RESUMEN
BACKGROUND: Acute posterior sternoclavicular dislocations (APSCD) are rare injuries that historically have prompted concern for injury to the great vessels and other mediastinal structures from initial trauma or subsequent treatment, resulting in the recommendation that a thoracic or vascular surgeon be present or available during operative treatment. The objectives of the study were to characterize the demographic, clinical, and radiographic characteristics of a large series of APSCDs in skeletally immature patients and to describe the rate and nature of any vascular or mediastinal complications that occurred during treatment. METHODS: Following Institutional Review Board approval, records of consecutive patients under 25 years of age treated for APSCD were collected from each of 6 participating centers. Only acute injuries (sustained fewer than 10 days before presentation) were included. Patient demographics, injury mechanism, associated mediastinal injuries, and need for thoracic/vascular surgery were recorded. Mediastinal structures injured or compressed by mass effect were specifically characterized by review of preoperative computed tomography imaging. RESULTS: Review identified 125 patients with a mean age of 14.7 years; 88% were male. APSCD most commonly resulted from a sporting injury (74%) followed by falls from standing height (10%) and high-energy motor vehicle trauma (10%). The most common finding on cross-sectional imaging was compression without laceration of the ipsilateral brachiocephalic vein (50%). Eleven patients had successful closed reduction, and 114 (90%) had open reduction and internal fixation, with 25 failed or unstable closed reductions preceding open treatment. There were no vascular or mediastinal injuries during reduction or fixation that required intervention. CONCLUSIONS: In this multicenter series of 125 APSCDs no injuries to the great vessels/mediastinal structures requiring intervention were identified. Although more than half of patients had evidence of extrinsic vascular compression at the time of injury, careful open reduction of acute injuries can be safely performed. Although vascular injuries following APSCD seem to be quite rare, vascular complications can be catastrophic. Treating providers should consider these data and their own institutional resources to maximize patient safety during the treatment of APSCD. LEVEL OF EVIDENCE: Level III-therapeutic case control study.
Asunto(s)
Luxaciones Articulares/complicaciones , Mediastino/lesiones , Articulación Esternoclavicular/lesiones , Lesiones del Sistema Vascular/etiología , Accidentes por Caídas , Adolescente , Niño , Preescolar , Femenino , Fijación Interna de Fracturas , Humanos , Luxaciones Articulares/diagnóstico por imagen , Luxaciones Articulares/cirugía , Masculino , Estudios Retrospectivos , Adulto JovenRESUMEN
To determine if orthopedic surgeons are more efficient than nonsurgical providers at care of operative injuries in walk-in clinics, patients in a walk-in clinic for evaluation of acute injury who subsequently had surgical treatment of isolated distal radial fracture were compared based on whether the initial visit was with a surgical or nonsurgical provider. Initial evaluation in a walk-in orthopedic clinic setting versus a conventional hand surgeon's clinic was associated with longer delay between initial evaluation and surgical treatment, but this difference may not be significant. Evaluation by a nonsurgical provider was not associated with increased duration to definitive treatment.
Asunto(s)
Fracturas del Radio/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Atención Ambulatoria , Instituciones de Atención Ambulatoria , Femenino , Fijación Interna de Fracturas , Curación de Fractura , Humanos , Masculino , Persona de Mediana Edad , Fracturas del Radio/terapia , Tiempo de Tratamiento , Adulto JovenRESUMEN
CASE: An immunosuppressed 51-year-old man sustained a ballistic injury about the site of a primary total hip arthroplasty, which had been performed for osteonecrosis of the femoral head 2 years earlier. He was treated with arthroscopic debridement and irrigation, inspection of the implants, and removal of foreign bodies. CONCLUSION: Ballistic injury to a hip arthroplasty site with retained foreign bodies is an unusual injury. Hip arthroscopy may represent a minimally invasive treatment option for implant inspection, joint debridement, and removal of intra-articular fragments while minimizing the risk of soft-tissue complications.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroscopía , Articulación de la Cadera , Heridas por Arma de Fuego , Articulación de la Cadera/diagnóstico por imagen , Articulación de la Cadera/patología , Articulación de la Cadera/cirugía , Humanos , Masculino , Persona de Mediana Edad , Heridas por Arma de Fuego/diagnóstico por imagen , Heridas por Arma de Fuego/cirugíaRESUMEN
BACKGROUND: Outpatient total shoulder arthroplasty (TSA) is increasing in frequency, but the selection of patients who are appropriate outpatient joint candidates remains challenging. We propose an algorithm for selecting outpatient TSA candidates, with validation by a cohort of patients from an ambulatory surgery center (ASC). METHODS: We identified 61 patients who had primary anatomic and reverse TSA. The selection algorithm, which stratifies patients referable to their age and cardiopulmonary comorbidities, was used to choose patients for outpatient surgery. Complications, including cardiopulmonary, thromboembolic, and postoperative wound problems, were recorded. RESULTS: All 61 patients were discharged from the ASC on the day of surgery. There were no cardiopulmonary events requiring intervention or hospital admission. One patient (2%) required a secondary operation, 3 patients (5%) experienced acute surgical complications, 3 patients (5%) had transient postoperative nausea, and 4 patients (7%) had additional complications within the 90-day episode of care. CONCLUSIONS: This study is the first to propose a patient selection method for outpatient TSA. Using this algorithm for patient selection produced a low rate of perioperative complications and no hospital admissions. We suggest this algorithm provides an evidence-based method for the standardization of outpatient TSA candidate selection.
Asunto(s)
Algoritmos , Procedimientos Quirúrgicos Ambulatorios , Artroplastía de Reemplazo de Hombro , Selección de Paciente , Adulto , Anciano , Estudios de Cohortes , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: We proposed to determine the complication and hospital admission rates for patients with total hip arthroplasty (THA) done by a single surgeon in a stand-alone ambulatory surgical center with same-day discharge. Given the recent emphasis on bundled payments for a 90-day episode of care, this same time frame after surgery was chosen to determine patient outcomes. METHODS: The records of patients with THAs done through a direct anterior approach by a single surgeon at 2 separate ambulatory surgery centers were reviewed. To analyze the learning curve for outpatient THA, the procedures were arbitrarily divided into 2 groups depending on when they were done: early in our experience or later. Complications were recorded, as were hospital admissions and surgical interventions, length of surgery and blood loss, and time spent at the outpatient facility. RESULTS: Over a 3-year period, 145 outpatient THAs were done in 125 patients; 73 were considered to be initial procedures, and 72 were considered to be later procedures. Only one of the 145 procedures (0.7%) required transfer from the outpatient facility to the hospital for a blood transfusion. No other direct admissions to the hospital or transfers to the emergency department from the surgery center were necessary. Surgical interventions were required after 3 (2%) of the 145 arthroplasties in the global period (90 days). CONCLUSION: This study demonstrated that same-day discharge to home following THA can be safely done without increased complications, readmissions, reoperations, or emergency room visits.
Asunto(s)
Instituciones de Atención Ambulatoria/estadística & datos numéricos , Artroplastia de Reemplazo de Cadera/efectos adversos , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Transfusión Sanguínea , Hospitalización , Humanos , Persona de Mediana Edad , Pacientes Ambulatorios , Alta del Paciente , Complicaciones Posoperatorias/etiología , Reoperación , Tennessee/epidemiologíaRESUMEN
Obesity is a problem that is increasing in prevalence in the United States and in other countries, and it is a common comorbidity in patients seeking total joint arthroplasty for degenerative musculoskeletal diseases. Obesity, as well as commonly associated comorbidities such as diabetes mellitus, cardiovascular disease, and those contributing to the diagnosis of metabolic syndrome, have been shown to have detrimental effects on total joint arthroplasty outcomes. Although there are effective surgical and nonsurgical interventions which can result in weight loss in these patients, concomitant benefit on arthroplasty outcomes is not clear. Preoperative optimization of surgical risk in obese total joint arthroplasty patients is an important point of intervention to improve arthroplasty outcomes.