Treatment of open hand injuries: does timing of surgery matter? A single-centre prospective analysis
ABSTRACT Abstract The 6-hour paradigm for surgical treatment of open injuries should be re-evaluated in the era of systematic use of antiseptic solutions and systemic antibiotics. The current study investigates prospectively the impact of timing of surgery on the outcome of open hand injuries. The prospective evaluation included adult patients presenting with open hand injuries between 1 September 2009 and 30 June 2010 to the emergency department of the University Hospital of Berne, Switzerland. Multiple trauma, bilateral hand injuries, bite injuries, and infections were excluded. All patients underwent a standardised treatment protocol with antiseptic solution, sterile dressing, antibiotic prophylaxis, and surgical treatment upon admission. Demographic data, injury details, and delay from trauma to therapy were recorded. Microbiology was gained at surgery. Outcome measurements included infections, complications, pain, and function (clinically, DASH, Mayo score). From 116 patients (mean age 43 years) six patients suffered an infection (5.2%). The observed infections were statistically not associated with delay to surgery, treatment protocol, or to injury complexity. Neither complications, pain, nor functional outcome were statistically associated with delay to surgery, wound disinfection, or administration of antibiotics. In conclusion, early or late timing of surgical treatment of open hand injuries did not show any impact on outcome (infections, complications, pain, function) in this prospective single-centre patient evaluation.
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ABSTRACT: There is a perception that after-hours hip surgery may result in increased complication rates. Surgeon fatigue, decreased availability of support staff, and other logistical factors may play an adverse role. However, there are little data supporting this perception in the hip fracture literature. We present a retrospective study comparing outcomes of hip fracture surgeries performed after hours versus regular daytime hours and outcomes before and after implementation of a dedicated orthopedic trauma room staffed by a fellowship trained traumatologist. A retrospective study of 767 consecutive patients with intertrochanteric, subtrochanteric, or femoral neck fractures was performed for the years 2000 to 2006. Surgeries were stratified by time of incision into two groups: day (07:00 AM-05:59 PM) and night (06:00 PM-06:59 PM). Each group was further divided into a period before the implementation of a trauma room and the period after (August 2004). Records were examined for procedure length, intraoperative blood loss, complications (nonunion, implant failure, infection, deep vein thrombosis, pulmonary embolus, and refracture), reoperation, and mortality. Four hundred ninety-nine patients were included the day group and 268 in the night group. There were no differences in terms of age, ethnicity, American Society of Anesthesiologists status, total number of comorbidities, and fracture type between groups. There were significantly more females in the night group than the day group. Intertrochanteric fractures were 64% of all fractures, femoral neck fractures were 34%, and subtrochanteric fractures were 2%. Duration of surgery for Dynamic Hip System procedures was significantly longer in the night group and also before the trauma room became available. These differences in duration of surgery also correlate with blood loss differences between the groups. Intramedullary nails also took longer to do at night. Hemiarthroplasties demonstrated no significant differences. The 1-year and 2-year mortalities of hip fracture patients operated during daytime hours in a trauma room (13 and 15%, respectively) were significantly less than they were before the implementation of the trauma room (25 and 37%, respectively). When the effect of the trauma room was eliminated, there were no significant differences between overall daytime and nighttime mortalities at 1 month, 1 year, and 2 years. There were no significant differences in other complications noted between the different groups. We recommend that nighttime surgery should not be dismissed in hip fracture patients that would otherwise benefit from an early operation. However, there seems to be a decreasing trend in mortality when hip fractures are operated in a dedicated daytime trauma room staffed by a dedicated traumatologist.The Journal of trauma 08/2011; 71(2):447-53; discussion 453. DOI:10.1097/TA.0b013e3182231ad7 · 2.96 Impact Factor
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ABSTRACT: Three cardinal factors influenced the infection rate in the 333 open fractures in this study: the presence or absence of pathogenic organisms in wounds when no antibiotic was given; the presence of resistant organisms in wounds when either the penicillin streptomycin combination or cephalothin was given; and the type of missile used in the open fracture gunshot wounds, which was the most important factor causing infection in these wounds. There was no statistically significant difference between the infection rates of the group receiving no antibiotics (Group I 13.9%) and the group receiving penicillin and streptomycin (Group II 9.7%). The infection rate for the group receiving cephalothin (Group III 2.3%) was significantly lower than those for the other two groups. This indicates that cephalothin is an effective antibiotic for prophylactic therapy of open fractures due to direct trauma. Only broad spectrum antibiotics that can be expected to be effective against coagulase positive Staphylococcus aureus should be selected for prophylactic therapy of open fractures caused by direct trauma. Their use should be guided by susceptibility tests to detect resistant organisms. The potential pathogen is most likely to be isolated in the culture obtained prior to any therapy. The use of the term prophylactic antibiotics is probably not appropriate because contaminated wounds are being treated.The Journal of Bone and Joint Surgery 05/1974; 56(3):532-41. · 4.31 Impact Factor
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ABSTRACT: This paper describes the development of an evaluative outcome measure for patients with upper extremity musculoskeletal conditions. The goal is to produce a brief, self-administered measure of symptoms and functional status, with a focus on physical function, to be used by clinicians in daily practice and as a research tool. This is a joint initiative of the American Academy of Orthopedic Surgeons (AAOS), the Council of Musculoskeletal Specialty Societies (COMSS), and the Institute for Work and Health (Toronto, Ontario).Our approach is consistent with previously described strategies for scale development. In Stage 1, Item Generation, a group of methodologists and clinical experts reviewed 13 outcome measurement scales currently in use and generated a list of 821 items. In Stage 2a, Initial Item Reduction, these 821 items were reduced to 78 items using various strategies including removal of items which were generic, repetitive, not reflective of disability, or not relevant to the upper extremity or to one of the targeted concepts of symptoms and functional status. Items not highly endorsed in a survey of content experts were also eliminated. Stage 2b, Further Item Reduction, will be based on results of field testing in which patients complete the 78-item questionnaire. This field testing, which is currently underway in 20 centers in the United States, Canada, and Australia, will generate the final format and content of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Future work includes plants for validity and reliability testing. © 1996 Wiley-Liss, Inc.American Journal of Industrial Medicine 06/1996; 29(6):602 - 608. DOI:10.1002/(SICI)1097-0274(199606)29:6<602::AID-AJIM4>3.0.CO;2-L · 1.59 Impact Factor