Publications by authors named "Jeremy Hreha"

9 Publications

  • Page 1 of 1

Orthopaedic trauma during COVID-19: Is patient care compromised during a pandemic?

J Clin Orthop Trauma 2021 Jul 2;18:181-186. Epub 2021 May 2.

Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.

Background: The Coronavirus disease-2019 (COVID-19) placed unprecedented pressure on the healthcare system. Many institutions implemented a government-mandated restructured set of safety and administrative protocols to treat urgent orthopaedic trauma patients. The objective of this study was to compare two cohorts of patients, a COVID group and non-COVID control group, and to evaluate the effectiveness of safety measures outlined in the Rutgers Orthopaedic Trauma Patient Safety Protocol (ROTPSP). Secondary outcomes were to elucidate risk factors for complications associated with fractures and COVID-19.

Methods: Patients treated for orthopaedic traumatic injuries were retrospectively identified between March and May 2020, and compared to a series of patients from the same time period in 2018. Main outcome measures included surgical site infections (SSI), length of stay (LOS), post-operative LOS (poLOS), presentation to OR time (PORT), and length of surgery.

Results: After review, 349 patients (201 non-COVID, 148 COVID) undergoing 426 surgeries were included. Average LOS (11.91 days vs. 9.27 days, p = 0.04), poLOS (9.68 days vs. 7.39 days, p = 0.03), and PORT (30.56 vs. 25.59 h, p < 0.01) was significantly shorter in the COVID cohort. There were less SSI in the COVID group (5) compared to the non-COVID group (14) (p = 0.03). Overall complications were significantly lower in the COVID group. Patients receiving Cepheid tests had significantly shorter LOS and poLOS compared to patients receiving the RNA and DiaSorin tests (p < 0.01 and p < 0.01, respectively). The Cepheid test carried the best benefit-to-cost ratio, 0.10, p < 0.05.

Conclusion: The restructuring of care protocols caused by COVID-19 did not negatively impact perioperative complication rates, PORT or LOS. Cepheid COVID test type administered upon admission plays an integral role in a patient's hospital course by reducing both length of stay and hospital costs. This information demonstrates we can continue to treat orthopaedic trauma patients safely during the COVID-19 pandemic by utilizing strict safety protocols.
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July 2021

A Machine Learning Algorithm to Predict the Probability of (Occult) Posterior Malleolar Fractures Associated With Tibial Shaft Fractures to Guide "Malleolus First" Fixation.

J Orthop Trauma 2020 Mar;34(3):131-138

Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia.

Objectives: To develop an accurate machine learning (ML) predictive model incorporating patient, fracture, and trauma characteristics to identify individual patients at risk of an (occult) PMF.

Methods: Databases of 2 studies including patients with TSFs from 2 Level 1 trauma centers were combined for analysis. Using ten-fold cross-validation, 4 supervised ML algorithms were trained in recognizing patterns associated with PMFs: (1) Bayes point machine; (2) support vector machine; (3) neural network; and (4) boosted decision tree. Performance of each ML algorithm was evaluated and compared based on (1) C-statistic; (2) calibration slope and intercept; and (3) Brier score. The best-performing ML algorithm was incorporated into an online open-access prediction tool.

Results: Total data set included 263 patients, of which 28% had a PMF. Training of the Bayes point machine resulted in the best-performing prediction model reflected by good C-statistic, calibration slope, calibration intercept, and Brier score of 0.89, 1.02, -0.06, and 0.106, respectively. This prediction model was deployed as an open-access online prediction tool.

Conclusion: A ML-based prediction model accurately predicted the probability of a (occult) PMF in patients with a TSF based on patient- and fracture-specific characteristics. This prediction model can guide surgeons in their diagnostic workup and preoperative planning. Further research is required to externally validate the model before implementation in clinical practice.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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March 2020

What Is the Normal Ulnar Bow in Adult Patients?

Clin Orthop Relat Res 2020 01;478(1):136-141

J. Hreha, D. V. Congiusta, I. H. Ahmed, M. M. Vosbikian, Department of Orthopaedic Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA.

Background: Rotation of the forearm is a result of the complex interaction among the radius, ulna, and interosseous membrane. Although the radius is recognized as curved, the ulna is generally thought of as a "straight bone." To better describe normal anatomy, which may lead to more successful anatomic fixation of forearm fractures, we aimed to apply a method of measuring the normal ulnar bow and determine the mean ulnar bow in adults.

Questions/purposes: (1) To what degree is the ulna bowed in the coronal and sagittal planes in normal adult forearms? (2) To what degree is the radius bowed in the coronal plane in normal adult forearms?

Methods: Radiographs of the forearms of adults taken during a 1-year period were initially obtained retrospectively. These radiographs were performed for various reasons, including forearm pain and routine radiographic follow-up. Radiographs were excluded if evidence of a fracture or post-fracture fixation was found, if a patient had missing AP or lateral images, or if a suboptimal technique was used. The coronal and sagittal bow of the ulna was measured with a method adapted from previous studies that assessed radial bow using AP and lateral radiographs, respectively. Similar measurements were made in the coronal plane for the radius. All measurements were performed independently by the four authors. There was excellent interobserver reliability for ulnar bow in the coronal and sagittal planes (interclass correlation coefficient = 0.96 and 0.97, respectively) and for radial bow in the coronal plane (interclass correlation coefficient = 0.90).

Results: The mean maximal coronal ulnar bow was 7 ± 2 mm and was located at 75% of the ulnar length, measured proximally to distally. The location of coronal bow was consistently distal to the radial bow location. The mean maximal sagittal ulnar bow was 6 ± 3 mm and was located at 39% of the ulnar length. The mean maximal coronal bow of the radius was 14 ± 2.0 mm and was 59% of the total length of the radius from proximal to distal.

Conclusions: The ulna is not a "straight bone," as is commonly thought, but rather has a bow in both the coronal and sagittal planes.

Clinical Relevance: Knowledge of the standard ulnar bow may be pivotal to prevent malunion of the ulna during surgery. Future research using these data in preoperative planning may lead to changes in plate contouring and clinical outcomes in forearm fracture management.
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January 2020

Local Zinc Chloride Release From a Calcium Sulfate Carrier Enhances Fracture Healing.

J Orthop Trauma 2017 Mar;31(3):168-174

*Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, NJ; †Department of Biological Sciences, Seton Hall University, South Orange, NJ; and ‡Department of Biochemistry and Molecular Biology, Rutgers New Jersey Medical School, Newark, NJ.

Background: This study examined the efficacy of calcium sulfate (CaSO4) as a carrier for intramedullary delivery of zinc chloride (ZnCl2) to treat fracture healing in a BB Wistar rat model. A non-carrier-mediated injection of 3.0 mg/kg of ZnCl2 has previously been shown to enhance fracture healing.

Methods: A heterogeneous mixture of ZnCl2 and CaSO4 was administered into the intramedullary femoral canal and a mid-diaphyseal femur fracture was created unilaterally. Early and late parameters of fracture healing were assessed using biomechanical testing, radiographic scoring, quantitative histomorphometry (for percentage of new cartilage and bone within the fracture callus), and long-term histologic evaluation.

Results: Fractures treated with 1.0 mg/kg of ZnCl2/CaSO4 demonstrated a significantly higher maximum torque to failure compared with both CaSO4 (P = 0.048) and saline (P = 0.005) controls at 4 weeks postfracture (396.4 versus 251.3 versus 178.7 N mm, respectively). Statistically significant increases in torsional rigidity, effective shear modulus, and effective shear stress were also found, as well as a 3.5 times increase in radiographic score (based on bone union). Histologic examination of the fracture callus indicated enhanced chondrogenesis at day 14 postfracture, with increased percent cartilage for the ZnCl2/CaSO4 group compared with saline (P = 0.0004) and CaSO4 (P = 0.0453) controls. Long-term radiographic and histologic evaluation revealed no abnormal bone formation or infection up to 12 weeks postoperatively.

Conclusions: The effective dose of ZnCl2 augmentation for the enhancement of fracture healing in rats was reduced 3-fold in this study compared with previous findings. Furthermore, CaSO4 acted synergistically with ZnCl2 to increase the mechanical strength and stability at the fracture site.
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March 2017

Role of Recombinant Human Bone Morphogenetic Protein-2 on Hindfoot Arthrodesis.

Foot Ankle Clin 2016 Dec;21(4):793-802

Department of Orthopaedics, The Rubin Institute for Advanced Orthopaedics at Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA. Electronic address:

Despite advances in understanding bone healing physiology and surgical techniques, delayed union and nonunion still occur after the treatment of hindfoot arthrodesis. There is increasing appeal of bone morphogenetic proteins (BMPs) owing to the innate osteoinductive abilities of BMPs. Effective treatment with BMPs has been shown in animal studies. Human clinical studies have also shown success. The only study investigating the use of recombinant human BMP (rhBMP)-2 in hindfoot arthrodesis found a significant increase in fusion rate. Treatment cost effective. Complications from their use remain low. rhBMP-2 is a safe and effective bone-healing adjunct in hindfoot arthrodesis surgery.
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December 2016

Local manganese chloride treatment accelerates fracture healing in a rat model.

J Orthop Res 2015 Jan 17;33(1):122-30. Epub 2014 Sep 17.

Department of Orthopaedics, Rutgers-New Jersey Medical School, 90 Bergen Street, Suite 7300, Newark, New Jersey, 07103.

This study investigated the effects of local delivery of manganese chloride (MnCl2), an insulin-mimetic compound, upon fracture healing using a rat femoral fracture model. Mechanical testing, histomorphometry, and immunohistochemistry were performed to assess early and late parameters of fracture healing. At 4 weeks post-fracture, maximum torque to failure was 70% higher (P<0.05) and maximum torsional rigidity increased 133% (P<0.05) in animals treated with 0.125 mg/kg MnCl2 compared to saline controls. Histological analysis of the fracture callus revealed percent new mineralized tissue was 17% higher (P<0.05) at day 10. Immunohistochemical analysis of the 0.125 mg/kg MnCl2 treated group, compared to saline controls, showed a 379% increase in the density of VEGF-C+ cells. In addition, compared to saline controls, the 0.125 mg/kg MnCl2 treated group showed a 233% and 150% increase in blood vessel density in the subperiosteal region at day 10 post-fracture as assessed by detection of PECAM and smooth muscle α actin, respectively. The results suggest that local MnCl2 treatment accelerates fracture healing by increasing mechanical parameters via a potential mechanism of amplified early angiogenesis leading to increased osteogenesis. Therefore, local administration of MnCl2 is a potential therapeutic adjunct for fracture healing.
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January 2015

Local ZnCl2 accelerates fracture healing.

J Orthop Res 2014 Jun 26;32(6):834-41. Epub 2014 Feb 26.

Rutgers New Jersey Medical School, Department of Orthopaedics, 90 Bergen Street, Suite 7300, Newark, New Jersey, 07103.

This study evaluated the effect of local zinc chloride (ZnCl2 ), an insulin mimetic agent, upon the early and late parameters of fracture healing in rats using a standard femur fracture model. Mechanical testing, radiographic scoring, histomorphometry, qualitative histological scoring, PCNA immunohistochemistry, and local growth factor analysis were performed. Fractures treated with local ZnCl2 possessed significantly increased mechanical properties compared to controls at 4 weeks post fracture. The radiographic scoring analysis showed increased cortical bridging at 4 weeks in the 1.0 (p=0.0015) and 3.0 (p<0.0001) mg/kg ZnCl2 treated groups. Histomorphometry of the fracture callus at day 7 showed 177% increase (p=0.036) in percent cartilage and 133% increase (p=0.002) in percent mineralized tissue with local ZnCl2 treatment compared to controls. Qualitative histological scoring showed a 2.1× higher value at day 7 in the ZnCl2 treated group compared to control (p = 0.004). Cell proliferation and growth factors, VEGF and IGF-I, within fracture calluses treated with local ZnCl2 were increased at day 7. The results suggest local administration of ZnCl2 increases cell proliferation, causing increased growth factor production which yields improved chondrogenesis and endochondral ossification. Ultimately, these events lead to accelerated fracture healing as early as 4 weeks post fracture.
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June 2014

Local vanadium release from a calcium sulfate carrier accelerates fracture healing.

J Orthop Res 2014 May 30;32(5):727-34. Epub 2013 Dec 30.

Department of Orthopaedics, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 7300, Newark, New Jersey, 07103.

This study evaluated the efficacy of using calcium sulfate (CaSO4 ) as a carrier for intramedullary delivery of an organic vanadium salt, vanadyl acetylacetonate (VAC) after femoral fracture. VAC can act as an insulin-mimetic and can be used to accelerate fracture healing in rats. A heterogenous mixture of VAC and CaSO4 was delivered to the fracture site of BB Wistar rats, and mechanical testing, histomorphometry, micro-computed tomography (micro-CT) were performed to measure healing. At 4 weeks after fracture, maximum torque to failure, effective shear modulus, and effective shear stress were all significantly higher (p < 0.05) in rats treated with 0.25 mg/kg VAC-CaSO4 as compared to carrier control rats. Histomorphometry found a 71% increase in percent cartilage matrix (p < 0.05) and a 64% decrease in percent mineralized tissue (p < 0.05) at 2 weeks after fracture in rats treated with 0.25 mg/kg of VAC-CaSO4 . Micro-CT analyses at 4 weeks found a more organized callus structure and higher trending maximum connected z-ray. fraction for VAC-CaSO4 groups. Evaluation of radiographs and serial histological sections at 12 weeks did not show any evidence of ectopic bone formation. As compared to previous studies, CaSO4 was an effective carrier for reducing the dose of VAC required to accelerate femoral fracture healing in rats.
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May 2014

Local insulin therapy affects fracture healing in a rat model.

J Orthop Res 2013 May 13;31(5):776-82. Epub 2012 Dec 13.

Department of Orthopaedics, University of Medicine, Dentistry of New Jersey-New Jersey Medical School, 185 South Orange Avenue, 90 Bergen Street, Suite 7300, Newark, NJ 07103, USA.

A significant number of lower extremity fractures result in mal-union necessitating effective treatments to restore ambulation. Prior research in diabetic animal fracture models demonstrated improved healing following local insulin application to the fracture site and indicated that local insulin therapy can aid bone regeneration, at least within an insulin-dependent diabetic animal model. This study tested whether local insulin therapy could accelerate femur fracture repair in normal, non-diabetic rats. High (20 units) and low (10 units) doses of insulin were delivered in a calcium sulfate carrier which provided sustained release of the exogenous insulin for 7 days after fracture. Histomorphometry, radiographic scoring, and torsional mechanical testing were used to measure fracture healing. The fracture calluses from rats treated with high-dose insulin had significantly more cartilage than untreated rats after 7 and 14 days of healing. After 4 weeks of healing, femurs from rats treated with low-dose insulin had significantly higher radiographic scores and mechanical strength (p < 0.05), compared to the no treatment control groups. The results of this study suggest that locally delivered insulin is a potential therapeutic agent for treating bone fractures. Further studies are necessary, such as large animal proof of concepts, prior to the clinical use of insulin for bone fracture treatment.
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May 2013