Browsing by Author "Mullis, Brian"

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    A Liberal Transfusion Strategy Leads to Higher Infection Rates, ORthopaedic Trauma and Anemia: Conservative vs. Liberal Transfusion Strategy (ORACL), a Prospective Randomized Study 30 Day Inpatient Complications
    (2022-09-17) Mullis, Leilani; Mullis, Brian; Virkus, Walter; Kempton, Laurence
    Purpose: There is ongoing debate what level of anemia should be used as a transfusion trigger for asymptomatic trauma patients no longer in a resuscitative phase immediately following trauma. A previous retrospective case-control study by one of the lead investigators showed there was a higher risk of complications with a more liberal strategy, and this appeared to be dose-dependent. Multiple previous studies have shown allogeneic blood transfusion is immunosuppressive and may increase infection rates in surgical patients. This study was completed to determine if a more conservative strategy was safe and might decrease the risk of infection. Methods: The ORACL pilot study randomized 100 patients ages 18-50 to a conservative transfusion strategy of 5.5 g/dL vs a liberal strategy of 7.0 g/dL in asymptomatic patients no longer being resuscitated who required inpatient admission for an associated musculoskeletal injury. Enrollment was performed at 3 level 1 trauma centers from 2014-2021. Ninety-nine patients completed 30 day follow up. Results: There was a significant association between a liberal transfusion strategy and higher rate of deep infection (defined as unplanned return to OR for debridement or admission for IV antibiotics) but superficial infection (defined as oral antibiotics alone needed without admission or debridement) did not reach statistical significance (Table 1). Multiple secondary outcomes or complications that might occur due to anemia or transfusion were not different between the two groups. Conclusion: This study shows a conservative transfusion strategy of 5.5 g/dL in an asymptomatic young Orthopaedic trauma patient leads to a lower deep infection rate without an increase in adverse outcomes.
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    Augmented Reality Future Step Visualization for Robust Surgical Telementoring
    (Wolters Kluwer, 2019-02) Andersen, Daniel S.; Cabrera, Maria E.; Rojas-Muñoz, Edgar J.; Popescu, Voicu S.; Gonzalez, Glebys T.; Mullis, Brian; Marley, Sherri; Zarzaur, Ben L.; Wachs, Juan P.; Surgery, School of Medicine
    Introduction Surgical telementoring connects expert mentors with trainees performing urgent care in austere environments. However, such environments impose unreliable network quality, with significant latency and low bandwidth. We have developed an augmented reality telementoring system that includes future step visualization of the medical procedure. Pregenerated video instructions of the procedure are dynamically overlaid onto the trainee's view of the operating field when the network connection with a mentor is unreliable. Methods Our future step visualization uses a tablet suspended above the patient's body, through which the trainee views the operating field. Before trainee use, an expert records a “future library” of step-by-step video footage of the operation. Videos are displayed to the trainee as semitransparent graphical overlays. We conducted a study where participants completed a cricothyroidotomy under telementored guidance. Participants used one of two telementoring conditions: conventional telestrator or our system with future step visualization. During the operation, the connection between trainee and mentor was bandwidth throttled. Recorded metrics were idle time ratio, recall error, and task performance. Results Participants in the future step visualization condition had 48% smaller idle time ratio (14.5% vs. 27.9%, P < 0.001), 26% less recall error (119 vs. 161, P = 0.042), and 10% higher task performance scores (rater 1 = 90.83 vs. 81.88, P = 0.008; rater 2 = 88.54 vs. 79.17, P = 0.042) than participants in the telestrator condition. Conclusions Future step visualization in surgical telementoring is an important fallback mechanism when trainee/mentor network connection is poor, and it is a key step towards semiautonomous and then completely mentor-free medical assistance systems.
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    Chitosan Sponges Are Associated With Higher Rates of Wound Complications Compared to Calcium Sulfate Beads
    (Springer Nature, 2023-05-03) McKee, Kelsey; Easton, Joseph; Mullis, Brian; Hadad, Ivan; Surgery, School of Medicine
    Background: In this study, we aimed to determine if there is a difference in the rates of wound dehiscence, delayed union, nonunion, and unanticipated surgery after the use of bioabsorbable local antibiotic-delivery systems (LADS), specifically comparing antibiotic-impregnated calcium sulfate pellets (Osteoset-T, Wright Medical Technology Inc., Arlington, TN, USA, hereafter referred to as beads) and chitosan sponge (Sentrex BioSponge, Bionova Medical, Germantown, TN, USA, hereafter referred to as sponges) in the management of acute and chronic extremity wounds. Methodology: We conducted a retrospective comparative cohort study in the setting of a level 1 trauma center. All patients who received either beads or sponges as an adjunct to surgical debridement from January 2010 to December 2017 were included, and 136 patients met the inclusion criteria. The intervention studied was extremity wounds that were treated with bioabsorbable LADS, either beads or sponges. The main outcome measurement was wound dehiscence and the need for unanticipated surgery. Results: Of the 136 patients in the study cohort, 78% (106/136) were treated with beads, and 22% (30/136) were treated with sponges. Of the 136 patients, 50 (37%) experienced wound dehiscence, and 49 patients required unanticipated surgery. Overall, 62% (31/50) of patients with wound dehiscence and 67.4% (33/49) of patients requiring unanticipated surgery were seen in the bead cohort (p = 0.0001 and 0.025, respectively). However, in multivariable analyses, we found that the odds of having wound dehiscence and undergoing unanticipated surgery were, respectively, 4.9 (p = 0.001) and 2.8 (p = 0.021) times more likely to occur in the sponge than in the bead group. Conclusions: Sentrex sponges appear to be associated with higher rates of wound dehiscence and the need for unanticipated surgery compared to Osteoset beads.
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    Henry Versus Thompson Approach for Fixation of Proximal Third Radial Shaft Fractures: A Multicenter Study
    (Wolters Kluwer, 2020) Dashe, Jesse; Murray, Brett; Tornetta, Paul, III; Grott, Kelly M.; Mullis, Brian; Bellevue, Kate D.; Firoozabadi, Reza; Kempegowda, Harish; Horwitz, Daniel S.; Patel, Shaan; Westberg, Jerald; Sandberg, Benjamin; Bramlett, Kasey J.; Marcantonio, Andrew J.; Sadauskas, Alex J.; Cannada, Lisa K.; Goodwin, Alexandra; Miller, Anna N.; Fox, Mary Patricia; Klatman, Samuel H.; Orthopaedic Surgery, School of Medicine
    Objective: To compare the volar Henry and dorsal Thompson approaches with respect to outcomes and complications for proximal third radial shaft fractures. Design: Multicenter retrospective cohort study. Patients/Participants: Patients with proximal third radial shaft fractures ± associated ulna fractures (OTA/AO 2R1 ± 2U1) treated operatively at 11 trauma centers were included. Intervention: Patient demographics and injury, fracture, and surgical data were recorded. Final range of motion and complications of infection, neurologic injury, compartment syndrome, and malunion/nonunion were compared for volar versus dorsal approaches. Main Outcome: The main outcome was difference in complications between patients treated with volar versus dorsal approach. Results: At an average follow-up of 292 days, 202 patients (range, 18–84 years) with proximal third radial shaft fractures were followed through union or nonunion. One hundred fifty-five patients were fixed via volar and 47 via dorsal approach. Patients treated via dorsal approach had fractures that were on average 16 mm more proximal than those approached volarly, which did not translate to more screw fixation proximal to the fracture. Complications occurred in 11% of volar and 21% of dorsal approaches with no statistical difference. Conclusions: There was no statistical difference in complication rates between volar and dorsal approaches. Specifically, fixation to the level of the tuberosity is safely accomplished via the volar approach. This series demonstrates the safety of the volar Henry approach for proximal third radial shaft fractures.
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    Medical Telementoring Using an Augmented Reality Transparent Display
    (Elsevier, 2016-06) Andersen, Daniel; Popescu, Voicu; Cabrera, Maria Eugenia; Shanghavi, Aditya; Gomez, Gerardo; Marley, Sherri; Mullis, Brian; Wachs, Juan; IU School of Nursing
    Background The goal of this study was to design and implement a novel surgical telementoring system called the System for Telementoring with Augmented Reality (STAR) that uses a virtual transparent display to convey precise locations in the operating field to a trainee surgeon. This system was compared with a conventional system based on a telestrator for surgical instruction. Methods A telementoring system was developed and evaluated in a study which used a 1 × 2 between-subjects design with telementoring system, that is, STAR or conventional, as the independent variable. The participants in the study were 20 premedical or medical students who had no prior experience with telementoring. Each participant completed a task of port placement and a task of abdominal incision under telementoring using either the STAR or the conventional system. The metrics used to test performance when using the system were placement error, number of focus shifts, and time to task completion. Results When compared with the conventional system, participants using STAR completed the 2 tasks with less placement error (45% and 68%) and with fewer focus shifts (86% and 44%), but more slowly (19% for each task). Conclusions Using STAR resulted in decreased annotation placement error, fewer focus shifts, but greater times to task completion. STAR placed virtual annotations directly onto the trainee surgeon's field of view of the operating field by conveying location with great accuracy; this technology helped to avoid shifts in focus, decreased depth perception, and enabled fine-tuning execution of the task to match telementored instruction, but led to greater times to task completion.
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    Overlapping Surgery for Ankle Fractures: Is It Safe?
    (Wolters Kluwer, 2020-08) Baessler, Aaron; Mullis, Brian; Loder, Randall; Corn, Karsen; Mavros, Charles; Orthopaedic Surgery, School of Medicine
    Objective: To determine whether the practice of overlapping surgery influenced patient safety after open reduction internal fixation (ORIF) for ankle fractures. Design: Retrospective case–control. Setting: Level 1 Academic Midwest trauma center. Patients: All patients who underwent ankle fracture ORIF by a single surgeon were eligible for our study, with 478 total patients. Intervention: Cases that were overlapping were compared against cases that were not overlapping. Cases were defined as overlapping if there was greater than 30 minutes of overlap between procedural times. Patient complications were recorded up to a year from the index surgery. Main Outcome Measure: Unexpected return to surgery. Results: There were 478 ankle fracture ORIF patients, 238 with at least 3 months follow-up; 124 (52%) in the overlapping group and 114 (48%) in the nonoverlapping group. There was no difference in the rate of unexpected return to surgery (P = 0.76), infection (P = 0.52), readmission (P = 0.96), painful implant (P = 0.62), malunion (P = 0.27), nonunion (P = 0.52), or arthritis (P = 0.39) between the overlapping and nonoverlapping groups. There were 467 isolated ankle fractures used for time analysis. Average procedure time was 26 minutes longer for the overlapping group than the nonoverlapping group (P < 0.01). Conclusions: Overlapping surgery causes increased operative time for ankle ORIF, but there was no apparent increased risk to the patients for short-term complications. The need for graduated resident responsibility required by ACGME guidelines need to be weighed against the decreased efficiency of operating room time.
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    Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures
    (Wolters Kluwer, 2021-05-11) Friedman, Lisa G.M.; Sanchez, Daniela; Zachos, Terri A.; Marcantonio, Andrew; Audet, Megan; Vallier, Heather; Mullis, Brian; Myers-White, Adam; Kempton, Laurence; Watts, Jeffrey; Horwitz, Daniel S.; Orthopaedic Surgery, School of Medicine
    Introduction: Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed. Methods: IRB approval was obtained at four academic trauma centers. A retrospective chart review was done to identify adults with healed unimalleolar and bimalleolar ankle fractures treated surgically with at least 12 months of follow-up. Based on postoperative radiographs, changes in fracture alignment and implant position from radiographic union to final follow-up were documented. The average reimbursement for a final follow-up clinic visit and a set of ankle radiographs were estimated. Results: A total of 140 patients met inclusion criteria. The mean age at injury was 49.5 years, and 67.9% of patients were female. The mean time to healing was 82.2 days (±33.5 days). After radiographic healing, one patient had radiographic changes but was asymptomatic and full weight bearing at their final follow-up. On average, our institution was reimbursed $46 to $49 for a follow-up clinic visit and $364 to $497 for a set of ankle radiographs. Conclusion: Given the average time to healing, there is limited utility in routine radiographic and clinical follow-up beyond 16 weeks in asymptomatic patients. In our series, this would result in a savings of $950 to $1,200 per patient. However, after ankle fractures were deemed healed, 0.7% patients had radiographic evidence of a change in implant position. Documenting this change did not modify the immediate course of fracture treatment. Surgeons will need to balance the need for routine follow-up with the potential economic benefits in reducing costs to the healthcare system.