2084
Letters to the Editor / Injury, Int. J. Care Injured 46 (2015) 2073–2087
given spinal anaesthesia compared with patients given general anaesthesia. A single-centre analysis of 1998 elderly patients undergoing the total joint replacement shows that there are significant differences in mortality risk-factors between early and late periods after surgery. The early mortality is most likely related to the surgery and perioperative managements, and lasts about a month. However, the longer-term mortality primarily represents the natural process of ageing or potential diseases [6]. Thus, an important question that remains unanswered in this study is whether an increased longer-term mortality with spinal anaesthesia should really be attributable to anaesthesia method itself. To address this issue, we agree with the authors that further large-scale multicentre randomised controlled trials are still needed, and these new studies should have enough power for postoperative outcomes and mortality. In this way, one can better understand exactly how the two anaesthesia methods really differ. If further studies show consistent beneficial effect of regional or general anaesthesia on outcomes and mortality following hip fracture surgery, the implications for practice are immense. Conflict of interest None declared. References [1] Parker MJ, Griffiths R. General versus regional anaesthesia for hip fractures. A pilot randomised controlled trial of 322 patients. Injury 2015;46:1562–6. [2] Rasouli MR, Maltenfort MG, Ross D, Hozack WJ, Memtsoudis SG, Parvizi J. Perioperative morbidity and mortality following bilateral total hip arthroplasty. J Arthroplasty 2014;29(1):142–8. [3] Pugely AJ, Martin CT, Gao Y, Klocke NF, Callaghan JJ, Marsh JL. A risk calculator for short-term morbidity and mortality after hip fracture surgery. J Orthop Trauma 2014;28(2):63–9. [4] O’Malley NT, Fleming FJ, Gunzler DD, Messing SP, Kates SL. Factors independently associated with complications and length of stay after hip arthroplasty: analysis of the National Surgical Quality Improvement Program. J Arthroplasty 2012;27(10):1832–7. [5] Kim SD, Park SJ, Lee DH, Jee DL. Risk factors of morbidity and mortality following hip fracture surgery. Korean J Anesthesiol 2013;64(6):505–10. [6] Ja¨msen E, Puolakka T, Eskelinen A, Ja¨ntti P, Kalliovalkama J, Nieminen J, et al. Predictors of mortality following primary hip and knee replacement in the aged. A single-center analysis of 1,998 primary hip and knee replacements for primary osteoarthritis. Acta Orthop 2013;84(1):44–53.
Fu-Shan Xue* Gao-Pu Liu Chao Sun Rui-Ping Li Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, People’s Republic of China
Letter to the Editor The clamshell incision can be easily taught to both emergency physicians and surgeons We read with great interest the article ‘‘Clamshell thoracotomy and open heart massage – A potential life-saving procedure can be taught to emergency physicians An educational cadaveric pilot study’’ [1]. The clamshell incision (CI) was chosen for its excellent exposure and rapidity [2,3]. The conclusion was that the CI can indeed be performed fast enough and safely by emergency physicians, at least on a cadaver. Moreover, the emergency physicians were able to perform it correctly from the very first time after having been instructed for only 20 min, a week before the incision. In our cadaveric study ‘‘Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited’’ [4], we explored whether the CI was faster than the left anterolateral thoracotomy when having to repair a heart wound. The clamshell was not longer and moreover, it could be easily and correctly performed by surgical residents without any prior experience in thoracotomies. They had only watched a 5 min video prior to the incision. Interestingly, the time needed to perform the clamshell incision (from the skin incision until the sternum was divided), is similar in the two studies. When comparing the times achieved during the first try in Puchwein’s et al. study (by adding Time 1 and Time 2, 105 s [69–331 s], median [range], groups 1–3, n = 11) with our times (Access Time, 140 s [82–409 s], n = 8), (Table 1) there is no statistical difference: Wilcoxon’s rank sum test for these two populations yields a p of 0.26 (Fig. 1). This is an important finding, because it increases the validity of both studies’ results, especially since they have small sample sizes. Furthermore they complement each other: the results apply for both doctors with and without prior surgical experience. Even though the conclusions cannot be translated directly to real life scenarios, since the experiments were performed on cadavers, both studies point towards the same direction: the clamshell incision is easy to perform even without experience, after having attended only a short theoretical course. Despite recent controversy [5,6] the take home message is clear: in trauma, when the non-specialist has to enter the thorax, the clamshell incision is the way to go.
Table 1 Time needed from skin incision till division of the sternum when operators perform the clamshell incision for the first time.
*Correspondence to: Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 33 Ba-Da-Chu Road, Shi-Jing-Shan District, Beijing 100144, People’s Republic of China. Tel.: +86 13911177655; fax: +86 10 88772106 E-mail address: [email protected] (F.-S. Xue).
http://dx.doi.org/10.1016/j.injury.2015.07.008
Median
Puchwein et al.
Flaris et al.
Operator
Time (Time 1 + Time 2) (s)
Operator
A1a A2a A3a I1a I2a I3a S1a S2a S3a S4a S5a
331 69 130 134 82 78 129 270 94 100 76
Resident Resident Resident Resident Resident Resident Resident Resident
100
Time (access time) (s) #2 #3 #5 #9 #11 #13 #15 #17
120 94 159 303 258 409 96 82
139.5
Letters to the Editor / Injury, Int. J. Care Injured 46 (2015) 2073–2087
a
2085
Eric R. Simmsa,b Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France b Tulane University School of Medicine, New Orleans, LA, USA
Nicolas J. Prat Institut de Recherche Biome´dicale des Arme´es, SMCF F-91223 Bre´tigny sur Orge, France Floran A. Reynarda,b Universite´ de Lyon, Lyon F-69007, France b Universite´ Lyon 1, Faculte´ de Me´decine Lyon Est, UMR T9405, Lyon F-69008, France a
Jean-Louis Caillota,b Universite´ de Lyon, Lyon F-69007, France b Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France a
Fig. 1. Boxplots of the data presented in Table 1. The thick dark line represents the median and the box edges run from the 25th to the 75th percentiles. The whiskers cover all values. The p value was calculated with Wilcoxon’s rank sum test (obtained with Rv3.1.3 for Windows).
*Corresponding author at: Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France E-mail address: [email protected] (E.J. Voiglio).
2 July 2015
http://dx.doi.org/10.1016/j.injury.2015.07.029
Conflict of interest None declared. References
Letter to the Editor [1] Puchwein P, Sommerauer F, Clement HG, Matzi V, Tesch NP, Hallmann B, et al. Clamshell thoracotomy and open heart massage – a potential life-saving procedure can be taught to emergency physicians: an educational cadaveric pilot study. Injury 2015;46:1738–42. http://dx.doi.org/10.1016/j.injury.2015.05.045. [2] Wise D, Davies G, Coats T, Lockey D, Hyde J, Good A. Emergency thoracotomy: how to do it. Emerg Med J 2005;22:22–4. http://dx.doi.org/10.1136/emj.2003. 012963. [3] Simms ER, Flaris AN, Franchino X, Thomas MS, Caillot J-L, Voiglio EJ. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study. World J Surg 2013;37:1277–85. http://dx.doi.org/ 10.1007/s00268-013-1961-5. [4] Flaris AN, Simms ER, Prat N, Reynard F, Caillot J-L, Voiglio EJ. Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited. World J Surg 2015;39:1306–11. http://dx.doi.org/10.1007/s00268-014-2924-1. [5] Vassiliu P, Yilmaz T, Degiannis E. On the ideal emergency thoracotomy incision. World J Surg 2014;38:1001–2. http://dx.doi.org/10.1007/s00268-013-2253-9. [6] Voiglio EJ, Simms ER, Flaris AN, Franchino X, Thomas MS, Caillot J-L. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomical study: reply. World J Surg 2014;38:1003–5. http:// dx.doi.org/10.1007/s00268-013-2368-z.
Eric J. Voiglioa,b,c,* Universite´ de Lyon, Lyon F-69007, France b Universite´ Lyon 1, Faculte´ de Me´decine Lyon Est, UMR T9405, Lyon F-69008, France c Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France a
Alexandros N. Flarisa,b,c,d Universite´ de Lyon, Lyon F-69007, France b Universite´ Lyon 1, Faculte´ de Me´decine Lyon Est, UMR T9405, Lyon F-69008, France c Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France d Protypon Neurological-Neuromuscular Center, Thessaloniki, Greece a
Can a trochanter stabilising plate prevent lateral wall fractures in AO/OTA 31-A2 pertrochanteric fractures with critical thin femoral lateral walls? We read the article ‘Trochanter stabilising plate improves treatment outcomes in AO/OTA 31-A2 intertrochanteric fractures with critical thin femoral lateral walls’ with great interest and congratulate the authors for their study [Injury 2015 Jun;46(6):1047–53. doi: 10.1016/j.injury.2015.03.007]. However, we have some concerns: 1) To evaluate the effect of trochanter stabilising plate (TSP) on patients with high risk of postoperative lateral wall fracture, the authors studied 171 patients with preoperative lateral thickness of less than 2.24 cm. Among these 171 patients, 125 patients were treated with DHS alone, and 46 patients were treated with DHS–TSP. The authors found that, decreased lag screw sliding distances, lower postoperative lateral wall fracture rate and lower reoperation rates were found in patients treated with DHS–TSP than in patients treated with DHS alone (P < 0.001, P = 0.037 and P < 0.001, respectively). Specifically, 58/125 (46%) patients in the DHS group and only 2/46 (4%) patients in the DHS–TSP group developed a postoperative lateral wall fracture. It is understandable that a TSP could prevent medialisation after a lateral wall fracture occurs and thus have decreased lag screw sliding distances and therefore a lower reoperation rate. But it is difficult to understand how a TSP could prevent a lateral wall fracture in this setting. A lateral wall fracture has a high risk if the remnant lateral wall at the region that the reamer will pass is small (
Letters to the Editor / Injury, Int. J. Care Injured 46 (2015) 2073–2087
given spinal anaesthesia compared with patients given general anaesthesia. A single-centre analysis of 1998 elderly patients undergoing the total joint replacement shows that there are significant differences in mortality risk-factors between early and late periods after surgery. The early mortality is most likely related to the surgery and perioperative managements, and lasts about a month. However, the longer-term mortality primarily represents the natural process of ageing or potential diseases [6]. Thus, an important question that remains unanswered in this study is whether an increased longer-term mortality with spinal anaesthesia should really be attributable to anaesthesia method itself. To address this issue, we agree with the authors that further large-scale multicentre randomised controlled trials are still needed, and these new studies should have enough power for postoperative outcomes and mortality. In this way, one can better understand exactly how the two anaesthesia methods really differ. If further studies show consistent beneficial effect of regional or general anaesthesia on outcomes and mortality following hip fracture surgery, the implications for practice are immense. Conflict of interest None declared. References [1] Parker MJ, Griffiths R. General versus regional anaesthesia for hip fractures. A pilot randomised controlled trial of 322 patients. Injury 2015;46:1562–6. [2] Rasouli MR, Maltenfort MG, Ross D, Hozack WJ, Memtsoudis SG, Parvizi J. Perioperative morbidity and mortality following bilateral total hip arthroplasty. J Arthroplasty 2014;29(1):142–8. [3] Pugely AJ, Martin CT, Gao Y, Klocke NF, Callaghan JJ, Marsh JL. A risk calculator for short-term morbidity and mortality after hip fracture surgery. J Orthop Trauma 2014;28(2):63–9. [4] O’Malley NT, Fleming FJ, Gunzler DD, Messing SP, Kates SL. Factors independently associated with complications and length of stay after hip arthroplasty: analysis of the National Surgical Quality Improvement Program. J Arthroplasty 2012;27(10):1832–7. [5] Kim SD, Park SJ, Lee DH, Jee DL. Risk factors of morbidity and mortality following hip fracture surgery. Korean J Anesthesiol 2013;64(6):505–10. [6] Ja¨msen E, Puolakka T, Eskelinen A, Ja¨ntti P, Kalliovalkama J, Nieminen J, et al. Predictors of mortality following primary hip and knee replacement in the aged. A single-center analysis of 1,998 primary hip and knee replacements for primary osteoarthritis. Acta Orthop 2013;84(1):44–53.
Fu-Shan Xue* Gao-Pu Liu Chao Sun Rui-Ping Li Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, People’s Republic of China
Letter to the Editor The clamshell incision can be easily taught to both emergency physicians and surgeons We read with great interest the article ‘‘Clamshell thoracotomy and open heart massage – A potential life-saving procedure can be taught to emergency physicians An educational cadaveric pilot study’’ [1]. The clamshell incision (CI) was chosen for its excellent exposure and rapidity [2,3]. The conclusion was that the CI can indeed be performed fast enough and safely by emergency physicians, at least on a cadaver. Moreover, the emergency physicians were able to perform it correctly from the very first time after having been instructed for only 20 min, a week before the incision. In our cadaveric study ‘‘Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited’’ [4], we explored whether the CI was faster than the left anterolateral thoracotomy when having to repair a heart wound. The clamshell was not longer and moreover, it could be easily and correctly performed by surgical residents without any prior experience in thoracotomies. They had only watched a 5 min video prior to the incision. Interestingly, the time needed to perform the clamshell incision (from the skin incision until the sternum was divided), is similar in the two studies. When comparing the times achieved during the first try in Puchwein’s et al. study (by adding Time 1 and Time 2, 105 s [69–331 s], median [range], groups 1–3, n = 11) with our times (Access Time, 140 s [82–409 s], n = 8), (Table 1) there is no statistical difference: Wilcoxon’s rank sum test for these two populations yields a p of 0.26 (Fig. 1). This is an important finding, because it increases the validity of both studies’ results, especially since they have small sample sizes. Furthermore they complement each other: the results apply for both doctors with and without prior surgical experience. Even though the conclusions cannot be translated directly to real life scenarios, since the experiments were performed on cadavers, both studies point towards the same direction: the clamshell incision is easy to perform even without experience, after having attended only a short theoretical course. Despite recent controversy [5,6] the take home message is clear: in trauma, when the non-specialist has to enter the thorax, the clamshell incision is the way to go.
Table 1 Time needed from skin incision till division of the sternum when operators perform the clamshell incision for the first time.
*Correspondence to: Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 33 Ba-Da-Chu Road, Shi-Jing-Shan District, Beijing 100144, People’s Republic of China. Tel.: +86 13911177655; fax: +86 10 88772106 E-mail address: [email protected] (F.-S. Xue).
http://dx.doi.org/10.1016/j.injury.2015.07.008
Median
Puchwein et al.
Flaris et al.
Operator
Time (Time 1 + Time 2) (s)
Operator
A1a A2a A3a I1a I2a I3a S1a S2a S3a S4a S5a
331 69 130 134 82 78 129 270 94 100 76
Resident Resident Resident Resident Resident Resident Resident Resident
100
Time (access time) (s) #2 #3 #5 #9 #11 #13 #15 #17
120 94 159 303 258 409 96 82
139.5
Letters to the Editor / Injury, Int. J. Care Injured 46 (2015) 2073–2087
a
2085
Eric R. Simmsa,b Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France b Tulane University School of Medicine, New Orleans, LA, USA
Nicolas J. Prat Institut de Recherche Biome´dicale des Arme´es, SMCF F-91223 Bre´tigny sur Orge, France Floran A. Reynarda,b Universite´ de Lyon, Lyon F-69007, France b Universite´ Lyon 1, Faculte´ de Me´decine Lyon Est, UMR T9405, Lyon F-69008, France a
Jean-Louis Caillota,b Universite´ de Lyon, Lyon F-69007, France b Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France a
Fig. 1. Boxplots of the data presented in Table 1. The thick dark line represents the median and the box edges run from the 25th to the 75th percentiles. The whiskers cover all values. The p value was calculated with Wilcoxon’s rank sum test (obtained with Rv3.1.3 for Windows).
*Corresponding author at: Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France E-mail address: [email protected] (E.J. Voiglio).
2 July 2015
http://dx.doi.org/10.1016/j.injury.2015.07.029
Conflict of interest None declared. References
Letter to the Editor [1] Puchwein P, Sommerauer F, Clement HG, Matzi V, Tesch NP, Hallmann B, et al. Clamshell thoracotomy and open heart massage – a potential life-saving procedure can be taught to emergency physicians: an educational cadaveric pilot study. Injury 2015;46:1738–42. http://dx.doi.org/10.1016/j.injury.2015.05.045. [2] Wise D, Davies G, Coats T, Lockey D, Hyde J, Good A. Emergency thoracotomy: how to do it. Emerg Med J 2005;22:22–4. http://dx.doi.org/10.1136/emj.2003. 012963. [3] Simms ER, Flaris AN, Franchino X, Thomas MS, Caillot J-L, Voiglio EJ. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomic study. World J Surg 2013;37:1277–85. http://dx.doi.org/ 10.1007/s00268-013-1961-5. [4] Flaris AN, Simms ER, Prat N, Reynard F, Caillot J-L, Voiglio EJ. Clamshell incision versus left anterolateral thoracotomy. Which one is faster when performing a resuscitative thoracotomy? The tortoise and the hare revisited. World J Surg 2015;39:1306–11. http://dx.doi.org/10.1007/s00268-014-2924-1. [5] Vassiliu P, Yilmaz T, Degiannis E. On the ideal emergency thoracotomy incision. World J Surg 2014;38:1001–2. http://dx.doi.org/10.1007/s00268-013-2253-9. [6] Voiglio EJ, Simms ER, Flaris AN, Franchino X, Thomas MS, Caillot J-L. Bilateral anterior thoracotomy (clamshell incision) is the ideal emergency thoracotomy incision: an anatomical study: reply. World J Surg 2014;38:1003–5. http:// dx.doi.org/10.1007/s00268-013-2368-z.
Eric J. Voiglioa,b,c,* Universite´ de Lyon, Lyon F-69007, France b Universite´ Lyon 1, Faculte´ de Me´decine Lyon Est, UMR T9405, Lyon F-69008, France c Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France a
Alexandros N. Flarisa,b,c,d Universite´ de Lyon, Lyon F-69007, France b Universite´ Lyon 1, Faculte´ de Me´decine Lyon Est, UMR T9405, Lyon F-69008, France c Hospices Civils de Lyon, Unite´ de Chirurgie d’Urgence, Centre Hospitalier Lyon-Sud, Pierre-Be´nite F-69495, France d Protypon Neurological-Neuromuscular Center, Thessaloniki, Greece a
Can a trochanter stabilising plate prevent lateral wall fractures in AO/OTA 31-A2 pertrochanteric fractures with critical thin femoral lateral walls? We read the article ‘Trochanter stabilising plate improves treatment outcomes in AO/OTA 31-A2 intertrochanteric fractures with critical thin femoral lateral walls’ with great interest and congratulate the authors for their study [Injury 2015 Jun;46(6):1047–53. doi: 10.1016/j.injury.2015.03.007]. However, we have some concerns: 1) To evaluate the effect of trochanter stabilising plate (TSP) on patients with high risk of postoperative lateral wall fracture, the authors studied 171 patients with preoperative lateral thickness of less than 2.24 cm. Among these 171 patients, 125 patients were treated with DHS alone, and 46 patients were treated with DHS–TSP. The authors found that, decreased lag screw sliding distances, lower postoperative lateral wall fracture rate and lower reoperation rates were found in patients treated with DHS–TSP than in patients treated with DHS alone (P < 0.001, P = 0.037 and P < 0.001, respectively). Specifically, 58/125 (46%) patients in the DHS group and only 2/46 (4%) patients in the DHS–TSP group developed a postoperative lateral wall fracture. It is understandable that a TSP could prevent medialisation after a lateral wall fracture occurs and thus have decreased lag screw sliding distances and therefore a lower reoperation rate. But it is difficult to understand how a TSP could prevent a lateral wall fracture in this setting. A lateral wall fracture has a high risk if the remnant lateral wall at the region that the reamer will pass is small (
