The Efficiency of Skeletal Traction with TrakPak®: A Retrospective Cohort Analysis

The Efficiency of Skeletal Traction with TrakPak®: A Retrospective Cohort Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Efficiency of Skeletal Traction with TrakPak®: A Retrospective Cohort Analysis Brian Rust, Mitchel Obey, Jenna-Leigh Wilson, Christopher McAndrew, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7536967/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Skeletal traction is commonly used for acute management of lower extremity and pelvic injuries but is associated with inefficiencies that can prolong emergency department stays and delay definitive care. The TrakPak® system was designed to improve efficiency by streamlining equipment acquisition, eliminating the need for specialized traction beds, and reducing costs. This study aimed to evaluate the clinical impact of TrakPak® adoption on time to traction, surgery, and MRI and overall hospital length of stay. Materials and Methods We conducted a retrospective cohort study of adult trauma patients undergoing skeletal traction at a single Level 1 trauma center between May 2023 and May 2025. Patients were divided into pre-TrakPak® (n=64) and post-TrakPak® (n=101) groups. Time from admission to traction, surgery, MRI, and hospital discharge were collected, along with injury severity scores (ISS, NISS, TRISS). Comparisons were made using t-tests or Mann-Whitney U tests depending on data distribution. Sub-analyses at 1000-, 600-, and 360-minute cutoffs were performed to assess the impact of outliers. Results A total of 165 patients were analyzed. There were no significant differences in ISS, NISS, or TRISS between cohorts. Median time to traction was 3.80 hours pre-TrakPak® and 4.23 hours post-TrakPak® (p=0.59). Time to surgery was significantly longer after TrakPak® adoption (16.02 vs. 21.43 hours, p=0.031) but remained within 24 hours. Time to MRI (35.80 vs. 57.38 hours, p=0.174) and hospital length of stay (7 vs. 7 days, p=0.535) were not significantly different. Results were consistent across the cutoff analyses. Conclusion Adoption of the TrakPak® system did not significantly improve the measured variables in this single-center study. However, TrakPak® remains advantageous due to its user-friendliness, portability, elimination of traction bed requirements, and cost savings. Future multi-center studies are warranted to better evaluate its potential efficiency benefits. Level of Evidence: Level III, retrospective comparative study Skeletal traction lower extremity stabilization efficiency Introduction Skeletal traction is a common method used to acutely manage select injuries of the lower limb and pelvis. Indications include unstable femoral shaft fractures, specific pelvic and acetabular injuries, or cases where definitive surgical fixation is delayed. Pins are usually placed in the proximal tibia or distal femur, with the selection based on the type of injury and individual patient considerations [ 1 ]. The time required to apply skeletal traction is an inefficiency that can result in a prolonged stay in the emergency department. Supply acquisition, preparation, pin insertion, and traction setup has been reported to take on average 57.1 ± 33.6 minutes for on-call practitioners [ 2 ]. This time requirement may cause a backup in the flow of emergency patient care as well as potentially delay downstream patient treatments. The TrakPak® skeletal traction pin kit by Arbutus Medical (Vancouver, British Columbia) seeks to remove inefficiencies in traction application and potentially offer a time savings [ 3 ]. The kit features a Drill Cover system that can be applied over a modified hardware drill as opposed to a typical sterile surgical drill [ 3 ]. It has previously been shown that this drill cover system is noninferior to conventional surgical drills for pin placement in terms of infection rates at the pin site [ 4 ]. Not only are equipment portability and material procurement times improved, but this system can be up to 94% cheaper than standard surgical drills [ 5 ]. This benefit would especially be felt at smaller institutions since increased efficiency and decreased material cost can improve department spending. The system also can place a patient in traction without the need for transfer to a specialized traction bed. The included QuikLine™ rope system can apply and maintain traction in a standard hospital bed [ 3 ]. Therefore, any time spent waiting for a traction bed to be delivered to the emergency department, transferring the patient to that bed, and maneuvering the larger bed through the hospital can reportedly be eliminated. Finally, the pin and associated equipment are MRI compatible which may improve patient access to MRI studies if needed and expedite downstream care. The purpose of this study is to identify and quantify the extent of the TrakPak® system’s benefits compared to traditional traction pin methods. It is hypothesized that utilization of TrakPak® reduces overall length of stay and decreases time from admission to traction placement, MRI, and definitive surgical fixation. This study examines a single Level 1 trauma center to compare these variables 12 months before the institution-wide adoption of the TrakPak® system and 12 months after. This will hopefully provide valuable information that can be used to increase surgical care efficiency. Methods Study Design, Patient Population, and Data Collection A retrospective review was conducted of adult patients who underwent application of lower extremity skeletal traction treated at a single Level 1, tertiary referral trauma center between May 15, 2023, and May 14, 2025. Institutional Review Board approval was obtained. Patients were identified in the institution’s trauma database using CPT code (CPT 20650). Inclusion criteria included all adult patients 18 and older who presented to the emergency department requiring skeletal traction. Exclusion criteria included any patient under the age of 18. The initial cohort included 165 patients that received skeletal traction during the time period analyzed. Since the TrakPak® system was adopted institution-wide on May 15, 2024, patients were divided into a preintervention group (May 15, 2023 – May 14, 2024) and a postintervention group (May 15, 2024 – May 15, 2025). There were 64 patients before the adoption of TrakPak® and 101 patients after. There were 25 patients that received an MRI (16 pre-TrakPak® and 9 TrakPak®). Collected Variables Patients were placed into their respective cohort based on the date of their encounter. The institutional trauma database was used to extract admission date/time, discharge date/time, traction placement date/time, and first orthopedic surgery date/time for each patient as well as the following scores: injury severity score (ISS), new injury severity score (NISS), and trauma and injury severity score (TRISS). For the subset of each cohort that received an MRI after traction pin placement, the time from admission to MRI was also extracted. Time from admission to traction placement, time from admission to definitive surgical fixation, and total length of hospital stay were calculated for each group based on the information from the database. For the subgroup of MRI patients, there was a calculation of the average time from admission to MRI. Statistical Analysis Comparisons of each variable were made between the two cohorts using IBM SPSS Statistics Version 27 (IBM Corp., Armonk, NY). All statistical analyses were conducted at alpha = 0.05. Normally distributed variables were compared between groups using independent samples t-tests, while non-normally distributed variables were compared using Mann-Whitney U tests. Statistical tests were run for the entire cohort as well as sub-analyses with cutoffs at 1000, 600, and 360 minutes to control for the effects of outliers. Results Out of the 165 patients that received skeletal traction during the time period analyzed, there was 1 patient that had an unknown traction placement time (pre-TrakPak®) and 4 patients that did not undergo surgical fixation after traction was applied (1 pre-TrakPak® and 3 TrakPak®). The before vs after median comparison for the severity scores are as follows: ISS – 14 vs 10 (p = 0.50), NISS – 17 vs 17 (p = 0.56), TRISS – 0.99 vs 0.99 (p = 0.61). The medians and means for each variable are found in Table 1 . The before vs after median comparison for the time variables are as follows: time to traction – 3.80 vs 4.23 hours (p = 0.59), time to surgery – 16.02 vs 21.43 hours (p = 0.031), time to MRI – 35.80 vs 57.38 hours (p = 0.174), length of stay – 7 vs 7 days (p = 0.535). Results for the various cutoffs can be found in Tables 2 – 4 . Table 1 Full Data Comparisons of Medians and Means Median Cohort 1 (Before TrakPak) Cohort 2 (After TrakPak) P value Time to Traction 3.80 hours 4.23 hours 0.590 Time to OR 16.02 hours 21.43 hours 0.031 Time to MRI 35.80 hours 57.38 hours 0.174 Length of Stay (LOS 7 days 7 days 0.535 Mean Time to Traction 5.20 hours 8.37 hours Time to OR 20.47 hours 25.58 hours Time to MRI 48.11 hours 182.29 hours Length of Stay (LOS) 11.72 days 9.34 days 64 total 101 total Table 2 1000 minute cutoff Median Cohort 1 (Before TrakPak) Cohort 2 (After TrakPak) P value Time to Traction 3.70 hours 4.13 hours 0.483 Time to OR 16.02 hours 21.37 hours 0.043 Time to MRI 32.12 hours 57.29 hours 0.238 Length of Stay (LOS 7 days 7 days 0.611 Mean Time to Traction 4.27 hours 4.70 hours Time to OR 20.70 hours 25.35 hours Time to MRI 41.29 hours 189.74 hours Length of Stay (LOS) 11.55 days 9.40 days 61 total 99 total Table 3 600 minute cutoff Median Cohort 1 (Before TrakPak) Cohort 2 (After TrakPak) P value Time to Traction 3.68 hours 3.88 hours 0.551 Time to OR 15.57 hours 20.58 hours 0.041 Time to MRI 32.12 hours 30.15 hours 0.849 Length of Stay (LOS 7 days 6 days 0.464 Mean Time to Traction 3.96 hours 4.12 hours Time to OR 19.27 hours 23.21 hours Time to MRI 43.86 hours 212.61 hours Length of Stay (LOS) 11.15 days 8.69 days 58 total 93 total Table 4 360 minute cutoff Median Cohort 1 (Before TrakPak) Cohort 2 (After TrakPak) P value Time to Traction 3.32 hours 3.64 hours Time to OR 15.37 hours 18.07 hours 0.045 Time to MRI 47.28 hours 102.60 hours 0.414 Length of Stay (LOS 7 days 6 days 0.554 Mean Time to Traction 3.40 hours 3.54 hours 0.560 Time to OR 18.10 hours 22.70 hours Time to MRI 50.66 hours 340.95 hours Length of Stay (LOS) 9.82 days 8.32 days 51 total 80 total Discussion The analysis of the three severity scores had no statistical difference between cohorts. That being said, the above analysis did not demonstrate any difference that TrakPak® may have on the efficiency of skeletal traction or MRI or on the total length of stay. In this particular study, the relatively small sample sizes (64 vs 101) reduce the power of the analysis. Although different cutoff thresholds were used in secondary analyses to help control the impact of outliers, the overall findings remained consistent (Tables 2 – 4 ). As such, this is a study that could benefit from significantly more traction cases. Including other institutions not only would be the best way to see how TrakPak® functions on average regardless of location, but also it would increase the patient population and give the study much needed power. Anecdotally, the TrakPak® kit improves the ease of gathering materials to apply traction, which suggests it could shorten time to traction in practice. However, we were unable to demonstrate in this retrospective dataset that this translated into decreased time to traction application and surgical fixation. Several factors may explain this. Delays in time from arrival to orthopedic consultation, variable workflow and experience among residents in a teaching facility, and other system-based changes implemented during the study period all may have influenced timing. Most importantly, time from the decision to apply traction to traction application was not available in the database, limiting our ability to directly measure improved efficiency. Of note, the length of stay, although not statistically significant, was consistently lower on average in the TrakPak® cohort. Currently, it is unknown why this is the case, as it cannot be attributed to the TrakPak® system with the data currently available. Using the above broad time categories does not account for time-consuming factors unrelated to the type of skeletal traction used such as operating room availability, patient cooperativity, and time to orthopedic staff availability which could mask the effect of any traction-related time savings. For future analysis, it would be helpful to include more specific timing comparisons. For example, a direct comparison of the time to apply traction from initiation to completion would be worthwhile to investigate the ease of TrakPak® application. Also, a direct comparison of transfer time from the emergency department to the patient’s room assignment would be helpful to quantify the extent of time saved with the elimination of a traction bed. Insights such as these would require a prospective study as they are not included in the institution’s trauma database. However, breaking down the timing of the various components of the encounter would yield a more detailed view of the effects TrakPak® has on efficiency. Despite these results, this is an important topic that would benefit from further research. It has been shown that prolonged emergency department stays are associated with a statistically significant increase in all-cause 30-day mortality. For every 82 admitted patients whose transfer to an inpatient bed is delayed beyond 6 to 8 hours, there is one additional death [ 6 ]. Older adults are particularly vulnerable, with overnight ED stays linked to higher in-hospital mortality, longer hospitalizations, and more adverse events, including delirium and missed medications [ 7 , 8 ]. Also, increased time in traction waiting for surgery can be an issue as well. For example, one study found that time in traction for acetabular fractures over 120 hours resulted in 40 times higher odds of developing a pulmonary complication and increased intensive care unit stay duration (17 days vs 5 days) [ 9 ]. All of these examples demonstrate why it is important to find ways to minimize both time to traction and surgical fixation. Even without definitive superiority found in this study, the TrakPak® system can still be very useful to healthcare systems. As stated before, the system is much less expensive than traditional traction methods [ 5 ]. Therefore, even if an expanded study continues to show no significant difference in these measured variables, the cost savings alone may be enough of a benefit to justify its adoption. Coupled with the user convenience of portability and elimination of a specialized traction bed, the full picture of this system’s benefit may not be told by timing metrics alone. As with all retrospective studies, there are several limitations to our results. Since the data was collected from the institution's preexisting trauma database, there was no control over how the data was collected, and so the data may have been affected by confounding variables not included in the database query. As stated before, this study was completed at a single Level 1 academic trauma center which limits the sample size and further generalizability of results. Also, there was no standardization of the staff members providing care, and so interpersonal differences in traction application may have affected the speed among cases. Conclusion The TrakPak® system aims to increase the efficiency of skeletal traction placement to reduce the time to establish traction, achieve surgical fixation, and acquire MRI. The results of this single center analysis do not demonstrate any significant difference between previous methods of skeletal traction and the TrakPak® system since its adoption. The results, however, were limited to a single institution and would benefit from including other sites in the analysis to increase power and generalizability. Despite this, TrakPak® is a user-friendly kit, and it still has benefits that institutions can appreciate such as significant cost savings, ease of portability, and the eliminated need for a specialized traction bed. Declarations Ethics approval and consent to participate: This study was reviewed and approved by the local Institutional Review Board (IRB) with waiver of consent. Consent for publication: Not applicable Funding: No funding was utilized in this project. Author Contribution MB was the primary investigator for this project. BR contributed data collection, analysis, and primary manuscript preparation. MB, MO, JW, and CM contributed to manuscript composition and edits prior to submission. Acknowledgements: Not applicable Data Availability Protected patient data from Barnes-Jewish Hospital/Washington University School of Medicine was utilized and is thus not publicly available. Data is available from the authors upon reasonable request. References Matullo KS, Gangavalli A, Nwachuku C. Review of lower extremity traction in current orthopaedic trauma. J Am Acad Orthop Surg. 2016;24(9):600–6. Even JL, Richards JE, Crosby CG, Kregor PJ, Mitchell EJ, Jahangir AA, et al. Preoperative skeletal versus cutaneous traction for femoral shaft fractures treated within 24 hours. J Orthop Trauma. 2012;26(10):e177–82. Arbutus Medical. Inefficiencies of skeletal traction in the emergency department [Internet]. Vancouver: Arbutus Medical. 2024 [cited 2025 Jul 3]. Available from: https://arbutusmedical.com/inefficiencies-of-skeletal-traction-in-the-emergency-department/ Selhorst S, O’Toole RV, Slobogean GP, Harris M, Bhatti Y, Enobun B, et al. Is a low-cost drill cover system noninferior to conventional surgical drills for skeletal traction pin placement? J Orthop Trauma. 2021;35(11):e433–6. Prime M, Attaelmanan I, Imbuldeniya A, Harris M, Darzi A, Bhatti Y. From Malawi to Middlesex: the case of the Arbutus Drill Cover System as an example of the cost-saving potential of frugal innovations for the UK NHS. BMJ Innov. 2018;bmjinnov. Jones S, Moulton C, Swift S, Molyneux P, Black S, Mason N, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emerg Med J. 2022;39(3):168–73. Roussel M, Teissandier D, Yordanov Y, Balen F, Noizet M, Tazarourte K, et al. Overnight stay in the emergency department and mortality in older patients. JAMA Intern Med. 2023;183(12):1378–85. Burgess L, Ray-Barruel G, Kynoch K. Association between emergency department length of stay and patient outcomes: a systematic review. Res Nurs Health. 2022;45(1):59–93. Boissonneault AR, Schenker M, Wilson J, Schwartz A, Staley C, Maceroli M. Impact of prolonged skeletal traction in patients with acetabular fractures. J Orthop Trauma. 2020;34(2):77–81. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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manage select injuries of the lower limb and pelvis. Indications include unstable femoral shaft fractures, specific pelvic and acetabular injuries, or cases where definitive surgical fixation is delayed. Pins are usually placed in the proximal tibia or distal femur, with the selection based on the type of injury and individual patient considerations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The time required to apply skeletal traction is an inefficiency that can result in a prolonged stay in the emergency department. Supply acquisition, preparation, pin insertion, and traction setup has been reported to take on average 57.1\u0026thinsp;\u0026plusmn;\u0026thinsp;33.6 minutes for on-call practitioners [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This time requirement may cause a backup in the flow of emergency patient care as well as potentially delay downstream patient treatments.\u003c/p\u003e\u003cp\u003eThe TrakPak\u0026reg; skeletal traction pin kit by Arbutus Medical (Vancouver, British Columbia) seeks to remove inefficiencies in traction application and potentially offer a time savings [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The kit features a Drill Cover system that can be applied over a modified hardware drill as opposed to a typical sterile surgical drill [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It has previously been shown that this drill cover system is noninferior to conventional surgical drills for pin placement in terms of infection rates at the pin site [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Not only are equipment portability and material procurement times improved, but this system can be up to 94% cheaper than standard surgical drills [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This benefit would especially be felt at smaller institutions since increased efficiency and decreased material cost can improve department spending.\u003c/p\u003e\u003cp\u003eThe system also can place a patient in traction without the need for transfer to a specialized traction bed. The included QuikLine\u0026trade; rope system can apply and maintain traction in a standard hospital bed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Therefore, any time spent waiting for a traction bed to be delivered to the emergency department, transferring the patient to that bed, and maneuvering the larger bed through the hospital can reportedly be eliminated. Finally, the pin and associated equipment are MRI compatible which may improve patient access to MRI studies if needed and expedite downstream care.\u003c/p\u003e\u003cp\u003eThe purpose of this study is to identify and quantify the extent of the TrakPak\u0026reg; system\u0026rsquo;s benefits compared to traditional traction pin methods. It is hypothesized that utilization of TrakPak\u0026reg; reduces overall length of stay and decreases time from admission to traction placement, MRI, and definitive surgical fixation. This study examines a single Level 1 trauma center to compare these variables 12 months before the institution-wide adoption of the TrakPak\u0026reg; system and 12 months after. This will hopefully provide valuable information that can be used to increase surgical care efficiency.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design, Patient Population, and Data Collection\u003c/h2\u003e\u003cp\u003e A retrospective review was conducted of adult patients who underwent application of lower extremity skeletal traction treated at a single Level 1, tertiary referral trauma center between May 15, 2023, and May 14, 2025. Institutional Review Board approval was obtained. Patients were identified in the institution\u0026rsquo;s trauma database using CPT code (CPT 20650). Inclusion criteria included all adult patients 18 and older who presented to the emergency department requiring skeletal traction. Exclusion criteria included any patient under the age of 18. The initial cohort included 165 patients that received skeletal traction during the time period analyzed. Since the TrakPak\u0026reg; system was adopted institution-wide on May 15, 2024, patients were divided into a preintervention group (May 15, 2023 \u0026ndash; May 14, 2024) and a postintervention group (May 15, 2024 \u0026ndash; May 15, 2025). There were 64 patients before the adoption of TrakPak\u0026reg; and 101 patients after. There were 25 patients that received an MRI (16 pre-TrakPak\u0026reg; and 9 TrakPak\u0026reg;).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCollected Variables\u003c/h3\u003e\n\u003cp\u003ePatients were placed into their respective cohort based on the date of their encounter. The institutional trauma database was used to extract admission date/time, discharge date/time, traction placement date/time, and first orthopedic surgery date/time for each patient as well as the following scores: injury severity score (ISS), new injury severity score (NISS), and trauma and injury severity score (TRISS). For the subset of each cohort that received an MRI after traction pin placement, the time from admission to MRI was also extracted. Time from admission to traction placement, time from admission to definitive surgical fixation, and total length of hospital stay were calculated for each group based on the information from the database. For the subgroup of MRI patients, there was a calculation of the average time from admission to MRI.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eComparisons of each variable were made between the two cohorts using IBM SPSS Statistics Version 27 (IBM Corp., Armonk, NY). All statistical analyses were conducted at alpha\u0026thinsp;=\u0026thinsp;0.05. Normally distributed variables were compared between groups using independent samples t-tests, while non-normally distributed variables were compared using Mann-Whitney U tests. Statistical tests were run for the entire cohort as well as sub-analyses with cutoffs at 1000, 600, and 360 minutes to control for the effects of outliers.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOut of the 165 patients that received skeletal traction during the time period analyzed, there was 1 patient that had an unknown traction placement time (pre-TrakPak\u0026reg;) and 4 patients that did not undergo surgical fixation after traction was applied (1 pre-TrakPak\u0026reg; and 3 TrakPak\u0026reg;).\u003c/p\u003e\n\u003cp\u003eThe before vs after median comparison for the severity scores are as follows: ISS \u0026ndash; 14 vs 10 (p\u0026thinsp;=\u0026thinsp;0.50), NISS \u0026ndash; 17 vs 17 (p\u0026thinsp;=\u0026thinsp;0.56), TRISS \u0026ndash; 0.99 vs 0.99 (p\u0026thinsp;=\u0026thinsp;0.61).\u003c/p\u003e\n\u003cp\u003eThe medians and means for each variable are found in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The before vs after median comparison for the time variables are as follows: time to traction \u0026ndash; 3.80 vs 4.23 hours (p\u0026thinsp;=\u0026thinsp;0.59), time to surgery \u0026ndash; 16.02 vs 21.43 hours (p\u0026thinsp;=\u0026thinsp;0.031), time to MRI \u0026ndash; 35.80 vs 57.38 hours (p\u0026thinsp;=\u0026thinsp;0.174), length of stay \u0026ndash; 7 vs 7 days (p\u0026thinsp;=\u0026thinsp;0.535). Results for the various cutoffs can be found in Tables \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFull Data Comparisons of Medians and Means\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 1 (Before TrakPak)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 2 (After TrakPak)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Traction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.80 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.23 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.590\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.02 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.43 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.80 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.38 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Stay (LOS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.535\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Traction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.20 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.37 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.47 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.58 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.11 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e182.29 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Stay (LOS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.72 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.34 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e64 total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e101 total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e1000 minute cutoff\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 1 (Before TrakPak)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 2 (After TrakPak)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Traction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.70 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.13 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.483\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.02 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.37 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.043\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.12 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.29 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.238\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Stay (LOS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.611\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Traction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.27 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.70 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.70 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.35 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.29 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e189.74 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Stay (LOS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.55 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.40 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e61 total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e99 total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e600 minute cutoff\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 1 (Before TrakPak)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 2 (After TrakPak)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Traction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.68 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.88 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.551\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.57 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.58 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.041\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.12 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30.15 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.849\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Stay (LOS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Traction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.96 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.12 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.27 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.21 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.86 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e212.61 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Stay (LOS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.15 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.69 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e58 total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e93 total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e360 minute cutoff\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 1 (Before TrakPak)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohort 2 (After TrakPak)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Traction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.32 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.64 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.37 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.07 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.28 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e102.60 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Stay (LOS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.554\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Traction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.40 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.54 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.560\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to OR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.10 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.70 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to MRI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.66 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e340.95 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Stay (LOS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.82 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.32 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e51 total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e80 total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe analysis of the three severity scores had no statistical difference between cohorts. That being said, the above analysis did not demonstrate any difference that TrakPak\u0026reg; may have on the efficiency of skeletal traction or MRI or on the total length of stay. In this particular study, the relatively small sample sizes (64 vs 101) reduce the power of the analysis. Although different cutoff thresholds were used in secondary analyses to help control the impact of outliers, the overall findings remained consistent (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). As such, this is a study that could benefit from significantly more traction cases. Including other institutions not only would be the best way to see how TrakPak\u0026reg; functions on average regardless of location, but also it would increase the patient population and give the study much needed power.\u003c/p\u003e\u003cp\u003eAnecdotally, the TrakPak\u0026reg; kit improves the ease of gathering materials to apply traction, which suggests it could shorten time to traction in practice. However, we were unable to demonstrate in this retrospective dataset that this translated into decreased time to traction application and surgical fixation. Several factors may explain this. Delays in time from arrival to orthopedic consultation, variable workflow and experience among residents in a teaching facility, and other system-based changes implemented during the study period all may have influenced timing. Most importantly, time from the decision to apply traction to traction application was not available in the database, limiting our ability to directly measure improved efficiency. Of note, the length of stay, although not statistically significant, was consistently lower on average in the TrakPak\u0026reg; cohort. Currently, it is unknown why this is the case, as it cannot be attributed to the TrakPak\u0026reg; system with the data currently available.\u003c/p\u003e\u003cp\u003eUsing the above broad time categories does not account for time-consuming factors unrelated to the type of skeletal traction used such as operating room availability, patient cooperativity, and time to orthopedic staff availability which could mask the effect of any traction-related time savings. For future analysis, it would be helpful to include more specific timing comparisons. For example, a direct comparison of the time to apply traction from initiation to completion would be worthwhile to investigate the ease of TrakPak\u0026reg; application. Also, a direct comparison of transfer time from the emergency department to the patient\u0026rsquo;s room assignment would be helpful to quantify the extent of time saved with the elimination of a traction bed. Insights such as these would require a prospective study as they are not included in the institution\u0026rsquo;s trauma database. However, breaking down the timing of the various components of the encounter would yield a more detailed view of the effects TrakPak\u0026reg; has on efficiency.\u003c/p\u003e\u003cp\u003eDespite these results, this is an important topic that would benefit from further research. It has been shown that prolonged emergency department stays are associated with a statistically significant increase in all-cause 30-day mortality. For every 82 admitted patients whose transfer to an inpatient bed is delayed beyond 6 to 8 hours, there is one additional death [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Older adults are particularly vulnerable, with overnight ED stays linked to higher in-hospital mortality, longer hospitalizations, and more adverse events, including delirium and missed medications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Also, increased time in traction waiting for surgery can be an issue as well. For example, one study found that time in traction for acetabular fractures over 120 hours resulted in 40 times higher odds of developing a pulmonary complication and increased intensive care unit stay duration (17 days vs 5 days) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. All of these examples demonstrate why it is important to find ways to minimize both time to traction and surgical fixation.\u003c/p\u003e\u003cp\u003eEven without definitive superiority found in this study, the TrakPak\u0026reg; system can still be very useful to healthcare systems. As stated before, the system is much less expensive than traditional traction methods [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Therefore, even if an expanded study continues to show no significant difference in these measured variables, the cost savings alone may be enough of a benefit to justify its adoption. Coupled with the user convenience of portability and elimination of a specialized traction bed, the full picture of this system\u0026rsquo;s benefit may not be told by timing metrics alone.\u003c/p\u003e\u003cp\u003eAs with all retrospective studies, there are several limitations to our results. Since the data was collected from the institution's preexisting trauma database, there was no control over how the data was collected, and so the data may have been affected by confounding variables not included in the database query. As stated before, this study was completed at a single Level 1 academic trauma center which limits the sample size and further generalizability of results. Also, there was no standardization of the staff members providing care, and so interpersonal differences in traction application may have affected the speed among cases.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe TrakPak\u0026reg; system aims to increase the efficiency of skeletal traction placement to reduce the time to establish traction, achieve surgical fixation, and acquire MRI. The results of this single center analysis do not demonstrate any significant difference between previous methods of skeletal traction and the TrakPak\u0026reg; system since its adoption. The results, however, were limited to a single institution and would benefit from including other sites in the analysis to increase power and generalizability. Despite this, TrakPak\u0026reg; is a user-friendly kit, and it still has benefits that institutions can appreciate such as significant cost savings, ease of portability, and the eliminated need for a specialized traction bed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cp\u003e This study was reviewed and approved by the local Institutional Review Board (IRB) with waiver of consent.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eNo funding was utilized in this project.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMB was the primary investigator for this project. BR contributed data collection, analysis, and primary manuscript preparation. MB, MO, JW, and CM contributed to manuscript composition and edits prior to submission.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eProtected patient data from Barnes-Jewish Hospital/Washington University School of Medicine was utilized and is thus not publicly available. Data is available from the authors upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMatullo KS, Gangavalli A, Nwachuku C. Review of lower extremity traction in current orthopaedic trauma. J Am Acad Orthop Surg. 2016;24(9):600\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEven JL, Richards JE, Crosby CG, Kregor PJ, Mitchell EJ, Jahangir AA, et al. Preoperative skeletal versus cutaneous traction for femoral shaft fractures treated within 24 hours. J Orthop Trauma. 2012;26(10):e177\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArbutus Medical. Inefficiencies of skeletal traction in the emergency department [Internet]. Vancouver: Arbutus Medical. 2024 [cited 2025 Jul 3]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://arbutusmedical.com/inefficiencies-of-skeletal-traction-in-the-emergency-department/\u003c/span\u003e\u003cspan address=\"https://arbutusmedical.com/inefficiencies-of-skeletal-traction-in-the-emergency-department/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSelhorst S, O\u0026rsquo;Toole RV, Slobogean GP, Harris M, Bhatti Y, Enobun B, et al. Is a low-cost drill cover system noninferior to conventional surgical drills for skeletal traction pin placement? J Orthop Trauma. 2021;35(11):e433\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrime M, Attaelmanan I, Imbuldeniya A, Harris M, Darzi A, Bhatti Y. From Malawi to Middlesex: the case of the Arbutus Drill Cover System as an example of the cost-saving potential of frugal innovations for the UK NHS. BMJ Innov. 2018;bmjinnov.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJones S, Moulton C, Swift S, Molyneux P, Black S, Mason N, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emerg Med J. 2022;39(3):168\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoussel M, Teissandier D, Yordanov Y, Balen F, Noizet M, Tazarourte K, et al. Overnight stay in the emergency department and mortality in older patients. JAMA Intern Med. 2023;183(12):1378\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBurgess L, Ray-Barruel G, Kynoch K. Association between emergency department length of stay and patient outcomes: a systematic review. Res Nurs Health. 2022;45(1):59\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoissonneault AR, Schenker M, Wilson J, Schwartz A, Staley C, Maceroli M. Impact of prolonged skeletal traction in patients with acetabular fractures. J Orthop Trauma. 2020;34(2):77\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Skeletal traction, lower extremity, stabilization, efficiency","lastPublishedDoi":"10.21203/rs.3.rs-7536967/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7536967/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eIntroduction\u003c/em\u003e\u003cbr\u003e\nSkeletal traction is commonly used for acute management of lower extremity and pelvic injuries but is associated with inefficiencies that can prolong emergency department stays and delay definitive care. The TrakPak® system was designed to improve efficiency by streamlining equipment acquisition, eliminating the need for specialized traction beds, and reducing costs. This study aimed to evaluate the clinical impact of TrakPak® adoption on time to traction, surgery, and MRI and overall hospital length of stay.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMaterials and Methods\u003c/em\u003e\u003cbr\u003e\nWe conducted a retrospective cohort study of adult trauma patients undergoing skeletal traction at a single Level 1 trauma center between May 2023 and May 2025. Patients were divided into pre-TrakPak® (n=64) and post-TrakPak® (n=101) groups. Time from admission to traction, surgery, MRI, and hospital discharge were collected, along with injury severity scores (ISS, NISS, TRISS). Comparisons were made using t-tests or Mann-Whitney U tests depending on data distribution. Sub-analyses at 1000-, 600-, and 360-minute cutoffs were performed to assess the impact of outliers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults\u003c/em\u003e\u003cbr\u003e\nA total of 165 patients were analyzed. There were no significant differences in ISS, NISS, or TRISS between cohorts. Median time to traction was 3.80 hours pre-TrakPak® and 4.23 hours post-TrakPak® (p=0.59). Time to surgery was significantly longer after TrakPak® adoption (16.02 vs. 21.43 hours, p=0.031) but remained within 24 hours. Time to MRI (35.80 vs. 57.38 hours, p=0.174) and hospital length of stay (7 vs. 7 days, p=0.535) were not significantly different. Results were consistent across the cutoff analyses.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusion\u003c/em\u003e\u003cbr\u003e\nAdoption of the TrakPak® system did not significantly improve the measured variables in this single-center study. However, TrakPak® remains advantageous due to its user-friendliness, portability, elimination of traction bed requirements, and cost savings. Future multi-center studies are warranted to better evaluate its potential efficiency benefits.\u003c/p\u003e\n\u003cp\u003eLevel of Evidence: Level III, retrospective comparative study\u003c/p\u003e","manuscriptTitle":"The Efficiency of Skeletal Traction with TrakPak®: A Retrospective Cohort Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-24 10:55:44","doi":"10.21203/rs.3.rs-7536967/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f1a6ed5b-96b0-4d57-a94d-a6c92ccb9f75","owner":[],"postedDate":"September 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-30T10:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-24 10:55:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7536967","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7536967","identity":"rs-7536967","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}