(1):101-107. Epub 2016 Jun 9.

Department of Oral and Maxillofacial Surgery, Bhagwan Mahaveer Jain Hospital, 104, Shalimar Residency, Flat No. 103, First Floor, Second Main Road, Sheshadripuram, Bengaluru, Karnataka 560 020 India.

Purpose: To study a series of cases where vascularised fibula flap was used in various combinations of bone with muscle and skin along with its modifications for reconstruction of simple and composite defects of the facial region.

Patients And Methods: The investigators designed a retrospective study composed of patients with any pathology or defect who underwent reconstruction of maxilla or mandible with vascularised fibula free flap from 2009 to 2013. All patients were evaluated for age, gender, location and type of defect, incorporation of adjoining skin paddle and muscle, number of fibula osteotomies, ischaemia time, anticoagulant regimen, length of hospital stay, flap failure rate, dental implant rehabilitation. All patients with a minimum follow-up of 3 months post-operatively, were included in this study.

Results: The study sample composed of 30 patients with average age of 39.5 years. Immediate reconstruction was done in 86.66 % of patients. 93.1 % were mandibular reconstructions. In 40 % of patients, the fibula was double barrelled. Skin island was included with the fibula in 20 % of patients. 10 % patients underwent dental rehabilitation using implants with 6.66 % requiring distraction osteogenesis of the fibula which was not required with double barrel reconstructions. Hematoma at the recipient site was the commonest post-operative complication, although its frequency was low. A significant donor site morbidity of around 3.33 % was seen. Average stay in hospital was about 7 days. Post-operatively all patients ambulated normally and none used assisted devices. A reconstruction plate was used to achieve the ideal contour of the jaw in most cases. Aesthetic results were usually good, especially in young patients. The overall success rate was 93.33 %.

Conclusion: The fibula has many assets which make it the ideal choice for bony reconstruction of facial skeleton and adjoining soft tissue with predictable results.
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http://dx.doi.org/10.1007/s12663-016-0930-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5328874PMC
March 2017

Percutaneous or Open Reduction of Closed Tibial Shaft Fractures During Intramedullary Nailing Does Not Increase Wound Complications, Infection or Nonunion Rates.

J Orthop Trauma 2017 Apr;31(4):215-219

*Florida Orthopaedic Institute, Orthopaedic Trauma Service, Tampa General Hospital, Tampa, FL; †Upstate Orthopedics, Syracuse, NY; ‡University of South Florida School of Medicine, Tampa, FL; and §Hughston Trauma, Fort Walton Beach, FL.

Objective: To compare the incidence of complications (wound, infection, and nonunion) among those patients treated with closed, percutaneous, and open intramedullary nailing for closed tibial shaft fractures.

Design: Retrospective review.

Setting: Multiple trauma centers.

Patients: Skeletally mature patients with closed tibia fractures amenable to treatment with an intramedullary device.

Intervention: Intramedullary fixation with closed, percutaneous, or open reduction.

Main Outcome Measurements: Superficial wound complication, deep infection, nonunion.

Results: A total of 317 tibial shaft fractures in 315 patients were included in the study. Two-hundred fractures in 198 patients were treated with closed reduction, 61 fractures in 61 patients were treated with percutaneous reduction, and 56 fractures in 56 patients were treated with formal open reduction. The superficial wound complication rate was 1% (2/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 3.6% (2/56) for the open group with no statistical difference between the groups (P = 0.179). The deep infection rate was 2% (4/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 7.1% (4/56) for the open group with no significant difference between the groups (P = 0.133). Nonunion rate was 5.0% (10/200) for the closed group, 4.9% (3/61) for the percutaneous group, and 7.1% (4/56) for the open group, with no statistical difference between the groups (P = 0.492).

Conclusions: This is the largest reported series of closed tibial shaft fractures nailed with percutaneous and open reduction. Percutaneous or open reduction did not result in increased wound complications, infection, or nonunion rates. Carefully performed percutaneous or open approaches can be safely used in obtaining reduction of difficult tibial shaft fractures treated with intramedullary devices.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000777DOI Listing
April 2017
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