Ian A. Harris

Institutional practice guidelines on management of pelvic fracture-related hemodynamic instability : Do they make a difference?

BACKGROUND The management of patients with hemodynamic instability related to pelvic fracture is a major challenge, with high morbidity and mortality. Evidence-based institutional practice guidelines (PG) were developed as a strategy to optimize the care of these patients. The aims of this study were to evaluate the adherence to the new PG and compare the outcomes before and after their implementation. METHODS Major blunt trauma patients (Injury Severity Score [ISS] > 15) with hemodynamic instability (initial base deficit > 6 mEq/L or received > 6 units of packed red blood cells [PRBCs] during the first 12 hours) related to pelvic fracture were investigated. Patients presenting with ongoing bleeding from other regions or with severe head injury (Glasgow Coma Scale score < 9) were excluded. The pre-PG group (n = 17) were patients managed during the 18 months ending on December 31, 2001. The post-PG group (n = 14) consisted of patients managed during the subsequent 18 months. Demographics, ISS, shock severity, resuscitation, and outcome data were prospectively collected. The adherence to the key steps of PG was evaluated retrospectively in the pre-PG and prospectively in the post-PG group, including abdominal clearance (AC) with diagnostic peritoneal aspiration/lavage or ultrasound (<15 minutes), noninvasive pelvic binding (PB) (<15 minutes), pelvic angiography (PA) (<90 minutes after admission), and minimally invasive orthopedic fixation (MIOF) (<24 hours). Data are presented as mean +/- SEM or percentages. RESULTS The pre-PG and post-PG groups were similar regarding age (40 +/- 4 years vs. 42 +/- 6 years), gender (both 71% male), ISS (39 +/- 3 vs. 37 +/- 4), admission base deficit (9 +/- 1 vs. 10 +/- 1) admission systolic blood pressure (116 +/- 7 vs. 112 +/- 6 mm Hg), Glasgow Coma Scale score (12 +/- 1 vs. 12 +/- 1), and PRBC transfusion in the first 12 hours (9 +/- 2 U vs. 9 +/- 2 U). The adherence to the guidelines in the post-PG period was as follows: AC, 100%; PB, 86% (p < 0.05 based on t test or chi test); PA, 93% (p < 0.05 based on t test or chi test); and MIOF, 86%. In the pre-PG period, adherence to the guidelines was as follows: AC, 65%; PB, 0%; PA, 30%; and MIOF 52%. In the post-PG period, the 24-hour PRBC transfusion decreased from 16 +/- 2 U to 11 +/- 1 U and the mortality decreased from 35% to 7% (p < 0.05 based on t test or chi test for both). CONCLUSION The adherence to the PG as a reflection of optimal management was significantly improved. PG focusing particular on timely hemorrhage control reduced the 24-hour transfusion requirements and the mortality rate in the post-PG group.

Hemodynamically Unstable Pelvic Fractures: Recent Care and New Guidelines

Consistent care of hemodynamically unstable pelvic fracture patients is a major management issue. It was uncertain whether the introduction of newly developed clinical practice guidelines would require much change in current delivery of care at our institution. Assessment of recent care was undertaken and compared with the newly developed evidence-based best practice guidelines. A multidisciplinary project team developed clinical practice guidelines for determination of early optimum management of hemodynamically unstable patients with pelvic fractures. The guidelines recommend a definitive management plan to arrest hemorrhage within 30 minutes. Intra-abdominal hemorrhage should be assessed with diagnostic peritoneal aspiration (DPA) and/or focused assessment with sonography for trauma (FAST). Early noninvasive stabilization of the pelvis followed by angiography within 90 minutes are recommended if intra-abdominal hemorrhage is not found. Recent care was assessed in a historical cohort of patients, identified in a prospectively maintained trauma registry, between June 1999 and December 2001. Investigations, interventions, and times were then compared with the new guidelines. The delivery of care to 30 patients (mortality 37%, mean ISS 37.8 ± 20.9) was studied. Compared with the new guidelines, the abdominal assessment rate with DPA and/or FAST was 53% and early (< 90 minutes) angiography rate was 38%. A form of pelvic external stabilization was applied in 27% of cases. Noninvasive pelvic stabilization was not performed at all. The recent care of hemodynamically unstable pelvic fracture patients was not in line with newly developed guidelines. There is an opportunity to markedly improve the rates of initial assessment of the abdomen, pelvic stabilization, and early angiography.

Predictors of General Health After Major Trauma

BACKGROUND Traumatic injury is a leading contributor to the global burden of disease, yet there has been little research on possible predictors of general health after major trauma. This study aims to explore possible predictors of general health after major physical trauma. METHODS A survey was performed of 731 surviving consecutive adult patients presenting to a major trauma center with accidental major trauma, between 1 year and 5 years postinjury. Data pertaining to general patient factors, injury severity factors, socioeconomic factors, and claim-related factors were abstracted from the hospital trauma database and the questionnaire. Multiple linear regression was used to develop a predictive model for the main outcome, the physical and mental component summaries of the SF-36 General Health Survey. RESULTS One hundred and forty nine patients were excluded, 93 refused to participate, and 134 did not respond, leaving 355 participants. On multivariate analysis, better physical health was significantly associated with increasing time since the injury and lower Injury Severity Scores (p = 0.03 and 0.02, respectively). Having a settled compensation claim, having an unsettled compensation claim, and using a lawyer were independently associated with poor physical health (p = 0.02, 0.006, and <0.0001, respectively). Measures of injury severity or socioeconomic status were not associated with mental health. However, having an unsettled compensation claim was strongly associated with poor mental health (p < 0.0001). CONCLUSION General health after major physical trauma is more strongly associated with factors relating to compensation than with the severity of the injury. Processes involved with claiming compensation after major trauma may contribute to poor patient outcomes.

DELAY TO SURGERY AND MORTALITY AFTER HIP FRACTURE

Background:  Hip fractures in elderly patients are associated with increased mortality. These patients frequently experience a delay to surgery for both medical and non‐medical reasons. The effect of this delay on patient morbidity and mortality is controversial.

Understanding the effect of compensation on recovery from severe motor vehicle crash injuries: a qualitative study

Objective To explore the factors that influence recovery from serious injuries sustained in motor vehicle crashes, particularly differences between those with compensable and non-compensable injuries. Design and setting Qualitative study using grounded theory and focus group methods within the trauma service of a university teaching hospital. Participants 34 subjects (27 male, 7 female), of whom 21 were participants with a compensation claim and 13 were not. Each had sustained injuries in motor vehicle crashes between two and seven years previously. Main outcome measure Themes identified from transcripts of the focus groups. Results The themes identified from participants claiming compensation were a strong sense of entitlement and injustice, a difficult claims and settlement process, an inability to move on with life during the claims process, an extreme dislike of medico-legal assessments, the necessity of legal representation to assist with the claims process, and a perceived lack of trust about having to prove an injury or disability. The themes common to all participants were the significance of the trauma experience, the importance of family and social support, and, if self-employed, financial hardship and difficult experiences in returning to work. Conclusions The injury recovery experience was difficult for all subjects, but it was particularly stressful for those claiming compensation. Based on this study, the claims process, particularly medico-legal examinations, and other factors that could impact on injury recovery, are targets for further research, possible policy review, or legislative change.

Cryotherapy after total knee arthroplasty a systematic review and meta-analysis of randomized controlled trials.

Cryotherapy has theoretical and practical applications in the reduction of pain, swelling, and blood loss after trauma. We performed a systematic review and meta-analysis of randomized controlled trials on the efficacy of cryotherapy after total knee arthroplasty (TKA). Eleven studies involving 793 TKAs were included. There was considerable clinical and methodological heterogeneity. Cryotherapy resulted in small benefits in blood loss and discharge knee range of motion. There were no benefits in transfusion and analgesia requirements, pain, swelling, length of stay, and gains in knee range of motion after discharge. Despite some early gains, cryotherapy after TKA yields no apparent lasting benefits. Patient-centered outcomes remain underinvestigated. The current evidence does not support the routine use of cryotherapy after TKA.

Using magnetic resonance imaging to predict adequate graft diameters for autologous hamstring double-bundle anterior cruciate ligament reconstruction.

PURPOSE To determine whether the preoperative magnetic resonance imaging (MRI) cross-sectional area (CSA) of the hamstring tendons can predict intraoperative bundle diameters during double-bundle anterior cruciate ligament reconstruction. METHODS A prospective study of 34 patients undergoing anterior cruciate ligament reconstruction with hamstring autografts was performed. CSAs of independent and combined hamstring tendon diameters were correlated to preoperative magnetic resonance images. RESULTS Intraoperative tendon diameter measurement positively correlated with preoperative MRI tendon CSA measurement for gracilis (P = .0006), semitendinosus (P = .001), and final graft size (P = .001). Double-stranded gracilis grafts greater than or equal to 5 mm in diameter had a mean preoperative MRI gracilis CSA of 9.98 mm(2) compared with a mean of 7.76 mm(2) for grafts less than 5 mm (P = .002). Double-stranded semitendinosus grafts greater than or equal to 6 mm had a mean preoperative MRI tendon CSA of 17.33 mm(2) compared with 14.80 mm(2) for grafts less than 6 mm (P = .02). Final grafts of diameter greater than or equal to 7 mm had a mean preoperative MRI total tendon CSA of 26.54 mm(2) compared with 22.22 mm(2) for grafts under 7 mm (P = .06). CONCLUSIONS Preoperative MRI is a clinically useful tool to assess hamstring tendon graft diameter. We recommend preoperative CSA threshold values of 10 mm(2) and 17 mm(2) for the gracilis and semitendinosus tendons, respectively, to reliably predict the potential for a double-bundle anterior cruciate ligament reconstruction. LEVEL OF EVIDENCE Level IV, therapeutic case series.

The effect of compensation on general health in patients sustaining fractures in motor vehicle trauma

Objectives: The receipt or pursuit of compensation after injury has been associated with poor outcomes. This study aims to determine the association between compensation-related factors and general health in patients with fractures sustained in motor vehicle trauma. Design: Prospective survey. Setting: Metropolitan trauma centers. Patients/Participants: The study population was patients aged 18 years and older, presenting acutely with at least one fracture involving the long bones, pelvis, patella, talus, or calcaneus, resulting from motor vehicle trauma, and presenting acutely to 1 of 15 hospitals. Intervention: Patients were surveyed on admission to determine general factors, injury factors, and socioeconomic factors. Employment status at follow-up, compensation-related factors, and the main outcome variables were measured by survey at 6 months after injury. Multiple regression was used to determine significant predictors of outcome. Main Outcome Measurement: Physical and mental health summaries of the SF-36 General Health Survey. Results: Of the 306 patients recruited to the study, five were excluded, and completed questionnaires were available for 232 (75.8%). Claiming compensation was strongly associated with poor physical and mental health on univariate analysis, but it was not significant on multivariate analysis. The use of a lawyer in relation to the injury was the most significant variable associated with poor physical and mental health, after adjusting for other factors. Conclusions: Lawyer involvement, rather than pursuit of compensation, is associated with poor general health after fractures sustained in motor vehicle injuries. Although this may represent a direct effect, further research is recommended to determine the cause for this association.

The six-minute walk test is an excellent predictor of functional ambulation after total knee arthroplasty

BackgroundThe Six-minute walk (6MW) and Timed-Up-and-Go (TUG) are short walk tests commonly used to evaluate functional recovery after total knee arthroplasty (TKA). However, little is known about walking capacity of TKA recipients over extended periods typical of everyday living and whether these short walk tests actually predict longer, more functional distances. Further, short walk tests only correlate moderately with patient-reported outcomes. The overarching aims of this study were to compare the performance of TKA recipients in an extended walk test to healthy age-matched controls and to determine the utility of this extended walk test as a research tool to evaluate longer term functional mobility in TKA recipients.MethodsThe mobility of 32 TKA recipients one year post-surgery and 43 healthy age-matched controls were assessed using the TUG, 6MW and 30-minute walk (30MW) tests. The latter test was repeated one week later. Self-reported function was measured using the WOMAC Index and a physical activity questionnaire.Results30MW distance was significantly shorter amongst TKA recipients (mean 2108 m [95% CI 1837 to 2381 m]; Controls 3086 m [2981 to 3191 m], P < 0.001). Test-retest repeatability was high (ICC = 0.97, TKA; 0.96, Controls). Amongst TKA recipients, the 30MW distance correlated strongly with the shorter tests (6MW, r = 0.97, P < 0.001; TUG, r = −0.82, P < 0.001). Multiple regression modeling found 6MW distance to be the only significant predictor (P < 0.001) of 30MW distance, explaining 96% of the variability. The TUG test models were moderate predictors of WOMAC function (55%) and physical activity (36%) and were stronger predictors than 6MW and 30 MW tests.ConclusionsThough TKA recipients are able to walk for 30 minutes one year post-surgery, their performance falls significantly short of age-matched norms. The 30MW test is strongly predicted by 6MW test performance, thus providing strong construct validity for the use of the 6MW test in the TKA population. Neither a short nor long walk test is a strong predictor of patient-reported function after TKA.

CONSORT compliance in surgical randomized trials: are we there yet? A systematic review.

Objective: We performed a systematic review assessing the reporting quality of trials of surgical interventions, and explored associated trial level variables. Background: Randomized controlled trials (RCTs) provide clinicians with the best evidence for the effects of interventions, but may not be reported with necessary detail. Methods: In May 2009, 3 databases (MEDLINE, EMBASE, and CENTRAL) were searched for RCTs that assessed a surgical intervention using a comprehensive electronic strategy developed by the Cochrane Collaboration. The Consolidated Standards of Reporting Trials (CONSORT) checklist was used as a measure of reporting quality. An overall CONSORT score was calculated and expressed as a proportion. This was supplemented with domains related to external validity. We also collected data on characteristics hypothesized to improve reporting quality, and exploratory regression was performed to determine associations. Results: One hundred fifty recently published RCTs were included. The most commonly represented surgical subspecialties were general (29%), orthopedic (23%), and cardiothoracic (13%). Most (65%) were published in subspecialty surgical journals. Overall reporting quality was low, with only 55% of CONSORT items addressed. Less than half of trials described adequate methods for sample size calculation (45%), random sequence generation (43%), allocation concealment (45%), and blinding (37%). The strongest associations with reporting quality were adequate methods related to methodological domains, an author with an epidemiology/statistics degree, and a longer report length. Conclusions: There remains much room for improvement for the reporting of surgical intervention trials. Authors and journal editors should apply existing reporting guidelines, and guidelines specific to the reporting of surgical interventions should be developed.