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   Table of Contents - Current issue
Coverpage
January-December 2020
Volume 5 | Issue 1
Page Nos. 1-40

Online since Thursday, December 24, 2020

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EDITORIALS  

Covid-19 and cardiothoracic surgery p. 1
Kenneth L Mattox
DOI:10.4103/jctt.jctt_11_20  
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COVID-19 impact on the global surgical practice of cardiothoracic trauma Highly accessed article p. 6
Moheb A Rashid, Kenneth L Mattox, Paul L Tahalele, Merlinda Dwintasari, Yasser ElSaid, Abdelghaffar Alzaanin, Leonardo Peixoto, Jose Luis Ruiz Pier, Bhavik Patel
DOI:10.4103/jctt.jctt_10_20  
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ORIGINAL ARTICLES Top

Surgical stabilization of rib fractures after penetrating thoracic injury: A chest wall injury society multicenter study p. 11
John P Skendelas, Erin R Lewis, Babak Sarani, Mauricio Velasquez Galvis, Marisol Aguirre Rojas, Jody M Kaban
DOI:10.4103/jctt.jctt_5_20  
Introduction: Surgical stabilization of rib fractures (SSRF) has emerged as an acceptable modality to manage chest wall injuries in select patients after blunt thoracic injury; however, its use in penetrating trauma has not been described. Materials and Methods: An international, retrospective study was carried out in two centers who reported experience with SSRF following penetrating chest wall trauma. All adult patients (≥18 years) who underwent SSRF after penetrating thoracic trauma between January 1, 2008, and December 13, 2017 were included. Results: Thirteen patients were enrolled in the study. The entire cohort was male with a median age of 28 years (interquartile range [IQR] 22, 33). Chest wall injury was due to firearm and impalement injuries in 10 (77%) and 3 (23%) patients, respectively. Indications for SSRF included chest wall instability (n = 8), mechanical ventilation or impending respiratory failure (n = 7), and pain (n = 4). Median time to SSRF was 24 h (IQR 20, 48). A median of 3 rib fracture lines (IQR 2, 4) were identified on imaging, and a median of 3 plates (IQR 2, 4) were placed in each patient. Six patients (46%) were extubated immediately after SSRF and the remainder required 3 (IQR 2, 6) days of mechanical ventilation. No patient required a tracheostomy. There were no cases of hardware failure, empyema, hemothorax, or death during hospitalization. Conclusion: In this series, 13 patients with penetrating thoracic injuries underwent SSRF with improved clinical outcomes. These data demonstrate that SSRF can be safely and effectively utilized in patients with penetrating chest wall injuries.
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National readmission rates after surgical stabilization of traumatic rib fractures p. 16
Peter I Cha, Nicholas A Hakes, Jeff Choi, Graeme Rosenberg, Lakshika Tennakoon, David A Spain, Joseph D Forrester
DOI:10.4103/jctt.jctt_6_20  
Introduction: Little is known about the risk of readmission after surgical stabilization of rib fractures (SSRFs). Materials and Methods: We performed a retrospective analysis of the National Readmissions Database, a representative sample of all hospitalized patients in the US, from January 2012 to December 2014. All inpatient encounters with a primary trauma diagnosis of rib fractures were included in the study. Patients who underwent SSRF were compared to those who did not. Outcomes evaluated included readmission frequency and mortality. Results: There were 411,169 patients admitted after trauma with rib fractures from 2012 to 2014; of these, 382 (<1%) underwent SSRF. Among non-SSRF patients, ≥3 rib fractures (odds ratio = 1.41, 95% confidence interval 1.23–1.62) were associated with readmission. Compared to the non-SSRF group, patients undergoing SSRF had a greater incidence of flail chest (26% vs. 2%; P < 0.0001), were more likely to have an injury severity score >15 (55% vs. 37%; P < 0.0001), and more likely to have a coexisting diagnosis of respiratory failure (35% vs. 18%, P < 0.0001). Despite the increased severity of injury among patients having SSRF, there was neither a statistically significant increase in patient deaths (<1% for SSRF vs. 4% no SSRF, P = 0.03) nor readmissions (<1% for SSRF vs. 1% for non SSRF, P = 1.0). Conclusions: Long-term readmission rates for traumatic rib fracture patients are low. If nonoperative management is pursued, the presence of ≥3 rib fractures increases the risk of readmission. Patients requiring SSRF do not have higher readmission or mortality rates despite having a higher burden of injury during their initial hospitalization, suggesting the clinical benefit of surgical fixation.
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Preliminary feasibility of a physical therapy protocol following surgical stabilization of rib fractures p. 22
Christina Pelo, Annika Bickford Kay, David S Morris, Thomas W White, Sarah Majercik
DOI:10.4103/jctt.jctt_3_20  
Background: Surgical stabilization of rib fractures (SSRFs) is increasing in popularity. During the operation, disruption of the chest wall musculature occurs, which may affect chest wall and glenohumeral–scapular movement. Although postoperative physical therapy (PT) is widely recommended, specific, validated, protocols for SSRF patients do not exist. The purpose of this study was to evaluate the feasibility and safety of a PT protocol specifically designed for SSRF patients. Methods: This was a pilot study of all SSRF patients admitted to a single level-I trauma center between December 2017 and February 2019. Included patients received a PT evaluation within 72 h of operation. This evaluation included implementation of specific PT interventions and a written home exercise program. Objective measures included: patient reported pain scores, shoulder strength, chest expansion, spirometry, and the disabilities of the arm, shoulder, and hand (DASH) survey. These measures were obtained at initial inpatient evaluation, 1–week and 1–month post discharge in an outpatient visit, and at 3 months through telephone DASH survey. Results: Nineteen patients were analyzed. Patients were primarily male (74%), suffering from blunt trauma, with a median 8 (interquartile range [IQR]: 7–10) rib fractures and Injury Severity Score (ISS) of 17 (12–23). The median (IQR) time from SSRF to PT evaluation was 1 (1–2) day. Median chest expansion doubled from PT evaluation to 1–month follow–up (1.9 cm PT evaluation; 2.5 cm 1 week; 4.5 cm 1–month, P = 0.014). The median age-predicted spirometry improved from 29% preoperatively, to 38% at PT evaluation and to 86% at 1-month postdischarge (P ≤ 0.05 for the trend). Shoulder strength improved from PT evaluation to 1–month follow–up. The median DASH scoring improved at all follow–up intervals, with no clinically significant functional impairments at 3 months (86 on PT evaluation; 56 at 1–week, 21 at 1–month; 8 at 3–month phone interview). Conclusion: A specific, novel, PT protocol for patients after SSRF appears to be feasible and safe. Our results demonstrate a significant decrease in patient-perceived disability, improved shoulder strength, chest expansion, and spirometry compared to immediate postoperative levels. Although we cannot determine the effect of the protocol on recovery, our results provide the preliminary data on which to base a larger, randomized trial to determine if a beneficial effect of the protocol is present.
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Outcomes in obese patients undergoing rib stabilization at a single institution over 9 years p. 29
Nathaniel Robinson, Wade Stinson, Martin Zielinski, Daniel Stephens, Brian Kim
DOI:10.4103/jctt.jctt_8_20  
Background: We hypothesized that obese patients undergoing rib stabilization would have a smaller ratio of ribs repaired to those fractured, increased days to operation, increased length of operation, were mechanically ventilated longer, required a longer stay in the intensive care unit (ICU) and hospital, and had an increased risk of developing pneumonia. Materials and Methods: This was a retrospective evaluation of patients who underwent surgical rib stabilization after trauma at a single institution over 9 years. Two hundred and seventy-three patients were divided according to body mass index (BMI) into three groups: group 1 (BMI: 15–29, n = 149), Group 2 (BMI: 30–35, n = 80), and Group 3 (BMI: 35–48, n = 44). Analysis of variance was performed to evaluate differences in outcomes in association with BMI. Two-tail t-tests were further utilized to compare Group 1 and Group 3. Results are reported in P values, with P < 0.05 being significant. Results: Sixty-eight percent were male, the mean age was 61, and 96% were Caucasian. Comorbidities: asthma (15%), chronic obstructive pulmonary disease (12%), smokers (22%), hypertension (40%), and type 2 diabetes mellitus (15%). Patients with a higher BMI had a longer average hospital length of stay (12.0, 13.4, and 15.6 days, P < 0.05). The incidence of postoperative pneumonia was increased in those with a higher BMI (10%, 12%, and 30%, P < 0.05). The remaining variables were not significant. Conclusion: Those with a higher BMI had a longer hospital stay and were at increased risk for developing pneumonia after rib stabilization. BMI did not have a significant effect on the ratio of ribs stabilized, time to operation, length of operation, days on mechanical ventilation, or ICU length of stay.
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SURGICAL TECHNIQUES AND VIDEOS Top

Chest tube removal: Safety and rationality p. 33
Moheb A Rashid
DOI:10.4103/jctt.jctt_12_20  
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CASE REPORT Top

Man versus wild: A case report of a bear attack with thoracic complications p. 35
Dyan DíSouza, Sreekar Balasundaram
DOI:10.4103/jctt.jctt_8_19  
Bear attacks on humans are rare and are even more rarely reported in medical literature. Each year people have numerous accidental interactions with bears around the world. In India, bear attack incidences have been reported in and around Kashmir and in Central India. A very small fraction of these bear attacks result in human injury. Injuries due to bear attacks include skin lacerations, bites etc. The most common areas of injury are the face, legs and hands. Thoracic injuries due to a bear attack hasn't been reported earlier. We present the case of a 55 year old with bear attack, suffered among other injuries, a right Hemo-Pneumothorax. A flail segment was also noted on the right anterolateral region. The patient did not need any invasive ventilation. Right Inter-costal Drain tube inserted ICD drain was discontinued on day 4 of admission. Post drain removal a subcutaneous collection was noted on the back with suspicious pleural tear near the 12th rib detected on MRI. ICD was re-inserted and the patient, conservatively managed. Bear attacks are rare in India, and thoracic injuries causing a flail segment, pleural tear and a hemo-pneumothorax hasn't yet been reported. This case report hence, highlights the fact that bear attacks, like a blunt/penetrating trauma can provide with a challenging scenario in the emergency room. Right knowledge and stepwise management of these cases can therefore ensure complete and wholesome treatment, even in cases with thoracic injuries.
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IMAGES IN CARDIOTHORACIC TRAUMA Top

Thoracic duct injury after gunshot wound of the chest p. 39
Josť Luis Ruiz Pier, Serrano Jaimes Jesķs, Moreno Galeana Salvador
DOI:10.4103/jctt.jctt_9_20  
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Gingko leaf sign: Radiographic manifestation of extensive subcutaneous emphysema p. 40
M Muniraju, Vikas Bhatia
DOI:10.4103/jctt.jctt_4_20  
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