Trauma Surgery Research Articles

Fallen Yet Beautiful

Iridodialysis can occur due to blunt trauma or intraocular surgeries. Symptoms include glare, photophobia, eye pain, Diplopia. Signs include elevated Intraocular Pressure , Hyphema. In this report, we describe a case of total Iridodialysis during manual small incision cataract surgery. The disinserted Iris was left insitu and on postoperative day 1, the Iris was in place without getting crumpled or obstructing the visual axis. The postoperative 6 week follow up has the same picture where Iris tissue remained the same without getting necrosed. This is an unusual presentation of the Iris tissue

See one, do one, teach one - Trends in resident autonomy and teaching assistant cases during general surgery residency in the United States: A nationwide retrospective analysis

IntroductionAutonomy during residency is crucial to the training and development of competent surgeons. An essential component of this process is the ‘teaching assistant (TA)’ case, an indispensable opportunity for residents to gain confidence and hone intraoperative skills. However, high-quality data on the volume and diversity of cases that graduates perform are scarce. MethodsA retrospective analysis was performed from publicly collected data of operative case logs from general surgery residents graduating from ACGME-accredited programs from 2006 to 2023. Data on the median overall number of surgeon chief and TA cases were retrieved. Collected data were organized based on sub-specialties. The Mann-Kendall trend test was used to investigate trends in TA cases and surgeon chief operative volume. ResultsBetween 2007 and 2023, the surgeon chief cases gradually increased from 229 to 274 (19.6 ​% increase; τ ​= ​0.610, p ​= ​0.001). There was a concurrent 72.7 ​% increase in TA cases from a median of 22–38 (τ ​= ​0.574, p ​= ​0.001). Surgeon chief (283 per resident) and TA cases (43 per resident) peaked in 2018–2019 and 2016–2017.The uptrend in TA cases was associated with the significant increase in colorectal (τ ​= ​0.559, p ​= ​0.001), general surgery-other (τ ​= ​0.404, p ​= ​0.018), and hepatopancreaticobiliary (HPB) (τ ​= ​0.596, p ​= ​0.001) subspecialties. Trauma and vascular surgery did not change significantly. With respect to total chief cases, general surgery-other (τ ​= ​0.956, p=<0.001), HPB (τ ​= ​0.713, p=<0.001) and colorectal (τ ​= ​0.522, p ​= ​0.004) volume increased. There was no significant change in trauma and foregut volume, while the volume of endocrine (τ ​= ​−0.485, p ​= ​0.006) and vascular surgery (τ ​= ​0.603, p ​= ​0.001) dropped significantly.The procedural category with the highest chief and TA volume was ‘colorectal tract - large intestine.’ Most procedural categories (53.49 ​%) retained a median of 0 teaching cases. No chief cases were logged for the specialties generally not considered part of general surgery (genitourinary, nervous system, orthopedics, and gynecology), although a median of 1 surgeon chief genitourinary case was recorded from 2018 to 2023. ConclusionsOver the past seventeen years, there has been a gradual uptrend in the number of surgeon chief and TA cases. While this is a positive indicator of improved autonomy, further research must focus on strategies to improve resident autonomy to train well-rounded surgeons safely.

Performance of trauma-trained large language models on surgical assessment questions: A new approach in resource identification

BackgroundLarge language models have successfully navigated simulated medical board examination questions. However, whether and how language models can be used in surgical education is less understood. Our study evaluates the efficacy of domain-specific large language models in curating study materials for surgical board style questions. MethodsWe developed EAST-GPT and ACS-GPT, custom large language models with domain-specific knowledge from published guidelines from the Eastern Association of the Surgery of Trauma and the American College of Surgeons Trauma Quality Programs. EAST-GPT, ACS-GPT, and an untrained GPT-4 performance were assessed trauma-related questions from Surgical Education and Self-Assessment Program (18th edition). Large language models were asked to choose answers and provide answer rationales. Rationales were assessed against an educational framework with 5 domains: accuracy, relevance, comprehensiveness, evidence-base, and clarity. ResultsNinety guidelines trained EAST-GPT and 10 trained ACS-GPT. All large language models were tested on 62 trauma questions. EAST-GPT correctly answered 76%, whereas ACS-GPT answered 68% correctly. Both models outperformed ChatGPT-4 (P < .05), which answered 45% correctly. For reasoning, EAST-GPT achieved the gratest mean scores across all 5 educational framework metrics. ACS-GPT scored lower than ChatGPT-4 in comprehensiveness and evidence-base; however, these differences were not statistically significant. ConclusionOur study presents a novel methodology in identifying test-preparation resources by training a large language model to answer board-style multiple choice questions. Both trained models outperformed ChatGPT-4, demonstrating its answers were accurate, relevant, and evidence-based. Potential implications of such AI integration into surgical education must be explored.

Imaging Findings Associated With Failure of Conservative Management After Blunt Extraperitoneal Bladder Injury

ObjectivesTo identify risk factors for failure of conservative management (CM) for uncomplicated extraperitoneal bladder injuries (EBI). MethodsThe trauma registry at a single Level 1 trauma center was queried for patients presenting with a blunt EBI between 2004 and 2022. Patients with CM and follow-up through at least one postoperative cystogram or catheter removal were included. A univariable analysis for associations with a composite outcome of either persistent leakage or delayed cystorrhaphy was completed. ResultsEighty-four patients with an EBI underwent CM. Seventy-eight (93%) patients had an associated pelvic fracture and 17 of 84 (20%) underwent embolization for pelvic hemorrhage. Thirty-four (41%) patients also had delayed phase imaging, 17 (20%) of whom had extravasation from their bladder on delays. Six (7%) patients failed initial CM. There was no association between the composite outcome and pelvic fracture (p=0.35) or embolization (p=0.41). American Association for the Surgery of Trauma (AAST) grade 5 injuries (p=0.01) and the presence of extravasation on delayed-phase Computed Tomography (p=0.03) were associated with the composite outcome. ConclusionsContrast extravasation on initial delayed-phase imaging despite urethral catheter drainage and AAST injury grade were associated with failed CM after EBI. This may reflect injuries that mechanistically yield incomplete antegrade drainage with CM.

Treatment options for unstable posterior pelvic ring lesions: A multicenter retrospective cohort study of the Italian Society for the Traumatology of the Pelvis.

Posterior pelvic ring lesions are a common finding in patients with pelvic trauma, representing a challenging condition for trauma surgeons. Surgical options are different and there is not yet evidence about the best option. Aim of the study are: (i) to compare Lumbopelvic fixation (LPF) and ilio-sacral screw fixation (ISS) regarding clinical and radiological outcome in unstable posterior pelvic ring injuries, both as whole population and single similar fracture types according to Tile classification (C1vsC1, C2vsC2, C3vsC3); (ii) to analyze clinical outcomes and complications in lumbopelvic fixation group, comparing open and closed reduction technique. A retrospective multicenter study was performed. Data of the patients were collected. Inclusion criteria were: (i) unstable posterior ring lesions Tile C type, (ii) surgically treated either through ISS (Group A) or LPF (Group B), (iii) minimum follow-up 12 months. Radiological evaluation was made through plain radiographs in Antero-posterior (AP), inlet and outlet views. Last clinical evaluation at 12 months was assessed through Majeed Score, and quality of life (QoL) through SF-12. Group A was represented by 76 patients, and Group B by 42. Group B had better result in Majeed score for non-workers (average 60.1 ± 21.6 vs 65.0 ± 15.6, p = 0.016*). Comparing only C3-type lesions, Group A showed a higher rate of implants breakage (p = 0.032*). Other differences had p > 0.05. Comparing patients underwent open (ORIF) or closed (CRIF) reduction in Group B, CRIF group had shorter hospitalization (47.2 vs 23.4 days, p = 0.020*), an earlier full weight-bearing recovery (4.1 vs 2.6 months, p = 0.035*) and a better Majeed score in workers patients (70.3 vs 82.8, p = 0.019*). Better results for CRIF group were also recorded in quality of life (QoL), both in mental (45.1 vs 55.2, p = 0.040*) and physical outcome (31.9 vs 50.7, p < 0.001*). ISS and LPF represent both good choices in posterior pelvic ring lesions, however some significant differences were noted. LPF seems to be preferable if the patient did not work before the trauma, due to better clinical outcome. In Tile C3 lesions, LPF have lower breakage rates. If LPF is chosen, CRIF provides better clinical outcomes, QoL and lower hospitalization.

Lung ultrasonography underdiagnoses clinically significant pneumothorax

BackgroundUltrasonography for trauma is an integral part of the Advanced Trauma Life Support algorithm and supported extensively in the literature. The reliability of chest ultrasonography as a screening examination for pneumothorax during initial trauma evaluation is unclear. We performed a prospective study where we hypothesized that chest ultrasonography would have low sensitivity for detecting clinically significant pneumothorax. MethodsA prospective observational analysis of patients with blunt chest trauma at a level 1 trauma center was performed. Patients included had supine chest radiography and chest ultrasonography performed prior to intervention as well as confirmatory computed tomographic imaging. All chest ultrasonography was performed in the trauma bay by a registered sonographer. All imaging was evaluated by an attending trauma surgeon and radiologist in real time. ResultsOf 2,185 patients screened with a diagnosis of blunt thoracic trauma, 1,489 patients had chest radiography, chest ultrasonography, and confirmatory computed tomography and were included for analysis. Patients were 71% male, with median age of 42 years, and mean Injury Severity Score of 6. The sensitivity of chest ultrasonography to detect pneumothorax was low. Chest ultrasonography had a false negative rate of 72% (n = 58), with 22% (n = 13) undergoing tube thoracostomy. Patients with false negative examinations had lower initial O2 saturation and systolic blood pressure and were more likely to have rib fractures compared with true negative chest ultrasonography examinations. ConclusionChest ultrasonography performed on initial trauma evaluation has low sensitivity with a high rate of false negative examinations. Because many of these false negative results are clinically significant requiring thoracostomy, using chest ultrasonography alone to screen for pneumothorax should be done with caution.

CT of Periarticular Adult Knee Fractures: Classification and Management Implications.

Periarticular knee fractures, which include fractures of the distal femur, tibial plateau, and patella, account for 5%-10% of musculoskeletal injuries encountered in trauma centers and emergency rooms. These injuries are frequently complex, with articular surface involvement. Surgical principles center on reconstruction of the articular surface as well as restoration of limb length, alignment, and rotation to reestablish functional knee biomechanics. Fixation principles are guided by fracture morphology, and thus, CT with multiplanar reformats and volume rendering is routinely used to help plan surgical intervention. Fractures involving the distal femur, tibial plateau, and patella have distinct management considerations. This comprehensive CT primer of periarticular knee fractures promotes succinct and clinically relevant reporting as well as optimized communication with orthopedic trauma surgeon colleagues by tying fracture type and key CT findings with surgical decision making. Fracture patterns are presented within commonly employed fracture classification systems, rooted in specific biomechanical principles. Fracture typing of distal femur fractures and patellar fractures is performed using Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification schemes. Tibial plateau fractures are graded using the Schatzker system, informed by a newer explicitly CT-based three-column concept. For each anatomic region, the fracture pattern helps determine the surgical access required, whether bone grafting is warranted, and the choice of hardware that achieves suitable functional outcomes while minimizing the risk of articular collapse and accelerated osteoarthritis. Emphasis is also placed on recognizing bony avulsive patterns that suggest ligament injury to help guide stress testing in the early acute period. ©RSNA, 2024 Supplemental material is available for this article.

CASEMIX study: Assessment of patient factors influencing the subprocedure duration of trauma/orthopaedic surgeries

IntroductionThe social and financial burdens of the operative environment remains to be a major problem in modern society. We analyse the impact of the introduction and application of a perioperative cloud system that cross-analyzes the pre-/intraoperative risks to minimize surgical time and maximize operation theater efficiency through improved planning. MethodsTCC-CASEMIX© was introduced to our Department of Trauma Surgery of the University of Szeged to objectively measure intraoperative time durations according to each essential subprocedure. The study is largely divided into pre-operative assessments and intraoperative measurements. Patient data (age, sex, and ethnicity etc.) was registered preoperatively, and the expected time per each essential intraoperative step (skin incision, reduction, fixation etc.) was entered. The steps were then timed intraoperatively by surveyors, and postoperative cross analysis was performed. Our study was divided into two phases; phase 1, the surveying of general trauma / orthopedic cases, and phase two; the examination of high volume surgeries. ResultsAcute cases of Open Reductions and Internal Fixation (ORIF) procedures depended heavily on the presentation of the fracture, and no clear correlations in the risk factors were found. Arthroscopies were a short, high-volume procedure, but there was a large difference between the surgeon's estimates and the operation duration. In high volume surgeries, although individual factors only slightly influenced surgical duration, patient cohort stratification led to a better understanding of factors that impact surgeries, namely the combination of BMI and surgeon years of experience. While the average (Intraoperative Duration) seemed to increase with BMI, younger surgeons were more influenced by the patients BMI. ConclusionA data filtering algorithm-assisted cloud system can be a reliable way to facilitate the planning of operating theater schedules. Patient stratification according to BMI and surgeon years of experience seems to affect intraoperative duration significantly, and the understanding of the risks and intraoperative steps has the potential to forecast surgeries with high precision.

Low-value surgical innovation under peer-review: A sham study of abstracts on proximal humerus fractures submitted to scientific meetings.

Innovation has in common the promise of benefit for patients; however, past experience has shown that this promise is not always delivered. Instead, low-value innovation might encourage treatment variation and dilute the available body of evidence. This study aims to investigate (1) whether the peer-review process is capable of filtering out low-value innovation appropriately, and (2) whether low-value surgical innovation would be preferred more often than nonoperative innovation by peer-reviewers in the treatment of proximal humeral fractures in the elderly. Two duplicated sham scientific abstracts, respectively introducing a low-value surgical innovation and a valuable nonsurgical innovation, were submitted to nineteen peer-reviewed scientific meetings worldwide for orthopedic trauma surgery with submission deadlines between 01/01/2022 and 31/12/2022. Decision regarding abstract acceptance was compared. There was a high acceptance rate for the abstract introducing low-value surgical innovation (12 out of 19 (63.2 %)), which was higher than that of a nonoperative duplicate (10 out of 19 (52.6 %)), but this difference was not statistically significant (p = 0.5). The majority of the ten meetings that accepted both abstracts placed both in equivalent programmatic tiers (oral presentation (4) and poster presentation (2)). In three meetings, the surgical abstract received superior program placement (oral presentation). In one case, it was the opposite. There is a high acceptance rate for low-value surgical innovation among peer-reviewed scientific meetings. However, we can not conclude that low-value surgical innovation is preferred more often than nonoperative innovation by peer-reviewers as the differences in acceptance rate were small and not statistically significant. The peer-review process may be suitable as value-based medicine emerges. Scientists should be encouraged to pursue value-based innovation.

Quality ofIntegration ofAir Force Trauma Surgeons Within the Center forSustainment ofTrauma andReadiness Skills, Cincinnati: A Pilot Study.

While previous studies have analyzed military surgeon experience within military-civilian partnerships (MCPs), there has never been an assessment of how well military providers are integrated within an MCP. The Center for Sustainment of Trauma and Readiness Skills, Cincinnati supports the Critical Care Air Transport Advanced Course and maintains the clinical skills of its staff by embedding them within the University of Cincinnati Medical Center. We hypothesized that military trauma surgeons are well integrated within University of Cincinnati Medical Center and that they are exposed to a similar range of complex surgical pathophysiology as their civilian partners. After Institutional Review Board approval, Current Procedural Terminology (CPT) codes were abstracted from billing data for trauma surgeons covering University of Cincinnati Hospitals in 2019. The number of trauma resuscitations and patient acuity metrics were abstracted from the Trauma Registry and surgeon Knowledge, Skills, and Abilities clinical activity (KSA-CA) scores were calculated using their CPT codes. Finally, surgeon case distributions were studied by sorting their CPT codes into 23 categories based on procedure type and anatomic location. Appropriate, chi-squared or Mann-Whitney U-tests were used to compare these metrics between the military and civilian surgeon groups and the metrics were normalized by the group's full-time equivalent (FTE) to adjust for varying weeks on service between groups. Data were available for two active duty military and nine civilian staff. The FTEs were significantly lower in the military group: military 0.583-0.583 (median 0.583) vs. civilian 0.625-1.165 (median 1.0), P = 0.04. Per median FTE and surgeon number, both groups performed a similar number of trauma resuscitations (civilian 214 ± 54 vs. military 280 ± 13, P = 0.146) and KSA-CA points (civilian 55,629 ± 25,104 vs. military 36,286 ± 11,267; P = 0.582). Although the civilian surgeons had a higher proportion of hernia repairs (P < 0.001) and laparoscopic procedures (P = 0.006), the CPT code categories most relevant to combat surgery (those relating to solid organ, hollow viscus, cardiac, thoracic, abdominal, and tissue debridement procedures) were similar between the surgeon groups. Finally, patient acuity metrics were similar between groups. This is the first assessment of U.S. Air Force trauma surgeon integration relative to their civilian partners within an MCP. Normalized by FTE, there was no difference between the two groups' trauma experience to include patient acuity metrics and KSA-CA scores. The proportion of CPT codes that was most relevant to expeditionary surgery was similar between the military and civilian partners, thus optimizing the surgical experience for the military trauma surgeons within University of Cincinnati Medical Center. The methods used within this pilot study can be generalized to any American College of Surgeons verified Trauma Center MCP, as standard databases were used.

Renal angioembolization vs. surgery for high-grade renal trauma: a nationwide comparative analysis.

Renal angioembolization (RAE) is widely employed in low-grade renal injuries and associated with improved patient outcomes, while surgery remains the mainstay for managing high-grade injuries. We compared the outcomes following surgery and RAE in high-grade renal trauma (HGRT). We used the ACS TQIP 2016-2020 to identify patients ≥ 16 years with HGRT who underwent RAE or surgery. Morbidity was the primary outcome, while mortality and lengths of stay were secondary outcomes. We accounted for clinically relevant characteristics using multilevel logistic regression analyses. We included 591 patients, of whom 279 (47.2%) underwent RAE. After adjusting, there was no difference in morbidity, hospital LOS, or ICU LOS. The surgery cohort had increased odds of mortality (aOR 4.93; [95% CI] 1.53-15.82; p = 0.007) compared to RAE. In the penetrating injury subgroup, no associations between management and outcomes were observed. In the grade V injury subgroup, morbidity was significantly higher after surgery (aOR 4.64; [95% CI] 1.49-14.47; p = 0.008). Overall, RAE did not significantly impact morbidity but was associated with improved mortality. RAE could safeguard renal function by augmenting the efficacy of concurrent non-operative interventions. Randomized studies are needed to further validate the utility of RAE in HGRT.

Effect of mechanical stability of osteosynthesis on infection rates: Timing of temporary and definitive fixation

Fracture related infection (FRI) remains one of the most challenging complications of orthopaedic trauma surgery. Several factors contribute to FRI development but, among those, particularly interesting from the orthopaedic surgeon's perspective is the contribution of mechanical stability and timing of fracture fixation. These are indeed crucial factors both in prevention and treatment of FRI and are directly influenced by the surgeon's work. While the role of stability has been studied and discussed, the pathophysiological process regulating such role and how this influences surgeon's treatment decision making is still debated. The same applies to the ideal timing of temporary or definitive fixation which varies according to the clinical scenario considered.In the present narrative review, we described the influence of mechanical stability on both FRI pathophysiology and on the decision making of FRI treatment. In addition, we analysed the impact of the timing of fracture fixation on the risk of FRI development particularly in those clinical scenarios where it has been shown to be specifically relevant, such as fractures affecting segments with poor soft tissue envelope, open fractures, damage control orthopaedics, and the need for soft tissue coverage.

Obesity is a predictor of abdominal computed tomography imaging in pediatric trauma patients.

Computed tomography (CT) has helped to reduce the morbidity due to missed injuries. However, CT imaging is associated with radiation exposure and thus has limited indications in pediatric patients. In this study, we aimed to identify the association between obesity and abdominal CT imaging in pediatric trauma patients. We performed a 4-year retrospective analysis of the American College of Surgeons Trauma Quality Improvement 2017-2020. We identified all pediatric trauma patients aged between 7 and 17 years presenting with isolated abdominal trauma (nonabdominal Abbreviated Injury Scale score, 0). We excluded patients undergoing hemorrhage control surgeries and those with missing information in height and weight. Patients were stratified by body mass index into four groups (underweight, normal, overweight, and obese [body mass index, ≥30 kg/m2]). Outcomes were predictors of undergoing CT imaging of the abdomen. Descriptive statistics and multivariable logistic regression analyses were performed. We identified a total of 10,204 pediatric trauma patients. The mean age was 13 years, 68% were male, and 77% were White. The median abdominal Abbreviated Injury Scale score in all the four groups was 2. On univariate analysis, underweight patients had lowest rates (25%), whereas obese patients had highest rates of CT imaging (38%) (p < 0.001). On multivariable regression analysis, increasing age (adjusted odds ratio [aOR], 1.08; 95% confidence interval [CI], 1.06-1.10; p < 0.001), male sex (aOR, 1.14; 95% CI, 1.03-1.26; p = 0.009), White race (aOR, 0.84; 95% CI, 0.76-0.92; p < 0.011), penetrating injury (aOR, 1.16; 95% CI, 1.03-1.32; p = 0.017), obesity (aOR, 1.30; 95% CI, 1.07-1.57; p = 0.008), and management at American College of Surgeons level II (aOR, 1.63; 95% CI, 1.44-1.85; p < 0.001) and level III or lower centers (aOR, 1.17; 95% CI, 1.06-1.26; p = 0.002) were identified as independent predictors of receiving CT imaging. Obesity is associated with increased odds of undergoing CT imaging in pediatric trauma patients independent of injury characteristics. Future efforts to define the appropriate indications for CT imaging in pediatric trauma patients are warranted to reduce the adverse effects of CT radiation. Prognostic and Epidemiological; Level III.

Delirium in Lower Limb Trauma: The Incidence and Risk Factors in a Prospective Observational Study.

Delirium poses a significant challenge in musculoskeletal trauma patients, particularly the elderly, contributing to elevated morbidity and mortality. Despite unclear pathogenesis, various risk factors have been identified. This prospective observational study, conducted in a tertiary center, aims to estimate delirium incidence and identify associated risk factors in adult patients undergoing lower limb trauma surgeries. Between August 2021 and December 2022, 150 patients with lower limb trauma admitted for surgery were included. Initial assessments recorded Mini-Mental State Examination scores, Injury Severity Scores, and potential risk factors. Confusion Assessment Method scoring done preoperatively (excluding emergencies) and postoperatively on days 2 and 5 or at discharge. Daily delirium screening utilized Nursing 4-Abbreviated Trauma score, with severity assessed using CAM-Severity score. Risk factor analysis categorized patients into Group A (delirium) and Group B (non-delirium), with primary endpoint being delirium occurrence. The study revealed a 10% delirium incidence. Delirium severity ranged from mild to severe. The median age (in years) was 79 vs 46 in delirium and non-delirium group respectively. Delirium patients had longer hospital stay (13 vs 8, p value 0.011). Similarly, factors like female gender, delayed surgery, hyponatremia, hypoproteinaemia, increased injury severity, midazolam use during induction, multiple blood transfusions, and heightened postoperative pain intensity were found significant (p value < 0.05). This study enhances our understanding of delirium in lower limb trauma patients undergoing surgeries. Identified risk factors offer insights for targeted interventions, emphasizing the need for comprehensive preoperative assessments and management strategies to reduce delirium incidence and improve patient outcomes.

Improving Patient Recall Following Operative Orthopaedic Trauma.

Orthopaedic trauma patients may experience poor recall regarding their injury and treatment, impairing postoperative outcomes. We sought to evaluate the impact of a standardized postoperative educational protocol on patient recall, adherence to the treatment plan, and satisfaction. Two hundred and twenty adult, English-speaking patients with surgically treated lower-extremity fractures were prospectively included. One hundred and ten patients in the educational intervention cohort met with a non-physician study member after surgery but before hospital discharge. They were given a written questionnaire evaluating knowledge of key aspects of their injury and treatment plan. For incorrectly answered questions, the study team member told the patient the correct answer (e.g., "No, you broke your tibia."). Immediately after, the patient was verbally asked the question again (e.g., "Which bone did you break?"), repeating the process until the answer was correct. The 110 patients in the control cohort did not receive this "teach-back" protocol. During their first postoperative appointment, all 220 patients completed a follow-up questionnaire assessing recall, adherence to the treatment plan, and satisfaction. The control cohort correctly answered 64% of recall-oriented questions versus 89% in the intervention cohort (p < 0.001). Eighty-two percent of control patients versus 89% patients in the intervention cohort adhered to postoperative weight-bearing restrictions (p = 0.09). Eighty-four percent of controls adhered to their deep venous thrombosis prophylaxis regimen versus 99% of the intervention cohort (p < 0.001). On a 5-point Likert scale, controls were less satisfied with their overall orthopaedic care compared with patients in the intervention cohort (mean of 4.38 ± 0.84 versus 4.54 ± 0.63 points; p = 0.02), although this difference was less than the minimal clinically relevant difference of 10% that was defined at study onset. On propensity score-weighted multivariable analysis, receipt of the postoperative educational intervention was the only modifiable factor associated with improvement in patient recall (26% improvement [95% confidence interval, 20% to 31%]; p < 0.001). Some orthopaedic trauma patients' nonadherence to surgeon recommendations and dissatisfaction with care may be mitigated by postoperative education. This standardized postoperative educational protocol improves orthopaedic trauma patients' recall, adherence to their treatment plan, and satisfaction in a manner requiring minimal time. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Analysis of Sex Diversity Within Orthopedic Trauma Surgery Fellowship Programs

Background: Women continue to be underrepresented in orthopedic surgery and in orthopedic fellowship programs, especially in orthopedic trauma. Purpose: We aimed to assess sex diversity among faculty and trainees in orthopedic trauma surgery fellowship programs and investigate whether the presence of female faculty in those programs is associated with the recruitment of female fellows. Methods: This was a cross-sectional analysis of 63 orthopedic trauma surgery fellowship programs. Information regarding program faculty (as of October 2023) and fellows from 2018 to 2024 was gathered. For programs without publicly accessible information, fellowship coordinators were e-mailed for de-identified sex breakdown of fellows categorized by year. The sex of each fellow and faculty member was categorized as male or female and determined by inference from the fellow’s first name and confirmed via Internet search using photos, biographies, and preferred pronouns when available. Results: Of 63 programs with 323 orthopedic trauma faculty, 30 (47.6%) programs had at least 1 female faculty member, with only 4 (6.4%) programs having female fellowship directors. Women made up 12% ( n = 39) of orthopedic trauma faculty. Of 399 total fellows identified over the 6-year period, 67 (16.7%) were women, with a notable increase in the representation of female fellows over time, from 10.8% in 2018 to 25.4% in 2024. Although programs with female faculty had a similar proportion of female fellows over the 6-year period as those without, in the most recent fellowship year (2023–2024), programs with female faculty had a higher proportion of female fellows than those without (38.2% vs 13.5%, respectively). Conclusion: This cross-sectional, observational study suggests that female surgeons remain underrepresented in orthopedic trauma fellowship director roles, although we observed an increasing number of female trainees entering orthopedic trauma surgery fellowship programs in recent years. In the most recent fellowship class studied, programs with female faculty had more than double the proportion of female fellows compared to programs without any female faculty.

Impact of Surgical Team Involvement at the Time of Trauma Activation for Pediatric Patients With Motorized Cycle or All-Terrain Vehicle Injury Mechanism.

At our institution, level 2 trauma (L2T) activations are primarily managed by pediatric emergency medicine (PEM) physicians, whereas level 1 activations are co-managed by pediatric surgery and PEM. Starting in September 2019, the response to L2T activations due to all-terrain vehicles or motorized cycles (ATVs/MCs) changed to include surgical assessment upon patient arrival due to increased likelihood of significant injuries and need for higher level of care. The impact of PEM/surgery co-management of ATV/MC L2T patients on time to an admission decision is unknown. We retrospectively reviewed patients <18 years of age presenting to our American College of Surgeons-verified level 1 pediatric trauma center as L2T activations with ATV/MC mechanism between 1/2016 and 10/2022. Patient demographics, injury characteristics, details of imaging, interventions, and emergency department (ED) course were recorded. The χ2 and Fisher exact tests were performed. One hundred fifty-five patients met the inclusion criteria prior to augmenting our response to include surgical presence at L2T-ATV/MC activations, and 216 patients were treated after our protocol change. There were no statistically significant differences in age, sex, race, transfer status, vehicle subtype, or Injury Severity Scores between groups. Trauma surgery was involved in the care of 74.8% of L2T-ATV/MC patients before protocol augmentation and 87% after (P = 0.003). Time to an admission decision significantly decreased by 22.5 minutes (117 minutes [interquartile range, 72-178] vs 94.5 minutes [interquartile range, 60-139]; P = 0.023) after protocol augmentation. There was a trend toward increased completion of mandated postsecondary survey communication huddles after protocol change (84.6% to 91.2%, P = 0.089). The median total ED length of stay did not differ between admitted and discharged patients. Early surgical assessment for pediatric patients with ATV/MC injuries improved time to an admission decision and trauma communication huddle compliance. Next steps include identifying process improvement opportunities to decrease ED total length of stay for patients with ATV/MC injuries.

Application of objective optical quality analysis system in guiding early posterior capsule opacification laser treatment: An observational study.

In the present study, we aimed to demonstrate the objective guiding role of objective scatter index (OSI) in patients with early stage posterior capsule opacification (PCO), especially in patients with multifocal intraocular lens (IOL) implantation. A prospective randomized case analysis was conducted on elderly patients experiencing PCO, exhibiting best-corrected visual acuity (BCVA) below 0.2 LogMAR. Exclusion criteria comprised patients with diabetes, glaucoma, high myopia, trauma, endothelial dystrophy, maculopathy or prior eye surgery affecting visual acuity. The main observational indicators were patient gender, age, post-cataract surgery duration, BCVA (LogMAR), and OSI values. For patients undergoing laser posterior capsulotomy, meticulous documentation of pre-laser OSI values and post-laser OSI values was undertaken. Subjective visual quality was then compared using the Chinese version visual function index-14 (VF-14-CN). The study comprised 65 eyes from 56 patients. PCO developed, on average, 2.06 ± 0.94 years (ranging from 0.5 to 4 years) after the initial surgery, with the OSI consistently exceeding 3.0. Among these cases, only 40 eyes underwent laser posterior capsulotomy using Nd:YAG laser, including 26 eyes implanted with monofocal IOLs and 14 eyes implanted with multifocal IOLs. Following laser posterior capsulotomy for early-stage secondary cataracts, there was a significant decrease in OSI values compared to the presurgery state, coupled with a notable increase in VF-14-CN scores. Among the 14 cases with multifocal IOL implantation, pre-laser VF-14-CN scores were lower compared to those with monofocal IOLs. Post-laser posterior capsulotomy, patients reported a marked improvement in self-perceived symptoms. The OQAS functioned as an objective assessment metric for the laser treatment of early stage PCO. In cases involving multifocal IOL implantation, the visual disturbance caused by PCO was more pronounced, underscoring the significance of OSI as a valuable guide for laser treatment in these patients.

Systemic and cerebro-cardiac biomarkers following traumatic brain injury: an interim analysis of randomized controlled clinical trial of early administration of beta blockers

This is an interim analysis of the Beta-blocker (Propranolol) use in traumatic brain injury (TBI) based on the high-sensitive troponin status (BBTBBT) study. The BBTBBT is an ongoing double-blind placebo-controlled randomized clinical trial with a target sample size of 771 patients with TBI. We sought, after attaining 50% of the sample size, to explore the impact of early administration of beta-blockers (BBs) on the adrenergic surge, pro-inflammatory cytokines, and the TBI biomarkers linked to the status of high-sensitivity troponin T (HsTnT). Patients were stratified based on the severity of TBI using the Glasgow coma scale (GCS) and HsTnT status (positive vs negative) before randomization. Patients with positive HsTnT (non-randomized) received propranolol (Group-1; n = 110), and those with negative test were randomized to receive propranolol (Group-2; n = 129) or placebo (Group-3; n = 111). Propranolol was administered within 24 h of injury for 6 days, guided by the heart rate (> 60 bpm), systolic blood pressure (≥ 100 mmHg), or mean arterial pressure (> 70 mmHg). Luminex and ELISA-based immunoassays were used to quantify the serum levels of pro-inflammatory cytokines (Interleukin (IL)-1β, IL-6, IL-8, and IL-18), TBI biomarkers [S100B, Neuron-Specific Enolase (NSE), and epinephrine]. Three hundred and fifty patients with comparable age (mean 34.8 ± 9.9 years) and gender were enrolled in the interim analysis. Group 1 had significantly higher baseline levels of IL-6, IL-1B, S100B, lactate, and base deficit than the randomized groups (p = 0.001). Group 1 showed a significant temporal reduction in serum IL-6, IL-1β, epinephrine, and NSE levels from baseline to 48 h post-injury (p = 0.001). Patients with severe head injuries had higher baseline levels of IL-6, IL-1B, S100B, and HsTnT than mild and moderate TBI (p = 0.01). HsTnT levels significantly correlated with the Injury Severity Score (ISS) (r = 0.275, p = 0.001), GCS (r = − 0.125, p = 0.02), and serum S100B (r = 0.205, p = 0.001). Early Propranolol administration showed a significant reduction in cytokine levels and TBI biomarkers from baseline to 48 h post-injury, particularly among patients with positive HsTnT, indicating the potential role in modulating inflammation post-TBI.Trial registration: ClinicalTrials.gov NCT04508244. It was registered first on 11/08/2020. Recruitment started on 29 December 2020 and is ongoing. The study was partly presented at the 23rd European Congress of Trauma and Emergency Surgery (ECTES), April 28–30, 2024, in Estoril, Lisbon, Portugal.

DiffErential attainment and Factors AssoCiated with Training applications and Outcomes (DE FACTO) study: Trauma & Orthopaedic surgery in the UK.

The aims of this study were to describe the demographic, socioeconomic, and educational factors associated with core surgical trainees (CSTs) who apply to and receive offers for higher surgical training (ST3) posts in Trauma & Orthopaedics (T&O). Data collected by the UK Medical Education Database (UKMED) between 1 January 2014 and 31 December 2019 were used in this retrospective longitudinal cohort study comprising 1,960 CSTs eligible for ST3. The primary outcome measures were whether CSTs applied for a T&O ST3 post and if they were subsequently offered a post. A directed acyclic graph was used for detecting confounders and adjusting logistic regression models to calculate odds ratios (ORs), which assessed the association between the primary outcomes and relevant exposures of interest, including: age, sex, ethnicity, parental socioeconomic status (SES), domiciliary status, category of medical school, Situational Judgement Test (SJT) scores at medical school, and success in postgraduate examinations. This study followed STROBE guidelines. Compared to the overall cohort of CSTs, females were significantly less likely to apply to T&O (OR 0.37, 95% CI 0.30 to 0.46; n = 155/720 female vs n = 535/1,240 male; p < 0.001). CSTs who were not UK-domiciled prior to university were nearly twice as likely to apply to T&O (OR 1.99, 95% CI 1.39 to 2.85; n = 50/205 vs not UK-domiciled vs n = 585/1,580 UK-domiciled; p < 0.001). Age, ethnicity, SES, and medical school category were not associated with applying to T&O. Applicants who identified as 'black and minority ethnic' (BME) were significantly less likely to be offered a T&O ST3 post (OR 0.70, 95% CI 0.51 to 0.97; n = 165/265 BME vs n = 265/385 white; p = 0.034). Differences in age, sex, SES, medical school category, and SJT scores were not significantly associated with being offered a T&O ST3 post. There is an evident disparity in sex between T&O applicants and an ethnic disparity between those who receive offers on their first attempt. Further high-quality, prospective research in the post-COVID-19 pandemic period is needed to improve equality, diversity, and inclusion in T&O training.