Pelvic Ring Fracture Management and Subsequent Pregnancy: A Summary of Current Literature

INTRODUCTION

The incidence of pelvic ring injuries is 34.3% per 100,000 capita. No studies have determined the ability of a female patient to have a vaginal delivery after undergoing pelvic fracture fixation. However, many obstetricians are generally unwilling to have their patients attempt a vaginal delivery in the setting of symphyseal or sacroiliac fixation.

METHODS

An exhaustive search of the National Library of Medicine database was performed, and it is hypothesized that cesarean section rates would be higher for women who have a child after one of these pelvic ring injuries.

RESULTS

There is a 15% increase in cesarean rates using data from the National Center for Health Statistics. In addition, there is an observable increase in new cesarean rates.

DISCUSSION

Currently, there is no clear evidence to support an elective cesarean section as the sole indication after a prior pelvic fracture. To date, no studies have determined the ability of a female patient to have a vaginal delivery after undergoing pelvic fracture fixation.

CONCLUSION

Thus, until the increased cesarean section rate has been explained, it could be problematic to counsel the patient to avoid a vaginal delivery after sustaining a pelvic ring fracture. Hence, conducting additional studies on this topic would deem to be necessary.

Financial Analysis of Preoperative Nasal Decolonization With Povidone-Iodine in Closed Pilon Fracture Definitive Fixation

The purpose of this study is to determine the financial practicality for the use of nasal povidone-iodine (NP-I) in the preoperative holding area in attempt to decrease the rate of infection that is associated with operative fixation of closed pilon fractures. Institutional costs for treating postoperative infection following a closed pilon fracture, along with costs associated with preoperative NP-I use, were obtained. A break-even equation was used to analyze these costs to determine if the use of NP-I would decrease the current infection rate (17%) enough to be financially beneficial for routine use preoperatively. The total cost of treating a postoperative infection was found to be $18,912, with the cost of NP-I being $30 per patient dose. Considering a 17% infection rate and utilizing the break-even equation, NP-I was found to be economically viable if it decreased the current infection rate by 0.0016% (Number Needed to Treat = 63,051.7). This break-even model suggests that the use of NP-I in the preoperative holding area is financially beneficial for decreasing the rate of infection associated with the treatment of closed pilon fractures.

Simplified soft tissue coverage of the distal lower extremity: The reverse sural flap

Soft tissue defects involving the distal lower extremity present challenging problems for orthopaedic surgeons to manage. Historically, wounds not amenable to primary closure have necessitated assistance from multidisciplinary teams using plastic surgeons to obtain adequate soft tissue coverage through rotational flap or free tissue transfer procedures. Techniques related to soft tissue rearrangement and local rotational flap coverage have advanced over the years with a growing knowledge of local anatomy and vasculature. The reverse sural flap may be performed to cover soft tissue defects within 10 cm of the foot or ankle region, negating the need for microvascular intervention. The simplistic nature of the reverse sural flap is appealing to orthopaedic surgeons as a means to provide timely patient care without additional support because it does not require microvasculature work or the need for intraoperative microscopes and has been popularized among orthopaedic trauma surgeons as a necessary tool to possess. Here, we discuss the reverse sural flap to include history, relevant anatomy, clinical indications, and a description of the technique for application.

Tibial Bone Transport With a Single Implant All-Internal Bone Transport Nail

SUMMARY

A single implant all-internal magnet-driven bone transport nail (BTN-NuVasive Specialized Orthopaedics Inc) has recently been introduced as a treatment method for segmental tibial bone defects. This innovation provides promise in the management of segmental bone defects because it negates numerous complications associated with circular external fixation and the need for multiple implants when considering hybrid plate-assisted bone segment transport constructs. Given the novelty of the BTN, description of the surgical application and patient outcome measures are scarce in the current literature. To date, we have treated 4 patients with an average age of 27 years (range 19-44 years) using the BTN for segmental tibial defects ranging from 50 to 128 mm. We have accumulated data over an average follow-up of 18.07 months (range 12.96-25.13 months), demonstrating good patient tolerance of the device. Three patients successfully completed their treatment course with a calculated average bone healing index of 41.4 days/cm (range 31.41-54.82 days/cm). One patient was noted to experience an asymptomatic docking site nonunion requiring subsequent surgery for nonunion repair. Implant-associated complications included symptomatic implant, axial malalignment, docking site nonunion, and external remote control technical malfunction. Injury-related complications were encountered and noted to include: superficial infection, wound dehiscence, peroneal tendonitis, and joint rigidity. In this study, the authors present a case series using this implant to date and discuss our experiences with the BTN with reference to clinical indications, tibial bone preparation, BTN implantation, transport protocol, docking site procedure, and clinical/radiographic outcomes.

Injuries Sustained With Falls From Height in Crossing the United States-Mexico Border at a Level I Trauma Center: A Prospective Cohort Study

INTRODUCTION

The US Department of Homeland Security has reported increases in encounters and apprehensions at the US Southwest border for the past several years. The purposes of this study were to assess the demographics, patterns of injuries, and surgical interventions, associated with falls from height along the US-Mexico border.

METHODS

A prospective cohort study was conducted at a Level I trauma center from January 2016 through December 2021 of all patients who fell from height crossing the US-Mexico border and presented with injuries requiring admission.

RESULTS

A total of 448 patients were admitted with a median age of 30 years (interquartile range [IQR] 16, range 6 to 65). Monthly frequency of admissions increased markedly with a median of 18.5 (IQR 5.3) in 2021. Patients presented with limited health data, and comorbidities were identified in 111 patients (24.7%). Median height fallen was 5.5 m (18 ft). Patients sustaining a fall from ≥ 5.5 m were markedly more likely to have an Injury Severity Score (ISS) of > 15. Median length of stay was 9 days (IQR 11). There were a total of 1,066 injuries with 723 extremity and pelvic; 236 spine; and 107 head or neck, face, thorax, or abdominal injuries. Median ISS was 9.0 (IQR 7, range 1 to 75, 33% > 15). Tibial plafond fracture and spine injury were markedly associated with longer lengths of stay and ISS > 15. All injuries resulted in 635 separate surgical events and 930 procedures. Clinical follow-up occurred in 55 patients (12.2%), with median duration of 28 days (range 6 days to 8 months).

DISCUSSION

Injuries associated with border crossings and falls from height were serious and increased in frequency. As the US policy on border security evolves, surgeons in these regions should be prepared to handle the associated injuries and sequelae. Prevention of these serious and debilitating injuries should be undertaken to decrease the burden of disease.

Assessment of quality, absorbability, and educational value of YouTube videos regarding ankle fractures

Aims & objectives

YouTube is a non-peer-reviewed platform with a large library of healthcare-related videos which attempt to provide educational content. The goal of this study is to analyze the quality, absorbability, and educational content of videos available to patients on YouTube regarding ankle fractures.

Materials & methods

On May 31, 2022, over 550 videos populated the initial search of "ankle fracture" within YouTube's platform. The first 100 videos were reviewed, and 62 videos were included in the final analysis. Video characteristics were recorded and evaluated. Videos were assessed using three objective scoring systems: (1) the Journal of American Medical Association (JAMA) benchmark criteria, (2) the Patient Education Materials Assessment Tool for audio and visual materials (PEMAT), and (3) the novel Ankle Fracture Content Score (AFCS).

Results

Each scoring system had high internal consistency and interrater reliability. The mean JAMA, PEMAT understandability, PEMAT actionability, and AFCS were 2.92, 61.85%, 16.38%, and 4.67, respectively. No association was seen between video popularity metrics and quality of information. The understandability of the patient-targeted videos was greater than those targeted at healthcare professionals (P = 0.049).

Conclusion

The information regarding ankle fractures available on YouTube for patient education is poor with no correlation between quality and popularity. This study illustrates the need for future collaboration between YouTube and trusted medical societies to provide patients with the highest quality information.

Treatment patterns of ABOS part II candidates: A decline of operative management among geriatric proximal humerus fractures over the decade (2010-2020)

BACKGROUND

The purpose of this study was to assess trends in ABOS part II candidate's operative management of geriatric (≥65 years) proximal humerus fractures over the 2010-2020 decade.

METHODS

This retrospective database cohort study utilized the American Board of Orthopaedic Surgery (ABOS) database for candidates taking Part II of their boards. Surgical coding was reviewed and the ICD10 data was correlated to the CPT code for shoulder arthroplasty or open reduction internal fixation. We investigated the number of proximal humerus fracture operative cases per year, the percent arthroplasty used per year, the stratification of percent arthroplasty per orthopaedic fellowship subspecialty and geographic region.

RESULTS

A total of 2,409 operative cases for proximal humerus fractures in patients 65 years of age and older were submitted by 1,420 ABOS candidates. There was a 37% reduction in operatively managed proximal humerus fractures among ABOS part II candidates between the first half of the decade (2010-2015, 263.2 +/- 13.4) and the second half of the decade (2016-2020, 166 +/- 31.2; p<.05). There also was a downward trend with a 53% reduction in percent treated with arthroplasty as compared to ORIF during those same windows (2010-2015, 34.4 +/-11.7) and (2016-2020, 16.2 +/- 6.4; p<.5). Partitioned by single fellowship training, Shoulder and Elbow (S&E) surgeons performed the highest percent arthroplasty at 25.2%, followed by Sports at 23.1% and the lowest percent arthroplasty was Trauma at 11.7%. The Southeast United States had the lowest percentage arthroplasty at 15.8% as compared to the Midwest (23.8%) and Northeast (25.8%).

CONCLUSION

Despite the rapid growth of both the elderly population and related geriatric proximal humerus fractures, ABOS candidates are treating less with surgery. There has been approximately a 37% decrease in the total number of operatively treated proximal humerus fractures between the first and second half 2010-2020 decade. When operative treatment is performed, there is a trend towards ORIF over an arthroplasty. Trauma fellowship trained surgeons are less likely to perform an arthroplasty as compared to other subspecialties. The Southeast region is least likely to perform an arthroplasty as compared to the Midwest or Northeast.

Antibiotic cement-coated intramedullary nail is cost-effective for the initial treatment of GAⅢ open tibia fractures

OBJECTIVE

To evaluate the cost-effectiveness of antibiotic cement-coated intramedullary nails (IMN) in the initial management of Gustilo-Anderson type Ⅲ (GAIII) open tibia fractures.

METHODS

A break-even equation was used to analyze the costs associated with antibiotic cement-coated IMN and postoperative infection following GAⅢ open tibia fractures. This equation produced a new infection rate, which defines what percentage the antibiotic coated IMN needs to decrease the initial infection rate for its prophylactic use to be cost-effective. The postoperative infection rate used for calculations was 30%, a value established in current literature for these fracture types (6-33%). The institutional costs associated with a single operative debridement and resultant inpatient stay and treatment were determined. A sensitivity analysis was conducted to demonstrate how various total costs of infection and different infection rates affected the break-even rate, the absolute risk reduction (ARR), and the number needed to treat (NNT).

RESULTS

Financial review yielded an average institutional cost of treating a postoperative infection to be $13,282.85. This number was inclusive of all procedures during an inpatient stay. The added cost of the antibiotic coated implant to the hospital is $743.42. Utilizing the break-even formula with these costs and a 30% initial infection rate, antibiotic coated IMN was economically viable if it decreased infection rate by 0.056% (NNT = 1,785.714).

CONCLUSION

This break-even analysis model suggests the initial use of an antibiotic coated IMN in the setting of GAⅢ open tibia fractures is cost-effective.

Posttraumatic Soft Tissue Coverage of the Lower Leg for the Orthopedic Surgeon

Soft tissue reconstructive techniques are powerful tools for the orthopedic surgeon caring for lower extremity trauma. This article seeks to inform orthopedic surgeons about useful techniques for skin closure, secondary wound closure techniques, and rotational flaps of the lower leg. Split thickness skin grafting, piecrusting, and the use of negative pressure wound therapy for skin closure, as well as rotational gastrocnemius, soleus, and reverse sural artery flaps are discussed with emphasis on techniques for the nonvascular and nonmicrovascular orthopedic surgeon.

Occupational Outcomes and Return to Running After Operative Management of Lisfranc Injuries in a High-Demand Population

Background: Literature evaluating outcomes following operative fixation of Lisfranc injuries has demonstrated high rates of chronic disability, particularly in those returning to prior levels of physical function. The purpose of this study is to evaluate the occupational outcomes and return to running after open reduction and internal fixation (ORIF) or arthrodesis for Lisfranc fracture-dislocations in a moderate- to high-demand military cohort. Methods: All active-duty servicemembers undergoing ORIF or primary arthrodesis (Current Procedural Terminology 28615 and 28730, respectively) for confirmed Lisfranc fracture-dislocations (International Classification of Diseases, Ninth Revision codes 838.03 or 838.13) with minimum 2-year follow-up were isolated from the Military Health System. Demographic and surgical variables were recorded. Return to military function, return to running, perioperative morbidity, and rates of reoperation for complication were the outcomes of interest. Univariate analysis followed by multivariate logistic regression determined the association between patient demographics, type of fracture fixation (ie, ORIF vs arthrodesis) and functional outcomes, including medical separation. Results: Among Lisfranc injuries, 64 patients underwent ORIF while 6 underwent primary arthrodeses with a mean age of 28.1 years. At mean follow-up of 3.5 years (range, 2.0-6.3 years), 20% of servicemembers underwent medical separation due to limitations related to their injuries. body mass index (BMI) ≥30 kg/m² (OR 17.67; 95% CI, 3.69-84.53) and Army or Marines service branch (OR 3.86; 95% CI, 1.08-13.86) were significant independent predictors for medical separation. Among servicemembers undergoing ORIF or primary arthrodeses, 69% returned to occupationally required daily running during the follow-up period. Servicemembers with a BMI <30 kg/m² were more likely to return to running (OR 13.14, 95% CI, 2.50-69.19). Radiographic evidence of posttraumatic Lisfranc osteoarthritis occurred in 10 (16%) servicemembers who underwent internal fixation, and 82% of ORIF patients underwent implant removal. Conclusions: At mean 3.5-year follow-up, 80% of servicemembers undergoing ORIF or primary arthrodeses for Lisfranc injuries remained on active duty or successfully completed their military service, and 69% were able to resume occupationally required daily running. Surgeons should preoperatively counsel patients with these injuries on the possibility of persistent long-term disability.Levels of Evidence: Level IV: Retrospective series.

There Is No Role for Damage Control Orthopedics Within the Golden Hour

INTRODUCTION

Trauma systems within the United States have adapted the "golden hour" principle to guide prehospital planning with the goal to deliver the injured to the trauma facility in under 60 minutes. In an effort to reduce preventable prehospital death, in 2009, Secretary of Defense Robert M. Gates mandated that prehospital transport of injured combat casualties must be less than 60 minutes. The U.S. Military has implemented a 60-minute timeline for the transport of battlefield causalities to medical teams to include Forward Surgical Teams and Forward Resuscitative Surgical Teams. The inclusion of orthopedic surgeons on Forward Surgical Teams has been extrapolated from the concept of damage control orthopedics (DCO). However, it is not clear if orthopedic surgeons have yielded a demonstrable benefit in morbidity or mortality reduction. The purpose of this article is to investigate the function of orthopedic surgeons during the military "golden hour."

MATERIALS AND METHODS

The English literature was reviewed for evidence supporting the use of orthopedic surgeons within the golden hour. Literature was reviewed in light of the 2009 golden hour mandate by Secretary Gates as well as those papers which highlighted the utility of DCO within the golden hour.

RESULTS

Evidence for orthopedic surgery within the "golden hour" or in the current conflicts when the United States enjoys air superiority was not identified.

CONCLUSIONS

Within the military context, DCO, specifically pertaining to fracture fixation, should not be considered an element of golden hour planning and thus orthopedic surgeons are best utilized at more centralized Role 3 facility locations. The focus within the first hour after injury on the battlefield should be maintained on rapid and effective prehospital care combined with timely evacuation, as these are the most critical factors to reducing mortality.

Mortality effects of timing alternatives for hip fracture surgery

BACKGROUND

The appropriate timing of hip fracture surgery remains a matter of debate. We sought to estimate the effect of changes in timing policy and the proportion of deaths attributable to surgical delay.

METHODS

We obtained discharge abstracts from the Canadian Institute for Health Information for hip fracture surgery in Canada (excluding Quebec) between 2004 and 2012. We estimated the expected population-average risks of inpatient death within 30 days if patients were surgically treated on day of admission, inpatient day 2, day 3 or after day 3. We weighted observations with the inverse propensity score of surgical timing according to confounders selected from a causal diagram.

RESULTS

Of 139 119 medically stable patients with hip fracture who were aged 65 years or older, 32 120 (23.1%) underwent surgery on admission day, 60 505 (43.5%) on inpatient day 2, 29 236 (21.0%) on day 3 and 17 258 (12.4%) after day 3. Cumulative 30-day in-hospital mortality was 4.9% among patients who were surgically treated on admission day, increasing to 6.9% for surgery done after day 3. We projected an additional 10.9 (95% confidence interval [CI] 6.8 to 15.1) deaths per 1000 surgeries if all surgeries were done after inpatient day 3 instead of admission day. The attributable proportion of deaths for delays beyond inpatient day 2 was 16.5% (95% CI 12.0% to 21.0%).

INTERPRETATION

Surgery on admission day or the following day was estimated to reduce postoperative mortality among medically stable patients with hip fracture. Hospitals should expedite operating room access for patients whose surgery has already been delayed for nonmedical reasons.

Prognostic factors of in-hospital complications after hip fracture surgery: a scoping review

INTRODUCTION

To examine prognostic factors that influence complications after hip fracture surgery. To summarize proposed underlying mechanisms for their influence.

METHODS

We reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Scoping Review extension. We searched MEDLINE, Embase, CINAHL, AgeLine, Cochrane Library, and reference lists of retrieved studies for studies of prognostic factor/s of postoperative in-hospital medical complication/s among patients 50 years and older treated surgically for non-pathological closed hip fracture, published in English on January 2008-January 2018. We excluded studies of surgery type or in-hospital medications. Screening was duplicated by two independent reviewers. One reviewer completed the extraction with accuracy checks by the second reviewer. We summarized the extent, nature, and proposed underlying mechanisms for the prognostic factors of complications narratively and in a dependency graph.

RESULTS

We identified 44 prognostic factors of in-hospital complications after hip fracture surgery from 56 studies. Of these, we identified 7 patient factors-dehydration, anemia, hypotension, heart rate variability, pressure risk, nutrition, and indwelling catheter use; and 7 process factors-time to surgery, anesthetic type, transfusion strategy, orthopedic versus geriatric/co-managed care, multidisciplinary care pathway, and potentially modifiable during index hospitalization. We identified underlying mechanisms for 15 of 44 factors. The reported association between 12 prognostic factors and complications was inconsistent across studies.

CONCLUSIONS

Most factors were reported by one study with no proposed underlying mechanism for their influence. Where reported by more than one study, there was inconsistency in reported associations and the conceptualization of complications differed, limiting comparison across studies. It is therefore not possible to be certain whether intervening on these factors would reduce the rate of complications after hip fracture surgery.

Early Stabilization of Femur Fractures in the Setting of Polytrauma Is Associated With Decreased Risk of Pulmonary Complications and Mortality

Timing of definitive fixation of femoral shaft fractures is a subject of continued controversy. The purpose of this study was to determine if early definitive fixation of femoral shaft fractures in the setting of polytrauma decreased the risk of pulmonary complications and mortality. The 2009-2012 National Sample Program of the National Trauma Data Bank was queried for all patients 18 to 65 years with Injury Severity Scores (ISS) >15 who underwent definitive fixation of femoral shaft fractures. Mortality, perioperative complications, and length of intensive care unit (ICU) and hospital stay were the primary outcome measures of interest. Following multivariate analyses, increased time to surgery was found to portend a statistically significant increased risk of acute respiratory distress syndrome(ARDS), mean ventilator time, length of ICU and hospital stay, and mortality. Earlier definitive fixation of femoral shaft fractures in the setting of polytrauma is associated with significantly decreased risk of ARDS, mean ventilator time, length of ICU and hospital stay, and mortality. (Journal of Surgical Orthopaedic Advances 28(2):137-143, 2019).

Comparison of Calcaneal Exposure Through the Extensile Lateral and Sinus Tarsi Approaches

The purpose of this study was to compare the exposure of the posterior facet with the extensile lateral (EL) approach compared with the sinus tarsi (ST) approach. We hypothesized that the ST approach will provide a similar exposure of the posterior calcaneal facet. A total of 8 sequential ST then EL approaches were performed on cadavers. Calcaneal landmarks were identified by visualization or palpation. Calibrated digital photographs of the posterior facet and lateral calcaneal body were obtained from standardized positions and used to calculate the exposed surface area. No significant difference was found in the average square area of the posterior facet exposed with the 2 approaches. Significantly more of the lateral calcaneal body was seen with the EL approach. Excluding the posterior facet superomedial quadrant, all the landmarks were visualized in 100% of approaches. The superomedial corner was visualized in significantly more of the cadavers with the EL approach and was palpable in 12.5% of the remaining cadavers in both approaches. Whereas the ST approach exposes less of the lateral wall of the calcaneus, it exposes similar amounts of the posterior facet when compared with the EL approach.

LEVELS OF EVIDENCE

Therapeutic, Level V.

Open reduction-internal fixation versus intramedullary nailing for humeral shaft fractures: an expected value decision analysis

BACKGROUND

Previous randomized controlled studies and meta-analyses have failed to collectively favor either open reduction-internal fixation (ORIF) or intramedullary nailing (IMN) fixation. The purpose of our investigation was to elucidate the optimal decision between ORIF and IMN for acute traumatic operative humeral shaft fractures through an expected value decision analysis.

METHODS

We performed an expected value decision analysis and sensitivity analysis to elucidate the difference between ORIF and IMN fixation for patients with acute traumatic humeral shaft fractures. We surveyed 100 consecutive, randomly selected volunteers for their outcome preferences. Outcomes included union, delayed union, major complications, minor complications, and infection. A literature review was used to establish probabilities for each of these respective outcomes. A decision tree was constructed and a fold-back analysis was performed to find an expected patient value for each treatment option.

RESULTS

The overall patient expected values for ORIF and IMN were 12.7 and 11.2, respectively. Despite artificially decreasing the rates of major complications, infection, delayed union, and nonunion each to 0% for IMN fixation (sensitivity analysis), ORIF continued to maintain a greater overall patient expected value (12.7 vs. 11.4, 11.2, 11.2, and 12.1, respectively). Only if the rate of nonunion after ORIF was increased from 6.1% to 16.8% did the overall expected outcome after ORIF equal that of IMN (11.2).

CONCLUSION

Our expected value decision analysis demonstrates that patients favor ORIF over IMN as the optimal treatment decision for an acute traumatic humeral shaft fracture.

Predictors of Acute Complications Following Traumatic Upper Extremity Amputation

Current literature is deficient in its description of acute complications following major traumatic upper extremity amputations (UEAs). This study sought to identify acute complications following major UEAs by the 2009-2012 National Trauma Databank to extract demographics, comorbidities, concomitant injuries, and surgical characteristics for major traumatic UEA patients. Multivariate analyses identified significant predictors of mortality and major systemic complications. Major traumatic upper extremity amputations were identified in 1190 patients. Major systemic complications occurred in 13% of patients and most often involved pulmonary (7.4%) or renal (4.7%) systems. Overall in-hospital mortality rate was 11%. Male sex, prehospital systolic blood pressure less than 90, Injury Severity Score > 16, and initial Glasgow Coma Scale > 8 were risk factors for complications or in-hospital mortality. Acute replantation was performed in 0.12%. Systemic complications following major traumatic UEA typically affect the pulmonary system. Injury or patient-dependent factors did not influence acute treatment with revision amputation versus replantation. (Journal of Surgical Orthopaedic Advances 27(2):113-118, 2018).

Feasibility of administrative data for studying complications after hip fracture surgery

PURPOSE

There is limited information in administrative databases on the occurrence of serious but treatable complications after hip fracture surgery. This study sought to determine the feasibility of identifying the occurrence of serious but treatable complications after hip fracture surgery from discharge abstracts by applying the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 4 (PSI-4) case-finding tool.

METHODS

We obtained Canadian Institute for Health Information discharge abstracts for patients 65 years or older, who were surgically treated for non-pathological first hip fracture between 1 January 2004 and 31 December 2012 in Canada, except for Quebec. We applied specifications of AHRQ Patient Safety Indicators 04, Version 5.0 to identify complications from hip fracture discharge abstracts.

RESULTS

Out of 153 613 patients admitted with hip fracture, we identified 12 383 (8.1%) patients with at least one postsurgical complication. From patients with postsurgical complications, we identified 3066 (24.8%) patient admissions to intensive care unit. Overall, 7487 (4.9%) patients developed pneumonia, 1664 (1.1%) developed shock/myocardial infarction, 651 (0.4%) developed sepsis, 1862 (1.1%) developed deep venous thrombosis/pulmonary embolism and 1919 (1.3%) developed gastrointestinal haemorrhage/acute ulcer.

CONCLUSIONS

We report that 8.1% of patients developed at least one inhospital complication after hip fracture surgery in Canada between 2004 and 2012. The AHRQ PSI-4 case-finding tool can be considered to identify these serious complications for evaluation of postsurgical care after hip fracture.

Predictors of Inpatient Mortality and Systemic Complications in Acetabular Fractures Requiring Operative Treatment

Patient demographics, physiologic variables, and injury characteristics predictive of mortality and major systemic complications following operative fixation of acetabulum fractures were identified using the National Sample Program of the National Trauma Data Bank. Age older than 60 years, obesity, and Injury Severity Score greater than 15 portended a statistically significant increase in mortality and major systemic complications (P≤.05). Systolic blood pressure less than 90 mm Hg and Glasgow Coma Scale score less than 8 were also significant predictors of mortality and major systemic complications (P<.0001). Time to surgery and hospital length of stay did not affect mortality. The most common potentially modifiable risk factors were smoking (22.3%) and obesity (body mass index ≥30 kg/m²) (9.1%). Increasing age, Injury Severity Score, and obesity independently predicted a statistically significant increase in both mortality and major systemic complications. A better understanding of the associated risk factors and unique complication profile will provide orthopedic surgeons with a basis on which to effectively counsel and care for patients. [Orthopedics. 2017; 40(2):e223-e228.].

Collaborative Establishment of an Integrated Orthotic and Rehabilitation Pathway

Returning to active military duty and to recreational activities has been difficult for service members sustaining combat-related high-energy lower extremity trauma (HELET). The Return to Run (RTR) clinical pathway was introduced in 2009 with favorable results in returning active duty service members to running, sports participation, active duty, and deployments. The RTR pathway was introduced at a second institution in 2011 to determine if the pathway could be reproduced at a different institution. In this study, a series of patients is presented who underwent limb salvage procedures after sustaining HELET at an outside military treatment facility and subsequently participated in the authors' RTR protocol. They received a novel orthotic device from the San Antonio Military Medical Center and returned to their home institution for rehabilitation. In this cohort, an improvement in functional capability was obtained in nearly all patients. In conclusion, successful translation of the integrated orthotic and rehabilitation initiative to outside institutions is possible.

Exposure of the distal humerus using a triceps hemi-peel approach

This study evaluates the exposure of the distal humerus articular surface obtained using a triceps hemi-peel approach versus the triceps-flexor carpi ulnaris (TRIFCU) approach. Twelve cadaveric upper extremity specimens were dissected using a lateral-to-medial hemi-peel modification of the TRIFCU approach to the elbow. After completing the hemi-peel exposure, the visible border of the articular surface was marked with a permanent ink pen. The dissection was continued to complete a standard TRIFCU approach, and the visible border of the exposure was again marked. The elbow was disarticulated, and calibrated digital images were taken to quantify the humeral surface area exposed through each approach. During both approaches, the surgeon's ability to visualize the intertrochlear groove, medial crista anterior crest, medial crista posterior crest, anterior capitulum, and posterior capitulum was recorded. No difference was found in the surgeons' ability to identify the 5 designated anatomic landmarks using the hemi-peel versus the TRIFCU approach. The TRIFCU exposed an average of 6.68 cm(2) of the trochlear articular surface, whereas the hemi-peel approach exposed an average of 5.93 cm(2). The average difference between the exposures was 0.75 cm(2) (P<.001), or 12.5%. The hemi-peel and TRIFCU approaches to the elbow both allow excellent visualization of the distal humerus articular surface. The hemi-peel exposure is a useful approach for the accurate reduction and fixation of displaced intra-articular distal humerus fractures.

Functional rehabilitation with a foot plate modification for circular external fixation

BACKGROUND

Customized foot plates attached to the foot ring of an ankle-spanning circular external fixator present a unique opportunity for patients undergoing complex lower-extremity limb salvage to participate in highly advanced weight-bearing physical therapy. The purpose of this study was to identify the rehabilitation capabilities afforded by this external fixator modification.

METHODS

Surgical logs and radiographs were reviewed to identify all lower-extremity limb salvage patients from February 2008 to December 2010 treated with an ankle-spanning circular external fixator and a customized foot plate treated by the same orthopedic surgeon and enrolled in our institution's Return To Run clinical pathway. Medical records were reviewed to identify a series of exercises that each patient was able to perform.

RESULTS

Eleven patients were identified. All patients were treated by the same physical therapist. All 11 patients were able to bear full weight on their foot plates and perform regular and split squats. Six of 11 patients were able to ambulate unassisted, and 5 patients required a cane. All 11 patients could navigate stairs and use an elliptical and stair-stepping machine. Six of 11 patients could perform single-leg hack squats. Eight of 11 patients were able to perform double-leg shuttle jumps, although only 5 of 11 patients could perform single-leg shuttle jumps. Five of 11 patients were able to perform a single-leg balance. Only 1 patient was able to run on the foot plate.

CONCLUSIONS

Patients undergoing lower-extremity limb salvage with an ankle-spanning circular external fixator and a customized foot plate were able to participate in highly advanced weight-bearing physical therapy exercises during the osseous and soft-tissue healing process.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Articular exposure with the swashbuckler versus a "Mini-swashbuckler" approach

OBJECTIVE

To quantify the articular exposure obtained with a Swashbuckler approach to the distal femur and compare this to a "Mini-swashbuckler" approach.

METHODS

Forty surgical approaches in 20 fresh-frozen hemipelvis specimens were performed using a Mini-swashbuckler approach followed by a traditional Swashbuckler. Key anatomic landmarks, including the posterior femoral condyles, intercondylar notch, and medial articular margin, were either directly visualised or palpated with a tonsil clamp. Calibrated digital photographs were taken from the surgeon's viewing perspective after each approach. The digital images were then analyzed using a computer software programme, ImageJ (NIH, Bethesda, MD), to calculate the articular surface square area exposed.

RESULTS

The Mini-swashbuckler exposed 87% of the articular surface compared to the Swashbuckler approach (29.48cm(2) vs 34.03cm(2), p<0.0001). Key anatomic landmarks were directly visualised with both exposures in all subjects, including limbs with severe osteoarthritis. Greater exposure with the Mini-swashbuckler correlated with male gender (p<0.05) and height (p=0.03) but not weight or BMI.

CONCLUSIONS

Although exposure is improved with the use of a Swashbuckler, this difference may not be of clinical importance, since both approaches give either direct visual or tactile access to all critical areas of the distal femur, including the trochlea, entire medial compartment, and both posterior femoral condyles. A less invasive approach allows a smaller surgical dissection without sacrificing the ability to visualise the majority of the articular surface.

Spinal column injuries among Americans in the global war on terrorism

BACKGROUND

While combat spinal injuries have been documented since the fourth century BC, a comprehensive analysis of such injuries has not been performed for any American military conflict. Recent literature has suggested that spinal injuries account for substantial disability in wounded service members.

METHODS

The Joint Theater Trauma Registry was queried to identify all American military personnel who sustained injuries to the back, spinal column, and/or spinal cord in Iraq or Afghanistan from October 2001 to December 2009. Spinal injuries were categorized according to anatomic location, neurological involvement, mechanism of injury, and concomitant wounds.

RESULTS

Of 10,979 evacuated combat casualties, 598 (5.45%) sustained 2101 spinal injuries. Explosions accounted for 56% of spinal injuries, motor vehicle collisions for 29%, and gunshots for 15%. Ninety-two percent of all injuries were fractures, with transverse process, compression, and burst fractures the most common. Spinal cord injuries were present in 17% (104) of the 598 patients. Concomitant injuries frequently occurred in the abdomen, chest, head, and face.

CONCLUSIONS

The incidence of spine trauma sustained by military personnel in Iraq and Afghanistan is higher than that reported for previous conflicts, and the nature of these injuries may be similar to those in severely injured civilians. Further research into optimal management and rehabilitation is critical for military service members and severely injured civilians with spine trauma.

Multiple associated injuries are common with spine fractures during war

BACKGROUND CONTEXT

The nature of concomitant injuries associated with spine fractures in American military personnel engaged in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) has been poorly documented in the literature.

PURPOSE

To characterize the incidence and epidemiology of associated injuries (AIs) in American military personnel with spine fractures sustained during OEF and OIF from 2001 to 2009.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR).

OUTCOME MEASURES

Not applicable.

METHODS

The JTTR was queried using International Statistical Classification of Disease, Ninth Revision codes to identify all individuals who sustained spine injuries in OEF or OIF from October 2001 to December 2009. Medical records of all identified service members were abstracted to ensure accuracy and avoid duplication. Demographic information, including sex, age, and military rank, were obtained for all patients. Information regarding fracture type, spine region, mechanism of injury, and the presence of AIs was collected for all patients.

RESULTS

Seventy-eight percent of patients with a spine fracture sustained at least one AI, with an average of 3.4 AIs per patient. Musculoskeletal injuries were most common, followed by chest, abdomen, and traumatic brain injuries. Most patients were injured by an explosive mechanism (62%). Head and face traumas were more common with cervical fractures, chest with thoracic injuries, and abdominopelvic injuries with lumbosacral fractures. Pelvis and acetabulum fractures were common after helicopter crashes, tibia/fibula injuries after explosions, thoracoabdominal injuries after gunshot wounds, and traumatic brain injuries after falls. Most patients (76%) sustained multiple spine fractures.

CONCLUSION

Spine fractures sustained in OEF and OIF have high rates of AIs. Musculoskeletal AIs are the most common, but visceral injuries adjacent to the spine fracture frequently occur. Multiple spine injuries are more prevalent after military trauma.

Military penetrating spine injuries compared with blunt

BACKGROUND CONTEXT

The nature of blunt and penetrating injuries to the spine and spinal column in a military combat setting has been poorly documented in the literature. To date, no study has attempted to characterize and compare blunt and penetrating spine injuries sustained by American servicemembers.

PURPOSE

The purpose of this study was to compare the military penetrating spine injuries with blunt spine injuries in the current military conflicts.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

All American military servicemembers who have been injured while deployed in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) whose medical data have been entered into the Joint Theater Trauma Registry (JTTR).

METHODS

The JTTR was queried for all American servicemembers sustaining an injury to the spinal column or spinal cord while deployed in Iraq or Afghanistan. These data were manually reviewed for relevant information regarding demographics, mechanism of injury, surgical intervention, and neurologic injury.

RESULTS

A total of 598 servicemembers sustained injuries to the spine or spinal cord. Isolated blunt injuries were recorded in 396 (66%) servicemembers and 165 (28%) sustained isolating penetrating injuries. Thirty servicemembers (5%) sustained combined blunt and penetrating injuries to the spine. The most commonly documented injuries were transverse process fractures, compression fractures, and burst fractures in the blunt-injured servicemembers versus transverse process fractures, lamina fractures, and spinous process fractures in those injured with a penetrating injury. One hundred four (17%) servicemembers sustained spinal cord injuries, comprising 10% of blunt injuries and 38% of penetrating injuries (p<.0001). Twenty-eight percent (28%) of blunt-injured servicemembers underwent a surgical procedure compared with 41% of those injured by penetrating mechanisms (p=.4). Sixty percent (n=12/20) of blunt-injured servicemembers experienced a neurologic improvement after surgical intervention at follow-up compared with 43% of servicemembers (n=10/23) who underwent a surgical intervention after a penetrating trauma (p=.28). Explosions accounted for 58% of blunt injuries and 47% of penetrating injuries, whereas motor vehicle collisions accounted for 40% of blunt injuries and 2% of penetrating injuries. Concomitant injuries to the abdomen, chest, and head were common in both groups.

CONCLUSIONS

Blunt and penetrating injuries to the spinal column and spinal cord occur frequently in the current conflicts in Iraq and Afghanistan. Penetrating injuries result in significantly higher rates of spinal cord injury and trend toward increased rates of operative interventions and decreased neurologic improvement at follow-up.

Complications associated with military spine injuries

BACKGROUND CONTEXT

To assess the presence of complications associated with spine injuries in the Global War on Terror.

PURPOSE

To characterize the effect of complications in and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

American servicemembers sustaining spine injury during combat.

METHODS

Extracted medical records of warriors identified by the Joint Theater Trauma Registry from October 2001 to December 2009. Complications were defined as unplanned medical events that required further intervention. Complications were classified as major or minor and further subdivided among groups, including surgical and nonsurgical management, mounted (in an armored vehicle) or dismounted at the time of injury, and blunt or penetrating trauma.

RESULTS

Major complications were encountered in 55 servicemembers (9%), and 38 (6%) sustained minor complications. Forty-four percent (n=24) of those with major complications had more than one complication. Eleven servicemembers sustained three or more complications. There were five intraoperative complications, and 50 occurred in the perioperative period. Intraoperative complications included gastrointestinal injury, dural tear, and instrument malposition. Among patients who sustained complications, precipitating spinal injuries occurred primarily in combat (n=43 [78%]) and resulted from blunt (18) or penetrating (25) mechanisms. Complications occurred in 10 (3%) of those treated nonoperatively and 45 (25%) of those receiving surgery. Complications were higher in the dismounted group (80%) as compared with those who were mounted in vehicles at the time of injury (20%). Thirty-five percent (n=24) of surgically treated, dismounted, and penetrating injured servicemembers had complications. Seventeen percent (n=8) of surgically treated and blunt injured mounted servicemembers and 20% (n=13) of dismounted servicemembers had complications. Among the dismounted and nonspinal cord-injured servicemembers, both blunt (p=.002) and penetrating injured (p<.0005) treated with surgery were correlated with complications. Only the dismounted servicemembers with spinal cord injuries because of a penetrating mechanism were also at an increased risk for complications (p<.0005).

CONCLUSIONS

Patients treated with surgery appear to be at increased complication risk regardless of the mechanism of injury. Uparmored vehicles may safeguard servicemembers from spine injuries and complications associated with their treatment. This may be reflective of the fact that less severe spinal and concomitant injuries are sustained in the precipitating trauma because of the protection afforded by the vehicle. Dismounted soldiers had more complications in all groups regardless of type of management or injury mechanism.

Are spine injuries sustained in battle truly different?

BACKGROUND CONTEXT

The severity and prognosis of combat-related injuries to the spine and spine injuries sustained unrelated to direct combat have not been previously compared. Differences may have implications on tactics, treatment strategies, and directions for future research.

PURPOSE

Compare the severity and prognosis of battle and nonbattle injuries to the spine.

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

American military personnel who were injured in a combat zone and whose medical data were abstracted in the Joint Theater Trauma Registry (JTTR).

METHODS

The JTTR was queried using International Statistical Classification of Diseases, Ninth Revision codes to identify all individuals who sustained battle and nonbattle injuries to the neck, back, spinal column, or spinal cord in Operation Iraqi Freedom or Operation Enduring Freedom from October 2001 to December 2009. Medical records of all identified servicemembers were individually reviewed. Demographic information, including sex, age, military rank, date of injury, and final disposition, was obtained for all patients. Spinal injuries were categorized according to anatomic location, associated neurologic involvement, precipitating mechanism of injury (MOI), and concomitant wounds. These data points were compared for the groups battle spine injuries (BSIs) and nonbattle spine injuries (NBSIs).

RESULTS

Five hundred two servicemembers sustained a total of 1,834 battle injuries to the spinal column, including 1,687 fractures (92%), compared with 92 servicemembers sustaining 267 nonbattle spinal column injuries, with 241 (90%) fractures. Ninety-one BSI servicemembers (18% of patients) sustained spinal cord injuries (SCIs) with 41 (45%) complete SCIs, compared with 13 (14% of patients) nonbattle SCIs with six (46.2%) complete injuries (p=.92). The reported MOI for 335 BSI servicemembers (66.7%) was an explosion compared with one NBSI explosive injury. Eighty-four patients (17%) sustained gunshot wounds (GSWs) in battle compared with five (5.2%) nonbattle GSWs. Fifteen patients (3.0%) sustained a battle-related fall compared with 29 (30%) nonbattle-related falls. Battle spine injury servicemembers underwent significantly higher rates of surgical interventions (p<.0001), were injured by high-energy injury mechanisms at a significantly greater rate (p<.0001), and demonstrated a trend toward lower neurologic recovery rates after SCI (p=.16).

CONCLUSIONS

Battle spine injury and NBSI are separate entities that may ultimately have disparate long-term prognoses. Nonbattle spine injury patients, although having similar MOIs compared with civilian spinal trauma, maintain a different patient demographic. Further research must be directed at accurately quantifying the long-term disabilities of all spine injuries sustained in a combat theater, whether they are the result of battle or not.

The effect of vehicle protection on spine injuries in military conflict

BACKGROUND CONTEXT

To evaluate the effect of critical time periods in vehicle protection on spine injuries in the Global War on Terror.

PURPOSE

To characterize the effect of method of movement on and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009 in terms of its impact on the incidence and severity of spinal fractures sustained in combat.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

Mounted and dismounted American servicemembers who were injured during combat.

METHODS

Extracted medical records of servicemembers identified in the Joint Theater Trauma Registry from October 2001 to December 2009. Methods of movement were defined as mounted or dismounted. Two time periods were compared. Cohorts were created for 2×2 analysis based on method of movement and the time period in which the injury occurred. Time period 1 and 2 were separated by April 1, 2007, which correlates with the initial fielding of the modern class of uparmored fighting vehicles with thickened underbelly armor and a V-shaped hull. Our four comparison groups were Dismounted in Time Period 1 (D1), Dismounted in Time Period 2 (D2), Mounted in Time Period 1 (M1), and Mounted in Time Period 2 (M2).

RESULTS

In total, 1,819 spine fractures occurred over the entire study period. Four hundred seventy-two fractures (26%) were sustained in 145 servicemembers who were mounted at the time of injury, and 1,347 (74%) were sustained by 404 servicemembers who were dismounted (p<.0005). The incidence of fractures in the dismounted cohort (D1+D2) was significantly higher than in the mounted cohort (M1+M2) in both time periods (D1 vs. M1, 13.75 vs. 3.95/10,000 warrior-years [p<.001] and D2 vs. M2, 11.15 vs. 4.89/10,000 warrior-years [p<.0001]). In both the mounted and dismounted groups, the thoracolumbar (TL) junction was the most common site of injury (36.1%). Fractures to the TL junction (T10-L3) increased significantly from Time Period 1 to 2 (34% vs. 40% of all fractures, respectively, p=.03). Thoracolumbar fractures were significantly more severe in that there were more Arbeitsgemeinschaft fur Osteosynthesefragen/Magerl Type A injuries versus all TL fractures, 1.75 versus 2.68/10,000 or 27% of all spine fractures in Time Period 1 versus 40% in Time Period 2 (p=.007). Furthermore, there were significantly fewer minor fractures (spinous process and transverse process fractures) (p<.0001). In Time Period 2, significantly more TL spine fractures were classified as major fractures, according to the Denis classification system, in both the mounted and dismounted groups; M1 group, 61 of 226 (27%) versus the M2 group, 86 of 246 (34%) (p<.0005) and 173 of 786 (22%) in the D1 group versus 193 of 561 (34%) in the D2 group. The spinal cord injury (SCI) incidence did not change in the mounted groups in Time Period 1 (7 of 71, 9.9%) versus Time Period 2 (7 of 74, 9.5%) (p=.935). In the dismounted groups, SCI actually decreased from D1 (55 of 228, 24%) to D2 (28 of 176, 16%) (p=.0428).

CONCLUSIONS

The incidence of spine fractures and SCI is significantly higher in dismounted operations. The data suggest that current uparmored vehicles convey greater protection against spinal fracture compared with dismounted operations in which servicemembers are engaged on foot, outside their vehicles. The TL junction is at greatest risk for spine fractures sustained in mounted and dismounted combat operations. Recently, the incidence of TL fractures, especially severe fractures, has significantly increased in mounted operations. Although there has been an increased incidence of TL spine fractures, in context of the number of servicemembers deployed in support of Operation Enduring Freedom/Operation Iraqi Freedom, these severe fractures still represent a relatively rare event.

Do plans and execution agree in a humanitarian medical mission?

There is a significant need for orthopaedic care in developing countries. For the past 10 years, the United States Army has supported annual orthopaedic hand surgery humanitarian missions to Honduras. The goal of this article is to compare the premission planning to the realities of mission execution to provide a template for future missions. Premission planning began 1 year before the mission. Based on previous missions, supplies were brought for 50 surgical cases. The mission began with 1 preoperative clinic day followed by 8 operative days and 1 postoperative clinic day. Of the 99 prescreened patients, 65 were indicated for surgery. A total of 58 surgeries were performed using innovative methods to stretch available supplies. A multidisciplinary and multination concerted effort is required for a successful humanitarian medical mission. A premission plan is critical prior to arrival and a contingency plan must be in place for missing mission-critical items.

Comparison of dorsal and volar approaches to the proximal radius

Proximal radius exposure may be acquired by either the dorsal or volar approach depending on surgical requirements. The dorsal approach is traditionally recommended for fracture fixation of the proximal radius because of theoretically improved exposure and because the dorsal aspect of the bone is the tensile surface. The posterior interosseous nerve can be visualized and protected using this approach. The volar approach is preferred for biceps repair and boasts a distal extensile approach with adequate soft tissue coverage. Impingement on the bicipital tuberosity and biceps tendon, in addition to positioning on the compression side of the bone, makes the anterior or anterolateral position for plate placement less desirable. The goal of this study was to quantify and compare in a cadaver model the area of bone exposed using both approaches. We hypothesized that equivalent exposures can be obtained and the posterior interosseous nerve can be identified with either the Thompson or Henry approach. Standard dorsal and volar approaches were performed on 10 fresh-frozen adult cadaveric upper-limb specimens. Cross-sectional area of exposure was quantified from digital photographs using software. The 2 approaches did not result in a significant difference in area exposed. Depending on case requirements, either the dorsal or volar approach will provide adequate exposure to the proximal radius.

Can an ankle-foot orthosis change hearts and minds?

The current military conflicts of Operation Enduring Freedom and Operation Iraqi Freedom have been characterized by high-energy explosive wounding patterns, with the majority affecting the extremities. While many injuries have resulted in amputation, surgical advances have allowed the orthopaedic surgeon to pursue limb salvage in the face of injuries once considered unsalvageable. The military limb salvage patient is frequently highly active and motivated and expresses significant frustration with the slow nature of limb salvage rehabilitation and continued functional deficits. Inspired by these patients, efforts at this institution began to provide them with a more dynamic orthosis. Utilizing techniques and technology resulting from cerebral palsy, stroke, and amputation research, the Intrepid Dynamic Exoskeletal Orthosis was created. To date, this device has significantly improved the functional capabilities of the limb salvage wounded warrior population when combined with a high-intensity rehabilitation program. Clinical and biomechanical research is currently underway at this institution in order to fully characterize the device, its effect on patients, and what can be done to modify future generations of the device to best serve the combat-wounded limb salvage population.

Sustained release of insulin from sodium hyaluronate based dry powder formulations after pulmonary delivery to beagle dogs

Hyaluronic acid (HA) and recombinant human insulin were co-spray dried to form a dry powder suitable for inhalation (Mass Median Aerodynamic Diameter, MMAD=1 to 4 microm). Insulin systemic levels and corresponding glucose levels were monitored following administration of the microparticles to the lungs of male Beagle dogs. Release kinetics were modified by addition of excess zinc ions (Zn2+) or hydroxypropyl cellulose (HPC). HA formulations containing insulin (10%w/w) were found to extend the mean residence time (MRT) and terminal half-life (t(1/2)) when compared to spray dried pure insulin. Addition of Zn2+ also improved MRT (>9 fold), AUC/dose (2.5 fold) and Tmax (by a factor of 3) when compared to spray dried pure insulin. Addition of HPC improved MRT (>7 fold), AUC/dose (5 fold) and Tmax (by a factor of 3) when compared to spray dried pure insulin. Our results demonstrate the potential of HA-based dry powder drug delivery systems in the pulmonary controlled release of insulin.

Modifying the release of leuprolide from spray dried OED microparticles

A range of oligosaccharide ester derivatives (OEDs) have been designed as drug delivery matrices for controlled release. The synthetic hormone analogue, leuprolide, was encapsulated within these matrices using hydrophobic ion pairing and solvent spray drying. The particles produced modified the release of leuprolide in vitro (dissolution in phosphate buffered saline) and in vivo (subcutaneous and pulmonary delivery in the rat). Release rate was dependent on drug loading and could be manipulated by choice of OED and by combining different OEDs in different ratios. Leuprolide encapsulated in the OEDs retained biological activity as evidenced by elevation in plasma luteinising hormone levels following subcutaneous injection of leuprolide recovered from OED particles in vitro prior to in vivo administration.

Early predictors of myoglobinuria and acute renal failure following electrical injury

Myoglobinuria-induced acute renal failure (ARF) is a potentially lethal consequence of electrical injury. We describe clinical variables that can predict the risk of myoglobinuria and ARF following electrical injury. This was a retrospective multivariate analysis of risk factors among electrically injured patients over a 26-year period. Urine myoglobin status was documented in 162 patients; 14% had myoglobinuria. No patient developed ARF. Multivariate modeling revealed that high-voltage exposure, prehospital cardiac arrest, full-thickness burns, and compartment syndrome were associated with myoglobinuria. Using a prediction rule defined as positive when a patient had > or = 2 risk factors yielded a sensitivity of 96% and negative predictive value of 99%. Electrical injury patients with myoglobinuria have little risk of developing ARF. A prediction rule can be used to screen out patients at low risk for myoglobinuria and identify high-risk patients who warrant early aggressive treatment and a more definitive myoglobin test.

Mechanisms of pediatric electrical injury. New implications for product safety and injury prevention

OBJECTIVES

To determine age-specific mechanisms of electrical injury in children, to examine product safety regulation of the major sources of electrical injury hazard, and to assess the adequacy of current prevention strategies.

DESIGN

Case series of 144 pediatric and adolescent electrical injuries in patients seen in the specialized burn center and tertiary care hospital between 1970 and 1995, examination of Consumer Product Safety Commission product recall reports for electrical injury hazards between 1973 and 1995, and review of the National Electric Code.

RESULTS

Eighty-six cases of electrical injuries resulted from low-voltage (< 1000-V) exposures, all occurring within the home. In children aged 12 years and younger, household appliance electrical cords and extension cords caused more than 64 (63%) of 102 injuries, whereas wall outlets were responsible for only 14 (15%) of injuries. Fifty-eight cases resulted from high-voltage exposures, accounting for 38 (90%) of 42 injuries in children older than 12 years. No federal safety regulations for electrical cords exist, although voluntary standards have been adopted by many manufacturers. Among 383 consumer products identified by the Consumer Product Safety Commission to be electrical injury hazards, 119 were appliance cords, extension cords, or holiday stringed light sets. Several products numbered more than 1.5 million units in US household distribution prior to the investigation by the Consumer Product Safety Commission.

CONCLUSIONS

Household electrical cords are the major electrocution hazard for children younger than 12 years, yet no federal safety mandates exist. Despite voluntary standards, noncompliant manufacturers can introduce vast numbers of unsafe cords onto the US household market every year. Conversion of existing voluntary safety guidelines into federally legislated standards may be the most effective intervention against pediatric electrocutions.

Mechanisms of aluminum absorption in rats

Aluminum has become a dietary toxin in modern times but its mechanism of absorption is poorly understood. After ingestion, the systemic transfer of aluminum is small but it is greatly affected by the coingestion of certain dietary agents, such as citrate, that complex with the metal in the intestinal lumen or transiently alter the permeability of the mucosa. Here, mechanisms of aluminum absorption were studied by using freshly prepared aluminum hydroxide and aluminum citrate. Everted sacs of rat gut were used to investigate the site of absorption, effect of chemical charge on absorption of aluminum citrate, and presence of active or passive absorption with use of the metabolic inhibitor ouabain. Absorption was biphasic with a large tissue uptake that was consistent with adhesion to mucus-mucosal surface but little tissue transport, which was consistent with passive paracellular permeation. Citrate reduced the uptake-transport ratio both by competing with the mucosal uptake and by increasing mucus-mucosal permeation but not by affecting the charge of the luminal aluminum species. Despite the potential for hydroxypolymerization of aluminum at intestinal pH, the small bowel and colon absorbed aluminum passively and paracellularly but the stomach did not. The predominantly proximal absorption of aluminum observed in vivo is a reflection of the proximal absorption, and therefore removal, of dietary constituents (eg, citrate) that enhance mucosal permeation of aluminum. The colon should be investigated further as a site of significant paracellular permeability.

Gallium-transferrin binding in treated and untreated Parkinson's disease

The binding of gallium (Ga) to transferrin (Tf) was studied in plasma from control patients, in patients with untreated Parkinson's disease (PD) and in patients with PD treated either with levodopa (L-dopa) alone or in combination with selegiline. Mean percentage Ga-Tf binding was significantly reduced in untreated and treated PD compared with controls. Binding, however, was significantly greater in treated than in untreated patients. There was no difference in binding between patients treated with L-dopa alone and those treated with L-dopa and selegiline. The data support the hypothesis that oxidation reactions may be of pathogenic significance in PD.

Aluminium and Alzheimer's disease: review of possible pathogenic mechanisms

Chronic exposure to aluminium (Al) remains a controversial possible cause of sporadic forms of Alzheimer's disease (AD). This article reviews the evidence that once Al enters the brain and individual brain cells, it may be involved in three pathological processes: (1) the production of abnormal forms of tau leading to the formation of cellular neurofibrillary tangles and neuropil threads; (2) the processing of the amyloid precursor protein, resulting in the formation of beta-amyloid deposits and senile plaques, and (3) that via the mutual histocompatibility system, Al could be involved in the initiation of the immune response observed in AD patients. Despite recent evidence that Al could be involved in these processes, a conclusive case that exposure to Al initiates the primary pathological process in sporadic AD remains to be established.

The role of pterins in depression and the effects of antidepressive therapy

Urinary excretion of neopterins (N) and biopterins (B) was measured in 48 patients with depression before and after treatment with placebo, antidepressants, or electroconvulsive therapy (ECT), and in 26 healthy control subjects. Patients prior to and after treatment had a significantly greater neopterin/biopterin (N:B) ratio than control subjects. There was a significant correlation between N:B ratios and the severity of depression and plasma cortisol. As a raised N:B ratio implies failure to convert neopterin to biopterin, it is possible that reduced availability of tetrahydrobiopterin, the essential cofactor for the formation of noradrenaline, serotonin and dopamine, may exert rate-limiting control over the synthesis of monoamines implicated in the pathogenesis of depressive illness.

Hypothesis: is Alzheimer's disease a metal-induced immune disorder?

A hypothesis that a metal-induced immune disorder may be involved in the pathogenesis of some forms of Alzheimer's disease (AD) is presented. The classical complement pathway is activated in AD and T cells and reactive microglia appear in the brain. Studies of metal induced autoimmunity and the use of compounds containing aluminium as vaccine adjuvants suggest that metals can activate complement and can be taken up by antigen presenting cells. The consequent immune response could contribute to neuronal damage, beta-amyloid deposition and cell death. The strengths and weaknesses of this hypothesis are discussed and tests of some aspects are proposed.

5-Methyltetrahydrofolate level in the serum of depressed subjects and its relationship to the outcome of ECT

Serum 5-MeTHF levels are reported in 26 subjects, before and after completing a course of ECT, and compared to 21 healthy volunteers. 5-MeTHF levels of depressed subjects were significantly lower than controls before and after ECT. There was no difference in 5-MeTHF levels between ECT responders and non-responders but folate deficiency was related to severity of depression before ECT. Serum 5-MeTHF was not related to treatment response and values remained markedly low even after a good response to treatment.

Recovery from depression after electroconvulsive therapy is accompanied by evidence of increased tetrahydrobiopterin-dependent hydroxylation

Serum phenylalanine and tyrosine levels were measured in 26 patients with severe depression before and after receiving electroconvulsive therapy. The phenylalanine:tyrosine [P:T] ratio declined significantly for those responding to treatment but not for nonresponders. These findings are discussed in relation to tetrahydrobiopterin, the essential cofactor for the formation of noradrenaline, dopamine and serotonin and the hydroxylation of phenylalanine to tyrosine.

Pre-injury emotional trauma and chronic back pain. An unexpected finding

STUDY DESIGN

A retrospective study investigated pre-injury emotional trauma in out-of-work, blue collar patients with chronic back pain (N = 27) who participated in a 30-hour workshop in which a wide range of cognitive skills was taught to help patients with rehabilitation and return them to work.

OBJECTIVES

This study identified categories of pre-injury emotional trauma, calculated summary statistics, and performed category comparisons.

METHODS

The categories of abandonment, emotional abuse, physical abuse, and sexual abuse emerged from the data. Frequencies and percentages in each category were calculated. Chi-square tests compared the differences in emotional trauma and gender.

RESULTS

Statistically more patients reported abandonment and emotional abuse than physical and sexual abuse. There were no differences in trauma rates by gender. The results of the study revealed a high rate of pre-injury emotional trauma in patients with chronic back pain.

CONCLUSION

Including pre-injury emotional trauma in psychologic evaluations of patients with chronic back pain and high psychologic test scores is recommended.

Reduced transferrin binding in Down syndrome: a route to senile plaque formation and dementia

Plasma transferrin binding in Down syndrome and Alzheimer's disease is significantly reduced compared with age matched controls and it was thought this may help elucidate a pathological time sequence for the onset of dementia in Down syndrome. In Down syndrome, there was a reduction in gallium and aluminium transferrin binding both with age and the onset of dementia. Non-transferrin bound gallium species were identified as non-transportable phosphate or silicate. Thus, the route of entry of metals into the brain must be via a transferrin mediated complex only. A clear sequence of pathological events has been demonstrated in Down syndrome which shows the pathway to development of plaques and dementia and this is believed to have an immunological origin.

Pterin metabolism in depression: an extension of the amine hypothesis and possible marker of response to ECT

Urinary excretion of neopterins and biopterins was measured in 23 patients with severe depression before and after receiving electroconvulsive therapy (ECT) and 26 healthy control subjects. Patients with psychotic depression and those responding to ECT had neopterin:biopterin (N:B) ratio significantly higher than controls before commencing ECT and positive therapeutic response was associated with reduction of N:B ratio towards control values. As a raised N:B ratio implies failure to convert neopterin to biopterin it is possible that reduced availability of tetrahydrobiopterin, the essential cofactor for the formation of noradrenaline, serotonin and dopamine, may exert rate limiting control over the synthesis of monoamines implicated in the pathogenesis of depressive disorders. The N:B ratio may be a marker for certain depressive subtypes and response to ECT.