INTRODUCTION:The US military is transitioning into a posture preparing for large-scale combat operations in which delays in evacuation may become common. It remains unclear which casualty population can have their initial surgical interventions delayed, thus reducing the evacuation demands.METHODS:We performed a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR) focused on casualties who received prehospital care. In this, we sought to determine (1) of those who underwent operative intervention, the proportion of surgeries occurring ≥3 days post-injury, and (2) of those who underwent early versus delayed surgery, the proportions who required blood products.RESULTS:There were 6,558 US military casualties who underwent surgical intervention-6,224 early (less than 3 days from injury) and 333 delayed (≥ 3 days from injury). The median Injury Severity Score (ISS) was higher in the early cohort (10 versus 6, p is less than 0.001). Serious injuries to the head were more common in the early cohort (12% versus 5%, p is less than 0.001), as were the thorax (13% versus 9%, p=0.041), abdomen (10% versus 5%, p=0.001), extremities (37% versus 14%, p is less than 0.001), and skin (4% versus less than 1%, p=0.001). Survival to discharge was lower in the early cohort (97% versus 100%, p is less than 0.001). Mean whole blood consumption was higher in the early cohort (0.5 versus 0 units, p is less than 0.001), as was packed red blood cells (6.3 versus 0.5, p is less than 0.001), platelets (0.9 versus 0, p is less than 0.001), and fresh frozen plasma (4.5 versus 0.2, p is less than 0.001). The administration of any units of packed red blood cells and whole blood was higher for the early cohort (37% versus 7%, p is less than 0.001), as was a ≥3 units threshold (30% versus 3%, p is less than 0.001), and ≥10 units threshold (18% versus 1%, p is less than 0.001).CONCLUSIONS:Few combat casualties underwent delayed surgical interventions defined as ≥3 days post injury, and only a small number of casualties with delayed surgical intervention received blood products. Casualties who received early surgical intervention were more likely to have higher injury severity scores, and more likely to receive blood.

Take-Home MessageAmong adult patients with penetrating chest trauma resulting in hemothorax or pneumothorax who undergo tube thoracostomy, antibiotic prophylaxis may decrease the risk of developing an empyema.MethodsData SourcesA professional librarian searched published literature through MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov databases from January 1900 to March 2020 for relevant literature. Medical subject heading (MeSH) terms included chest tube, thoracostomy, trauma, hemothorax, pneumothorax, and antibiotics.Study SelectionThe authors evaluated prospective trials, retrospective cohorts, and case-control studies, including adult trauma patients with chest injuries resulting in hemothorax or pneumothorax who underwent tube thoracostomy.1Freeman J.J. Asfaw S.H. Vatsaas C.J. et al.Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.Trauma Surg Acute Care Open. 2022; 7e000886Crossref PubMed Scopus (2) Google Scholar Included studies had to have a clear comparison of patients receiving prophylactic antibiotics versus those who did not. Outcomes of interest included all-cause mortality, empyema formation, and development of pneumonia during the time frame from the performance of tube thoracostomy to the end of hospital stay. The authors excluded animal studies, case reports, commentaries, editorials, and reviews. Two authors independently screened studies for inclusion, with conflicts resolved by a third author.Data Extraction and SynthesisThe authors extracted data using standardized collection sheets. They defined skin flora as bacteria found on human skin, whereas they defined respiratory flora as bacteria commonly found in the respiratory tract. The authors used random-effects modeling and calculated the treatment effects based on the study weight and number of patients contributing to each outcome. For binary outcomes, the authors calculated odds ratios (ORs). They calculated heterogeneity using I2, with >75% considered high, 50% to 74% considered moderate, and <50% considered low.2Schunemann H, Brozek J, Guyatt G, Oxman A. GRADE Handbook for grading quality of evidence and strength of recommendations. Published online 2013.Google Scholar Authors evaluated publication bias with the Egger test and applied the GRADE framework for the assessment of bias using external-GRADE experts and blind review.3Kerwin A.J. Haut E.R. Burns J.B. et al.The Eastern Association of the Surgery of Trauma approach to practice management guideline development using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.J Trauma Acute Care Surg. 2012; 73: S283Crossref PubMed Scopus (94) Google Scholar They also performed a sensitivity analysis based on the mechanism of injury (ie, blunt versus penetrating). Among adult patients with penetrating chest trauma resulting in hemothorax or pneumothorax who undergo tube thoracostomy, antibiotic prophylaxis may decrease the risk of developing an empyema. A professional librarian searched published literature through MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov databases from January 1900 to March 2020 for relevant literature. Medical subject heading (MeSH) terms included chest tube, thoracostomy, trauma, hemothorax, pneumothorax, and antibiotics. The authors evaluated prospective trials, retrospective cohorts, and case-control studies, including adult trauma patients with chest injuries resulting in hemothorax or pneumothorax who underwent tube thoracostomy.1Freeman J.J. Asfaw S.H. Vatsaas C.J. et al.Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.Trauma Surg Acute Care Open. 2022; 7e000886Crossref PubMed Scopus (2) Google Scholar Included studies had to have a clear comparison of patients receiving prophylactic antibiotics versus those who did not. Outcomes of interest included all-cause mortality, empyema formation, and development of pneumonia during the time frame from the performance of tube thoracostomy to the end of hospital stay. The authors excluded animal studies, case reports, commentaries, editorials, and reviews. Two authors independently screened studies for inclusion, with conflicts resolved by a third author. The authors extracted data using standardized collection sheets. They defined skin flora as bacteria found on human skin, whereas they defined respiratory flora as bacteria commonly found in the respiratory tract. The authors used random-effects modeling and calculated the treatment effects based on the study weight and number of patients contributing to each outcome. For binary outcomes, the authors calculated odds ratios (ORs). They calculated heterogeneity using I2, with >75% considered high, 50% to 74% considered moderate, and <50% considered low.2Schunemann H, Brozek J, Guyatt G, Oxman A. GRADE Handbook for grading quality of evidence and strength of recommendations. Published online 2013.Google Scholar Authors evaluated publication bias with the Egger test and applied the GRADE framework for the assessment of bias using external-GRADE experts and blind review.3Kerwin A.J. Haut E.R. Burns J.B. et al.The Eastern Association of the Surgery of Trauma approach to practice management guideline development using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.J Trauma Acute Care Surg. 2012; 73: S283Crossref PubMed Scopus (94) Google Scholar They also performed a sensitivity analysis based on the mechanism of injury (ie, blunt versus penetrating). TableRisk of empyema in all adult trauma patients who received tube thoracostomy with antibiotic prophylaxis versus those who did not.Study TypeNumber of Studies (Patients)OR (95% CI)Heterogeneity (I2)Prospective13 (2075)0.40 (0.22 to 0.75)26%Retrospective1 (939)2.60 (0.60 to 11.24)NANA, not applicable. Open table in a new tab NA, not applicable. The authors identified 596 applicable citations in their literature search, of which 14 (n = 3014 patients) were included in the quantitative meta-analysis.1Freeman J.J. Asfaw S.H. Vatsaas C.J. et al.Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.Trauma Surg Acute Care Open. 2022; 7e000886Crossref PubMed Scopus (2) Google Scholar Of these 14, 8 studies were prospective randomized control trials, 5 were prospective observational studies, and 1 was a retrospective observational study. Studies most commonly used cefazolin. Antibiotic protocols ranged from a single periprocedural dose, the total duration of thoracostomy insertion, to 48 hours after thoracostomy removal. Seven studies were published before 2000. All 14 studies assessed empyema. Twelve studies (n = 2533) assessed the development of pneumonia, and 4 studies (n = 1593) assessed all-cause mortality. Antibiotic prophylaxis was associated with a decreased risk of empyema in all trauma patients (Table). Subgroup analyses demonstrated a reduction in empyema in penetrating trauma (8 studies, OR 0.25, 95% confidence interval [CI] 0.10 to 0.59) but not blunt trauma (4 studies, OR 0.25, 95% CI 0.06 to 1.12). There was no difference in pneumonia based on the analysis of prospective data (OR 0.46, 95% CI 0.20 to 1.04) or retrospective data (OR 11.92, 95% CI 0.72 to 197.69). There was no difference in all-cause mortality based on the analysis of prospective data (OR 0.82, 95% CI 0.47 to 1.42) or retrospective data (OR 0.27, 95% CI 0.05 to 1.33). The overall quality of evidence for the randomized controlled trial data was high, although the evidence quality of the observational and retrospective data was very low. Approximately 60% of trauma patients experience a thoracic injury, with up to one-third of them having a pneumothorax, hemothorax, or hemopneumothorax.4Cook A. Hu C. Ward J. et al.Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study.Trauma Surg Acute Care Open. 2019; 4e000356Crossref PubMed Scopus (12) Google Scholar, 5Luchette F.A. Barrie P.S. Oswanski M.F. et al.Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. Eastern Association for Trauma.J Trauma. 2000; 48: 753-757Crossref PubMed Scopus (91) Google Scholar, 6Moore F.O. Duane T.M. Hu C.K.C. et al.Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax: an Eastern Association for the Surgery of Trauma practice management guideline.J Trauma Acute Care Surg. 2012; 73: S341Crossref PubMed Scopus (33) Google Scholar There are several options for treatment, including observation, tube thoracostomy placement, or thoracotomy. Antibiotics are often administered for prophylaxis of the surgical site infections in patients undergoing operative procedures.4Cook A. Hu C. Ward J. et al.Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study.Trauma Surg Acute Care Open. 2019; 4e000356Crossref PubMed Scopus (12) Google Scholar However, the benefit of this prophylaxis in patients undergoing tube thoracostomy is debatable, with varying recommendations from practice guidelines. The 2000 practice management guidelines from the Eastern Association for the Surgery of Trauma (EAST) provide a level III recommendation for prophylactic antibiotics in those undergoing tube thoracostomy, whereas the 2012 guidelines do not recommend for or against prophylactic antibiotics.5Luchette F.A. Barrie P.S. Oswanski M.F. et al.Practice Management Guidelines for Prophylactic Antibiotic Use in Tube Thoracostomy for Traumatic Hemopneumothorax: the EAST Practice Management Guidelines Work Group. Eastern Association for Trauma.J Trauma. 2000; 48: 753-757Crossref PubMed Scopus (91) Google Scholar,6Moore F.O. Duane T.M. Hu C.K.C. et al.Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax: an Eastern Association for the Surgery of Trauma practice management guideline.J Trauma Acute Care Surg. 2012; 73: S341Crossref PubMed Scopus (33) Google Scholar This meta-analysis evaluates the available data concerning prophylactic antibiotics for tube thoracostomy and is the first to use the GRADE methodology to develop a recommendation.1Freeman J.J. Asfaw S.H. Vatsaas C.J. et al.Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.Trauma Surg Acute Care Open. 2022; 7e000886Crossref PubMed Scopus (2) Google Scholar Based on the results of this meta-analysis, prophylactic antibiotics for tube thoracostomy may decrease the incidence of empyema, particularly in penetrating trauma, but they do not reduce pneumonia or all-cause mortality.1Freeman J.J. Asfaw S.H. Vatsaas C.J. et al.Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.Trauma Surg Acute Care Open. 2022; 7e000886Crossref PubMed Scopus (2) Google Scholar There are several limitations. First, 8 studies were published before the year 2000. Sterile techniques, tube thoracostomy placement strategies, and critical care management have improved in the current era, and these factors may increase the risk of confounding. No study provided information on skin preparation, sterile draping, or insertion protocols. Second, studies varied regarding the specific antibiotic used, the dose, and the timing and duration. Although the most common antibiotic used was a first-generation cephalosporin (cefazolin), several studies used a second-generation cephalosporin and one study used clindamycin. One study did not report the antibiotic given, and 2 studies did not control the antibiotic protocol, with broad-spectrum and narrow-spectrum antibiotics administered. The duration and timing of antibiotic administration varied significantly, contributing to the heterogeneity. Few studies have provided antibiotics only in the periprocedural setting. Most administered antibiotics for a set period after tube thoracostomy placement, including 24 hours, 7 days, the entire duration of the thoracostomy until removal, or the entire duration up to 2 days following removal. Third, most empyemas were due to penetrating trauma, not blunt trauma, and were the result of skin flora. It is unclear whether empyema was associated with the performance of tube thoracostomy, wound contamination from the initial trauma, or a combination. Fourth, studies had different definitions of pneumonia leading to higher heterogeneity for that topic specifically. Two studies diagnosed pneumonia on radiologic findings alone. Fifth, the authors were unable to perform a subgroup analysis based on penetrating versus blunt thoracic trauma for pneumonia and mortality. Finally, the authors did not include data concerning hospital length of stay or antibiotic adverse events, such as Clostridioides difficile infection or allergy. The authors of this meta-analysis conditionally recommend antibiotic prophylaxis at the time of tube thoracostomy to reduce empyema for adult trauma patients with hemothorax or pneumothorax.1Freeman J.J. Asfaw S.H. Vatsaas C.J. et al.Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.Trauma Surg Acute Care Open. 2022; 7e000886Crossref PubMed Scopus (2) Google Scholar Further data are needed regarding tube thoracostomy insertion technique, use of periprocedural antibiotics alone, all-cause mortality, pneumonia, hospital length of stay, and antibiotic adverse events, particularly with newer management strategies for traumatic hemothorax or pneumothorax.1Freeman J.J. Asfaw S.H. Vatsaas C.J. et al.Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.Trauma Surg Acute Care Open. 2022; 7e000886Crossref PubMed Scopus (2) Google Scholar,6Moore F.O. Duane T.M. Hu C.K.C. et al.Presumptive antibiotic use in tube thoracostomy for traumatic hemopneumothorax: an Eastern Association for the Surgery of Trauma practice management guideline.J Trauma Acute Care Surg. 2012; 73: S341Crossref PubMed Scopus (33) Google Scholar, 7Locurto J.J.J. Tischler C.D. Swan K.G. et al.Tube thoracostomy and trauma—antibiotics or not?.J Trauma Acute Care Surg. 1986; 26: 1067Crossref Scopus (44) Google Scholar, 8Cant P.J. Smyth S. Smart D.O. Antibiotic prophylaxis is indicated for chest stab wounds requiring closed tube thoracostomy.Br J Surg. 1993; 80: 464-466Crossref PubMed Scopus (44) Google Scholar

Objectives: To develop and validate a novel, low-cost shoulder arthroscopy partial task trainer. Study Design: Cross-sectional study Methods: A low-cost arthroscopy model was created to simulate navigation and triangulation skills in conjunction with ABOS-certified Orthopaedic surgeons' input. Each participant performed three trials of simulated labral repair and performance data was compared between experienced surgeons and novice medical students. Results: A total of 8 orthopaedic surgeons in the experienced group and 18 medical students in the novice group participated in the study. The average age of the experienced group was 43.1 years old, with 8.3 years of post-residency experience. The average age of the novice group was 24.3 years. The experienced group completed the simulation task faster than the novice group (16.6±7.6 vs. 96.4 ±102.2 seconds; p<0.001). Conclusion: The shoulder arthroscopy model demonstrated significant differences in performance between experienced orthopaedic surgeons and novices when used to assess a standardized basic arthroscopic technical skill. This low-cost trainer discriminates between varying skill levels and may be an effective option for simulation training of arthroscopic fundamentals to novice learners. Level of Evidence: III, Case Control Keywords: Arthroscopy, Simulation, Validity Evidence, Orthopaedics, Graduate Medical Education (J Ortho Business 2022; Volume 2, Issue 4:pages 1-4)

Objectives: To compare objective costs between an in-house developed arthroscopy simulator and commercially available options. Design: Cost analysis. Setting: Orthopaedic graduate medical education. Patients/Participants: Eight board-certified orthopaedic surgeons and nineteen novice learners. Intervention: Simulation Training. Main outcome measurement: Cost difference between an in-house developed simulator and a commercially available simulator. Results and conclusions: Significant price differences exist between in-house simulator production cost and commercially available simulators. Low-cost, in-house simulators improve access to arthroscopic simulation training for novice learners by reducing up front cost by 29% and reducing recurring costs by over 90% when compared to a similar commercially available option. Level of Evidence: IV; Cost Analysis Keywords: Education; Simulation; Orthopaedics; Arthroscopy; Simulation Based Learning Theory (J Ortho Business Jan 2022;2(1):7-9)

In Brief This systematic literature review (1980-2020) identified three distinct clinical Military-Civilian Partnerships (MCP): just-in-time, integrated and skills sustainment. Just-in-time MCP are under utilized and not adequate to sustain and replenish combat casualty relevant skills.

Lee, Joseph MD candidate; Hall, Andrew B. MD, FACS; MacDonald, Austin MD candidate; Edson, Theodore D. MD, FACS; Tadlock, Matthew D. MD, FACS Author Information