Bedside percutaneous cryoneurolysis technique for management of acute rib fracture pain in adult trauma patients
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SUBMITTER: Villalta C
PROVIDER: S-EPMC11344524 | biostudies-literature | 2024 Jan
REPOSITORIES: biostudies-literature
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Project description:BackgroundRib fractures are the most common traumatic injury. Hemothorax is one of the widespread complications associated with a rib fracture and occurs in 10-37 % of all rib fractures. Delayed hemothorax (DHTX) is defined as an accumulation of blood within the pleural cavity. Although there is extensive literature on hemothorax, there is limited literature on rib fractures and DHTX readmissions. The objective of this study was to identify potential risk factors for DHTX readmission and examine descriptive information on readmission.MethodsUsing the 2016-2019 National Readmission Database (NRD), patients that experienced an admission with a blunt traumatic rib fracture were included. It was determined if the patients experienced DHTX by screening for an admission containing an ICD-10 code for hemothorax within 30 days after an admission containing a ICD-10 code for rib fracture. Univariable and multivariable analysis was performed to determine independent risk factors associated with DHTX readmission. Additionally, information on the clinical and financial characteristics of DHTX readmissions were examined.ResultsA total of 242,071 patients were included, of whom 635 experienced DHTX readmission ≤30 days after discharge. Diagnosed with hemothorax on the index admission had the largest odds ratio for DHTX readmission (7.43 [6.14-8.99], P < 0.001). Complications found during DHTX readmission included acute respiratory failure (16.9 %), sepsis (6.9 %), and empyema (4.3 %). Treatment mainly consisted of pleural drainage (62.2 %) and video-assisted thoracoscopic surgery (VATS) evacuation of hemothorax (10.1 %).ConclusionPatients admitted for a rib fracture have a low incidence for DHTX readmission within 30 days. However, multivariable analysis has demonstrated some risk and protective factors associated with DHTX readmission. Further studies should focus on exploring these risk factors to screen for potential DHTX readmission and/or protective factors to decrease the change for DHTX readmission.
| S-EPMC10589369 | biostudies-literature
Project description:The following study was undertaken to determine if any specific occupant characteristics, crash factors, or associated injuries identified at autopsy could predict the occurrence or number of fractured ribs in adults. Data were accrued from the Traffic Accident Reporting System (TARS) and coronial autopsy reports from Forensic Science SA, Adelaide, South Australia, from January 2000 to December 2020. A total of 1475 motor vehicle fatalities were recorded in TARS between January 2000 and December 2020, and 1082 coronial autopsy reports were identified that corresponded to TARS fatal crash data. After applying exclusion criteria involving missing data, 874 cases were included in the analysis. Of the 874 cases, 685 cases had one or more rib fractures. The leading cause of death for those with rib fractures was multiple trauma (54%), followed by head injury (17%) and chest injuries (10%). The strongest predictor of one or more rib fractures was increasing age (p < 0.001). Other factors found in the regression to be predictive of the number of rib fractures were the presence of a variety of other injuries including thoracic spinal fracture, lower right extremity fracture, splenic injury, liver injury, pelvic fracture, aortic injury, lung laceration, and hemothorax. Age is most likely associated with increasing rib fractures due to reduced tolerance to chest deflection with greater injuries occurring at lower magnitudes of impact. The association of other injuries with rib fractures may be a marker of higher impact severity crashes.
| S-EPMC9375745 | biostudies-literature
Project description:BackgroundPostamputation phantom pain is notoriously persistent with few validated treatments. Cryoneurolysis involves the application of low temperatures to reversibly ablate peripheral nerves. The authors tested the hypothesis that a single cryoneurolysis treatment would decrease phantom pain 4 months later.MethodsThe authors enrolled patients with a lower-limb amputation and established phantom pain. Each received a single-injection femoral and sciatic nerve block with lidocaine and was subsequently randomized to receive either ultrasound-guided percutaneous cryoneurolysis or sham treatment at these same locations. The primary outcome was the change in average phantom pain intensity between baseline and 4 months as measured with a numeric rating scale (0 to 10), after which an optional crossover treatment was offered. Investigators, participants, and clinical staff were masked to treatment group assignment with the exception of the treating physician performing the cryoneurolysis, who had no subsequent participant interaction.ResultsPretreatment phantom pain scores were similar in both groups, with a median [quartiles] of 5.0 [4.0, 6.0] for active treatment and 5.0 [4.0, 7.0] for sham. After 4 months, pain intensity decreased by 0.5 [-0.5, 3.0] in patients given cryoneurolysis (n = 71) versus 0 [0, 3] in patients given sham (n = 73), with an estimated difference (95% CI) of -0.1 (-1.0 to 0.7), P = 0.759. Following their statistical gatekeeping protocol, the authors did not make inferences or draw conclusions on secondary endpoints. One serious adverse event occurred after a protocol deviation in which a femoral nerve cryolesion was induced just below the inguinal ligament-instead of the sensory-only saphenous nerve-which resulted in quadriceps weakness, and possibly a fall and clavicle fracture.ConclusionsPercutaneous cryoneurolysis did not decrease chronic lower extremity phantom limb pain 4 months after treatment. However, these results were based upon the authors' specific study protocol, and since the optimal cryoneurolysis treatment parameters such as freeze duration and anatomic treatment location remain unknown, further research is warranted.Editor’s perspective
| S-EPMC10374196 | biostudies-literature
Project description:Ketamine is a promising alternative agent for pain control that offers benefit to traditional strategies, particularly in the setting of rib fracture. Current pharmacologic therapies have clear adverse effects, and other options may be invasive, cost prohibitive, or marginally effective. We describe three consecutive patients with traumatic injuries including rib fracture for which a ketamine infusion was utilized as part of their pain control strategy. For each patient, use of a ketamine infusion trended toward reduced opioid requirements with stable pain scores. One patient experienced a dissociative adverse effect prompting decrease and discontinuation of ketamine. No pulmonary complications in the form of emergent intubation or new diagnosis of pneumonia were observed. We believe the addition of ketamine infusion to be a valid alternative strategy for managing pain associated with rib fracture.
| S-EPMC4989044 | biostudies-other
Project description:Tension-band wiring with metal such as Kirshner wire or soft steel wire is commonly used for the treatment of patellar fractures. In recent years, metal-free surgery using a strong suture with high breaking strength has been reported to have excellent outcomes. We report a case of patellar fracture treated with a minimally invasive percutaneous strong suture. The patient is a 57-year-old salesman who fell at work, hit his knee, and came to our hospital complaining of pain. His range of motion was -15° in extension and 60° in flexion. His X-ray results showed a transverse fracture of the right patella with a 3-mm displacement, and surgery was performed 7 days post-injury. A small incision of 1 cm was made distally and proximally on the patella. Two 2.0-mm perforated K-wires were inserted from distal to proximal sides, and the wire was pulled out proximally with FiberWire® No. 2. The distal end of the FiberWire was pulled through the proximal incision via the anterior surface of the patella and finally fastened. The procedure was completed in 21 min. The patient did not use a brace since the operation day and was not restricted in terms of load or range of motion. He was able to walk without any assistance after 10 days and returned to driving and office work 14 days postoperatively. At the final follow-up, no symptoms of skin irritation were detected, and the patient did not require suture removal.
| S-EPMC8437798 | biostudies-literature
Project description:BackgroundA retrospective analysis was conducted to determine if cryoneurolysis of superficial genicular nerves combined with standard care decreased postoperative opioids and pain after total knee arthroplasty (TKA).MethodsData from patients who underwent TKA at a single center were analyzed. Patients who received standardized cryoneurolysis before TKA were compared with a historical control group including patients who underwent TKA without cryoneurolysis. Both groups received a similar perioperative multimodal pain management protocol. The primary outcome was opioid intake at various time points from hospital stay to 6 weeks after discharge. Additional outcomes included pain, length of stay, and range of motion.ResultsThe analysis included 267 patients (cryoneurolysis group: n = 169; control group: n = 98). During the hospital stay, the cryoneurolysis group had 51% lower daily morphine milligram equivalents (MMEs) (47 vs 97 MMEs; ratio estimate, 0.49 [95% confidence interval (CI), 0.43-0.56]; P < .0001) and 22% lower mean pain score (ratio estimate, 0.78 [95% CI, 0.70-0.88]; P < .0001) vs the control group. The cryoneurolysis group received significantly fewer cumulative MMEs, including discharge prescriptions, than the control group at week 2 (855 vs 1312 MMEs; ratio estimate, 0.65 [95% CI, 0.59-0.73]; P < .0001) and week 6 (894 vs 1406 MMEs; ratio estimate, 0.64 [95% CI, 0.57-0.71]; P < .0001). The cryoneurolysis group had significant 44% reduction in overall length of stay (P < .0001) and greater flexion degree at discharge (P < .0001).ConclusionsAddition of preoperative cryoneurolysis to a multimodal pain management protocol reduced opioids and in-hospital pain and optimized outcomes during the 6-week recovery period after TKA.
| S-EPMC8280475 | biostudies-literature
Project description:Cryoneurolysis involves percutaneous insertion of a cryoprobe induced to extremely cold temperatures to disrupt peripheral nerve conduction. The primary objective of this scoping review is to summarize and critically appraise the current evidence for the benefits and safety of cryoneurolysis for non-cancer knee pain. The secondary objective is to describe the variations in cryoneurolysis techniques used. MEDLINE, EMBASE, PubMed, Cochrane Library, and Web of Science were searched from their inception to February 2023 for any primary literature investigating the use of cryoneurolysis for non-cancer-related knee pain. Data was extracted for study characteristics, intervention characteristics, and clinical outcomes. Fourteen studies were identified, including three randomized controlled trials, four retrospective cohort studies, and seven case studies/series. Two studies included knee osteoarthritis patients, three studies included non-specific chronic knee pain patients; and nine studies included pre- or post-total knee arthroplasty patients. Ten studies targeted the infrapatellar branch of the saphenous nerve while the remaining four studies did not report the nerve targeted. Studies consistently demonstrated improvements in pain, function, quality of life, and opioid consumption. Most adverse events were mild and self-limiting. Considerable variations in technique parameters were observed. Cryoneurolysis is a promising intervention to improve outcomes in non-cancer knee pain populations, particularly in mild-to-moderate knee osteoarthritis and pre-total knee arthroplasty populations. However, cryoneurolysis for knee pain remains largely investigational as more high-quality randomized controlled trials are required to further elucidate efficacy as well as optimal nerve selection and technique.
| S-EPMC11372926 | biostudies-literature
Project description:Rib fracture detection is time-consuming and demanding work for radiologists. This study aimed to introduce a novel rib fracture detection system based on deep learning which can help radiologists to diagnose rib fractures in chest computer tomography (CT) images conveniently and accurately. A total of 1707 patients were included in this study from a single center. We developed a novel rib fracture detection system on chest CT using a three-step algorithm. According to the examination time, 1507, 100 and 100 patients were allocated to the training set, the validation set and the testing set, respectively. Free Response ROC analysis was performed to evaluate the sensitivity and false positivity of the deep learning algorithm. Precision, recall, F1-score, negative predictive value (NPV) and detection and diagnosis were selected as evaluation metrics to compare the diagnostic efficiency of this system with radiologists. The radiologist-only study was used as a benchmark and the radiologist-model collaboration study was evaluated to assess the model's clinical applicability. A total of 50,170,399 blocks (fracture blocks, 91,574; normal blocks, 50,078,825) were labelled for training. The F1-score of the Rib Fracture Detection System was 0.890 and the precision, recall and NPV values were 0.869, 0.913 and 0.969, respectively. By interacting with this detection system, the F1-score of the junior and the experienced radiologists had improved from 0.796 to 0.925 and 0.889 to 0.970, respectively; the recall scores had increased from 0.693 to 0.920 and 0.853 to 0.972, respectively. On average, the diagnosis time of radiologist assisted with this detection system was reduced by 65.3 s. The constructed Rib Fracture Detection System has a comparable performance with the experienced radiologist and is readily available to automatically detect rib fracture in the clinical setting with high efficacy, which could reduce diagnosis time and radiologists' workload in the clinical practice.
| S-EPMC8648839 | biostudies-literature
Project description:BackgroundRib fractures are associated with significant morbidity and mortality. Despite the publication of management guidelines and national outcomes benchmarking, there is significant variation in evidence-based (EB) adherence and outcomes. Systems for clinical decision support intervention (CDSI) allow rapid ordering of bundled disease-specific EB treatments. We developed an EB rib fracture protocol and CDSI at our institution. The purpose of the current study was to evaluate implementation and clinical outcomes using this CDSI.Study designA rib fracture care CDSI was developed, disseminated, and implemented in July 2018. Implementation outcomes were evaluated using the Proctor framework. Adherence was tracked monthly via run charts and acceptance was evaluated on a 7-point Likert scale using the Unified Theory of Acceptance and Use of Technology questionnaire. Propensity score matching was used to compare in-hospital morbidity and mortality in pre-implementation (January 1, 2016 through December 31, 2016) vs post-implementation (September 1, 2018 through April 30, 2019) cohorts.ResultsA total of 197 patients were eligible for the intervention. Provider CDSI adherence was 83% at 1 month and reached 100% after 7 months. Acceptance of CDSI using the Unified Theory of Acceptance and Use of Technology had a mean Likert score higher than 6 (range 6.1 to 6.8, SD 0.5 to 1.5), indicating high acceptance. A significant reduction in hospital length of stay was found post implementation (incident rate ratio 0.80; 95% CI, 0.66 to 0.98; p = 0.03) comparing propensity-matched subjects.ConclusionsThe development and use of a CDSI resulted in improved provider delivery of EB practice and was associated with reduced hospital length of stay.
| S-EPMC8553577 | biostudies-literature
Project description:ObjectivePain is the principal symptom in knee osteoarthritis (OA). Current non-operative treatment options have only moderate effects and often patients experience persistent pain or side-effects. Novel advances in the field of cryoneurolysis applies low temperatures to disrupt nerve signaling at the painful area, providing pain relief. The primary aim of this randomized controlled trial (RCT) is to investigate if cryoneurolysis is superior to sham at decreasing pain intensity 2 weeks after the intervention in patients with knee OA. Secondary aims are to explore effects on pain, quality of life and functional performance over 24 months.MethodsThis two-arm, parallel-group RCT, approved by the Regional Ethics Committee, will randomly allocate patients (n = 94) to a cryoneurolysis intervention group + standardized education and exercise (CRYO) or a sham group + standardized education and exercise (SHAM) (1:1 ratio). Both groups will be assessed at baseline, 2 weeks post intervention, post education and exercise and at 6, 12 and 24 months after cryoneurolysis. The primary outcome is the NRS knee pain intensity score assessed 2 weeks post the intervention. Secondary outcome measures include functional performance (chair-stand test, 40 m walk, stair test and maximum voluntary contraction of the knee), patient reported outcomes (quality of life (EQ5D), Knee and osteoarthritis outcome scores (KOOS), among others), use of analgesics, and adverse events over 24 months.Impact statementCryoneurolysis could potentially provide an effective, safe and non-pharmacological therapeutic option to treat pain in OA patients. The potential benefits include increased functional capacity and quality of life as a result of significant pain relief and improved benefits of physical exercise.Trial registrationClinicaltrials.gov, NCT03774121 , registered 3 March 2018, http://www.clinicaltrials.gov.
| S-EPMC7913284 | biostudies-literature