Medicine and Health Sciences Commons^™

Cannulation Of The Axillary Artery For Cardiopulmonary Bypass: Safeguards And Pitfalls., Michael C Sinclair, Raymond Singer, Norman J Manley, Ralph M Montesano

Raymond L Singer MD

BACKGROUND: The ascending aorta is the customary site for arterial cannulation for cardiopulmonary bypass. Favorable experience at our institution and elsewhere using axillary artery cannulation in treating type A aortic dissections has caused us to broaden our indications for using this site for arterial cannulation for cardiopulmonary bypass.

METHODS: Medical records, operative notes, and perfusion records were reviewed in all patients in whom the axillary artery was cannulated directly or by a graft for cardiopulmonary bypass from January 1, 2000 through August 30, 2002.

RESULTS: Seventy-five patients underwent axillary artery cannulation during the 32-month interval. Eleven patients had ascending aortic …

The Effect Of Low-Dose Heparin On The Prevention Of Venous Thrombosis In Patients Receiving Short-Term Parenteral Nutrition., J A Macoviak, G Melnik, G Mclean, A Lunderquist, Raymond Singer, L Forlaw, J L Rombeau

Raymond L Singer MD

No abstract provided.

Complications From Heparin-Induced Thrombocytopenia In Patients Undergoing Cardiopulmonary Bypass., Raymond Singer, J D Mannion, T L Bauer, F R Armenti, R N Edie

Raymond L Singer MD

The purpose of this study was to evaluate retrospectively the incidence and severity of heparin-induced thrombocytopenia (HIT)-related complications in patients undergoing cardiopulmonary bypass. We reviewed the records of 1,500 consecutive patients who underwent cardiopulmonary bypass between August 1987 and December 1991 at Thomas Jefferson University Hospital. During this period of time, there were 1,155 coronary artery bypass graft operations (77 percent); 225 valve replacements and repairs, or both (15 percent); 60 combination coronary artery bypass graft or valve operations, or both (4 percent); and 60 miscellaneous procedures (4 percent). Although not all patients with postoperative complications were tested for the …

Thoracoscopic Excision Of A Malignant Schwannoma Of The Intrathoracic Vagus Nerve., Raymond Singer

Raymond L Singer MD

Malignant schwannomas of the intrathoracic vagus nerve are rare tumors. A patient underwent resection of a mediastinal malignant schwannoma of the vagus nerve using video-assisted thoracoscopy, with no recurrence at 18 months.

Extra-Anatomic Redo Of Midcab And Opcab: An Early Experience., M C Sinclair, M Leboutillier, W Gee, Theodore Phillips, Raymond Singer

Raymond L Singer MD

BACKGROUND: Eighteen patients with unstable angina underwent repeat myocardial revascularization without cardiopulmonary bypass using saphenous vein grafts from either the left (13) or right (2) axillary arteries or the descending thoracic aorta (3). Patients' ages ranged from 53 to 85 years. Left ventricular ejection fractions ranged from 15% to 60%. METHODS: In 14 patients, the heart was exposed through an anterior thoracotomy, a minimally invasive direct coronary artery bypass (MIDCAB) technique. In 3 patients a left posterolateral thoractomy (lateral MIDCAB) was performed. One patient underwent repeat sternotomy (off-pump coronary artery bypass: OPCAB). In MIDCAB and lateral MIDCAB patients, the "target" …

Outcome Of Blunt Thoracic Aortic Injury In A Level I Trauma Center: An 8-Year Review., E J Frick, M D Cipolle, Michael Pasquale, T E Wasser, M Rhodes, Raymond Singer, S A Nastasee

Raymond L Singer MD

BACKGROUND: The purpose of this study was to evaluate our experience with blunt thoracic aortic injury and identify factors predictive of outcome. METHODS: Hospital charts, trauma registry data, and autopsies of 64 patients with blunt thoracic aortic injury from 1988 to 1995 were reviewed. RESULTS: Patients were identified and segregated based on admission physiology. Group 1 patients (n = 19) arrived in arrest. Group 2 patients (n = 10) arrived in shock with systolic BP 90. Group 3 patients (n = 35) arrived with systolic BP>90. All patients in groups 1 and 2 expired. Injury Severity Scores for nonsurvivors …

Male Gender Is Associated With Increased Risk For Postinjury Pneumonia., Christopher J Gannon, Michael Pasquale, J Kathleen Tracy, Robert J Mccarter, Lena M Napolitano

Michael D Pasquale MD, FACS, FCCM

Nosocomial pneumonia in trauma patients is a significant source of resource utilization and mortality. We have previously described increased rates of pneumonia in male trauma patients in a single institution study. In that study, female trauma patients had a lower incidence of postinjury pneumonia but a higher relative risk for mortality when they did develop pneumonia. We sought to investigate the hypothesis that male trauma patients have an increased incidence of postinjury pneumonia in a separate population-based dataset. Prospective data were collected on 30,288 trauma patients (26,231 blunt injuries, 4057 penetrating injuries) admitted to all trauma centers (n = 26) …

Clinical Clearance Of The Cervical Spine In Blunt Trauma Patients Younger Than 3 Years: A Multi-Center Study Of The American Association For The Surgery Of Trauma., Rafael Pieretti-Vanmarcke, George C Velmahos, Michael L Nance, Saleem Islam, Richard A Falcone, Paul W Wales, Rebeccah L Brown, Barbara A Gaines, Christine Mckenna, Forrest O Moore, Pamela W Goslar, Kenji Inaba, Galinos Barmparas, Eric R Scaife, Ryan R Metzger, Douglas L Brockmeyer, Jeffrey S Upperman, Joaquin Estrada, David A Lanning, Sara K Rasmussen, Paul D Danielson, Michael P Hirsh, Heitor F X Consani, Steven Stylianos, Candace Pineda, Scott H Norwood, Steven W Bruch, Robert Drongowski, Robert Barraco, Michael Pasquale, Farheen Hussain, Erwin F Hirsch, P Daniel Mcneely, Mary E Fallat, David S Foley, Joseph A Iocono, Heather M Bennett, Kenneth Waxman, Kelly Kam, Lisa Bakhos, Laurie Petrovick, Yuchiao Chang, Peter T Masiakos

Michael D Pasquale MD, FACS, FCCM

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by …

Brother, Have You Got A Light? Assessing The Need For Intubation In Patients Sustaining Burn Injury Secondary To Home Oxygen Therapy., Hamed Amani, Daniel Lozano, Sigrid Blome-Eberwein

Sigrid A Blome-Eberwein MD

Home oxygen therapy use has steadily increased for the past 30 years. A majority of these patients suffer from chronic obstructive pulmonary disease secondary to smoking. Although warned of the danger of smoking while on oxygen, patients continue to do so, potentially resulting in cutaneous burns and suspected inhalation injury. Those suspected of inhalation injury are intubated for airway control. In the English literature, there is a paucity of data discussing the need for intubation. To date, this is the largest study to determine whether intubated patients had inhalation injury as observed by bronchoscopy and whether intubation was necessary. All …

Hydrofiber Dressing With Silver For The Management Of Split-Thickness Donor Sites: A Randomized Evaluation Of Two Protocols Of Care, Sigrid Blome-Eberwein, R Johnson, Sidney Miller, Daniel Caruso, Marion Jordan, Stephen Milner, Edward Tredget, Kevin Sittig, Leslie Smith

Sigrid A Blome-Eberwein MD

BACKGROUND: This randomized, open-label study evaluated Aquacel Ag Hydrofiber dressing with silver (HDS; ConvaTec, Skillman, NJ, USA) with an adherent or gelled protocol in the management of split-thickness donor sites. METHODS: HDS was the primary dressing in the adherent group (gauze as secondary covering) and gelled group (transparent film as secondary covering). Dressings were changed on study day 1 or 2 and study days 5 (optional), 10 (optional), and 14. The primary outcome was healing (>or=90% re-epithelialization) at study day 14. RESULTS: Seventy subjects were treated (36 adherent, 34 gelled). By study day 14, 77% of donor sites had …

Evaluation And Management Of Geriatric Trauma: An Eastern Association For The Surgery Of Trauma Practice Management Guideline., James Forrest Calland, Angela M Ingraham, Niels Martin, Gary T Marshall, Carl I Schulman, Tristan Stapleton, Robert Barraco

Robert D Barraco MD, MPH

BACKGROUND: Aging patients constitute an increasing proportion of patients treated at trauma centers. Previous and existing guidelines addressing care of the injured elder have not adequately addressed emerging data regarding optimal means for undertaking triage decisions, correcting coagulopathy, and the limitations of supraphysiologic resuscitation. METHODS: More than 400 MEDLINE citations published between the years 2000 and 2008 were identified and screened. A total of 90 references were selected for the evidentiary table followed by consensus-based discussions regarding the level of evidence and the strength of recommendations that could be derived from the related findings of the individual studies. RESULTS: In …

Evaluation And Management Of Mild Traumatic Brain Injury: An Eastern Association For The Surgery Of Trauma Practice Management Guideline., Ronald J. Bross Md, Randeep Jawa, Jennifer M Watters, Jennifer C. Knight, Andrew J Kerwin, Eleanor S Winston, Robert D. Barraco Md, Brian Tucker, James M Bardes, Susan E Rowell

Robert D Barraco MD, MPH

BACKGROUND: An estimated 1.1 million people sustain a mild traumatic brain injury (MTBI) annually in the United States. The natural history of MTBI remains poorly characterized, and its optimal clinical management is unclear. The Eastern Association for the Surgery of Trauma had previously published a set of practice management guidelines for MTBI in 2001. The purpose of this review was to update these guidelines to reflect the literature published since that time. METHODS: The PubMed and Cochrane Library databases were searched for articles related to MTBI published between 1998 and 2011. Selected older references were also examined. RESULTS: A total …

Odontoid Fractures In The Elderly: Should We Operate?, Alice Fagin, Mark Cipolle, Robert Barraco, Sherrine Eid, James Reed, P. Mark Li, Michael Pasquale

Robert D Barraco MD, MPH

BACKGROUND: : Treatment of odontoid fractures remains controversial. There are conflicting data in the literature with regard to timing of operative fixation (OP), as well as whether OP should be performed. Within our own institution, treatment is variable depending largely on surgeon preference. This study was undertaken in an attempt to develop management consensus by examining outcomes in elderly patients with odontoid fractures and comparing OP to a nonoperative (non-OP) approach.

METHODS: : The trauma registry of our level I trauma center was queried for elderly (age > or = 60) patients with odontoid fractures from January 2000 to May 2006. …

Clinical Clearance Of The Cervical Spine In Blunt Trauma Patients Younger Than 3 Years: A Multi-Center Study Of The American Association For The Surgery Of Trauma., Rafael Pieretti-Vanmarcke, George C Velmahos, Michael L Nance, Saleem Islam, Richard A Falcone, Paul W Wales, Rebeccah L Brown, Barbara A Gaines, Christine Mckenna, Forrest O Moore, Pamela W Goslar, Kenji Inaba, Galinos Barmparas, Eric R Scaife, Ryan R Metzger, Douglas L Brockmeyer, Jeffrey S Upperman, Joaquin Estrada, David A Lanning, Sara K Rasmussen, Paul D Danielson, Michael P Hirsh, Heitor F X Consani, Steven Stylianos, Candace Pineda, Scott H Norwood, Steven W Bruch, Robert Drongowski, Robert Barraco, Michael Pasquale, Farheen Hussain, Erwin F Hirsch, P Daniel Mcneely, Mary E Fallat, David S Foley, Joseph A Iocono, Heather M Bennett, Kenneth Waxman, Kelly Kam, Lisa Bakhos, Laurie Petrovick, Yuchiao Chang, Peter T Masiakos

Robert D Barraco MD, MPH

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by …

Evaluation And Management Of Mild Traumatic Brain Injury: An Eastern Association For The Surgery Of Trauma Practice Management Guideline, Ronald Barbosa, Randeep Jawa, Jennifer Watters, Jennifer Knight, Andrew Kerwin, Eleanor Winston, Robert Barraco, Brian Tucker, James Bardes, Susan Rowell

Robert D Barraco MD, MPH

BACKGROUND: An estimated 1.1 million people sustain a mild traumatic brain injury (MTBI) annually in the United States. The natural history of MTBI remains poorly characterized, and its optimal clinical management is unclear. The Eastern Association for the Surgery of Trauma had previously published a set of practice management guidelines for MTBI in 2001. The purpose of this review was to update these guidelines to reflect the literature published since that time.

METHODS: The PubMed and Cochrane Library databases were searched for articles related to MTBI published between 1998 and 2011. Selected older references were also examined.

RESULTS: A total …

Practice Management Guidelines For The Diagnosis And Management Of Injury In The Pregnant Patient: The East Practice Management Guidelines Work Group, Robert Barraco, William Chiu, Thomas Clancy, John Como, James Ebert, L Hess, William Hoff, Michele Holevar, J Quirk, Bruce J Simon, Patrice Weiss

Robert D Barraco MD, MPH

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for …

An Evidence-Based Review: Efficacy Of Safety Helmets In The Reduction Of Head Injuries In Recreational Skiers And Snowboarders, Adil H. Haider Md, Mph, Taimur Saleem Md, Jaroslaw W. Bilaniuk Md, Robert D. Barraco Md

Robert D Barraco MD, MPH

BACKGROUND: Approximately 600,000 ski- and snowboarding-related injuries occur in North America each year, with head injuries accounting for up to 20% of all injuries. Currently, there are no major institutional recommendations regarding helmet use for skiers and snowboaders in the United States, in part owing to previous conflicting evidence regarding their efficacy. The objective of this review was to evaluate existing evidence on the efficacy of safety helmets during skiing and snowboarding, particularly in regard to head injuries, neck and cervical spine injuries, and risk compensation behaviors. These data will then be used for potential recommendations regarding helmet use during …

Evaluation And Management Of Mild Traumatic Brain Injury: An Eastern Association For The Surgery Of Trauma Practice Management Guideline., Ronald J. Bross Md, Randeep Jawa, Jennifer M Watters, Jennifer C. Knight, Andrew J Kerwin, Eleanor S Winston, Robert D. Barraco Md, Brian Tucker, James M Bardes, Susan E Rowell

Robert D Barraco MD, MPH

BACKGROUND: An estimated 1.1 million people sustain a mild traumatic brain injury (MTBI) annually in the United States. The natural history of MTBI remains poorly characterized, and its optimal clinical management is unclear. The Eastern Association for the Surgery of Trauma had previously published a set of practice management guidelines for MTBI in 2001. The purpose of this review was to update these guidelines to reflect the literature published since that time. METHODS: The PubMed and Cochrane Library databases were searched for articles related to MTBI published between 1998 and 2011. Selected older references were also examined. RESULTS: A total …

Use Of Circular External Fixation For Combined Subtalar Joint Fusion And Ankle Distraction., Thomas Zgonis, John Stapleton, Thomas S Roukis

John J Stapleton DPM, FACFAS

The authors discuss a novel technique not previously published that incorporates a subtalar joint arthrodesis with an ankle joint arthrodiastasis as an alternative to a tibiotalocalcaneal arthrodesis. Young and active patients who experience refractory pain and stiffness to the rearfoot and ankle secondary to combined severe subtalar and ankle arthrosis are suitable candidates for this surgical procedure. This new approach is based on sound principles in the treatment of severe arthrosis affecting the ankle and subtalar joint. The authors are currently prospectively reviewing their surgical experience with this procedure and believe that it provides an alternative option for the patient, …

Surgical Management Of Diabetic Foot And Ankle Infections., Claire M Capobianco, John Stapleton, Thomas Zgonis

John J Stapleton DPM, FACFAS

Delayed treatment of any diabetic foot infection can lead to a limb- or life-threatening scenario. Urgent and/or emergent surgery may be necessary in the early diagnosis of a severe diabetic foot infection that is followed by staged reconstructive procedures. This article provides the reader with a thorough understanding of the surgical management of severe diabetic foot infections and describes and guides treatment based on a rational schematic approach that identifies the anatomic location of the diabetic foot infection.

Innovative Techniques In Preventing And Salvaging Neurovascular Pedicle Flaps In Reconstructive Foot And Ankle Surgery., Thomas Zgonis, John Stapleton

John J Stapleton DPM, FACFAS

Pedicle flaps to cover soft tissue defects of the foot, ankle, and lower extremity are invaluable. However, venous congestion and flap necrosis, a common complication, poses greater morbidity to the patient as few remaining options for attempted limb salvage remain. The authors discuss how to prevent flap failure by allowing close observation and strict offloading of the pedicle flap through current external fixation designs. This article also discusses the role of medicinal leeches in reestablishing blood flow through the pedicle flap to prevent tissue necrosis. In addition, the use of hydrosurgery as an innovative technique offers the surgeon another option …

A Case Report Of A Simultaneous Local Osteochondral Autografting And Ankle Arthrodiastasis For The Treatment Of A Talar Dome Defect., Ronald Belczyk, John Stapleton, Thomas Zgonis, Vasilios D Polyzois

John J Stapleton DPM, FACFAS

Talar osteochondral defects (OCDs) are a challenge for treating physicians because they frequently are missed or diagnosed incorrectly, often resulting in severe degenerative arthritis of the ankle joint. Surgical intervention becomes a viable option in the presence of larger OCDs associated with loose bodies or osteochondral lesions that have failed conservative treatment. The successful use of autologous osteochondral autograft in the knee has promoted the applicability in the ankle. This report describes a unique technique for the treatment of large talar osteochondral lesions using a local osteochondral autograft combined with an ankle arthrodiastasis.

Split-Thickness Skin Grafts For Closure Of Diabetic Foot And Ankle Wounds: A Retrospective Review Of 83 Patients., Crystal L Ramanujam, John Stapleton, Krista L Kilpadi, Roberto H Rodriguez, Luke C Jeffries, Thomas Zgonis

John J Stapleton DPM, FACFAS

The aim of this study was to determine if split-thickness skin grafts could be successfully used for closure of foot and ankle wounds in diabetic patients. The authors retrospectively reviewed the charts of 100 consecutive patients who underwent a soft tissue surgical reconstruction with split-thickness skin grafts to their foot and/or ankle in our institution from 2005 to 2008. After application of inclusion criteria, 83 eligible charts remained. Of the 83 patients, 54 (65%) healed uneventfully, 23 (28%) required regrafting, and 6 (7%) had a complication resolved with conservative management. All patients had a successful surgical outcome, defined as having …

Internal And External Fixation Approaches To The Surgical Management Of Calcaneal Fractures., John Stapleton, Gennady Kolodenker, Thomas Zgonis

John J Stapleton DPM, FACFAS

Calcaneal fractures are one of the most difficult fractures to surgically manage and often require a steep learning curve to achieve consistent results. They usually occur in young individuals with labor intensive occupations and are associated with major complications. Conservative treatment of intraarticular calcaneal fractures with displacement often results in significant deformity, bone loss, and posttraumatic arthrosis. Optimally, an open approach is required in most cases to achieve anatomic reduction and successful long-term outcomes.

Soft Tissue Reconstruction Pyramid In The Diabetic Foot., Claire M Capobianco, John Stapleton, Thomas Zgonis

John J Stapleton DPM, FACFAS

Foot complications and ulceration are well-known sequelae to uncontrolled diabetes. Patients with chronic foot ulcers or wounds resulting from surgical debridement of deep-space infections are at continued risk for development of osteomyelitis and potential amputation. Moreover, these wounds often necessitate multiple outpatient clinic visits, daily dressing care, and prolonged periods of non-weight bearing, all of which have been shown to adversely affect the patient's quality of life. After a prudent period of wound-healing response, the authors believe that early and aggressive soft tissue reconstruction is in the patient's best interest and is crucial for resolution of the chronic nonhealing wound. …

Advanced Plastic Surgery Techniques For Soft Tissue Coverage Of The Diabetic Foot., Thomas Zgonis, John Stapleton, Thomas S Roukis

John J Stapleton DPM, FACFAS

Obtaining stable, durable, and functional wound closure of a diabetic foot wound or open pedal amputation through plastic surgical techniques is essential to limit the potential for repeated ulceration, infection, and "supra-pedal" amputation. Myriad conservative and surgical techniques can be used to obtain wound closure. The authors discuss their approach and present operative pearls for their most commonly employed plastic surgical techniques to provide adequate soft tissue coverage of diabetic foot wounds. Emphasis is placed on the techniques necessary to perform these procedures and the surgical thought process involved in closing diabetic foot wounds.

Transmetatarsal Amputations., George F Wallace, John Stapleton

John J Stapleton DPM, FACFAS

Transmetatarsal amputation is an excellent procedure in the face of nonhealing ulceration, infection, trauma, peripheral vascular disease, and tumors. This article discusses transmetatarsal amputations, the decision-making process, timing of surgery, operative techniques, postoperative management, and salvage of the failed transmetatarsal amputation.

Plastic Surgery Reconstruction Of The Diabetic Foot., Thomas Zgonis, John Stapleton, Roberto H Rodriguez, Valerie A Girard-Powell, Douglas T Cromack

John J Stapleton DPM, FACFAS

Soft tissue reconstruction of the diabetic foot is a challenge for the perioperative team. Primary closure may not be an option and secondary healing may not be reliable. Therefore, surgery is vital and should be coordinated among a well-functioning multidisciplinary team that specializes in caring for patients with diabetes mellitus. Team members must have expertise in reconstructive surgery to ensure adequate wound healing. This article emphasizes the appropriate timing and staging of surgery, discusses the most common plastic surgery techniques, and underscores the importance of a team approach in the management of diabetic foot wounds.

Surgical Treatment Of Charcot Neuropathy., Thomas Zgonis, John Stapleton, Luke C Jeffries, Valerie A Girard-Powell, Lynanne J Foster

John J Stapleton DPM, FACFAS

Charcot neuroarthropathy, a chronic progressive destruction of joint integrity, is believed to result from a disturbance in pain and proprioceptive sensation. It is most commonly treated in patients with uncontrolled diabetes mellitus and dense peripheral neuropathy. Prevention, early diagnosis, and early treatment are key to a patient's successful outcome. Educating the patient is paramount to avoid further complications and subsequent amputations. This article describes the pathophysiology, staging, surgical treatment, and natural course of Charcot neuroarthropathy.

Diabetic Lisfranc Fracture-Dislocations And Charcot Neuroarthropathy., Bradley A Levitt, John Stapleton, Thomas Zgonis

John J Stapleton DPM, FACFAS

The goal with Lisfranc fracture-dislocations is to regain joint congruity and reestablish midfoot stability to avoid debilitating posttraumatic arthrosis and chronic pain in the sensate patient. In the diabetic population, dense peripheral neuropathy and/or vascular disease are equally important and may alter the surgical approach to traumatic tarsometatarsal injuries. The initial diagnosis in the diabetic population may be delayed due to subtle radiographic findings and/or patient unawareness of trauma in the insensate foot. Failure to initiate treatment in the early stages of acute diabetic neuropathic Lisfranc injuries can predispose the patient to midfoot instability, potential ulceration, infection, and Charcot neuroarthropathy.