Thomas W. White

Long-term patient outcomes after surgical stabilization of rib fractures

BACKGROUND Rib fractures are common, and can be disabling. Recently, there has been increased interest in surgical stabilization of rib fractures (SSRF). It is difficult to define long-term benefits of the procedure. This is a descriptive study of patient outcomes after SSRF. METHODS SSRF patients between April 2010 and August 2012 at a Level I trauma center were identified. Data were collected from the medical records. A telephone survey asking about pain, satisfaction, and employment was administered to patients after hospital discharge. RESULTS One hundred-one patients met inclusion criteria. Fifty (50%) patients completed the survey. Indications for SSRF included flail chest, displaced fractures, pain, and inability to wean from mechanical ventilation. Pain was gone at 5.4 ± 1.1 weeks post discharge. Satisfaction with SSRF on a scale of 1 to 10 was 9.2 ± .2. Ninety percent of employed patients returned to the same work at 8.5 ± 1.2 weeks. CONCLUSIONS SSRF patients are satisfied and are able to return to normal activity with few limitations. A prospective study using modern rib fixation technology is needed to further define benefits.

Weight-based enoxaparin dosing for venous thromboembolism prophylaxis in the obese trauma patient

BACKGROUND Limited data exist regarding the efficacy of weight-based dosing of low-molecular weight heparin for venous thromboembolism (VTE) prophylaxis in obese trauma patients. METHODS Consecutive obese trauma patients were placed on a weight-based protocol for VTE prophylaxis (enoxaparin .5 mg/kg subcutaneously every 12 hours). Peak anti-Xa levels were drawn, and bilateral lower extremity duplex ultrasound was performed. The incidence of VTE and bleeding complications were recorded. RESULTS Eighty-six patients met the study criteria. Seventy-four patients achieved target prophylactic anti-Xa concentrations, with a mean level of .42 ± .01 IU/mL. Eighteen patients were found to have deep vein thrombosis. However, in 16 of these patients, deep vein thrombosis was diagnosed before weight-based low-molecular weight heparin initiation. No bleeding complications occurred, and no symptomatic pulmonary emboli were identified. CONCLUSIONS In obese trauma patients, weight-based enoxaparin is an efficacious regimen that provides adequate VTE prophylaxis, as measured by anti-Xa levels, and appears to be safe without bleeding complications.

Validation of Bedside Ultrasound of Muscle Layer Thickness of the Quadriceps in the Critically Ill Patient (VALIDUM Study): A Prospective Multicenter Study.

Background: In critically ill patients, muscle atrophy is associated with long-term disability and mortality. Bedside ultrasound may quantify muscle mass, but it has not been validated in the intensive care unit (ICU). Here, we compared ultrasound-based quadriceps muscle layer thickness (QMLT) with precise quantifications of computed tomography (CT)–based muscle cross-sectional area (CSA). Methods: Patients ≥18 years old with abdominal CT scans performed for clinical reasons were recruited from 9 ICUs for an ultrasound assessment of the quadriceps. CT scans of the third lumbar vertebra, performed <24 hours before or <72 hours after ICU admission, were analyzed for CSA. Low muscularity was defined as 170 cm2 for men and 110 cm2 for women. The ultrasound probe was maximally compressed against the skin and QMLT was measured on 2 sites of each quadriceps <72 hours of the CT scan. Results: Mean CT-derived muscle CSA was 109 ± 25 cm2 for women and 168 ± 37 cm2 for men, where 58% of patients exhibited low muscularity; only 2.7% patients were underweight according to body mass index. QMLT was positively correlated with CT CSA (r = 0.45, P < .001). Based on logistic regression to predict low muscularity, QMLT independently generated a concordance index (c) of 0.67 (P < .002), which increased to 0.77 (P < .001) when age, sex, body mass index, Charlson Comorbidity Index, and admission type (surgical vs medical) were added. Conclusions: Our results suggest that QMLT alone with our current protocol may not accurately identify patients with low muscle mass.

Consensus statement: Surgical stabilization of rib fractures rib fracture colloquium clinical practice guidelines

Please cite this article as: Pieracci Fredric M, Majercik Sarah, Ali-Osman Francis, Ang Darwin, Doben Andrew, Edwards John G, French Bruce, Gasparri Mario, Marasco Silvana, Minshall Christian, Sarani Babak, Tisol William, VanBoerum Don H, White Thomas W.Consensus Statement: Surgical Stabilization of Rib Fractures Rib Fracture Colloquium Clinical Practice Guidelines.Injury http://dx.doi.org/10.1016/j.injury.2016.11.026

In-hospital outcomes and costs of surgical stabilization versus nonoperative management of severe rib fractures.

BACKGROUND One factor that has precluded the wide adoption of surgical stabilization of rib fractures (SSRF) is the perception that it is too expensive to surgically repair an injury that will eventually heal without intervention. The purpose of this study was to compare in-hospital outcomes, costs, and charges for SSRF patients with a series of propensity-matched, nonoperatively managed rib fracture (NON-OP) patients at a single Level 1 trauma center. METHODS All patients admitted with rib fractures between January 2009 and June 2013 were identified. Patient demographics, injury, cost, and charge data were collected. Two-to-one propensity score matching was used to identify NON-OP patients who were similar to the SSRF patients. Zero-inflated negative binomial regression was conducted to assess the relationship among SSRF, intensive care unit (ICU) length of stay (LOS), and ventilator days. Cost and charge information was compared using Wilcoxon rank-sum tests. RESULTS A total of 411 patients (137 SSRF, 274 NON-OP) were included in the analysis. Ventilator days and ICU LOS in days were not different between the SSRF and NON-OP groups when compared using the Wilcoxon rank-sum test. Ventilator and ICU days were less for SSRF by 2.24 days and 1.62 days, respectively, using zero-inflated negative binomial analysis to exclude the large number of patients who had 0 day on the ventilator and/or in the ICU. SSRF patients had higher hospital costs and total relevant charges compared with the NON-OP patients. Subgroup analysis of patients requiring mechanical ventilation who did not have head injury showed decreased ventilator days (median, 3 days vs. 5 days; p = 0.03) and need for tracheostomy (5% vs. 23%, p = 0.02) in SSRF versus NON-OP, respectively. In this subgroup, there was no difference in hospital costs and charges between SSRF and NON-OP. CONCLUSION SSRF patients have shorter ICU LOS and less ventilator days than NON-OP across a diverse group of patients. Hospital costs and charges for SSRF patients are higher. In mechanically ventilated patients who do not have head injury, in-hospital outcomes are better, and there is no difference in hospital costs and charges. Further prospective cost-effectiveness research will determine whether improved quality of life and ability to return to meaningful activity sooner outweighs the increased costs of the acute care episode for SSRF patients. LEVEL OF EVIDENCE Epidemiologic study, level III.

Surgical stabilization of severe rib fractures decreases incidence of retained hemothorax and empyema

BACKGROUND Retained hemothorax (RH) is relatively common after chest trauma and can lead to empyema. We hypothesized that patients who have surgical fixation of rib fractures (SSRF) have less RH and empyema than those who have medical management of rib fractures (MMRF). METHODS Admitted rib fracture patients from January 2009 to June 2013 were identified. A 2:1 propensity score model identified MMRF patients who were similar to SSRF. RH, and empyema and readmissions, were recorded. Variables were compared using Fisher exact test and Wilcoxon rank-sum tests. RESULTS One hundred thirty-seven SSRF and 274 MMRF were analyzed; 31 (7.5%) had RH requiring 35 interventions; 3 (2.2%) SSRF patients had RH compared with 28 (10.2%) MMRF (P = .003). Four (14.3%) MMRF subjects with RH developed empyema versus zero in the SSRF group (P = .008); 6 (19.3%) RH patients required readmission versus 14 (3.7%) in the non-RH group (P = .002). CONCLUSIONS Patients with rib fractures who have SSRF have less RH compared with similar MMRF patients. Although not a singular reason to perform SSRF, this clinical benefit should not be overlooked.

A role in trauma care for advanced practice clinicians.

Advanced practice clinicians (APCs) are increasingly being utilized to care for patients on trauma services, but the quality of care provided by these alternate delivery models has been questioned. We hypothesized that APCs could safely administer trauma care that had traditionally been provided by surgical residents. Outcomes from an APC trauma‐care delivery model were compared with those reported in the National Trauma Data Bank (NTDB). Parameters included in the comparison were mechanism of injury (MOI), length of hospital stay (LOS), injury severity score (ISS), and mortality. When MOI was used as the basis of comparison, the percentage of patients treated at the trauma center and the percentage of patients with information in the NTDB were similar. Despite having more seriously injured patients, the APC‐staffed trauma center demonstrated a shorter LOS for all ISS categories; comparisons of patients with ISS >24 did not reach statistical significance. In addition, the APC‐staffed trauma center had a statistically lower overall combined mortality rate when categorized by ISS. We conclude that an APC trauma‐care delivery model provides outcomes at least as good as those reported by the NTDB.

Regarding: Long-term patient outcomes after surgical stabilization of rib fractures

With interest we read the article by Tenofski et al. This article compares the immediate and long-term complications andconsequences of oncoplastic andnononcoplastic breast-conserving surgeries (BCS). It is a retrospective study of 142 procedures in 140 patients, of which 84 were traditional and 58 oncoplastic BCS. Among the oncoplastic group, the majority had simple level 1 oncoplastic procedures and the rest either reduction therapeutic or donut mammoplasty. The 2 groups had statistically not different size of tumors removed or number of cases needing re-excision. However, oncoplastic surgery caused delayed healing, fat necrosis, and pain 6 to 12 months after surgery more often. Finally, oncoplastic techniques did not seem to improve the cosmetic outcome even many months into the postoperative period. The aim of oncoplastic BCS is to achieve conservation in cases of large tumors. It also ‘‘hides’’ scars, reduces the contralateral breast to achieve symmetry, reconstructs the nipple, and so forth. And it does all thisdwith no compromise of the oncologic resultdwith the aim to improve the final cosmetic result. However, it is not a cheap exercise as it takes up significant time and resources in today’s cost-conscious environment. The latter should not be deterrent if oncoplastic BCS actually delivers on its promises. Being provocative, one can support that this publication does not seem to justify the application of oncoplastic BCS in this case. This type of procedure treated cancers of the same size, did not affect the rates of re-excision, increased the complications and complaints, andhadsimilar cosmetic results as themore traditional method. Therefore, it is reasonable to question its necessity. Surely, one has to acknowledge that attention to cosmesis has becomemore ‘‘fashionable’’ amongbreast cancer patients, and this increases patients’ expectations from their procedure. The younger age of the oncoplastic groupmaymean that these patients had higher cosmetic expectations and were stricter with the judgment of the esthetic result. Besides, radiotherapy may also affect cosmesis, and it seems that there was a difference between the groups. Finally, one cannot avoid noticing that the oncoplastic group was heterogeneous from the technical point of view, with about two thirds of it being adjacent tissue transfer. As different oncoplastic techniques have different indications and complications (rates and types), it would be methodologically more accurate not to put all the oncoplastic procedures in the same pot. Besides, we feel that the oncoplastic techniques ‘‘not’’ studied here are the ones that actually deliver on the promise and are able to remove large cancers with breast conservation. Being strong supporters of oncoplastic surgery but having become devil’s advocates for the purposes of this article, we are looking forward to the authors’ comments.

Medial scapular winging associated with rib fractures and plating corrected with pectoralis major transfer.

Highlights • Long thoracic nerve injury is a potential complication of rib fracture fixation.• Long thoracic nerve injury from rib fracture fixation has not been reported.• Long thoracic nerve injury can be corrected surgically by pectoralis major transfer.

Fracture of the Costal Cartilage: Presentation, Diagnosis, and Management

A 52-year-old woman sustained a fracture of the left 7th costal cartilage after a ski injury. She presented complaining of painful clicking over the area. Initial imaging studies were negative for fracture; however, 3-dimensional reconstruction of a chest computed tomography scan, formatted to costal cartilage, revealed the fracture. She was offered and underwent surgical fixation of the fracture with a plate and 4 screws using a biaxial, convergent construct. Postoperatively, her symptoms resolved. In this case report, we review the rationale for fixation of costal cartilage, including a summary of previous literature pertaining to this relatively rare thoracic injury.