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Arvind Nana, MD

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Effect of Preoperative Transthoracic Echocardiogram on Mortality and Surgical Timing in Elderly Adults with Hip Fracture.

Wed, 01/30/2019 - 07:28
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Effect of Preoperative Transthoracic Echocardiogram on Mortality and Surgical Timing in Elderly Adults with Hip Fracture.

J Am Geriatr Soc. 2015 Dec;63(12):2505-2509

Authors: Luttrell K, Nana A

Abstract
OBJECTIVES: To evaluate the effect of preoperative transthoracic echocardiogram (TTE) on mortality, postoperative complications, surgical timing, and length of stay in individuals with surgically treated hip fracture.
DESIGN: Retrospective chart review of hospital records.
SETTING: Level I and II trauma centers.
PARTICIPANTS: Individuals consecutively surgically treated for hip fracture (N = 694).
MEASUREMENTS: Demographic and injury characteristic, operative timing, preoperative echocardiogram, complications, mortality. Primary outcome measure was in hospital, 30-day, and 1-year mortality. Secondary outcome measures were complications (particularly cardiovascular) and time required for medical clearance and operative treatment.
RESULTS: Preoperative TTE was performed on 131 individuals (18.9%). There was no difference between the TTE group and the control group in hospital (3.8% vs 1.8%, P = .18), 30-day (6.9% vs 6.6%, P = .90), or 1-year (20.6% versus 20.1%, P = .89) mortality. There was no significant difference in major cardiac complications. Average time from admission to operative treatment was 66.5 hours in the TTE group and 34.8 hours in the control group (P < .001). Average time from admission to medical clearance was 43.2 hours in the TTE group and 12.4 hours in the control group (P < .001). The TTE group also had a significantly longer length of stay (8.68 vs 6.44 days, P < .001).
CONCLUSION: Preoperative TTE was not associated with lower mortality in elderly adults with hip fracture in the short- or long-term postoperative period. TTE was associated with delayed surgical treatment and longer length of stay and resulted in no cardiac intervention (e.g., cardiac catheterization, stent, stress test).

PMID: 26659463 [PubMed - as supplied by publisher]

Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part B: Management of Segmental Long Bone Defects. A Survey of Orthopaedic Trauma Association Members.

Wed, 01/30/2019 - 07:28
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Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part B: Management of Segmental Long Bone Defects. A Survey of Orthopaedic Trauma Association Members.

J Orthop Trauma. 2014 Aug;28(8):e203-7

Authors: Obremskey W, Molina C, Collinge C, Tornetta P, Sagi C, Schmidt A, Probe R, Ahn J, Nana A, Evidence-Based Quality Value and Safety Committee – Orthopaedic Trauma Association, Writing Committee

Abstract
OBJECTIVES: Treatment of segmental long bone defects is one of the areas of substantial controversy in current orthopaedic trauma. The main purpose of this survey was to determine current practice and practice variation within the Orthopaedic Trauma Association (OTA) membership on this topic.
DESIGN: Survey.
SETTING: Web-based survey.
PARTICIPANTS: Three hundred seventy-nine orthopaedic trauma surgeons.
METHODS: A 15-item questionnaire-based study titled "OTA Open Fracture Survey" was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze various aspects of open fracture management, focusing on definitive treatment and materials used for grafting in "critical-sized" segmental bone defects.
RESULTS: Between July and August 2012, a total of 379/1545 members responded for a 25% response rate. Overall, 89.5% (339/379) of respondents use some sort of antibiotic cement spacer before bone grafting. It was found that 92% of respondents preferred to use some type of autograft at time of definitive grafting of segmental defects. When using a grafting technique, 88% said they used some type of antibiotic cement. Within that context, 60.1% said graft placement should be done at 6 weeks.
CONCLUSIONS: There continues to be substantial variation in the timing of bone graft placement after soft tissue healing and the source and form of graft used. The use of antibiotic cement is common in segmental defects that require delayed bone grafting. Obtaining base-line practice characteristics on controversial topics will help provide a foundation for assessing research needs and, therefore, goals.
LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

PMID: 26057886 [PubMed - indexed for MEDLINE]

Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part A: Initial Management. A Survey of Orthopaedic Trauma Surgeons.

Wed, 01/30/2019 - 07:28
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Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part A: Initial Management. A Survey of Orthopaedic Trauma Surgeons.

J Orthop Trauma. 2014 Aug;28(8):e198-202

Authors: Obremskey W, Molina C, Collinge C, Nana A, Tornetta P, Sagi C, Schmidt A, Probe R, Ahn J, Browner BD, Evidence-Based Quality Value and Safety CommitteeOrthopaedic Trauma Association, Writing Committee

Abstract
OBJECTIVES: Open fractures are one of the injuries with the highest rate of infection that orthopaedic trauma surgeons treat. The main purpose of this survey was to determine current practice and practice variation among Orthopaedic Trauma Association (OTA) members and make treatment recommendations based on previously published resources.
DESIGN: Survey.
SETTING: Web-based survey.
PARTICIPANTS: Three hundred seventy-nine orthopaedic trauma surgeons.
METHODS: A 15-item questionnaire-based study titled "OTA Open Fracture Survey" was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze numerous aspects of open fracture management, focusing on parameters of initial and definitive treatment.
RESULTS: Eighty-six percent of participants responded that a period of time of less than 1 hour is the optimal time to antibiotic administration after identification of open fracture. Despite concerns with nephrotoxicity, 24.0%-76.3% of respondents reported the use of aminoglycosides in management of open fractures. A little over half of survey respondents continue antibiotics until next debridement in wounds that were not definitively closed after initial debridement and stabilization.
CONCLUSIONS: Rapid administration of antibiotics in open fracture management is important. Aminoglycoside use is still prevalent despite evidence questioning efficacy and toxicity concerns. Time to debridement of open fractures is controversial among OTA members. Antibiotic administration is commonly continued >48 hours despite concerns raised by Surgical Infection Society and The Eastern Association of the Surgery of Trauma. Regarding study logistics, survey participation reminders should be used when conducting this type of study as it can increase data accrual by 50%.
LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

PMID: 26057885 [PubMed - indexed for MEDLINE]

Dual small fragment plating improves screw-to-screw load sharing for mid-diaphyseal humeral fracture fixation: a finite element study.

Wed, 01/30/2019 - 07:28
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Dual small fragment plating improves screw-to-screw load sharing for mid-diaphyseal humeral fracture fixation: a finite element study.

Technol Health Care. 2015;23(1):83-92

Authors: Kosmopoulos V, Luedke C, Nana AD

Abstract
BACKGROUND: A smaller humerus in some patients makes the use of a large fragment fixation plate difficult. Dual small fragment plate constructs have been suggested as an alternative.
OBJECTIVE: This study compares the biomechanical performance of three single and one dual plate construct for mid-diaphyseal humeral fracture fixation.
METHODS: Five humeral shaft finite element models (1 intact and 4 fixation) were loaded in torsion, compression, posterior-anterior (PA) bending, and lateral-medial (LM) bending. A comminuted fracture was simulated by a 1-cm gap. Fracture fixation was modelled by: (A) 4.5-mm 9-hole large fragment plate (wide), (B) 4.5-mm 9-hole large fragment plate (narrow), (C) 3.5-mm 9-hole small fragment plate, and (D) one 3.5-mm 9-hole small fragment plate and one 3.5-mm 7-hole small fragment plate.
RESULTS: Model A showed the best outcomes in torsion and PA bending, whereas Model D outperformed the others in compression and LM bending. Stress concentrations were located near and around the unused screw holes for each of the single plate models and at the neck of the screws just below the plates for all the models studied. Other than in PA bending, Model D showed the best overall screw-to-screw load sharing characteristics.
CONCLUSION: The results support using a dual small fragment locking plate construct as an alternative in cases where crutch weight-bearing (compression) tolerance may be important and where anatomy limits the size of the humerus bone segment available for large fragment plate fixation.

PMID: 25408282 [PubMed - indexed for MEDLINE]

Plating of the distal radius.

Wed, 01/30/2019 - 07:28
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Plating of the distal radius.

J Am Acad Orthop Surg. 2005 May-Jun;13(3):159-71

Authors: Nana AD, Joshi A, Lichtman DM

Abstract
Distal radius fractures are common injuries that can be treated by a variety of methods. Restoration of the distal radius anatomy within established guidelines yields the best short- and long-term results. Guidelines for acceptable reduction are (1) radial shortening < 5 mm, (2) radial inclination > 15 degrees , (3) sagittal tilt on lateral projection between 15 degrees dorsal tilt and 20 degrees volar tilt, (4) intra-articular step-off < 2 mm of the radiocarpal joint, and (5) articular incongruity < 2 mm of the sigmoid notch of the distal radius. Treatment options range from closed reduction and immobilization to open reduction with plates and screws; options are differentiated based on their ability to reinforce and stabilize the three columns of the distal radius and ulna. Plating allows direct restoration of the anatomy, stable internal fixation, a decreased period of immobilization, and early return of wrist function. Buttress plates reduce and stabilize vertical shear intra-articular fractures through an antiglide effect, where-as conventional and locking plates address metaphyseal comminution and/or preserve articular congruity/reduction. With conventional and locking plates, intra-articular fractures are directly reduced; with buttress plates, the plate itself helps reduce the intra-articular fracture. Complications associated with plating include tendon irritation or rupture and the need for plate removal.

PMID: 15938605 [PubMed - indexed for MEDLINE]