Differences in Intraoperative Fluoroscopic Radiation Exposure During Ankle Fracture Open Reduction and Internal Fixation Between Orthopaedic Surgery and Podiatry.

Surgical ankle fractures pose a unique situation because both podiatrists and orthopaedic surgeons manage these injuries. Intraoperative fluoroscopy is routinely used; however, excessive radiation can be harmful to both the patient and the surgical team. The primary goal of this study was to determine whether there is a difference in the amount of intraoperative radiation exposure during ankle fracture open reduction and internal fixation (ORIF) when performed by orthopaedic surgeons versus podiatrists. This is a retrospective review of patients who underwent ankle fracture ORIF at an urban level I trauma center between January 1st, 2018, and April 1st, 2023. The electronic health record was queried using International Classification of Diseases nine and 10 codes associated with ankle fractures. Patients aged older than 18 years with an ankle fracture managed surgically were included. Subjects were then stratified by procedure. The mean total radiation dose (mRad) and mean total fluoroscopic time (seconds) were then compared between those performed by orthopaedic surgeons and podiatrists. Of the 333 included procedures, 186 were done by orthopaedic surgeons and 147 were done by podiatrists. Using multiple linear regression analysis to control for age, sex, race, ethnicity, and body mass index, patients undergoing isolated malleolus ORIF with syndesmosis repair performed by orthopaedic surgery were found to have a significantly lower mean fluoroscopic time compared with those performed by podiatry (68.4 s versus 104.8 s; P = 0.028). In addition, trimalleolar ORIF with syndesmotic repair performed by orthopaedic surgery had a significantly lower mean total radiation dose compared with those performed by podiatry (244.6 mRad v 565.6 mRad; P = 0.009). Patients and surgical teams are exposed to markedly less radiation in isolated malleolar and trimalleolar fracture ORIF with syndesmosis repair when performed by an orthopaedic surgeon as compared with those performed by a podiatrist.

Bullying in Orthopaedic Surgery: A Survey of US Orthopaedic Trainees and Attending Surgeons.

INTRODUCTION: Bullying is a notable problem in surgery, creating a hostile environment for surgeons and trainees, and may negatively affect patient care. However, specific details regarding bullying in orthopaedic surgery are lacking. The primary aim of this study was to determine the prevalence and nature of bullying within orthopaedic surgery in the United States. METHODS: A deidentified survey was developed using the survey created by the Royal College of Australasian Surgeons and the validated Negative Acts Questionnaire-Revised survey tool. This survey was distributed to orthopaedic trainees and attending surgeons in April 2021. RESULTS: Of the 105 survey respondents, 60 (60.6%) were trainees and 39 (39.4%) were attending surgeons. Although 21 respondents (24.7%) stated they had been bullied, 16 victims (28.1%) did not seek to address this behavior. Perpetrators of bullying were most commonly male (49/71, 67.2%) and the victims' superior (36/82, 43.9%). Five bullying victims (8.8%) reported the behavior, despite 46 respondents (92.0%) stating that their institution has a specific policy against bullying. CONCLUSION: Bullying behavior occurs in orthopaedic surgery, with perpetrators being most commonly male and the victims' superiors. Despite the fact that an overwhelming majority of institutions have policies against bullying, the reporting of such behavior is lacking.

Cost Analysis of Direct Oral Anticoagulants Compared with Warfarin in Patients with Blunt Traumatic Intracranial Hemorrhages.

Direct oral anticoagulants (DOACs) are rapidly gaining popularity as alternatives to warfarin in the prevention of stroke or systemic embolic events because of the simplicity of their dosing and lack of monitoring requirement. Many physicians feared that these novel agents would be cost-prohibitive not only in their administration but also in their sequelae of bleeding, given the few reversal agents available. Whereas the medication itself is more expensive than traditional warfarin, the total cost of a hospital admission has not been compared between patients on DOACs and warfarin who have sustained a blunt traumatic intracranial hemorrhage (ICH). We conducted a retrospective review of our hospital's trauma database from June 2011 through September 2015 at our Level II trauma center of patients who suffered from an ICH who were anticoagulated at the time of their trauma. Patients who died during their hospital admission or were exclusively on antiplatelet agents were excluded. Of the 136 patients studied, 79 were on warfarin and 57 were on a DOAC at the time of their presentation for a traumatic ICH. The average charged cost for the hospital stay of a patient with an ICH was significantly higher for patients on warfarin compared with DOACs [$70,384.08 vs $49,226.66 (P = 0.02)]. The average reimbursement rate for the hospital was also significantly higher for those patients on warfarin as compared with those on DOACs [$23,922.93 vs $14,705.77 (P = 0.02)]. DOACs are associated with a significant cost benefit in patients admitted for blunt traumatic ICHs when compared with those on warfarin.

Tourniquet use in the prehospital setting: Are they being used appropriately?

OBJECTIVE: The objective of this study was to evaluate tourniquet use in the Hartford prehospital setting during a 34-month period after the Hartford Consensus was published, which encouraged increasing tourniquet use in light of military research. DESIGN: This was a retrospective review of patients with bleeding from a serious extremity injury to determine appropriateness of tourniquet use or omission. SETTING: Level II trauma center between April 2014 and January 2017. PARTICIPANTS: Eighty-four patients met inclusion criteria and were stratified based on tourniquet use during prehospital care. MAIN OUTCOME MEASURES: Five of the 84 patients received a tourniquet. All five of those tourniquets (100 percent of the group, 6.0 percent of the population) were not indicated and deemed inappropriate. Three of the 84 patients did not receive a tourniquet when one was indicated (3.8 percent of the group, 3.6 percent of the population) and these omissions were also deemed inappropriate. Total error rate was 9.5 percent (8/84). RESULTS: There was a significant association between Mangled Extremity Severity Score (MESS) and likelihood of requiring a tourniquet (p = 0.0013) but not between MESS and likelihood of receiving a tourniquet (p = 0.1055). There was also a significant association between wrongly placed tourniquets and the type of providers who placed them [first responders, p = 0.0029; Emergency Medicine Technicians (EMTs), p = 0.0001]. CONCLUSIONS: Tourniquets are being used inappropriately in the Hartford prehospital setting. Misuse is associated with both EMTs and first responders, highlighting the need for better training and more consistent protocols.

Readmissions in Patients with Anticoagulated Intracranial Hemorrhage: A Retrospective Review.

OBJECTIVE: To determine the effect of direct oral anticoagulants (DOACs) compared with warfarin on the 30-day readmission rates in patients with traumatic intracranial hemorrhage (ICH). METHODS: We conducted a retrospective review of patients from our hospital's trauma database admitted between June 2011 and October 2015 to our level II trauma center after sustaining a traumatic ICH while receiving anticoagulant therapy. Patients were stratified based on the anticoagulation drug (DOAC or warfarin) prescribed on admission. The readmission rates between the 2 groups were compared using χ2 analysis and multivariate logistic regression. Patients who died during their initial admission were excluded. RESULTS: Over the 4-year period, 160 patients were admitted with traumatic ICH. Seventy-nine were receiving warfarin and 57 were receiving a DOAC at admission. Data collected included age, sex, injury severity score, admission Glasgow Coma Score, Abbreviated Injury Scale (head), mechanism of injury, hospital and intensive care unit lengths of stay, discharge destination (eg, home, rehabilitation facility, nursing facility), comorbidities, operative interventions, readmissions, and reasons for the readmissions. The rate of readmission for rebleeding of ICH was significantly lower in the DOAC group compared with the warfarin group (5.3% vs. 17.7%; P = 0.04). Multivariate logistic regression suggests that warfarin use, but not DOAC use, is associated with increased readmission both for all causes and for ICH rebleeding. CONCLUSIONS: Warfarin use is associated with higher readmission rates in patients with intracranial bleeding for both all-cause readmissions and for intracranial rebleeding.

Gamified Twitter Microblogging to Support Resident Preparation for the American Board of Surgery In-Service Training Examination.

OBJECTIVE: We sought to determine if a daily gamified microblogging project improves American Board of Surgery In-Service Training Examination (ABSITE) scores for participants. DESIGN: In July 2016, we instituted a gamified microblogging project using Twitter as the platform and modified questions from one of several available question banks. A question of the day was posted at 7-o׳clock each morning, Monday through Friday. Respondents were awarded points for speed, accuracy, and contribution to discussion topics. The moderator challenged respondents by asking additional questions and prompted them to find evidence for their claims to fuel further discussion. Since 4 months into the microblogging program, a survey was administered to all residents. Responses were collected and analyzed. After 6 months of tweeting, residents took the ABSITE examination. We compared participating residents׳ ABSITE percentile rank to those of their nonparticipating peers. We also compared residents׳ percentile rank from 2016 to those in 2017 after their participation in the microblogging project. SETTING: The University of Connecticut general surgery residency is an integrated program that is decentralized across 5 hospitals in the central Connecticut region, including Saint Francis Hospital and Medical Center, located in Hartford. PARTICIPANTS: We advertised our account to the University of Connecticut general surgery residents. Out of 45 residents, 11 participated in Twitter microblogging (24.4%) and 17 responded to the questionnaire (37.8%). RESULTS: In all, 100% of the residents who were participating in Twitter reported that daily microblogging prompted them to engage in academic reading. Twitter participants significantly increased their ABSITE percentile rank from 2016 to 2017 by an average of 13.7% (±14.1%) while nonparticipants on average decreased their ABSITE percentile rank by 10.0% (±16.6) (p = 0.003). CONCLUSIONS: Microblogging via Twitter with gamification is a feasible strategy to facilitate improving performance on the ABSITE, especially in a geographically distributed residency.

Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma.

METHODS: We queried our Trauma Quality Improvement Program registry for patients who presented between 6/1/2011 and 9/1/2015 with severe (injury severity score (ISS)>15) blunt traumatic injury during anticoagulant use. Patients were then grouped into those prescribed warfarin and patients prescribed any of the available novel Direct Oral Anticoagulants (DOAC) medications. We excluded severe (AIS≧4) head injuries. RESULTS: There were no differences between DOAC and warfarin groups in terms of age, gender mean ISS, median hospital or intensive care unit lengths of stay, complication proportions, numbers of complications per patient, or the proportion of patients requiring transfusion. Finally, excluding patients who died, the observed proportion of discharge to skilled nursing facility was similar. In our sample of trauma patients, DOAC use was associated with significantly lower mortality (DOAC group 8.3% vs. warfarin group 29.5%, p<0.015). The ratio of units transfused per patient was also lower in the DOAC group (2.8±1.8 units/patient in the DOAC group vs. 6.7±6.4 units per patient in the warfarin group; p=0.001). CONCLUSION: In conclusion, we report an association with decrease in mortality and a decrease in transfused blood products in severely injured trauma patients with likely minimal or no head injury taking novel DOACs over those anticoagulated with warfarin for outpatient anticoagulation.

Compared to warfarin, direct oral anticoagulants are associated with lower mortality in patients with blunt traumatic intracranial hemorrhage: A TQIP study.

BACKGROUND: Falls represent the leading cause of traumatic brain injury in adults older than 65, with nearly one third experiencing a fall each year. Evidence suggests that up to 0.5% of anticoagulated patients suffer from intracranial hemorrhage (ICH) annually. Direct oral anticoagulants (DOACs) have become an increasingly popular alternative to warfarin for anticoagulation; however, there is a dearth of research regarding the safety of DOACs, in particular on the outcome of traumatic ICH while taking DOACs. METHODS: We queried our Trauma Quality Improvement Project registry for patients who presented with traumatic intracranial hemorrhage during anticoagulant use. Patients were grouped into those prescribed warfarin and patients prescribed DOAC medications. The groups were compared with respect to age, gender, Glasgow Coma Score (GCS) on arrival, Abbreviated Injury Scale (AIS) (head), Injury Severity Score (ISS), mortality, need for operative intervention, hospital and ICU lengths of stay, proportion of patients transfused (and their transfusion requirements), and rates of discharge to skilled nursing facility. Poisson regression was conducted to determine the relationship between mortality and treatment group while controlling for covariates (comorbidities, ISS). RESULTS: There were no differences between DOAC and warfarin groups in terms of age, gender, median ISS, median AIS head, or median admission GCS. Mechanisms of injury, median hospital and ICU lengths of stay, ICU free days, and transfusion requirements were also not significantly different.DOAC use was associated with significantly lower mortality (4.9% vs. 20.8%; p < 0.008) and a lower rate of operative intervention (8.2% vs. 26.7%; p = 0.023) when compared with warfarin. Excluding patients who died, the observed rate of discharge to skilled nursing facility was lower in the DOAC group (28.8% compared with 39.7%; p = 0.03). Multivariate Poisson regression analysis demonstrated that warfarin use was associated with an increased mortality when controlling for injury severity, and comorbidities. CONCLUSIONS: We report improved mortality and reduced rates of operative intervention in patients with traumatic ICH associated with DOACs compared with a similar group taking warfarin. We also noted an association with decreased rate of discharge to SNF in patients taking DOACs compared with warfarin. LEVEL OF EVIDENCE: Therapeutic study, level IV.