Andrew Pollak | University of Maryland Medical Center (original) (raw)

Papers by Andrew Pollak

Journal of the American Academy of Orthopaedic Surgeons, 2008

The Journal of Trauma: Injury, Infection, and Critical Care, 1994

We reviewed the data on 47 closed femoral shaft fractures in 46 children 10 years of age or less ... more We reviewed the data on 47 closed femoral shaft fractures in 46 children 10 years of age or less treated by early closed reduction and spica cast immobilization from 1980 through 1988. These children were followed at least through the time of fracture union, spica cast removal, and onset of unprotected weight-bearing. Treatment was defined as being primarily by spica cast immobilization if less than 7 days of skin traction preceded closed reduction and cast application. The mean age at injury was 4.4 years (range, 0.2-9.9 years). Mechanisms of injury were identified and segregated into those involving high-energy and low-energy trauma. Twelve of 23 fractures (52%) caused by high energy required at least one repeat closed reduction or other treatment to correct excessive shortening or angulation that occurred following the initial reduction. Four children required prolonged skeletal traction before reapplication of a spica cast. In contrast, only 2 of 24 fractures (8%) caused by low-energy trauma required repeat closed reduction and none required skeletal traction. Whereas the mean age of the children sustaining high-energy trauma (6.1 years) was higher than that of children in the low-energy trauma group (2.9 years), 7 of 12 fractures caused by high energy that required repeat reduction occurred in children 7 years of age or less. Femoral shaft fractures in children caused by high energy are more likely to become displaced following closed reduction and early spica cast immobilization than fractures caused by low energy. These children require careful radiographic monitoring following this type of treatment to assess fracture alignment.

Journal of orthopaedic trauma, 2015

The dire challenges faced in Haiti, both preearthquake and postearthquake, highlight the need for... more The dire challenges faced in Haiti, both preearthquake and postearthquake, highlight the need for developing surgical infrastructure to care for traumatic musculoskeletal injuries. The proposed Orthopaedic Trauma Care Specialist (OTCS) residency program aims to close the critical human resource gap that limits the appropriate care of musculoskeletal trauma in Haiti. The OTCS program is a proposal for a 2-year residency program that will focus primarily on the management of orthopaedic trauma. The proposed program will be a comprehensive approach for implementing affordable and sustainable strategies to improve orthopaedic trauma care. Its curriculum will be tailored to the injuries seen in Haiti, and the treatments that can be delivered within their health care system. Its long-term sustainability will be based on a "train-the-trainers" approach for developing local faculty to continue the program. This proposal outlines the OTCS framework specifically for Haiti; however, ...

The Journal of Trauma: Injury, Infection, and Critical Care, 1999

The Journal of the American Academy of Orthopaedic Surgeons, 2010

The fourth annual Extremity War Injuries (EWI) Symposium addressed ongoing challenges and opportu... more The fourth annual Extremity War Injuries (EWI) Symposium addressed ongoing challenges and opportunities in the management of combat-related musculoskeletal injury. The symposium, which also examined host-nation care and disaster preparedness and response, defined opportunities for synergy between several organizations with similar missions and goals. Within the Department of Defense, the Orthopaedic Extremity Trauma Research Program (OETRP) has funded basic research related to a series of protocols first identified and validated at prior EWI symposia. A well-funded clinical research arm of OETRP has been developed to help translate and validate research advances from each of the protocols. The Armed Forces Institute for Regenerative Medicine, a consortium of academic research institutions, employs a tissue-engineering approach to EWI challenges, particularly with regard to tissue loss. Programs within the National Institute of Arthritis and Musculoskeletal and Skin Diseases and thro...

The Journal of the American Academy of Orthopaedic Surgeons, 2006

Although débridement within 6 to 8 hours of injury seems nearly universally accepted, the data su... more Although débridement within 6 to 8 hours of injury seems nearly universally accepted, the data supporting this recommendation are lacking. Most studies indicate that, in the context of modern antibiotic treatment, early débridement is not an independent predictor of decreased risk of infection. Achieving early débridement may pose unjustified risks to patient safety. Given the numerous factors that influence timing of surgical débridement in trauma centers, a prospective randomized trial of emergent versus urgent débridement is not feasible. However, a prospective longitudinal study could yield valuable data.

The Journal of the American Academy of Orthopaedic Surgeons, 2006

The Journal of the American Academy of Orthopaedic Surgeons, 2006

... There is a lack of controlled studies that define the role of timing of coverage in outcome f... more ... There is a lack of controlled studies that define the role of timing of coverage in outcome following high-energy extremity war injuries. Also necessary is more information about markers and indicators to help assess the readiness of a wound and host for coverage procedures. ...

Rehabilitation Psychology, 2014

Although the management of acute traumatic injury has improved, long-term functional outcomes rem... more Although the management of acute traumatic injury has improved, long-term functional outcomes remain poor. Data suggest major improvements in outcome will require comprehensive, self-management (SM) interventions. However, little is known about trauma survivors' willingness to participate in such interventions. The goal of this study was to create and validate an instrument based on the stages of change (SOC) framework to assess readiness to engage in SM programs following acute traumatic injury. The Readiness to Engage in Self-Management after Acute Traumatic Injury (RESMATI) was developed based on SOC theory. Participants (N = 150) were admitted to a Level I trauma center for treatment of severe trauma and completed the RESMATI 3 to 12 months postinjury. A random sample (n = 60) completed a reassessment 1 month later to determine item stability. A principal components analysis and an exploratory factor analysis were conducted. The analyses of the 34 RESMATI items yielded a 5-factor model, collapsed into 3 domains based on SOC theory. Two factors were classified as "precontemplation," 2 factors were classified as "contemplation," and 1 factor was classified as "action/maintenance." All 3 domains had good internal consistency reliability (.71 to .92) and moderate test-retest reliability (.56 and .73). The exploratory factor analysis yielded 3 domains that were consistent with the SOC model. Two notable exceptions were the lack of a "preparation" domain and lack of distinction between the action and maintenance stages. The RESMATI is a reliable instrument that requires further testing to establish validity and utility in identifying individuals' readiness to engage in SM following acute traumatic injury.

The Journal of Trauma: Injury, Infection, and Critical Care, 2006

A better understanding of the factors influencing return to work (RTW) after major limb trauma is... more A better understanding of the factors influencing return to work (RTW) after major limb trauma is essential in reducing the high costs associated with these injuries. Patients (n = 423) who underwent amputation or reconstruction after limb threatening lower extremity trauma and who were working before the injury were prospectively evaluated at 3, 6, 12, 24, and 84 months. Time to first RTW was assessed. For individuals working at 84 months, the percentage of time limited in performance at work was estimated using the Work Limitations Questionnaire. Estimates of the cumulative proportion returning to work at 3, 6, 12, 24, and 84 months were 0.12, 0.28, 0.42, 0.51, and 0.58. Patients working at 84 months were, on average, limited in their ability to perform the demands of their job 20 to 25% of the time. In the context of a Cox proportional hazards model, differences in RTW outcomes by treatment (amputation versus reconstruction) were not statistically significant. Factors that were significantly associated (p < 0.05) with higher rates of RTW include younger age, being White, higher education, being a nonsmoker, average to high self efficacy, preinjury job tenure, higher job involvement, and no litigation. Early (3 month) assessments of pain and physical functioning were significant predictors of RTW. Return to work after severe lower extremity trauma remains a challenge. Although the causal pathway from injury to impairment and work disability is complex, this study points to several factors that influence RTW that suggest strategies for intervention.

The Journal of Trauma: Injury, Infection, and Critical Care, 2002

The purpose of this study was to describe differences in demographics, injury pattern, transfusio... more The purpose of this study was to describe differences in demographics, injury pattern, transfusion needs, and outcome of pelvic fractures in older versus younger patients. This was a retrospective registry review of all patients with pelvic fractures admitted directly from the scene between January 1998 and December 1999. We cared for 234 patients with pelvic fractures during the study period. Mean age was 37.2 years, 51% were men, and mean Injury Severity Score (ISS) was 19. Overall mortality was 9%. Eighty-three percent were under the age of 55 years and 17% were older than 55 years. Severe pelvic fractures (AP3, LC3) were more common in young patients (p < 0.05). Admitting systolic blood pressure was lower and heart rate higher, although ISS was not different between the two age groups. Older patients were 2.8 times as likely to undergo transfusion (p < 0.005), and those undergoing transfusion required more blood (median, 7.5 units vs. 5 units). Older patients underwent angiography more frequently and were significantly more likely to die in the hospital even after adjusting for ISS (p < 0.005). This was most marked with ISS 15 to 25. Lateral compression (LC) fractures occurred 4.6 times more frequently in older patients than anteroposterior (AP) compression, and 8.2 times more frequently in those older patients undergoing transfusion as compared with AP compression. Ninety-eight percent of LC fractures in older patients were minor (LC1,2). However, older patients with LC fractures were nearly four times as likely to require blood compared with younger patients. In older patients, pelvic fractures are more likely to produce hemorrhage and require angiography. Fracture patterns differ in older patients, with LC fractures occurring more frequently, and commonly causing significant blood loss. The outcome of older patients with pelvic fractures is significantly worse than younger patients, particularly with higher injury severity. Recognition of these differences should help clinicians to identify patients at high risk for bleeding and death early, and to refine diagnostic and resuscitation strategies.

Journal of the American Academy of Orthopaedic Surgeons, 2012

Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and n... more Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and nongovernmental organizations, and medical associations struggled to mount an effective humanitarian aid response. The experiences of these groups have led to changes at their institutions regarding disaster preparedness and response to future events. One of the main challenges in a humanitarian medical response to a disaster is determining when to end response efforts and return responsibility for delivery of medical care back to the host nation. For such a transition to occur, the host nation must have the capacity to deliver medical care. In Haiti, minimal capacity to deliver such care existed before the earthquake, making subsequent transition difficult. If successful, several initiatives proposed to improve disaster response and increase surgical capacity in Haiti could be deployed to other low- and middle-income countries.

Journal of Orthopaedic Trauma, 2004

The advantages of early fracture fixation in patients with multiple injuries have been challenged... more The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. We report on the use of EF as a temporary fracture fixation in a group of patients with multiple injuries and with femoral shaft fractures. Retrospective review of charts and registry data of patients admitted to our Level 1 trauma center July of 1995 to June of 1998. Forty-three patients initially treated with EF of the femur were compared to 284 patients treated with primary IMN of the femur. Patients treated with EF had more severe injuries with significantly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treated with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe enough to require intracranial pressure monitoring. All 12 required therapy for intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindication to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time for EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes with an estimated blood loss of 400 mL. One patient died before IMN. One other patient with a mangled extremity was treated with amputation after EF. There was one complication of EF, i.e., bleeding around a pin site, which was self-limited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF followed by IMN had bone infection and another had acute hardware failure. EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed by IMN when the patient is stabilized. There were minimal orthopedic complications.

Journal of Orthopaedic Trauma, 2010

Journal of Orthopaedic Trauma, 2012

The Journal of Bone and Joint Surgery (American), 2007

Recent reports have suggested that functional outcomes are similar following either amputation or... more Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways. Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpatient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price Index. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of prosthetic devices. When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and 91,106forpatientstreatedwithamputation).Theprojectedlifetimehealth−carecostforthepatientswhohadundergoneamputationwasthreetimeshigherthanthatforthosetreatedwithreconstruction(91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction (91,106forpatientstreatedwithamputation).Theprojectedlifetimehealth−carecostforthepatientswhohadundergoneamputationwasthreetimeshigherthanthatforthosetreatedwithreconstruction(509,275 and $163,282, respectively). These estimates add support to previous conclusions that efforts to improve the rate of successful reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results in lower lifetime costs.

The Journal of Bone and Joint Surgery (American), 2012

Sleep deprivation may slow reaction time, cloud judgment, and impair the ability to think. Our pu... more Sleep deprivation may slow reaction time, cloud judgment, and impair the ability to think. Our purpose was to study the cognitive and psychomotor performances of orthopaedic trauma surgeons on the basis of the amount of sleep that they obtained. We prospectively studied the performances of thirty-two orthopaedic trauma surgeons (residents, fellows, and attending surgeons) over two four-week periods at an urban academic trauma center. Testing sessions used handheld computers to administer validated cognitive and psychomotor function tests. We conducted a multivariate analysis to examine the independent association between test performance and multiple covariates, including the amount of sleep the night before testing. Our analysis demonstrated that orthopaedic surgeons who had slept four hours or less the night before the test had 1.43 times the odds (95% confidence interval, 1.04 to 1.95; p = 0.03) of committing at least one error on an individual test compared with orthopaedic surgeons who had slept more than four hours the previous night. The Running Memory test, which assesses sustained attention, concentration, and working memory, was most sensitive to deterioration in performance in participants who had had four hours of sleep or less; when controlling for other covariates, the test demonstrated a 72% increase in the odds of making at least one error (odds ratio, 1.72 [95% confidence interval, 1.02 to 2.90]; p = 0.04). No significant decrease in performance with sleep deprivation was shown with the other three tests. Orthopaedic trauma surgeons showed deterioration in performance on a validated cognitive task when they had slept four hours or less the previous night. It is unknown how performance on this test relates to surgical performance.

Archives of Physical Medicine and Rehabilitation, 2008

Journal of the American Academy of Orthopaedic Surgeons, 2008

The Journal of Trauma: Injury, Infection, and Critical Care, 1994

We reviewed the data on 47 closed femoral shaft fractures in 46 children 10 years of age or less ... more We reviewed the data on 47 closed femoral shaft fractures in 46 children 10 years of age or less treated by early closed reduction and spica cast immobilization from 1980 through 1988. These children were followed at least through the time of fracture union, spica cast removal, and onset of unprotected weight-bearing. Treatment was defined as being primarily by spica cast immobilization if less than 7 days of skin traction preceded closed reduction and cast application. The mean age at injury was 4.4 years (range, 0.2-9.9 years). Mechanisms of injury were identified and segregated into those involving high-energy and low-energy trauma. Twelve of 23 fractures (52%) caused by high energy required at least one repeat closed reduction or other treatment to correct excessive shortening or angulation that occurred following the initial reduction. Four children required prolonged skeletal traction before reapplication of a spica cast. In contrast, only 2 of 24 fractures (8%) caused by low-energy trauma required repeat closed reduction and none required skeletal traction. Whereas the mean age of the children sustaining high-energy trauma (6.1 years) was higher than that of children in the low-energy trauma group (2.9 years), 7 of 12 fractures caused by high energy that required repeat reduction occurred in children 7 years of age or less. Femoral shaft fractures in children caused by high energy are more likely to become displaced following closed reduction and early spica cast immobilization than fractures caused by low energy. These children require careful radiographic monitoring following this type of treatment to assess fracture alignment.

Journal of orthopaedic trauma, 2015

The dire challenges faced in Haiti, both preearthquake and postearthquake, highlight the need for... more The dire challenges faced in Haiti, both preearthquake and postearthquake, highlight the need for developing surgical infrastructure to care for traumatic musculoskeletal injuries. The proposed Orthopaedic Trauma Care Specialist (OTCS) residency program aims to close the critical human resource gap that limits the appropriate care of musculoskeletal trauma in Haiti. The OTCS program is a proposal for a 2-year residency program that will focus primarily on the management of orthopaedic trauma. The proposed program will be a comprehensive approach for implementing affordable and sustainable strategies to improve orthopaedic trauma care. Its curriculum will be tailored to the injuries seen in Haiti, and the treatments that can be delivered within their health care system. Its long-term sustainability will be based on a "train-the-trainers" approach for developing local faculty to continue the program. This proposal outlines the OTCS framework specifically for Haiti; however, ...

The Journal of Trauma: Injury, Infection, and Critical Care, 1999

The Journal of the American Academy of Orthopaedic Surgeons, 2010

The fourth annual Extremity War Injuries (EWI) Symposium addressed ongoing challenges and opportu... more The fourth annual Extremity War Injuries (EWI) Symposium addressed ongoing challenges and opportunities in the management of combat-related musculoskeletal injury. The symposium, which also examined host-nation care and disaster preparedness and response, defined opportunities for synergy between several organizations with similar missions and goals. Within the Department of Defense, the Orthopaedic Extremity Trauma Research Program (OETRP) has funded basic research related to a series of protocols first identified and validated at prior EWI symposia. A well-funded clinical research arm of OETRP has been developed to help translate and validate research advances from each of the protocols. The Armed Forces Institute for Regenerative Medicine, a consortium of academic research institutions, employs a tissue-engineering approach to EWI challenges, particularly with regard to tissue loss. Programs within the National Institute of Arthritis and Musculoskeletal and Skin Diseases and thro...

The Journal of the American Academy of Orthopaedic Surgeons, 2006

Although débridement within 6 to 8 hours of injury seems nearly universally accepted, the data su... more Although débridement within 6 to 8 hours of injury seems nearly universally accepted, the data supporting this recommendation are lacking. Most studies indicate that, in the context of modern antibiotic treatment, early débridement is not an independent predictor of decreased risk of infection. Achieving early débridement may pose unjustified risks to patient safety. Given the numerous factors that influence timing of surgical débridement in trauma centers, a prospective randomized trial of emergent versus urgent débridement is not feasible. However, a prospective longitudinal study could yield valuable data.

The Journal of the American Academy of Orthopaedic Surgeons, 2006

The Journal of the American Academy of Orthopaedic Surgeons, 2006

... There is a lack of controlled studies that define the role of timing of coverage in outcome f... more ... There is a lack of controlled studies that define the role of timing of coverage in outcome following high-energy extremity war injuries. Also necessary is more information about markers and indicators to help assess the readiness of a wound and host for coverage procedures. ...

Rehabilitation Psychology, 2014

Although the management of acute traumatic injury has improved, long-term functional outcomes rem... more Although the management of acute traumatic injury has improved, long-term functional outcomes remain poor. Data suggest major improvements in outcome will require comprehensive, self-management (SM) interventions. However, little is known about trauma survivors' willingness to participate in such interventions. The goal of this study was to create and validate an instrument based on the stages of change (SOC) framework to assess readiness to engage in SM programs following acute traumatic injury. The Readiness to Engage in Self-Management after Acute Traumatic Injury (RESMATI) was developed based on SOC theory. Participants (N = 150) were admitted to a Level I trauma center for treatment of severe trauma and completed the RESMATI 3 to 12 months postinjury. A random sample (n = 60) completed a reassessment 1 month later to determine item stability. A principal components analysis and an exploratory factor analysis were conducted. The analyses of the 34 RESMATI items yielded a 5-factor model, collapsed into 3 domains based on SOC theory. Two factors were classified as "precontemplation," 2 factors were classified as "contemplation," and 1 factor was classified as "action/maintenance." All 3 domains had good internal consistency reliability (.71 to .92) and moderate test-retest reliability (.56 and .73). The exploratory factor analysis yielded 3 domains that were consistent with the SOC model. Two notable exceptions were the lack of a "preparation" domain and lack of distinction between the action and maintenance stages. The RESMATI is a reliable instrument that requires further testing to establish validity and utility in identifying individuals' readiness to engage in SM following acute traumatic injury.

The Journal of Trauma: Injury, Infection, and Critical Care, 2006

A better understanding of the factors influencing return to work (RTW) after major limb trauma is... more A better understanding of the factors influencing return to work (RTW) after major limb trauma is essential in reducing the high costs associated with these injuries. Patients (n = 423) who underwent amputation or reconstruction after limb threatening lower extremity trauma and who were working before the injury were prospectively evaluated at 3, 6, 12, 24, and 84 months. Time to first RTW was assessed. For individuals working at 84 months, the percentage of time limited in performance at work was estimated using the Work Limitations Questionnaire. Estimates of the cumulative proportion returning to work at 3, 6, 12, 24, and 84 months were 0.12, 0.28, 0.42, 0.51, and 0.58. Patients working at 84 months were, on average, limited in their ability to perform the demands of their job 20 to 25% of the time. In the context of a Cox proportional hazards model, differences in RTW outcomes by treatment (amputation versus reconstruction) were not statistically significant. Factors that were significantly associated (p < 0.05) with higher rates of RTW include younger age, being White, higher education, being a nonsmoker, average to high self efficacy, preinjury job tenure, higher job involvement, and no litigation. Early (3 month) assessments of pain and physical functioning were significant predictors of RTW. Return to work after severe lower extremity trauma remains a challenge. Although the causal pathway from injury to impairment and work disability is complex, this study points to several factors that influence RTW that suggest strategies for intervention.

The Journal of Trauma: Injury, Infection, and Critical Care, 2002

The purpose of this study was to describe differences in demographics, injury pattern, transfusio... more The purpose of this study was to describe differences in demographics, injury pattern, transfusion needs, and outcome of pelvic fractures in older versus younger patients. This was a retrospective registry review of all patients with pelvic fractures admitted directly from the scene between January 1998 and December 1999. We cared for 234 patients with pelvic fractures during the study period. Mean age was 37.2 years, 51% were men, and mean Injury Severity Score (ISS) was 19. Overall mortality was 9%. Eighty-three percent were under the age of 55 years and 17% were older than 55 years. Severe pelvic fractures (AP3, LC3) were more common in young patients (p < 0.05). Admitting systolic blood pressure was lower and heart rate higher, although ISS was not different between the two age groups. Older patients were 2.8 times as likely to undergo transfusion (p < 0.005), and those undergoing transfusion required more blood (median, 7.5 units vs. 5 units). Older patients underwent angiography more frequently and were significantly more likely to die in the hospital even after adjusting for ISS (p < 0.005). This was most marked with ISS 15 to 25. Lateral compression (LC) fractures occurred 4.6 times more frequently in older patients than anteroposterior (AP) compression, and 8.2 times more frequently in those older patients undergoing transfusion as compared with AP compression. Ninety-eight percent of LC fractures in older patients were minor (LC1,2). However, older patients with LC fractures were nearly four times as likely to require blood compared with younger patients. In older patients, pelvic fractures are more likely to produce hemorrhage and require angiography. Fracture patterns differ in older patients, with LC fractures occurring more frequently, and commonly causing significant blood loss. The outcome of older patients with pelvic fractures is significantly worse than younger patients, particularly with higher injury severity. Recognition of these differences should help clinicians to identify patients at high risk for bleeding and death early, and to refine diagnostic and resuscitation strategies.

Journal of the American Academy of Orthopaedic Surgeons, 2012

Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and n... more Immediately after the January 2010 earthquake in Haiti, many private citizens, governmental and nongovernmental organizations, and medical associations struggled to mount an effective humanitarian aid response. The experiences of these groups have led to changes at their institutions regarding disaster preparedness and response to future events. One of the main challenges in a humanitarian medical response to a disaster is determining when to end response efforts and return responsibility for delivery of medical care back to the host nation. For such a transition to occur, the host nation must have the capacity to deliver medical care. In Haiti, minimal capacity to deliver such care existed before the earthquake, making subsequent transition difficult. If successful, several initiatives proposed to improve disaster response and increase surgical capacity in Haiti could be deployed to other low- and middle-income countries.

Journal of Orthopaedic Trauma, 2004

The advantages of early fracture fixation in patients with multiple injuries have been challenged... more The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. We report on the use of EF as a temporary fracture fixation in a group of patients with multiple injuries and with femoral shaft fractures. Retrospective review of charts and registry data of patients admitted to our Level 1 trauma center July of 1995 to June of 1998. Forty-three patients initially treated with EF of the femur were compared to 284 patients treated with primary IMN of the femur. Patients treated with EF had more severe injuries with significantly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treated with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe enough to require intracranial pressure monitoring. All 12 required therapy for intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindication to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time for EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes with an estimated blood loss of 400 mL. One patient died before IMN. One other patient with a mangled extremity was treated with amputation after EF. There was one complication of EF, i.e., bleeding around a pin site, which was self-limited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF followed by IMN had bone infection and another had acute hardware failure. EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed by IMN when the patient is stabilized. There were minimal orthopedic complications.

Journal of Orthopaedic Trauma, 2010

Journal of Orthopaedic Trauma, 2012

The Journal of Bone and Joint Surgery (American), 2007

Recent reports have suggested that functional outcomes are similar following either amputation or... more Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways. Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpatient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price Index. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of prosthetic devices. When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and 91,106forpatientstreatedwithamputation).Theprojectedlifetimehealth−carecostforthepatientswhohadundergoneamputationwasthreetimeshigherthanthatforthosetreatedwithreconstruction(91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction (91,106forpatientstreatedwithamputation).Theprojectedlifetimehealth−carecostforthepatientswhohadundergoneamputationwasthreetimeshigherthanthatforthosetreatedwithreconstruction(509,275 and $163,282, respectively). These estimates add support to previous conclusions that efforts to improve the rate of successful reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results in lower lifetime costs.

The Journal of Bone and Joint Surgery (American), 2012

Sleep deprivation may slow reaction time, cloud judgment, and impair the ability to think. Our pu... more Sleep deprivation may slow reaction time, cloud judgment, and impair the ability to think. Our purpose was to study the cognitive and psychomotor performances of orthopaedic trauma surgeons on the basis of the amount of sleep that they obtained. We prospectively studied the performances of thirty-two orthopaedic trauma surgeons (residents, fellows, and attending surgeons) over two four-week periods at an urban academic trauma center. Testing sessions used handheld computers to administer validated cognitive and psychomotor function tests. We conducted a multivariate analysis to examine the independent association between test performance and multiple covariates, including the amount of sleep the night before testing. Our analysis demonstrated that orthopaedic surgeons who had slept four hours or less the night before the test had 1.43 times the odds (95% confidence interval, 1.04 to 1.95; p = 0.03) of committing at least one error on an individual test compared with orthopaedic surgeons who had slept more than four hours the previous night. The Running Memory test, which assesses sustained attention, concentration, and working memory, was most sensitive to deterioration in performance in participants who had had four hours of sleep or less; when controlling for other covariates, the test demonstrated a 72% increase in the odds of making at least one error (odds ratio, 1.72 [95% confidence interval, 1.02 to 2.90]; p = 0.04). No significant decrease in performance with sleep deprivation was shown with the other three tests. Orthopaedic trauma surgeons showed deterioration in performance on a validated cognitive task when they had slept four hours or less the previous night. It is unknown how performance on this test relates to surgical performance.

Archives of Physical Medicine and Rehabilitation, 2008