Appropriateness of patient transfer with associated orthopaedic injuries to a Level I trauma center.

OBJECTIVE: To prospectively evaluate the appropriateness, indications, risk factors, and epidemiology of patients with orthopaedic injuries transferred to a Level I trauma center. DESIGN: Prospective data were supplemented through chart review on all patients transferred to a Level I trauma center with orthopaedic injuries (n = 546) from January 1, 2007, to December 31, 2007. The accepting orthopaedic trauma surgeon evaluated the appropriateness of transfer by visual analog scale. SETTING: A Level I trauma center. PARTICIPANTS: Patients transferred to the trauma center requiring orthopaedic trauma service involvement. MAIN OUTCOME MEASUREMENTS: Demographics and visual analog scale appropriateness scores were collected on each patient. RESULTS: The authors considered 16.5% of the cohort inappropriate transfers, 49.3% appropriate, and the remaining 34.2% were designated as intermediate. The transfers came from an emergency department physician in 81% of cases, an orthopaedic surgeon in 14% of cases, and 5% by general surgeon or internist. One hundred forty-eight cases transferred primarily as a result of orthopaedic injuries had an available orthopaedic surgeon on-call at the original institution. Sixty percent were transferred as a result of orthopaedic injury complexity, but only 39% of the 148 were evaluated by an actual orthopaedic surgeon before transfer. Lack of orthopaedic coverage at the referring hospital accounted for 27% of transfers. CONCLUSIONS: A total of 16.5% of transfers were deemed completely inappropriate by the accepting orthopaedic traumatologist. Most transfers, both appropriate and inappropriate, were attributed to either complete lack of orthopaedic coverage or a lack of expertise at the referring center.

Canine investigation of rhBMP-2, autogenous bone graft, and rhBMP-2 with autogenous bone graft for the healing of a large segmental tibial defect.

OBJECTIVE: The purpose of this study was to compare the effects of bone morphogenetic protein, bone morphogenetic protein with autogenous bone graft (ABG), and ABG alone on the healing of a large bone defect in the canine tibia. METHODS: Fifteen 45- to 55-lb canines were randomly assigned to 1 of 5 treatment groups, 3 per group. The groups included (1) recombinant human bone morphogenetic protein (rhBMP-2, 0.43 mg/mL)/absorbable collagen sponge (ACS) + collagen/ceramic matrix (CCM), (2) rhBMP-2 (0.22 mg/mL) ACS + CCM, (3) rhBMP-2 (0.43 mg/mL) ACS + ABG, (4) rhBMP-2 (0.22 mg/mL) ACS + ABG, and (5) ABG alone. A 5-mL defect was created in the right tibia and fixed with a 4.5 mm locking plate and 1 of the grafts described above implanted. X-rays were taken biweekly for 12 weeks and evaluated for radiographic union. Representative histology was also examined. RESULTS: All defects treated with rhBMP-2 (any combination) healed at 6.0 +/- 0.9 weeks. None of the ABG alone-treated defects were healed at 12 weeks. Dogs receiving rhBMP-2/ACS + CCM healed at 5.7 +/- 0.8 weeks, whereas rhBMP-2/ACS + ABG defects healed at 6.3 +/- 0.8 weeks. Histology showed healing consistent with 12-week radiologic results. CONCLUSIONS: Large segmental defects in canine tibiae can be effectively healed with stable fixation and rhBMP-2/ACS + ABG or CCM. These conclusions may offer insight into the clinical treatment of segmental defect nonunions in the human.