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Minehara H, Zenke Y, Maruo A, Matsushita T, Miclau T. Management of open fracture and related complications: the Japanese way. OTA Int 2024; 7:e325. [PMID: 38708042 PMCID: PMC11064782 DOI: 10.1097/oi9.0000000000000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 05/07/2024]
Abstract
Open fractures continue to be a challenging clinical problem throughout the world, and Japan is no exception. Surgeons are faced with critical decisions throughout the care of these injuries that can have significant effects in clinical outcome, ranging from the type and timing of antibiotic administration, fixation, soft-tissue management, and interventions for postfracture complications. In October 2022, the Japanese Society for Fracture Repair (JSFR) was invited to represent Japan as the Guest Nation society at the 38th Annual Meeting of the Orthopaedic Trauma Society held in Tampa, Florida. The JSFR organized a symposium, entitled "Management of Open Fracture and related complications-the Japanese way," that featured cutting-edge approaches to open fractures in their country, including presentations on the "fix-and-flap" approach, local antibiotics perfusion delivery, and a "chipping" method for the stimulation of bone healing. This article summarizes the content of these 3 presentations from that symposium.
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Affiliation(s)
- Hiroaki Minehara
- Department of Traumatology, Fukushima Medical University, Trauma and Reconstruction Center, Shin-Yurigaoka General Hospital, Kawasaki, Japan
| | - Yukichi Zenke
- Trauma Reconstruction Center, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Akihiro Maruo
- Department of Orthopaedic Surgery, Harima-Himeji General Medical Center, Himeji, Japan
| | - Takashi Matsushita
- Department of Traumatology, Fukushima Medical University, Trauma and Reconstruction Center, Shin-Yurigaoka General Hospital, Kawasaki, Japan
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, School of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA
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Oberlohr V, Giordano V, Hungria JOS, Caiero M, Pires RE, da Silva LHP, Pallottino A, Sanchez GT, Labronici PJ, MacKechnie M, Miclau T. LEADERSHIP DEVELOPMENT TRAINING FOR BRAZILIAN ORTHOPEDIC SURGEONS. Acta Ortop Bras 2024; 32:e272375. [PMID: 38532865 PMCID: PMC10962097 DOI: 10.1590/1413-785220243201e272375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 03/30/2023] [Indexed: 03/28/2024]
Abstract
Objective To report on the experience and impressions of the Brazilian orthopedic trauma surgeons attending the Leadership Development Program (LDP) hosted by the Sociedade Brasileira do Trauma Ortopédico (SBTO) in Sao Paulo, Brazil on November 4, 2022. Methods Forty-eight orthopedic trauma surgeons from five different regions throughout Brazil were provided a link to complete The Big Five Test, a validated online personality assessment. The questionnaire was available in Portuguese and was intended to provide a background on individual personality traits and their influence on interpersonal interactions. The LDP integrated content from literature reviews specific to Latin America, established leadership programs from leading business schools, and various subject matter experts. Prior to the start of the LDP, participants received a pre-course survey evaluating demographic information, a needs assessment, and the prioritization of leadership topics utilizing a 5-point Likert-scale. Attendees participated in the one-day, interactive LDP focusing on the fundamental principles of leadership development, communication, personal development, emotional intelligence and negotiation. Following the LDP, a post-course evaluation was administered to determine the participants' overall experience, and suggestions for LDP improvement. Results Forty-one of the forty-eight course participants completed the pre-course evaluation, whereas forty-six of the forty-eight participants completed the post-course evaluations. Overwhelmingly, the lack of opportunity was most prevalently reported as the main obstacle to attending a leadership course, as cited by 56% of respondents. Conclusion Expanding the accessibility, diversity, and customizability of leadership programs can facilitate the development of personal tools needed to move healthcare forward. Critical topics include emotional intelligence and other differentiating leadership qualities that distinguish true transformational and servant leaders. Advancing leadership skills can stimulate networking, expose learners to experiential learning styles, inspire others to create positive change, and engender creative solutions for systematic improvements and health outcomes. Level of Evidence III; Individual Case-Control Studies.
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Affiliation(s)
- Verena Oberlohr
- University of California, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, San Francisco, School of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Vincenzo Giordano
- Hospital Municipal Miguel Couto, Prof. Nova Monteiro Orthopedics and Traumatology Department, Rio de Janeiro, RJ, Brazil
- Rede D’or São Luiz, Clínica São Vicente, Rio de Janeiro, RJ, Brazil
| | | | - Marcelo Caiero
- Hospital das Clínicas da Faculdade de Medicina da USP, Institute of Orthopedics and Traumatology, São Paulo, SP, Brazil
| | - Robinson Esteves Pires
- Universidade Federal de Minas Gerais (UFMG), Department of the Locomotor System, Belo Horizonte, MG, Brazil
| | | | - Alexandre Pallottino
- Hospital Central Aristarcho Pessoa - CBMERJ, Orthopedics Department, Rio de Janeiro, RJ, Brazil
| | - Gustavo Tadeu Sanchez
- UNIFESP (Universidade Federal de São Paulo), Paulista School of Medicine, Department of Orthopedics and Traumatology, São Paulo, SP, Brazil
| | - Pedro José Labronici
- Hospital Santa Teresa, Prof. Donato D’Ângelo Orthopedics and Traumatology Department, Petrópolis, Rio de Janeiro, RJ, Brazil
| | - Madeline MacKechnie
- University of California, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, San Francisco, School of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Theodore Miclau
- University of California, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, San Francisco, School of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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MacKechnie MC, Miclau E, MacKechnie MA, Miclau T. Leadership development training for orthopaedic trauma surgeons: an international survey. OTA Int 2024; 7:e302. [PMID: 38155733 PMCID: PMC10752451 DOI: 10.1097/oi9.0000000000000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 08/29/2023] [Accepted: 11/13/2023] [Indexed: 12/30/2023]
Abstract
Purpose This study examined the leadership development themes that global orthopaedic surgeons in differently resourced countries perceive as essential components and evaluated barriers to attending leadership development programs. Methods This multinational, 45-question survey engaged orthopaedic surgeons (one expert per country). The questionnaire collected participants' demographics, perception of effective leadership traits, and valuation of various leadership themes based on importance and interest. Results The survey was completed by 110 orthopaedic surgeons worldwide. Respondents most commonly reported holding a leadership position (87%) in hospital settings (62%), clinical settings (47%), and national orthopaedic societies (46%). The greatest proportion of participants reported having never attended a leadership course (42%). Participants regarded "high performing team-building," "professional ethics," and "organizational structure and ability to lead" as the most important leadership themes. No significant (P ≤ 0.05) differences were identified among perceived importance or interest in leadership themes between income levels; however, statistically significant differences were identified in the questionnaire; respondents in low- and middle-income countries (LICs/LMICs) demonstrated a stronger interest in attending a leadership course than those in high-income countries (HICs) (98% vs. 79%, P = 0.013), and fewer surgeons in LICs/LMICs had taken personality assessment tests than those in HICs (22% vs. 49%, P = 0.019). The most common barriers to attending leadership courses were lack of opportunities and invitations (57%), difficulty missing work (22%), and cost of course attendance (22%). Conclusions These findings can better inform the development of effective curricula and provide a framework for a successful model for the future. Level of Evidence V.
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Affiliation(s)
- Madeline C. MacKechnie
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, School of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | | | | | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, School of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA
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MacKechnie MC, Shearer DW, Verhofstad MHJ, Martin C, Graham SM, Pesantez R, Schuetz M, Hüttl T, Kojima K, Bernstein BP, Miclau T. Establishing Consensus on Essential Resources for Musculoskeletal Trauma Care Worldwide: A Modified Delphi Study. J Bone Joint Surg Am 2024; 106:47-55. [PMID: 37708306 DOI: 10.2106/jbjs.23.00387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND Despite evidence that formalized trauma systems enhance patient functional outcomes and decrease mortality rates, there remains a lack of such systems globally. Critical to trauma systems are the equipment, materials, and supplies needed to support care, which vary in availability regionally. The purpose of the present study was to identify essential resources for musculoskeletal trauma care across diverse resource settings worldwide. METHODS The modified Delphi method was utilized, with 3 rounds of electronic surveys. Respondents consisted of 1 surgeon with expertise in musculoskeletal trauma per country. Participants were identified with use of the AO Trauma, AO Alliance, Orthopaedic Trauma Association, and European Society for Trauma and Emergency Surgery networks. Respondents rated resources on a Likert scale from 1 (most important) to 9 (least important). The "most essential" resources were classified as those rated ≤2 by ≥75% of the sampled group. RESULTS One hundred and three of 111 invited surgeons completed the first survey and were included throughout the subsequent rounds (representing a 93% response rate). Most participants were fellowship-trained (78%) trauma and orthopaedic surgeons (90%) practicing in an academic setting (62%), and 46% had >20 years of experience. Respondents represented low-income and lower-middle-income countries (LMICs; 35%), upper-middle income countries (UMICs; 30%), and high-income countries (HICs; 35%). The initial survey identified 308 unique resources for pre-hospital, in-hospital, and post-hospital phases of care, of which 71 resources achieved consensus as the most essential. There was a significant difference (p < 0.0167) in ratings between income groups for 16 resources, all of which were related to general trauma care rather than musculoskeletal injury management. CONCLUSIONS There was agreement on a core list of essential musculoskeletal trauma care resources by respondents from LMICs, UMICs, and HICs. All significant differences in resource ratings were related to general trauma management. This study represents a first step toward establishing international consensus and underscores the need to prioritize resources that are locally available. The information can be used to develop effective guidelines and policies, create best-practice treatment standards, and advocate for necessary resources worldwide. CLINICAL RELEVANCE This study utilized the Delphi method representing expert opinion; however, this work did not examine patient management and therefore does not have a clinical Level of Evidence.
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Affiliation(s)
- Madeline C MacKechnie
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - David W Shearer
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Simon M Graham
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, United Kingdom
| | - Rodrigo Pesantez
- Department of Orthopedic Surgery, Fundación Santa Fe de Bogotá, Universidad de los Andes, Bogotá, Colombia
| | - Michael Schuetz
- Queensland University of Technology, Herston, Queensland, Australia
| | | | - Kodi Kojima
- Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Brian P Bernstein
- Division of Orthopaedic Surgery, University of Cape Town, Cape Town, South Africa
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
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Kleeblad LJ, Loggers SA, Zuidema WP, van Embden D, Miclau T, Ponsen KJ. Current consensus and clinical approach to fragility fractures of the pelvis: an international survey of expert opinion. OTA Int 2023; 6:e293. [PMID: 38152437 PMCID: PMC10750456 DOI: 10.1097/oi9.0000000000000293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/03/2023] [Accepted: 10/09/2023] [Indexed: 12/29/2023]
Abstract
Introduction Fragility fractures of the pelvis (FFP) in elderly patients are an underappreciated injury with a significant impact on mobility, independency, and mortality of affected patients and is a growing burden for society/health care. Given the lack of clinical practice guidelines for these injuries, the authors postulate there is heterogeneity in the current use of diagnostic modalities, treatment strategies (both operative and nonoperative), and follow-up of patients with FFP. The goal of this study was to assess international variation in the management of FFP. Methods All International Orthopaedic Trauma Association (IOTA) steering committee members were asked to select 15 to 20 experts in the field of pelvic surgery to complete a case-driven international survey. The survey addresses the definition of FFP, use of diagnostic modalities, timing of imaging, mobilization protocols, and indications for surgical management. Results In total, 143 experts within 16 IOTA societies responded to the survey. Among the experts, 86% have >10 years of experience and 80% works in a referral center for pelvic fractures. However, only 44% of experts reported having an institutional protocol for the management of FFP. More than 89% of experts feel the need for a (inter)national evidence-based guideline. Of all experts, 73% use both radiographs and computed tomography (CT) to diagnose FFP, of which 63% routinely use CT and 35% used CT imaging selectively. Treatment strategies of anterior ring fractures were compared with combined (anterior and posterior ring) fractures. Thirty-seven percent of patients with anterior ring fractures get admitted to the hospital compared with 75% of patients with combined fractures. Experts allow pain-guided mobilization in 72% after anterior ring fracture but propose restricted weight-bearing in case of a combined fracture in 44% of patients. Surgical indications are primarily based on the inability to mobilize during hospital admission (33%) or persistent pain after 2 weeks (25%). Over 92% plan outpatient follow-up independent of the type of fracture or treatment. Conclusion This study shows that there is a great worldwide heterogeneity in the current use of diagnostic modalities and both nonoperative and surgical management of FFP, emphasizing the need for a consensus meeting or guideline.
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Affiliation(s)
| | | | - Wietse P. Zuidema
- Department of Trauma Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Daphne van Embden
- Department of Trauma Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Kees-Jan Ponsen
- Department of Trauma Surgery, Northwest Clinics, Alkmaar, the Netherlands
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Bouklouch Y, Bernstein M, Bosse M, Cota A, Duckworth AD, Dunbar RP, Gamulin A, Guy P, Hak DJ, Haller JM, Hayda R, Jarragh A, Johnstone AJ, Karunakar M, Lawendy AR, Leighton R, Mavrogenis AF, Mauffrey C, Miclau T, Obremskey WT, Renninger C, Sanders DW, Schmidt AH, Schneider P, Sen MK, Taitsman L, Van Lancker H, Harvey EJ. Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg. J Orthop Trauma 2023; 37:581-585. [PMID: 37491711 DOI: 10.1097/bot.0000000000002663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.
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Affiliation(s)
| | | | - Michael Bosse
- Atrium Health Musculoskeletal Institute, Charlotte, NC
| | - Adam Cota
- St Mary's Medical Center-Intermountain Health, Grand Junction, CO
| | | | - Robert P Dunbar
- Harborview Medical Center/University of Washington, Seattle, WA
| | - Axel Gamulin
- University Hospitals of Geneva, Geneva, Switzerland
| | - Pierre Guy
- University of British Columbia, Vancouver, BC, Canada
| | - David J Hak
- Hughston Clinic/University of Central Florida, Orlando, FL
| | | | | | - Ali Jarragh
- Kuwait University, Dar Al Shifa Hospital, Kuwait City, Kuwait
| | | | | | | | | | | | | | | | | | | | | | | | - Prism Schneider
- Foothills Orthopaedic Trauma Service, University of Calgary, Calgary, AB, Canada
| | - Milan K Sen
- NYC Health+Hospitals/Jacobi, New York, NY; and
| | - Lisa Taitsman
- Harborview Medical Center/University of Washington, Seattle, WA
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O'Marr JM, Miclau T, Morshed S. Deciphering data: How should clinical trials change your clinical practice? Injury 2023; 54 Suppl 5:110928. [PMID: 37442740 DOI: 10.1016/j.injury.2023.110928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION The careful consideration of how to apply findings from the scientific literature is important to every physician's clinical practice. This can pose a difficult task, particularly with the increasing speed of technological advances and complexity involved in modern clinical trials. This review introduces a new method, the WHOM criteria (Who, How, Outcomes, Minimizing bias), from which orthopedic surgeons and other physicians can efficiently evaluate novel medical literature for inclusion into their clinical practice. WHOM CRITERIA The WHOM framework consists of four steps. The first step, Who, involves confirming whether a sample population studied is similar to one's patient under treatment, in order to ensure the results can be reasonably applied. Second, the How, comprises evaluating the intervention performed and ensuring that it could be reasonably replicated. The third step requires thoroughly evaluating the outcomes used in the study so as to ensure they are clinically meaningful to both the treating physician and the patient. Finally, there must be a careful evaluation of potential sources of bias and the ways in which errors and bias were minimized in all phases of the study. CONCLUSION Evidence-based practice should drive clinical decision making whenever the necessary literature is available. This requires the careful evaluation of new literature on a regular basis so that physicians can render safe and effective health care in partnership with their patients. The WHOM criteria are described in order to aid clinicians in navigating published research and change practice when appropriate.
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Affiliation(s)
- Jamieson M O'Marr
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, United States
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, United States
| | - Saam Morshed
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, United States; Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St 2nd floor, San Francisco, CA 94158, United States.
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Minehara H, Maruo A, Amadei R, Contini A, Braile A, Kelly M, Jenner L, Schemitsch GW, Schemitsch EH, Miclau T. Open fractures: Current treatment perspective. OTA Int 2023; 6:e240. [PMID: 37533445 PMCID: PMC10392445 DOI: 10.1097/oi9.0000000000000240] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/16/2022] [Indexed: 08/04/2023]
Abstract
Severe open fractures present challenges to orthopaedic surgeons worldwide, with increased risks of significant complications. Although different global regions have different resources and systems, there continue to be many consistent approaches to open fracture care. Management of these complex injures continues to evolve in areas ranging from timing of initial operative debridement to the management of critical-sized bone defects. This review, compiled by representative members of the International Orthopaedic Trauma Association, focuses on several critical areas of open fracture management, including antibiotic administration, timing of debridement, bone loss, soft tissue management, and areas of need for future investigation.
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Affiliation(s)
- Hiroaki Minehara
- Department of Traumatology, Fukushima Medical University, Trauma and Reconstruction Center, Shin-yurigaoka General Hospital, Kawasaki, Japan
| | - Akihiro Maruo
- Department of Orthopaedic Surgery, Harima-Himeji General Medical Center, Himeji, Japan
| | - Rafael Amadei
- Orthopaedics Trauma Unit, Cuenca Alta Cañuelas Hospital, Buenos Aires, Argentina
| | - Achille Contini
- Orthopedics and Traumatology Department, ASL 1 “Ospedale del Mare” Hospital, Napoli, Italy
| | - Adriano Braile
- Orthopedics and Traumatology Department, ASL 1 “Ospedale del Mare” Hospital, Napoli, Italy
- Multidisciplinary Department of Orthopedic and Dentistry Specialties, Università della Campania “Luigi Vanvitelli,” Napoli, Italy
| | | | | | | | - Emil H. Schemitsch
- Department of Surgery, University of Western Ontario, London Health Sciences Centre, London, ON, Canada; and
| | - Theodore Miclau
- Department of Orthopaedic Surgery; Orthopaedic Trauma Institute; University of California, San Francisco, CA
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Rivera KO, Cuylear DL, Duke VR, O’Hara KM, Zhong JX, Elghazali NA, Finbloom JA, Kharbikar BN, Kryger AN, Miclau T, Marcucio RS, Bahney CS, Desai TA. Encapsulation of β-NGF in injectable microrods for localized delivery accelerates endochondral fracture repair. Front Bioeng Biotechnol 2023; 11:1190371. [PMID: 37284244 PMCID: PMC10241161 DOI: 10.3389/fbioe.2023.1190371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/02/2023] [Indexed: 06/08/2023] Open
Abstract
Introduction: Currently, there are no non-surgical FDA-approved biological approaches to accelerate fracture repair. Injectable therapies designed to stimulate bone healing represent an exciting alternative to surgically implanted biologics, however, the translation of effective osteoinductive therapies remains challenging due to the need for safe and effective drug delivery. Hydrogel-based microparticle platforms may be a clinically relevant solution to create controlled and localized drug delivery to treat bone fractures. Here, we describe poly (ethylene glycol) dimethacrylate (PEGDMA)-based microparticles, in the shape of microrods, loaded with beta nerve growth factor (β-NGF) for the purpose of promoting fracture repair. Methods: Herein, PEGDMA microrods were fabricated through photolithography. PEGDMA microrods were loaded with β-NGF and in vitro release was examined. Subsequently, bioactivity assays were evaluated in vitro using the TF-1 tyrosine receptor kinase A (Trk-A) expressing cell line. Finally, in vivo studies using our well-established murine tibia fracture model were performed and a single injection of the β-NGF loaded PEGDMA microrods, non-loaded PEGDMA microrods, or soluble β-NGF was administered to assess the extent of fracture healing using Micro-computed tomography (µCT) and histomorphometry. Results: In vitro release studies showed there is significant retention of protein within the polymer matrix over 168 hours through physiochemical interactions. Bioactivity of protein post-loading was confirmed with the TF-1 cell line. In vivo studies using our murine tibia fracture model show that PEGDMA microrods injected at the site of fracture remained adjacent to the callus for over 7 days. Importantly, a single injection of β-NGF loaded PEGDMA microrods resulted in improved fracture healing as indicated by a significant increase in the percent bone in the fracture callus, trabecular connective density, and bone mineral density relative to soluble β-NGF control indicating improved drug retention within the tissue. The concomitant decrease in cartilage fraction supports our prior work showing that β-NGF promotes endochondral conversion of cartilage to bone to accelerate healing. Discussion: We demonstrate a novel and translational method wherein β-NGF can be encapsulated within PEGDMA microrods for local delivery and that β-NGF bioactivity is maintained resulting in improved bone fracture repair.
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Affiliation(s)
- Kevin O. Rivera
- Graduate Program in Oral and Craniofacial Sciences, School of Dentistry, University of California, San Francisco (UCSF), San Francisco, CA, United States
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco (UCSF), San Francisco, CA, United States
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Darnell L. Cuylear
- Graduate Program in Oral and Craniofacial Sciences, School of Dentistry, University of California, San Francisco (UCSF), San Francisco, CA, United States
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Victoria R. Duke
- Center for Regenerative and Personalized Medicine, The Steadman Philippon Research Institute (SPRI), Vail, CO, United States
| | - Kelsey M. O’Hara
- Center for Regenerative and Personalized Medicine, The Steadman Philippon Research Institute (SPRI), Vail, CO, United States
| | - Justin X. Zhong
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco (UCSF), San Francisco, CA, United States
- UC Berkeley—UCSF Graduate Program in Bioengineering, San Francisco, CA, United States
| | - Nafisa A. Elghazali
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco (UCSF), San Francisco, CA, United States
- UC Berkeley—UCSF Graduate Program in Bioengineering, San Francisco, CA, United States
| | - Joel A. Finbloom
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Bhushan N. Kharbikar
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Alex N. Kryger
- School of Dentistry, University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Ralph S. Marcucio
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Chelsea S. Bahney
- Graduate Program in Oral and Craniofacial Sciences, School of Dentistry, University of California, San Francisco (UCSF), San Francisco, CA, United States
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco (UCSF), San Francisco, CA, United States
- Center for Regenerative and Personalized Medicine, The Steadman Philippon Research Institute (SPRI), Vail, CO, United States
- UC Berkeley—UCSF Graduate Program in Bioengineering, San Francisco, CA, United States
| | - Tejal A. Desai
- Graduate Program in Oral and Craniofacial Sciences, School of Dentistry, University of California, San Francisco (UCSF), San Francisco, CA, United States
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco (UCSF), San Francisco, CA, United States
- Department of Bioengineering, University of California, Berkeley (UC Berkeley), Berkeley, CA, United States
- School of Engineering, Brown University, Providence, RI, United States
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10
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Clark D, Doelling J, Hu D, Miclau T, Nakamura M, Marcucio R. Age-related decrease in periostin expression may be associated with attenuated fracture healing in old mice. J Orthop Res 2023; 41:1022-1032. [PMID: 36058631 PMCID: PMC10411536 DOI: 10.1002/jor.25439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 08/16/2022] [Accepted: 08/29/2022] [Indexed: 02/04/2023]
Abstract
Older adults suffer more bone fractures with higher rates of healing complications and increased risk of morbidity and mortality. An improved understanding of the cellular and molecular mechanism of fracture healing and how such processes are perturbed with increasing age may allow for better treatment options to manage fractures in older adults. Macrophages are attractive therapeutics due to their role in several phases of fracture healing. After injury, bone marrow-derived macrophages are recruited to the injury and propagate the inflammatory response, contribute to resolution of inflammation, and promote bone regeneration. A tissue resident population of macrophages named osteal macrophages are present in the periosteum and are directly associated with osteoblasts and these cells contribute to bone formation. Here, we utilized bulk RNA sequencing to analyze the transcriptional activity of osteal macrophages from old and young mice present in primary calvarial cultures. Macrophages demonstrated a diverse transcriptional profile, expressing genes involved in immune function as well as wound healing and regeneration. Periostin was significantly downregulated in macrophages from old mice compared to young. Periostin is an extracellular matrix protein with important functions that promote osteoblast activity during bone regeneration. An age-related decrease of periostin expression was verified in the fracture callus of old mice compared to young. Young periostin knockout mice demonstrated attenuated fracture healing outcomes that reflected what is observed in old mice. This study supports an important role of periostin in fracture healing, and therapeutically targeting the age-related decrease in periostin may improve healing outcomes in older populations.
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Affiliation(s)
- Daniel Clark
- Department of Periodontics and Preventive Dentistry, School of Dental Medicine, University of Pittsburgh. 335 Sutherland Dr. Pittsburgh, PA 15261, USA
| | - Jeffrey Doelling
- College of Medicine, California Northstate University, 9700 West Taron Dr. Elk Grove, CA 95758, USA
| | - Diane Hu
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, School of Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd St. San Francisco, CA, 94110, USA
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, School of Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd St. San Francisco, CA, 94110, USA
| | - Mary Nakamura
- Division of Rheumatology, Department of Medicine, San Francisco VA Health Care System, 4150 Clement St. San Francisco, California, 94121 USA
| | - Ralph Marcucio
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, School of Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd St. San Francisco, CA, 94110, USA
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11
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Flores MJ, Brown KE, Pendleton MM, Albright PD, MacKechnie MC, Guerrero Rodriguez E, Ramírez C, Peña Martínez VM, Miclau T. Barriers to and Outcomes of Initiating Clinical Research at Two Trauma Centers in Mexico. J Surg Res 2023; 284:1-5. [PMID: 36525816 DOI: 10.1016/j.jss.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 11/01/2022] [Accepted: 11/06/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Despite efforts to advance clinical research through collaboration between Latin and North American partners, there remains persistent barriers to performing investigative work. To overcome these obstacles, a team of over 100 surgeon-leaders from 18 Latin American countries founded the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). One of ACTUAR's first major collaborative projects, initiated in 2018, was a prospective, observational, multicenter study evaluating quality of life after open tibia fracture management. The current study identified common barriers experienced during the initiation of this study, as exemplified through two sites in Mexico. The study aims to identify obstacles to proactively overcome these in future collaborative work. METHODS Two research assistants from University of California, San Francisco and two research coordinators from Mexico were recruited to share their experiences, identify common barriers experienced during site enrollment and on-boarding for the ACTUAR open tibia study, and discuss possible solutions. RESULTS Barriers were organized into three categories: structural, logistical, and intrapersonal. Structural barriers included differences in patient populations and resources between private and public hospitals. Logistical barriers included ambiguous ethical review processes, internet availability, and low patient follow-up. Primary enrollment as a resident responsibility led to some intrapersonal barriers. Potential solutions were identified for each barrier and agreed upon by all collaborators. CONCLUSIONS Multiple barriers were identified by research personnel who initiated a prospective surgical clinical research study in Mexico. Through collaborative approaches, many potential solutions may help overcome these barriers and build locally led research capacity in Latin America.
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Affiliation(s)
- Michael J Flores
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Kelsey E Brown
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Megan M Pendleton
- University of California, San Francisco, School of Medicine, San Francisco, California
| | - Patrick D Albright
- University of Minnesota, Department of Orthopedic Surgery, Minneapolis, Minnesota
| | - Madeline C MacKechnie
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | | | | | | | - Theodore Miclau
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California.
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12
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Urva M, Cortez A, Katyal T, Shearer DW, Morshed S, Miclau T, MacKechnie MC, Sabharwal S. Orthopaedic trauma observerships in North America for international surgeons: the visitors' perspective. OTA Int 2023; 6:e229. [PMID: 36760658 PMCID: PMC9904194 DOI: 10.1097/oi9.0000000000000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 10/30/2022] [Indexed: 06/18/2023]
Abstract
International observerships are one of many efforts aimed at addressing disparities in orthopaedic trauma care globally. However, their impact on visiting surgeons and their home countries, as well as the challenges faced by participating surgeons, are not well-documented. Methods A survey was distributed to overseas surgeons who participated in an orthopaedic trauma observership from 2009 to 2020. Surgeons were identified through North American institutions previously recognized by the authors as having hosted international observerships. Information gathered included participant demographics, details of and perceived impact of the observership, and barriers faced before, during, and after the program. Responses from 148 international surgeons (ISs) from 49 countries were analyzed. Results Sixty percent of observerships were at academic programs, 57% lasted 1-3 months, and 60% were self-funded. Participants identified cost and housing as primary barriers. After completing their observership, lack of funding, equipment and support staff, and excessive workload prevented participants from implementing changes at their clinical practice. Most observers believed that they gained relevant clinical (89%) and surgical knowledge (67%) and developed a professional network of North American hosts (63%). The most common suggested changes to the observership were greater hands-on experience in the operating room and structured goal setting relevant to the visiting surgeon. Conclusions Visiting surgeons find North American orthopaedic trauma observerships helpful in improving their surgical and clinical skills. However, financial constraints and resource limitations at their clinical practice and limited operative experience during the observership present barriers to maximizing this clinical experience. To enhance the relevance of clinical observerships for ISs and impact global orthopaedic trauma care, the unique needs and challenges facing ISs must be addressed. Level of Evidence IV-Cross-Sectional Study.
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Affiliation(s)
- Mayur Urva
- Institute for Global Orthopaedics and Traumatology,
Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of
California, San Francisco, San Francisco, CA; and
| | - Abigail Cortez
- Institute for Global Orthopaedics and Traumatology,
Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of
California, San Francisco, San Francisco, CA; and
| | - Toshali Katyal
- UCSF Benioff's Children's Hospital Oakland,
Department of Pediatric Orthopaedics, Oakland, CA
| | - David W. Shearer
- Institute for Global Orthopaedics and Traumatology,
Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of
California, San Francisco, San Francisco, CA; and
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology,
Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of
California, San Francisco, San Francisco, CA; and
| | - Theodore Miclau
- Institute for Global Orthopaedics and Traumatology,
Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of
California, San Francisco, San Francisco, CA; and
| | - Madeline C. MacKechnie
- Institute for Global Orthopaedics and Traumatology,
Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of
California, San Francisco, San Francisco, CA; and
| | - Sanjeev Sabharwal
- Institute for Global Orthopaedics and Traumatology,
Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of
California, San Francisco, San Francisco, CA; and
- UCSF Benioff's Children's Hospital Oakland,
Department of Pediatric Orthopaedics, Oakland, CA
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13
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Abstract
While formation and regeneration of the skeleton have been studied for a long period of time, significant scientific advances in this field continue to emerge based on an unmet clinical need to improve options to promote bone repair. In this review, we discuss the relationship between mechanisms of bone formation and bone regeneration. Data clearly show that regeneration is not simply a reinduction of the molecular and cellular programs that were used for development. Instead, the mechanical environment exerts a strong influence on the mode of repair, while during development, cell-intrinsic processes drive the mode of skeletal formation. A major advance in the field has shown that cell fate is flexible, rather than terminal, and that chondrocytes are able to differentiate into osteoblasts and other cell types during development and regeneration. This is discussed in a larger context of regeneration in vertebrates as well as the clinical implication that this shift in understanding presents.
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Affiliation(s)
- R.S. Marcucio
- University of California, San Francisco (UCSF), Orthopaedic Trauma Institute, San Francisco, CA, USA
| | - T. Miclau
- University of California, San Francisco (UCSF), Orthopaedic Trauma Institute, San Francisco, CA, USA
| | - C.S. Bahney
- University of California, San Francisco (UCSF), Orthopaedic Trauma Institute, San Francisco, CA, USA
- Steadman Philippon Research Institute, Vail, CO, USA
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14
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Haffner-Luntzer M, Weber B, Morioka K, Lackner I, Fischer V, Bahney C, Ignatius A, Kalbitz M, Marcucio R, Miclau T. Altered early immune response after fracture and traumatic brain injury. Front Immunol 2023; 14:1074207. [PMID: 36761764 PMCID: PMC9905106 DOI: 10.3389/fimmu.2023.1074207] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/10/2023] [Indexed: 01/26/2023] Open
Abstract
Introduction Clinical and preclinical data suggest accelerated bone fracture healing in subjects with an additional traumatic brain injury (TBI). Mechanistically, altered metabolism and neuro-endocrine regulations have been shown to influence bone formation after combined fracture and TBI, thereby increasing the bone content in the fracture callus. However, the early inflammatory response towards fracture and TBI has not been investigated in detail so far. This is of great importance, since the early inflammatory phase of fracture healing is known to be essential for the initiation of downstream regenerative processes for adequate fracture repair. Methods Therefore, we analyzed systemic and local inflammatory mediators and immune cells in mice which were exposed to fracture only or fracture + TBI 6h and 24h after injury. Results We found a dysregulated systemic immune response and significantly fewer neutrophils and mast cells locally in the fracture hematoma. Further, local CXCL10 expression was significantly decreased in the animals with combined trauma, which correlated significantly with the reduced mast cell numbers. Discussion Since mast cells and mast cell-derived CXCL10 have been shown to increase osteoclastogenesis, the reduced mast cell numbers might contribute to higher bone content in the fracture callus of fracture + TBI mice due to decreased callus remodeling.
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Affiliation(s)
- Melanie Haffner-Luntzer
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany.,Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Birte Weber
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, San Francisco, CA, United States.,Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany.,Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Kazuhito Morioka
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurological Surgery, Weill Institute for Neurosciences, Brain and Spinal Injury Center (BASIC), University of California, San Francisco (UCSF), San Francisco, CA, United States
| | - Ina Lackner
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Verena Fischer
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany
| | - Chelsea Bahney
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, San Francisco, CA, United States.,Steadman Phillipon Research Institute, Vail, CO, United States
| | - Anita Ignatius
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Ralph Marcucio
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, San Francisco, CA, United States
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15
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Brown KE, Solaiman RH, Flores MJ, Nadone H, MacKechnie MC, Shearer DW, Miclau T. Opportunities for International Orthopaedic Volunteerism: An Exploration of United States and Canada-Based Nonprofit Organizations. J Bone Joint Surg Am 2022; 105:571-577. [PMID: 36730608 DOI: 10.2106/jbjs.22.00801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In low and middle-income countries (LMICs), there are often not enough orthopaedic surgeons to treat musculoskeletal conditions. International volunteerism is 1 way that the orthopaedic community seeks to meet this need. This study explored the opportunities available for orthopaedic surgeons to volunteer overseas as offered by nonprofit organizations in the United States and Canada. METHODS A systematic internet search was conducted using 2 distinct search strategies. A website was considered a "hit" if it was that of a U.S. or Canada-based nonprofit, volunteer, or non-governmental organization that had opportunities for international orthopaedic volunteerism. Duplicate hits were eliminated to identify distinct organizations. Data regarding the work and geographical reach of the organization, as well as changes to its volunteer programs as a result of COVID-19, were extracted from each hit. RESULTS Of the 38 distinct organizations identified in the U.S. and Canada, the most common orthopaedic subspecialties represented were pediatrics (37%), hand (24%), and arthroplasty (18%). Foot and ankle (4 organizations; 11%), sports medicine (2 organizations; 5%), and oncology (1 organization; 3%) were the least represented subspecialities. The most common regions for volunteer trips included Latin America and the Caribbean, followed by West and East Africa. Twelve organizations (32%) were identified as having a religious affiliation. For most organizations, the trip duration was a minimum of 1 week. All volunteer organizations included operative or clinical experiences as part of their trips, and the majority of organizations (58%) reported that their trips included opportunities for training local surgeons. Many organizations (71%) reported having resumed trips after halting them during the COVID-19 pandemic. CONCLUSIONS Many opportunities exist for orthopaedic surgeons to volunteer their time and skills abroad. Future directions for the improvement of international volunteer efforts among the orthopaedic community could include expanding the number of existing volunteer opportunities and assessing the ethics, safety, efficacy, and longevity of these programs.
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Affiliation(s)
- Kelsey E Brown
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, California.,Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Rafat H Solaiman
- University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Michael J Flores
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, California.,Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Haley Nadone
- Reno School of Medicine, University of Nevada, Reno, Nevada
| | - Madeline C MacKechnie
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, California
| | - David W Shearer
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, California
| | - Theodore Miclau
- Institute of Global Orthopaedics and Traumatology, University of California San Francisco, San Francisco, California
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16
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Alt V, Van Lieshout EMM, Miclau T. New Technologies in Orthopaedic Traumatology. Injury 2022; 53 Suppl 3:S1. [PMID: 36229083 DOI: 10.1016/j.injury.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
| | - Esther M M Van Lieshout
- Trauma Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
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17
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Merle G, Miclau T, Parent-Harvey A, Harvey EJ. Sensor technology usage in orthopedic trauma. Injury 2022; 53 Suppl 3:S59-S63. [PMID: 36182592 DOI: 10.1016/j.injury.2022.09.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 08/25/2022] [Accepted: 09/08/2022] [Indexed: 02/02/2023]
Abstract
Medicine in general is quickly transitioning to a digital presence. Orthopaedic surgery is also being impacted by the tenets of digital health but there are also direct efforts with trauma surgery. Sensors are the pen and paper of the next wave of data acquisition. Orthopaedic trauma can and will be part of this new wave of medicine. Early sensor products that are now coming to market, or are in early development, will directly change the way we think about surgical diagnosis and outcomes. Sensor development for biometrics is already here. Wellness devices, pressure, temperature, and other parameters are already being measured. Data acquisition and analysis is going to be a fruitful addition to our research armamentarium with the volume of information now available. A combination of broadband internet, micro electrical machine systems (MEMS), and new wireless communication standards is driving this new wave of medicine. The Internet of Things (IoT) [1] now has a subset which is the Internet of Medical Devices [2-5] permitting a much more in-depth dive into patient procedures and outcomes. IoT devices are now being used to enable remote health monitoring, in hospital treatment, and guide therapies. This article reviews current sensor technology that looks to impact trauma care.
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Affiliation(s)
- Géraldine Merle
- École Polytechnique de Montréal, Université de Montréal, Montréal, Canada
| | - Theodore Miclau
- Orthopaedic Trauma Institute, University of Calfornia, School of Medicine, Department of Orthopaedics, San Francisco, USA
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18
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Slobogean GP, Sprague S, Wells JL, Bhandari M, Harris AD, Mullins CD, Thabane L, Wood A, Della Rocca GJ, Hebden JN, Jeray KJ, Marchand LS, O'Hara LM, Zura RD, Lee C, Patterson JT, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt G, Heels-Ansdell D, Marvel D, Palmer JE, Friedrich J, O'Hara NN, Grissom F, Gitajn IL, Morshed S, O'Toole RV, Petrisor B, Mossuto F, Joshi MG, D'Alleyrand JCG, Fowler J, Rivera JC, Talbot M, Pogorzelski D, Dodds S, Li S, Del Fabbro G, Szasz OP, Bzovsky S, McKay P, Minea A, Murphy K, Howe AL, Demyanovich HK, Hoskins W, Medeiros M, Polk G, Kettering E, Mahal N, Eglseder A, Johnson A, Langhammer C, Lebrun C, Nascone J, Pensy R, Pollak A, Sciadini M, Degani Y, Phipps H, Hempen E, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Gallant JL, Pusztai K, MacRae S, Renaud S, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich Jr RW, Lazarus DE, Millon SJ, Moody MC, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill Jr LE, Garitty MJ, Poole AS, Sims ML, Walker CM, Carlisle R, Hofer EA, Huggins B, Hunter M, Marshall W, Ray SB, Smith C, Altman KM, Pichiotino ER, Quirion JC, Loeffler MF, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Bray E, Sykes JW, Yoder K, Conner K, Abbott H, Natoli RM, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Mullis BH, Jang Y, Lopas LA, Hill LC, Fentz CL, Diaz MM, Brown K, Garst KM, Denari EW, Osborn P, Pierrie SN, Kessler B, Herrera M, Miclau T, Marmor MT, Matityahu A, McClellan RT, Shearer D, Toogood P, Ding A, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Pokhvashchev D, Obremskey WT, Jahangir AA, Sethi M, Boyce R, Stinner DJ, Mitchell PP, Trochez K, Rodriguez E, Pritchett C, Hogan N, Fidel Moreno A, Hagen JE, Patrick M, Vlasak R, Krupko T, Talerico M, Horodyski M, Pazik M, Lossada-Soto E, Gary JL, Warner SJ, Munz JW, Choo AM, Achor TS, Routt ML“C, Kutzler M, Boutte S, Warth RJ, Prayson MJ, Venkatarayappa I, Horne B, Jerele J, Clark L, Boulton C, Lowe J, Ruth JT, Askam B, Seach A, Cruz A, Featherston B, Carlson R, Romero I, Zarif I, Dehghan N, McKee M, Jones CB, Sietsema DL, Williams A, Dykes T, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Porcel-Vazquez JA, Andres-Peiro JV, Esteban-Feliu I, Vidal-Tarrason N, Serracanta J, Nuñez-Camarena J, del Mar Villar-Casares M, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Marcano-Fernández F, Martínez-Carreres L, Martí-Garín D, Serrano-Sanz J, Sánchez-Fernández J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Cámara-Cabrera J, Caparros-García A, Fillat-Gomà F, Fuentes-López R, Garcia-Rodriguez R, Gimeno-Calavia N, Martínez-Álvarez M, Martínez-Grau P, Pellejero-García R, Ràfols-Perramon O, Peñalver JM, Salomó Domènech M, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Cueva-Sevieri HE, Garcia-Gimenez S, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Spicer E, Payne K, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Gaski GE, Wills J, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Williams W, Hill T, Brotherton A, Romeo NM, Vallier HA, Vergon A, Higgins TF, Haller JM, Rothberg DL, Olsen ZM, McGowan AV, Hill S, Dauk MK, Bergin PF, Russell GV, Graves ML, Morellato J, McGee SL, Bhanat EL, Yener U, Khanna R, Nehete P, Potter D, VanDemark III R, Seabold K, Staudenmier N, Coe M, Dwyer K, Mullin DS, Chockbengboun TA, DePalo Sr. PA, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Bauer B, Meredith S, Talwar S, Domes CM, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Mehta S, Donegan D, Horan A, Dooley M, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial. Lancet 2022; 400:1334-1344. [PMID: 36244384 DOI: 10.1016/s0140-6736(22)01652-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture. METHODS We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304. FINDINGS Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4). INTERPRETATION For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds. FUNDING US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.
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Lackner I, Weber B, Pressmar J, Odwarka A, Lam C, Haffner-Luntzer M, Marcucio R, Miclau T, Kalbitz M. Cardiac alterations following experimental hip fracture - inflammaging as independent risk factor. Front Immunol 2022; 13:895888. [PMID: 36131923 PMCID: PMC9484325 DOI: 10.3389/fimmu.2022.895888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/08/2022] [Indexed: 12/04/2022] Open
Abstract
Background Cardiac injuries following trauma are associated with a worse clinical outcome. So-called trauma-induced secondary cardiac injuries have been recently described after experimental long bone fracture even in absence of direct heart damage. With the progressive aging of our society, the number of elderly trauma victims rises and therefore the incidence of hip fractures increases. Hip fractures were previously shown to be associated with adverse cardiac events in elderly individuals, which have mainly been attributed to pre-conditioned cardiac diseases. The aim of the present study was to investigate the effect of hip fractures on the heart in healthy young and middle-aged mice. Materials and Methods Young (12-week-old) and middle-aged (52-week-old) female C57BL/6 mice either received an intramedullary stabilized proximal femur fracture or sham treatment. The observation time points included 6 and 24 h. Systemic levels of pro-inflammatory mediators as well as local inflammation and alterations in myocardial structure, metabolism and calcium homeostasis in left ventricular tissue was analyzed following hip fracture by multiplex analysis, RT-qPCR and immunohistochemistry. Results After hip fracture young and middle-aged mice showed increased systemic IL-6 and KC levels, which were significantly elevated in the middle-aged animals. Furthermore, the middle-aged mice showed enhanced myocardial expression of HMGB1, TLR2/4, TNF, IL1β and NLRP3 as well as considerable alterations in the myocardial expression of glucose- and fatty acid transporters (HFABP, GLUT4), calcium homeostasis proteins (SERCA) and cardiac structure proteins (desmin, troponin I) compared to the young animals following hip fracture. Conclusion Young and middle-aged mice showed local myocardial alterations, which might predispose for the development of secondary cardiac injury following hip fracture. Age and the age-associated phenomenon of ‘inflammaging’ seemed to be an independent risk factor aggravating and accelerating cardiac alterations following hip fracture.
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Affiliation(s)
- Ina Lackner
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Birte Weber
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University of Frankfurt, Frankfurt, Germany
| | - Jochen Pressmar
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Anna Odwarka
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Charles Lam
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Melanie Haffner-Luntzer
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany
| | - Ralph Marcucio
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States
| | - Miriam Kalbitz
- Department of Trauma and Orthopedic Surgery, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Miriam Kalbitz,
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MacKechnie MC, Albright PD, Garabano G, Bidolegui F, Pereira S, Pesciallo CA, Miclau T. Open tibial shaft fracture management in Argentina: an evaluation of treatment standards in diverse resource settings. OTA Int 2022; 5:e209. [PMID: 36425094 PMCID: PMC9580262 DOI: 10.1097/oi9.0000000000000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/20/2022] [Indexed: 06/16/2023]
Abstract
Background Argentina is a country with varying access to orthopedic surgical care. The Argentine Association of Trauma and Orthopedics (AATO) "Interior Committee" was developed to address potential regional differences and promote standardization of orthopedic trauma care. The paper assesses the level of national standardization of the management of open tibia fractures across 9 provinces in Argentina. Methods Utilizing a matched-comparison group design, management of these injuries were assessed and compared between 3 groups: an "AATO Exterior Committee" consisting of surgeons that practice in Buenos Aires, and 2 "Interior Committees," comprising surgeons that practice in outlying provinces, 1 of which is affiliated with the AATO, and 1 that is not affiliated with the AATO. The study was conducted in 2 phases: phase 1 assessed open tibia fracture management characteristics, and phase 2 evaluated the management of soft-tissue wound coverage following open fractures. Results Soft-tissue coverage procedures for Gustilo Anderson Type IIIB fractures were more commonly performed by orthopedic surgeons in Interior Committees than the AATO Exterior Committee. Greater rates of definitive wound coverage within 7 days post-injury were reported in both Interior Committees compared to the Exterior Committee. Plastic surgeons were reported as more available to those in the AATO Exterior Committee group than in the AATO Interior Committees. Conclusion While treatment patterns were evident among groups, differences were identified in the management and timing of soft-tissue coverage in Gustilo Anderson Type IIIB fractures between the Exterior Committee and both Interior Committees. Future targeted educational and surgical hands-on training opportunities that emphasize challenges faced in resource-limited settings may improve the management of open tibia fractures in Argentina.
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Affiliation(s)
- Madeline C MacKechnie
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Patrick D Albright
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America
| | | | | | | | | | - Theodore Miclau
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
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Miclau T, MacKechnie MC, Born CT, MacKechnie MA, Dyer GSM, Yuan BJ, Dawson J, Lee C, Ishmael CR, Schreiber VM, Tejwani NC, Ulmer T, Shearer DW, Agarwal-Harding KJ, Johal H, Khormaee S, Sprague S, Whiting PS, Roberts HJ, Coughlin R, Gosselin R, Rosenwasser MP, Johnson A, Babu JM, Dworkin M, Makhni MC, McClellan T, Nwachuku CO, Miclau E, Morshed S. International Orthopaedic Volunteer Opportunities in Low and Middle-Income Countries. J Bone Joint Surg Am 2022; 104:e44. [PMID: 34932526 DOI: 10.2106/jbjs.21.00948] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Globally, the burden of musculoskeletal conditions continues to rise, disproportionately affecting low and middle-income countries (LMICs). The ability to meet these orthopaedic surgical care demands remains a challenge. To help address these issues, many orthopaedic surgeons seek opportunities to provide humanitarian assistance to the populations in need. While many global orthopaedic initiatives are well-intentioned and can offer short-term benefits to the local communities, it is essential to emphasize training and the integration of local surgeon-leaders. The commitment to developing educational and investigative capacity, as well as fostering sustainable, mutually beneficial partnerships in low-resource settings, is critical. To this end, global health organizations, such as the Consortium of Orthopaedic Academic Traumatologists (COACT), work to promote and ensure the lasting sustainability of musculoskeletal trauma care worldwide. This article describes global orthopaedic efforts that can effectively address musculoskeletal care through an examination of 5 domains: clinical care, clinical research, surgical education, disaster response, and advocacy.
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Affiliation(s)
- Theodore Miclau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Madeline C MacKechnie
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Christopher T Born
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael A MacKechnie
- Department of Orthopaedic Surgery, Cleveland Clinic Martin Health, Stuart, Florida
| | - George S M Dyer
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - John Dawson
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas
| | - Cassandra Lee
- Department of Orthopaedic Surgery, University of California at Davis Health, Sacramento, California
| | - Chad R Ishmael
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | | | | | - Todd Ulmer
- Adventist Medical Center, Oregon Health Sciences University, Portland, Oregon
| | - David W Shearer
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Massachusetts General Hospital/Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Herman Johal
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Sheila Sprague
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Heather J Roberts
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Richard Coughlin
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Rich Gosselin
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | | | - Anthony Johnson
- Department of Surgery and Perioperative Care, University of Texas at Austin, Austin, Texas
| | - Jacob M Babu
- Orthopaedic Division of Spine Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Myles Dworkin
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Melvin C Makhni
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Trigg McClellan
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | | | - Elizabeth Miclau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Saam Morshed
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
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22
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MacKechnie MC, Miclau TA, Cordero DM, Tahir P, Miclau T. Leadership development programs for healthcare professionals in low‐and middle‐income countries: A systematic review. Int J Health Plann Manage 2022; 37:2149-2166. [DOI: 10.1002/hpm.3457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 09/10/2021] [Accepted: 03/02/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Madeline C. MacKechnie
- Orthopaedic Trauma Institute Department of Orthopaedic Surgery University of California San Francisco School of Medicine Zuckerberg San Francisco General Hospital San Francisco California USA
| | - Theodore A. Miclau
- University of California San Francisco School of Medicine San Francisco California USA
| | - Daniella M. Cordero
- University of California San Francisco School of Medicine San Francisco California USA
| | - Peggy Tahir
- University of California San Francisco UCSF Library San Francisco California USA
| | - Theodore Miclau
- Orthopaedic Trauma Institute Department of Orthopaedic Surgery University of California San Francisco School of Medicine Zuckerberg San Francisco General Hospital San Francisco California USA
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Garabano G, MacKechnie MC, Pereira S, Brown K, Flores MJ, Pesciallo CA, Miclau T, Bidolegui F. Open Tibial Fracture Treatment in Argentina: Reoperation Rates Following Surgical Management. JB JS Open Access 2022; 7:e21.00153. [PMID: 35747171 PMCID: PMC9208878 DOI: 10.2106/jbjs.oa.21.00153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The purposes of the present study were (1) to characterize open tibial fractures and their treatment in trauma centers located across different regions of Argentina and (2) to evaluate the rates of and indications for reoperation after the surgical treatment of such fractures. Methods This retrospective multicenter study evaluated open tibial fractures in Argentina that were operatively treated by experienced orthopaedic trauma surgeon-members of the Argentine Association of Orthopedic Trauma (AATO) between January 2015 and June 2020. Data were collected from 13 hospital databases; 8 hospitals were designated as "interior," and 5 hospitals were designated as "exterior." The study included 701 skeletally mature patients, all of whom had a minimum of 12 months of follow-up. Information was collected on patient demographics, injury pattern and mechanism, fracture classification, treatment modality, reoperation rates, time between definitive fixation and reoperation, and indications for reoperation. Results Seventy-six percent of presenting injuries were the result of a high-energy mechanism. Intramedullary nailing represented the most common type of fixation (88%). One hundred and fifty patients (21%) required reoperation. Delayed union/nonunion was the most common indication for reoperation in patients who had been previously treated with intramedullary nail fixation (31%; 39 of 126), and infection was the most common indication for reoperation in patients who had been treated with plate fixation (43%; 3 of 7). The time between the injury and definitive fixation was significantly different between the interior and exterior trauma centers (13.8 versus 4.7 days; p < 0.001), as was the time between definitive fixation and reoperation (69.3 versus 25.2 days; p = 0.004). The reoperation rates for the interior and exterior trauma centers were similar (20% versus 24%; p = 0.2). Infection, delayed union/nonunion, and implant removal were the most common indications for reoperation across groups. Conclusions An improved understanding of the factors that influence treatment may help to guide future areas for improvement, establish educational goals, and create additional nationwide guidelines for open tibial fracture treatment. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Madeline C. MacKechnie
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | | | - Kelsey Brown
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | - Michael J. Flores
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
| | | | - Theodore Miclau
- Orthopaedic Trauma Institute, Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
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Working ZM, Peterson D, Lawson M, O’Hara K, Coghlan R, Provencher MT, Friess DM, Johnstone B, Miclau T, Bahney CS. Collagen X Longitudinal Fracture Biomarker Suggests Staged Fixation in Tibial Plateau Fractures Delays Rate of Endochondral Repair. J Orthop Trauma 2022; 36:S32-S39. [PMID: 35061649 PMCID: PMC10308601 DOI: 10.1097/bot.0000000000002307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To use a novel, validated bioassay to monitor serum concentrations of a breakdown product of collagen X in a prospective longitudinal study of patients sustaining isolated tibial plateau fractures. Collagen X is the hallmark extracellular matrix protein present during conversion of soft, cartilaginous callus to bone during endochondral repair. Previous preclinical and clinical studies demonstrated a distinct peak in collagen X biomarker (CXM) bioassay levels after long bone fractures. SETTING Level 1 academic trauma facility. PATIENTS/PARTICIPANTS Thirty-six patients; isolated tibial plateau fractures. INTERVENTION (3) Closed treatment, ex-fix (temporizing/definitive), and open reduction internal fixation. MAIN OUTCOME MEASUREMENTS Collagen X serum biomarker levels (CXM bioassay). RESULTS Twenty-two men and 14 women (average age: 46.3 y; 22.6-73.4, SD 13.3) enrolled (16 unicondylar and 20 bicondylar fractures). Twenty-five patients (72.2%) were treated operatively, including 12 (33.3%) provisionally or definitively treated by ex-fix. No difference was found in peak CXM values between sexes or age. Patients demonstrated peak expression near 1000 pg/mL (average: male-986.5 pg/mL, SD 369; female-953.2 pg/mL, SD 576). There was no difference in peak CXM by treatment protocol, external fixator use, or fracture severity (Schatzker). Patients treated with external fixation (P = 0.05) or staged open reduction internal fixation (P = 0.046) critically demonstrated delayed peaks. CONCLUSIONS Pilot analysis demonstrates a strong CXM peak after fractures commensurate with previous preclinical and clinical studies, which was delayed with staged fixation. This may represent the consequence of delayed construct loading. Further validation requires larger cohorts and long-term follow-up. Collagen X may provide an opportunity to support prospective interventional studies testing novel orthobiologics or fixation techniques. LEVEL OF EVIDENCE Level II, prospective clinical observational study.
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Affiliation(s)
- Zachary M. Working
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Danielle Peterson
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Michelle Lawson
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
| | | | | | | | - Darin M. Friess
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Brian Johnstone
- Department of Orthopaedics & Rehabilitation, Oregon Health and Science University, Portland, OR
- Portland Shriners Hospital, Portland, OR
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California at San Francisco, San Francisco, CA
| | - Chelsea S. Bahney
- Steadman Philippon Research Institute, Vail, CO
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California at San Francisco, San Francisco, CA
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Roberts HJ, MacKechnie MC, Shearer DW, Segovia Altieri J, de la Huerta F, Rio MW, Sánchez Valenciano C, Miclau T. Orthopaedic Trauma Research Priorities in Latin America: Developing Consensus Through a Modified Delphi Approach. J Bone Joint Surg Am 2021; 103:2318-2323. [PMID: 34559719 DOI: 10.2106/jbjs.21.00271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite a substantial burden of musculoskeletal injury, orthopaedic trauma studies in Latin America are lacking. The purpose of the present study was to identify research priorities among orthopaedic trauma surgeons in Latin America. METHODS Research questions were solicited from members of the Asociación de Cirujanos Traumatólogos de las Américas. Participants rated questions by importance from 1 to 9. All questions were redistributed with an aggregate rating, and participants rerated questions with knowledge of group responses. RESULTS Seventy-eight participants completed the first survey and were included in subsequent surveys. The mean age was 51.8 years, and most participants were male (92%), had completed an orthopaedic trauma fellowship (60.3%), and participated in research (80.8%). Seventeen countries were represented; 5 respondents were from a high-income country, 67 were from an upper middle-income country, and 6 were from a lower middle-income country. Sixty-five questions were identified. Six questions were rated from 1 to 3 ("more important") by >70% of participants: (1) What is the optimal treatment protocol for elderly patients with hip fracture? (2) What is the most effective initial and definitive management of musculoskeletal injury, including timing and surgical strategy, for the polytraumatized patient? (3) What is the ideal state of open fracture treatment, including timeliness and method of antibiotics, debridement, surgical fixation, and closure or coverage, at each hospital level in the health-care system? (4) What patient and fracture characteristics predict infection after musculoskeletal injury? (5) What is the current state of treatment for fracture-related infection, including timeliness and method of antibiotics and surgical intervention, at each hospital level in the health-care system? (6) What is the optimal protocol for temporary management for the hemodynamically unstable patient with a pelvic or acetabular fracture? CONCLUSIONS This modified Delphi study of orthopaedic trauma surgeons in Latin America identified geriatric hip fractures, polytrauma, open fractures, musculoskeletal infection, and pelvic and acetabular fractures as top research priorities. This information is important for resource allocation and goal setting for orthopaedic trauma in the region.
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Affiliation(s)
| | | | - David W Shearer
- University of California San Francisco, San Francisco, California
| | - Julio Segovia Altieri
- Instituto de Prevision Social, Servicio de Ortopaedia y Traumatología, Asunción, Paraguay
| | | | - Marcelo W Rio
- Ortopedia y Traumatología Clínica Zabala, Buenos Aires, Argentina
| | | | - Theodore Miclau
- University of California San Francisco, San Francisco, California
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Gitajn IL, Werth PM, Sprague S, O’Hara N, Della Rocca G, Zura R, Marmor M, Domes CM, Hill LC, Churchill C, Townsend C, Van C, Hogan N, Girardi C, Slobogean GP, Slobogean GP, Sprague S, Wells J, Bhandari M, D'Alleyrand JC, Harris AD, Mullins DC, Thabane L, Wood A, Della Rocca GJ, Hebden J, Jeray KJ, Marchand L, O'Hara LM, Zura R, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt GH, Heels-Ansdell D, Marvel D, Palmer J, Friedrich J, O'Hara NN, Grissom F, Gitajn IL, Morshed S, O'Toole RV, Petrisor BA, Camara M, Mossuto F, Joshi MG, Fowler J, Rivera J, Talbot M, Dodds S, Garibaldi A, Li S, Nguyen U, Pogorzelski D, Rojas A, Scott T, Del Fabbro G, Szasz OP, McKay P, Howe A, Rudnicki J, Demyanovich H, Little K, Boissonneault A, Medeiros M, Polk G, Kettering E, Hale D, Mahal N, Eglseder A, Johnson A, Langhammer C, Lebrun C, Manson T, Nascone J, Paryavi E, Pensy R, Pollak A, Sciadini M, Degano Y, Demyanovich HK, Joseph K, Phipps H, Hempen E, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Leonard J, Marcano-Fernández FA, Gallant J, Persico F, Gjorgjievski M, George A, McGaugh SM, Pusztai K, Piekarski S, Lyons M, Gennaccaro J, Natoli RN, Gaski GE, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Baele JR, Mullis BH, Jang Y, Hill LC, Hudgins A, Fentz CL, Diaz MM, Garst KM, Denari EW, Osborn P, Pierrie S, Martinez E, Kimmel J, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich RW, Lazarus DE, Millon SJ, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill LE, Garitty MJ, Poole AS, Sims ML, Carlisle RM, Adams-Hofer E, Huggins BS, Hunter MD, Marshall WA, Bielby Ray S, Smith CD, Altman KM, Bedard JC, Loeffler MF, Pichiotino ER, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Moody MC, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Skyes JW, Kandemir U, Marmor M, Matityahu A, McClellan RT, Meinberg E, Miclau T, Shearer D, Toogood P, Ding A, Donohue E, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Paul A, Garg K, Pokhvashchev D, Gary JL, Warner SJ, Munz JW, Choo AM, Schor TS, Routt ML"C, Rao M, Pechero G, Miller A, Kutzler M, Hagen JE, Patrick M, Vlasak R, Krupko T, Sadasivan K, Talerico M, Horodyski M, Koenig C, Bailey D, Wentworth D, Van C, Schwartz J, Pazik M, Dehghan N, Jones CB, Watson JT, McKee M, Karim A, Sietsema DL, Williams A, Dykes T, Obremsky WT, Jahangir AA, Sethi M, Boyce R, Mitchell P, Stinner DJ, Trochez K, Rodriguez A, Gajari V, Rodriguez E, Pritchett C, Hogan N, Moreno AF, Boulton C, Lowe J, Wild J, Ruth JT, Taylor M, Askam B, Seach A, Saeed S, Culbert H, Cruz A, Knapp T, Hurkett C, Lowney M, Featherston B, Prayson M, Venkatarayappa I, Horne B, Jerele J, Clark L, Marcano-Fernández F, Jornet-Gibert M, Martinez-Carreres L, Marti-Garin D, Serrano-Sanz J, Sanchez-Fernandez J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Camara-Cabrera J, Caparros-Garcia A, Fillat-Goma F, Fuentes-Lopez R, Garcia-Rodriguez R, Gimeno-Calavia N, Graells-Alonso G, Martinez-Alvarez M, Martinez-Grau P, Pellejero-Garcia R, Rafols-Perramon O, Penalver JM, Domenech MS, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Enrique Cueva-Sevieri H, Garcia-Gimenez S, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Antonio Porcel-Vasquez J, Vicente Andres-Peiro J, Minguell-Monyart J, Nuñez-Camarena J, del Mar Villar-Casares M, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Romeo NM, Vallier HA, Breslin MA, Fraifogl J, Wilson ES, Wadenpfuhl LK, Halliday PG, Heimke I, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Zomar M, Spicer E, Fan C"B, Payne K, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Bartel C, Mayberry RM, Brownrigg M, Girardi C, Mayfield A, Sweeney J, Pollock H, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Wills J, Ramsey L, Ahn JS, Panjshiri F, Das S, English AD, Haaser SM, Cuff JAN, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Bullard D, Williams W, Hill T, Brotherton A, Higgins TF, Haller JM, Rothberg DL, Marchand LS, Neese A, Russell M, Olsen ZM, McGowan AV, Hill S, Coe M, Dwyer K, Mullin D, Reilly CA, DePalo P, Hall AE, Dabrowski RE, Chockbengboun TA, Heng M, Harris MB, Smith RM, Lhowe DW, Esposito JG, Bansal M, McTague M, Alnasser A, Bergin PF, Russell GV, Graves ML, Morellato J, Champion HK, Johnson LN, McGee SL, Bhanat EL, Thimothee J, Serrano J, Mehta S, Donehan D, Ahn J, Horan A, Dooley M, Kuczinski A, Iwu A, Potter D, VanDemark R, Pfaff B, Hollinsworth T, Atkins K, Weaver MJ, von Keudell AG, Allen EM, Sagona AE, Jaeblon T, Beer R, Bauer B, Meredith S, Stone A, Gage MJ, Reilly RM, Sparrow C, Paniagua A. Association of COVID-19 With Achieving Time-to-Surgery Benchmarks in Patients With Musculoskeletal Trauma. JAMA Health Forum 2021; 2:e213460. [PMID: 35977160 PMCID: PMC8727030 DOI: 10.1001/jamahealthforum.2021.3460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/31/2021] [Indexed: 11/14/2022] Open
Abstract
Question Were resource constraints due to the COVID-19 pandemic associated with a delay in urgent fracture surgery beyond national time-to-surgery benchmarks? Findings In this cohort pre-post study that included 3589 patients, there was no association between time to surgery and COVID-19 in either open fracture or closed femur/hip fracture cohorts. Meaning Despite concerns that the unprecedented challenges associated with the COVID-19 pandemic would delay acute management of urgent surgery, many hospital systems within the US were able to implement strategies in keeping with time-to-surgery standards for orthopedic trauma. Importance In response to the COVID-19 pandemic, many hospital systems were forced to reduce operating room capacity and reallocate resources. The outcomes of these policies on the care of injured patients and the maintenance of emergency services have not been adequately reported. Objective To evaluate whether the COVID-19 pandemic was associated with delays in urgent fracture surgery beyond national time-to-surgery benchmarks. Design, Setting, and Participants This retrospective cohort study used data collected in the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma among at 20 sites throughout the US and Canada and included patients who sustained open fractures or closed femur or hip fractures. Exposure COVID-19–era operating room restrictions were compared with pre–COVID-19 data. Main Outcomes and Measures Surgery within 24 hours after injury. Results A total of 3589 patients (mean [SD] age, 55 [25.4] years; 1913 [53.3%] male) were included in this study, 2175 pre–COVID-19 and 1414 during COVID-19. A total of 54 patients (3.1%) in the open fracture cohort and 407 patients (21.8%) in the closed hip/femur fracture cohort did not meet 24-hour time-to-surgery benchmarks. We were unable to detect any association between time to operating room and COVID-19 era in either open fracture (odds ratio [OR], 1.40; 95% CI, 0.77-2.55; P = .28) or closed femur/hip fracture (OR, 1.01; 95% CI, 0.74-1.37; P = .97) cohorts. In the closed femur/hip fracture cohort, there was no association between time to operating room and regional COVID-19 prevalence (OR, 1.07; 95% CI, 0.70-1.64; P = .76). Conclusions and Relevance In this cohort study, there was no association between meeting time-to-surgery benchmarks in either open fracture or closed femur/hip fracture during the COVID-19 pandemic compared with before the pandemic. This is counter to concerns that the unprecedented challenges associated with managing the COVID-19 pandemic would be associated with clinically significant delays in acute management of urgent surgical cases and suggests that many hospital systems within the US were able to effectively implement policies consistent with time-to-surgery standards for orthopedic trauma in the context of COVID-19–related resource constraints.
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Affiliation(s)
| | - Paul M. Werth
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Nathan O’Hara
- University of Maryland School of Medicine, Baltimore
| | | | - Robert Zura
- Louisiana State University Medical Center, New Orleans
| | | | | | | | - Christine Churchill
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | - Chi Van
- University of Florida, Gainesville
| | | | - Cara Girardi
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Chi Van
- for the PREP-IT Investigators
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Patterson JT, Ishii K, Tornetta P, Leighton RK, Friess DM, Jones CB, Levine A, Maclean JJ, Miclau T, Mullis BH, Obremskey WT, Ostrum RF, Reid JS, Ruder JA, Saleh A, Schmidt AH, Teague DC, Tsismenakis A, Westberg JR, Morshed S. Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture. J Orthop Trauma 2021; 35:517-522. [PMID: 34510125 DOI: 10.1097/bot.0000000000002068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN Retrospective cohort study. SETTING Twelve Level 1 North American trauma centers. PATIENTS Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Keisuke Ishii
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA
| | - Ross K Leighton
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR
| | - Darin M Friess
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, NS
| | - Clifford B Jones
- Division of Orthopaedic Surgery, Dignity Health Arizona, Creighton Medical School, Phoenix, AZ
| | - Ari Levine
- Department of Orthopaedics, MetroHealth Medical Center, Cleveland, OH
| | - Jeffrey J Maclean
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Theodore Miclau
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Brian H Mullis
- Department of Orthopaedic Surgery, Indiana University, Indianapolis, IN
| | - William T Obremskey
- Department of Orthopaedic Surgery and Rehabilitation, Vanderbilt University, Nashville, TN
| | - Robert F Ostrum
- Department of Orthopaedic Surgery, University of North Carolina, Charlotte, NC
| | - J Spence Reid
- Department of Orthopaedics and Rehabilitation, Penn State University, Hersey Medical Center, Hersey, PA
| | - John A Ruder
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC
| | - Anas Saleh
- Department of Orthopaedics, MetroHealth Medical Center, Cleveland, OH
| | - Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN; and
| | - David C Teague
- Department of Orthopedic Surgery and Rehabilitation, University of Oklahoma, Oklahoma City, OK
| | | | - Jerald R Westberg
- Department of Orthopaedic Surgery, Hennepin Healthcare, Minneapolis, MN; and
| | - Saam Morshed
- Department of Orthopaedic Surgery, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
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28
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Wong SA, Hu DP, Slocum J, Lam C, Nguyen M, Miclau T, Marcucio RS, Bahney CS. Chondrocyte-to-osteoblast transformation in mandibular fracture repair. J Orthop Res 2021; 39:1622-1632. [PMID: 33140859 PMCID: PMC8451921 DOI: 10.1002/jor.24904] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 10/01/2020] [Accepted: 10/31/2020] [Indexed: 02/04/2023]
Abstract
The majority of fracture research has been conducted using long bone fracture models, with significantly less research into the mechanisms driving craniofacial repair. However, craniofacial bones differ from long bones in both their developmental mechanism and embryonic origin. Thus, it is possible that their healing mechanisms could differ. In this study we utilize stabilized and unstabilized mandible fracture models to investigate the pathways regulating repair. Whereas fully stable trephine defects in the ramus form bone directly, mechanical motion within a transverse fracture across the same anatomical location promoted robust cartilage formation before boney remodeling. Literature investigating long bone fractures show chondrocytes are a direct precursor of osteoblasts during endochondral repair. Lineage tracing with Aggrecan-CreERT2 ::Ai9 tdTomato mice demonstrated that mandibular callus chondrocytes also directly contribute to the formation of new bone. Furthermore, immunohistochemistry revealed that chondrocytes located at the chondro-osseous junction expressed Sox2, suggesting that plasticity of these chondrocytes may facilitate this chondrocyte-to-osteoblast transformation. Based on the direct role chondrocytes play in bone repair, we tested the efficacy of cartilage grafts in healing critical-sized mandibular defects. Whereas empty defects remained unbridged and filled with fibrous tissue, cartilage engraftment produced bony-bridging and robust marrow cavity formation, indicating healthy vascularization of the newly formed bone. Engrafted cartilage directly contributed to new bone formation since a significant portion of the newly formed bone was graft/donor-derived. Taken together these data demonstrate the important role of chondrocyte-to-osteoblast transformation during mandibular endochondral repair and the therapeutic promise of using cartilage as a tissue graft to heal craniofacial defects.
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Affiliation(s)
- Sarah A. Wong
- Department of Orthopaedic Surgery, Orthopaedic Trauma InstituteUniversity of California2550 23rd Street Building 9, 3rd FloorSan FranciscoCalifornia94110USA,Oral and Craniofacial Sciences Program, School of DentistryUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Diane P. Hu
- Department of Orthopaedic Surgery, Orthopaedic Trauma InstituteUniversity of California2550 23rd Street Building 9, 3rd FloorSan FranciscoCalifornia94110USA
| | - Joshua Slocum
- Department of Orthopaedic Surgery, Orthopaedic Trauma InstituteUniversity of California2550 23rd Street Building 9, 3rd FloorSan FranciscoCalifornia94110USA
| | - Charles Lam
- Department of Orthopaedic Surgery, Orthopaedic Trauma InstituteUniversity of California2550 23rd Street Building 9, 3rd FloorSan FranciscoCalifornia94110USA
| | - Michael Nguyen
- Department of Orthopaedic Surgery, Orthopaedic Trauma InstituteUniversity of California2550 23rd Street Building 9, 3rd FloorSan FranciscoCalifornia94110USA,Oral and Craniofacial Sciences Program, School of DentistryUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma InstituteUniversity of California2550 23rd Street Building 9, 3rd FloorSan FranciscoCalifornia94110USA
| | - Ralph S. Marcucio
- Department of Orthopaedic Surgery, Orthopaedic Trauma InstituteUniversity of California2550 23rd Street Building 9, 3rd FloorSan FranciscoCalifornia94110USA,Oral and Craniofacial Sciences Program, School of DentistryUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Chelsea S. Bahney
- Department of Orthopaedic Surgery, Orthopaedic Trauma InstituteUniversity of California2550 23rd Street Building 9, 3rd FloorSan FranciscoCalifornia94110USA,Steadman Philippon Research InstituteCenter for Regenerative Sports Medicine181 W Meadows DriveVailColorado81657USA
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29
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Marmor MT, Matz J, McClellan RT, Medam R, Miclau T. Use of Osteobiologics for Fracture Management: The When, What, and How. Injury 2021; 52 Suppl 2:S35-S43. [PMID: 33549314 DOI: 10.1016/j.injury.2021.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/17/2021] [Accepted: 01/18/2021] [Indexed: 02/02/2023]
Abstract
Osteobiologics are defined as a group of natural and synthetic materials used to augment bone healing. The selection of the most appropriate osteobiologic from the growing list of available options can be a challenging task. In selecting a material, surgeons should weigh a variety of considerations, including the indication for their use (the when), the most suitable substance (the what), and the correct mode of application (the how). This summary reviews these considerations and seeks to provide the surgeon with a basis for informed clinical evidence-based decision-making in their choice of a successful option.
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Affiliation(s)
- Meir T Marmor
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Jacob Matz
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Robert Trigg McClellan
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Ramapaada Medam
- University of Central Florida College of Medicine, Orlando, FL, USA
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
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Abstract
The prevalence of periodontal disease increases with age. Systemic inflammatory dysregulation also increases with age and has been reported to contribute to the myriad of diseases and conditions that become more prevalent with advanced age. As periodontal disease involves a dysregulated host inflammatory response, the age-related inflammatory dysregulation may contribute to the pathogenesis of periodontal disease in aging populations. However, our understanding of what drives the age-related inflammatory dysregulation is limited. Here, we investigate the macrophage and its contribution to periodontal disease in old and young mice using a ligature-induced periodontal disease model. We demonstrate that control old mice present with an aged periodontal phenotype, characterized by increased alveolar bone loss and increased local inflammatory cytokine expression compared to young mice. Macrophages were demonstrated to be present in the periodontium of old and young mice in equal numbers in controls, during disease induction, and during disease recovery. However, it appears age may have a detrimental effect on macrophage activity during disease recovery. Depletion of macrophages during disease recovery in old mice resulted in decreased inflammatory cytokines within the gingiva and decreased bone loss as measured by micro-computed tomography. In young mice, macrophage depletion during disease recovery had no beneficial or detrimental effect. Macrophage depletion during disease induction resulted in decreased disease severity similarly in young and old mice. Findings from this work support the diverse roles of macrophages in disease induction as well as the active roles of disease recovery, including the resolution of inflammation. Here, we conclude that age-related changes to the macrophage appear to be detrimental to the recovery from disease and may explain, in part, the age-related increase in prevalence of periodontal disease. Future studies examining the specific intrinsic age-related changes to the macrophage will help identify therapeutic targets.
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Affiliation(s)
- D Clark
- Orofacial Sciences, University of California San Francisco, San Francisco, CA, USA
| | - B Halpern
- Orofacial Sciences, University of California San Francisco, San Francisco, CA, USA
| | - T Miclau
- Orthopaedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA
| | - M Nakamura
- School of Medicine, University of California San Francisco, San Francisco, CA, USA.,Arthritis/Immunology Section, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Y Kapila
- Orofacial Sciences, University of California San Francisco, San Francisco, CA, USA
| | - R Marcucio
- Orthopaedic Trauma Institute, University of California San Francisco, San Francisco, CA, USA
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31
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Miclau T. Orthopaedic trauma care: initial global approaches to management during a pandemic. OTA Int 2021; 4:e120. [PMID: 38630065 PMCID: PMC7959860 DOI: 10.1097/oi9.0000000000000120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 12/31/2020] [Indexed: 11/29/2022]
Abstract
The coronavirus disease 2019 (COVID-19) has significantly affected the treatment of patients with surgical conditions, including those with acute and chronic musculoskeletal issues. While different global regions experienced different levels of COVID-19 activity and had different resources with which to deal with the pandemic, there were many consistent approaches to injury care and musculoskeletal trauma management. Understanding these approaches is necessary to improve current and future strategies to taking care of orthopaedic trauma patients in an infectious disease outbreak. This supplement focuses on approaches to musculoskeletal trauma care during the first months of the COVID-19 pandemic in 19 countries from 6 continents. This work represents a collaborative work of member societies of the International Orthopaedic Trauma Association (IOTA), an international association of orthopaedic societies dedicated to the promotion of musculoskeletal trauma care through advancements in patient care, research, and education. The information in these reports will aid efforts to understand and ultimately better address musculoskeletal trauma care worldwide during the first waves of the pandemic.
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Affiliation(s)
- Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA
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32
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Lackner I, Weber B, Haffner-Luntzer M, Hristova S, Gebhard F, Lam C, Morioka K, Marcucio RS, Miclau T, Kalbitz M. Systemic and local cardiac inflammation after experimental long bone fracture, traumatic brain injury and combined trauma in mice. J Orthop Translat 2021; 28:39-46. [PMID: 33717980 PMCID: PMC7906881 DOI: 10.1016/j.jot.2020.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/04/2020] [Accepted: 12/11/2020] [Indexed: 11/28/2022] Open
Abstract
Background Trauma is the leading cause of death and disability worldwide, especially in the young population. Cardiac injuries are an independent predictor for a poor overall outcome after trauma. The aim of the present study was to analyze systemic inflammation as well as local cardiac inflammation after experimental limb-, neuro- and combined trauma in mice. Methods Male C57BL/6 mice received either a closed tibia fracture (Fx), isolated traumatic brain injury (TBI) or a combination of both (Fx + TBI). Control animals underwent sham procedure. After 6 and 24 h, systemic levels of inflammatory mediators were analyzed, respectively. Locally, cardiac inflammation and cardiac structural alterations were investigated in left ventricular tissue of mice 6 and 24 h after trauma. Results Mice showed enhanced systemic inflammation after combined trauma, which was manifested by increased levels of KC, MCP-1 and G-CSF. Locally, mice exhibited increased expression of inflammatory cytokines (IL-1β, TNF) in heart tissue, which was probably mediated via toll-like receptor (TLR) signaling. Furthermore, mice demonstrated a redistribution of connexin 43 in cardiac tissue, which appeared predominantly after combined trauma. Besides inflammation and structural cardiac alterations, expression of glucose transporter 4 (GLUT4) mRNA was increased in the heart early after TBI and after combination of TBI and limb fracture, indicating a modification of energy metabolism. Early after combination of TBI and tibia fracture, nitrosative stress was increased, manifested by elevation of nitrotyrosine in cardiac tissue. Finally, mice showed a trend of increased systemic levels of cardiac troponin I and heart-fatty acid binding protein (HFABP) after combined trauma, which was associated with a significant decrease of troponin I and HFABP mRNA expression in cardiac tissue after TBI and combination of TBI and limb fracture. Conclusion Mice exhibited early cardiac alterations as well as alterations in cardiac glucose transporter expression, indicating a modification of energy metabolism, which might be linked to increased systemic- and local cardiac inflammation after limb-, neuro- and combined trauma. These cardiac alterations might predispose individuals for secondary cardiac damage after trauma that might compromise cardiac function after TBI and long bone fracture. Translational potential statement Injuries to the head and extremities frequently occur after severe trauma. In our study, we analyzed the effects of closed tibia fracture, isolated TBI, and the combination of both injuries with regard to the development of post-traumatic secondary cardiac injuries.
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Affiliation(s)
- Ina Lackner
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Birte Weber
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany.,Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Melanie Haffner-Luntzer
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany.,Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Simona Hristova
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Florian Gebhard
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Charles Lam
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Kazuhito Morioka
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Ralph S Marcucio
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany.,Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
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Abstract
INTRODUCTION TO THE PROBLEM Though declining in the recent decades, high-energy musculoskeletal trauma remains a major contributor to the burden of disease in high-income countries (HICs). However, due to limitations in the available body of the literature, evaluation of this burden is challenging. The purpose of this review is to assess: (1) the current epidemiologic data on the surgical burden of high-energy musculoskeletal trauma in HICs; (2) the current data on the economic impact of high-energy musculoskeletal trauma; and (3) potential strategies for addressing gaps in musculoskeletal trauma care for the future. REVIEW OF LITERATURE In 2016, mortality from road traffic injuries (RTIs) between the ages of 15-49 was reported to be 9.5% (9.0-9.9) in high-income countries, accounting for approximately 255 million DALYs. While RTIs do not fully capture the extent of high-energy musculoskeletal trauma, as the most common mechanism, they serve as a useful indicator of the impact on the surgical and economic burden. In 2009, the global losses related to RTIs were estimated to be 518 billion USD, costing governments between 1 and 3% of their gross domestic product (GDP). In the last decade, both the total direct per-person healthcare cost and the incremental direct per-person costs for those with a musculoskeletal injury in the USA rose 75 and 58%, respectively. FUTURE DIRECTIONS ADDRESSING THE GAPS: While its impact is large, research on musculoskeletal conditions, including high-energy trauma, is underfunded compared to other fields of medicine. An increased awareness among policy makers and healthcare professionals of the importance of care for the high-energy musculoskeletal trauma patient is critical. Full implementation of trauma systems is imperative, and metrics such as the ICD-DALY have the potential to allow for real-time evaluation of prevention and treatment programs aimed to reduce injury-related morbidity and mortality. The dearth in knowledge in optimal and cost-effective post-acute care for high-energy musculoskeletal trauma is a reason for concern, especially since almost half of the costs are attributed to this phase of care. Multidisciplinary rehabilitation teams as part of a musculoskeletal trauma system may be of interest to decrease further the long-term negative effects and the economic burden of high-energy musculoskeletal trauma.
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Affiliation(s)
- P Hoogervorst
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute of Global Orthopaedics and Traumatology, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd St, San Francisco, CA, 94110, USA
| | - D W Shearer
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute of Global Orthopaedics and Traumatology, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd St, San Francisco, CA, 94110, USA
| | - T Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Institute of Global Orthopaedics and Traumatology, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 2550 23rd St, San Francisco, CA, 94110, USA.
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Weber B, Lackner I, Gebhard F, Miclau T, Kalbitz M. Trauma, a Matter of the Heart-Molecular Mechanism of Post-Traumatic Cardiac Dysfunction. Int J Mol Sci 2021; 22:E737. [PMID: 33450984 PMCID: PMC7828409 DOI: 10.3390/ijms22020737] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 12/18/2022] Open
Abstract
Trauma remains a leading global cause of mortality, particularly in the young population. In the United States, approximately 30,000 patients with blunt cardiac trauma were recorded annually. Cardiac damage is a predictor for poor outcome after multiple trauma, with a poor prognosis and prolonged in-hospitalization. Systemic elevation of cardiac troponins was correlated with survival, injury severity score, and catecholamine consumption of patients after multiple trauma. The clinical features of the so-called "commotio cordis" are dysrhythmias, including ventricular fibrillation and sudden cardiac arrest as well as wall motion disorders. In trauma patients with inappropriate hypotension and inadequate response to fluid resuscitation, cardiac injury should be considered. Therefore, a combination of echocardiography (ECG) measurements, echocardiography, and systemic appearance of cardiomyocyte damage markers such as troponin appears to be an appropriate diagnostic approach to detect cardiac dysfunction after trauma. However, the mechanisms of post-traumatic cardiac dysfunction are still actively being investigated. This review aims to discuss cardiac damage following trauma, focusing on mechanisms of post-traumatic cardiac dysfunction associated with inflammation and complement activation. Herein, a causal relationship of cardiac dysfunction to traumatic brain injury, blunt chest trauma, multiple trauma, burn injury, psychosocial stress, fracture, and hemorrhagic shock are illustrated and therapeutic options are discussed.
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Affiliation(s)
- Birte Weber
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University of Ulm, 86081 Ulm, Germany; (B.W.); (I.L.); (F.G.)
| | - Ina Lackner
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University of Ulm, 86081 Ulm, Germany; (B.W.); (I.L.); (F.G.)
| | - Florian Gebhard
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University of Ulm, 86081 Ulm, Germany; (B.W.); (I.L.); (F.G.)
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, 2550 23rd Street, San Francisco, CA 94110, USA;
| | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic-, and Reconstructive Surgery, Center of Surgery, University of Ulm, 86081 Ulm, Germany; (B.W.); (I.L.); (F.G.)
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Working ZM, Morris ER, Chang JC, Coghlan RF, Johnstone B, Miclau T, Horton WA, Bahney CS. A quantitative serum biomarker of circulating collagen X effectively correlates with endochondral fracture healing. J Orthop Res 2021; 39:53-62. [PMID: 32533783 DOI: 10.1002/jor.24776] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/12/2020] [Accepted: 05/25/2020] [Indexed: 02/04/2023]
Abstract
Currently, there are no standardized methods for quantitatively measuring fracture repair. Physicians rely on subjective physical examinations and qualitative evaluation of radiographs to detect mineralized tissue. Since most fractures heal indirectly through a cartilage intermediate, these tools are limited in their diagnostic utility of early repair. Prior to converting to the bone, cartilage undergoes hypertrophic maturation, characterized by the deposition of a provisional collagen X matrix. The objective of this study was to characterize the kinetics of a novel collagen X biomarker relative to other biological measurements of fracture healing using a murine model of endochondral fracture repair in which a closed, mid-shaft tibia fracture was created using the classic drop-weight technique. Serum was collected 5 to 42 days post-fracture in male and female mice and compared to uninjured controls (n = 8-12). Collagen X in the serum was quantified using a recently validated ELISA-based bioassay ("Cxm")1 and compared to genetic and histological markers of fracture healing and inflammation. We found the Cxm biomarker reliably increased from baseline to a statistically unique peak 14 days post-fracture that then resolved to pre-fracture levels by 3 weeks following injury. The shape and timing of the Cxm curve followed the genetic and histological expression of collagen X but did not show a strong correlation with local inflammatory states. Assessment of fracture healing progress is crucial to making correct and timely clinical decisions for patients. This Cxm bioassay represents a minimally invasive, inexpensive technique that could provide reliable information on the biology of the fracture to significantly improve clinical care.
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Affiliation(s)
- Zachary M Working
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital (ZSFG), University of California, San Francisco (UCSF), San Francisco, California
- Orthopaedics and Rehabilitation, Oregon Health & Science University (OHSU), Portland, Oregon
| | - Elizabeth R Morris
- Center for Regenerative Sports Medicine, Steadman Philippon Research Institute (SPRI), Vail, Colorado
| | - Jiun Chiun Chang
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital (ZSFG), University of California, San Francisco (UCSF), San Francisco, California
| | - Ryan F Coghlan
- Shriners Hospitals for Children, Research Center, Portland, Oregon
| | - Brian Johnstone
- Orthopaedics and Rehabilitation, Oregon Health & Science University (OHSU), Portland, Oregon
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital (ZSFG), University of California, San Francisco (UCSF), San Francisco, California
| | - William A Horton
- Shriners Hospitals for Children, Research Center, Portland, Oregon
| | - Chelsea S Bahney
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital (ZSFG), University of California, San Francisco (UCSF), San Francisco, California
- Center for Regenerative Sports Medicine, Steadman Philippon Research Institute (SPRI), Vail, Colorado
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Lackner I, Weber B, Miclau T, Holzwarth N, Baur M, Gebhard F, Teuben M, Halvachizadeh S, Cinelli P, Pfeifer R, Lipiski M, Cesarovic N, Haffner-Luntzer M, Pape HC, Kalbitz M. Reaming of femoral fractures with different reaming irrigator aspirator systems shows distinct effects on cardiac function after experimental polytrauma. J Orthop Res 2020; 38:2608-2618. [PMID: 32827323 DOI: 10.1002/jor.24830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 02/04/2023]
Abstract
Cardiac injuries are recorded after multiple trauma and are associated with a poor patient outcome. Reaming prior to locked intramedullary nailing is a frequently used technique to stabilize femoral diaphysis fractures. However, in polytraumatized patients, complications such as fat emboli and acute respiratory distress syndrome have been associated with reaming. The reaming irrigator aspirator (RIA) system provides concomitant irrigation and suction of the intramedullary contents, and should, therefore, reduce reaming-associated complications. The aim of the study was to investigate cardiac function after multiple trauma with regard to two different RIA devices (RIAI vs RIAII). 15 male pigs were included in the study. Pigs received either sham treatment or multiple trauma (chest trauma, femur fracture, liver laceration, and hemorrhagic shock), followed by intramedullary nailing after reaming with either the RIAI or RIAII system (RIAII: reduced diameter of the reamer, improved control of irrigation and suction). Cardiac function was assessed by transesophageal echocardiography and systemic inflammation as well as local cardiac damage examined. Pigs of both treatment groups showed impaired cardiac function, valvular insufficiency, and cardiac damage. Systemic inflammation and local cardiac alterations were observed which might contribute to early myocardial damage in vivo. Multiple trauma including long-bone fracture and subsequent intramedullary reaming induces cardiac dysfunction and valvular insufficiency, which might be linked to both mechanical cardiac injury and increased systemic inflammation. 6 hours after trauma there are less differences between RIAI and RIAII treatment with regard to post-traumatic cardiac consequences in multiple injured pigs, indicating no beneficial effect of RIAII over RIAI.
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Affiliation(s)
- Ina Lackner
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Birte Weber
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, California
| | - Nina Holzwarth
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Meike Baur
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Florian Gebhard
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
| | - Michel Teuben
- Department of Trauma, University Hospital of Zurich, Zurich, Switzerland
| | | | - Paolo Cinelli
- Department of Trauma, University Hospital of Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital of Zurich, Zurich, Switzerland
| | - Miriam Lipiski
- Department of Surgical Research, University Hospital of Zurich, Zurich, Switzerland
| | - Nikola Cesarovic
- Department of Surgical Research, University Hospital of Zurich, Zurich, Switzerland
| | | | | | - Miriam Kalbitz
- Department of Traumatology, Hand-, Plastic- and Reconstructive Surgery, University Hospital Ulm, Ulm, Germany
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Albright PD, MacKechnie MC, Roberts HJ, Shearer DW, Padilla Rojas LG, Segovia J, Quintero JE, Amadei R, Baldy Dos Reis F, Miclau T. Open Tibial Shaft Fractures: Treatment Patterns in Latin America. J Bone Joint Surg Am 2020; 102:e126. [PMID: 32890042 DOI: 10.2106/jbjs.20.00292] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Open tibial shaft fractures are an important source of disability in Latin America. High-income countries (HICs) worldwide have established standardized treatment protocols for open tibial fractures, but less is known about their treatment in middle-income countries (MICs) in Latin America. This survey of Latin American orthopaedic surgeons characterizes open tibial fracture treatment patterns. METHODS Orthopaedic surgeons from 20 national orthopaedic societies throughout Latin America completed an online survey assessing their treatment of open tibial fractures. Demographic information was collected. Treatment patterns were queried according to 2 groupings of Gustilo-Anderson (GA) fracture types: treatment of type-I and type-II fractures (GA-I/II) and treatment of type-III fractures (GA-III). Treatment patterns were evaluated across 4 domains: antibiotic prophylaxis, irrigation and debridement, fracture stabilization, and wound management. Summary statistics were reported; analysis was performed using the Fisher exact test (p < 0.05). RESULTS There were 616 survey participants from 20 Latin American countries (4 HICs and 16 MICs). Initial external fixation followed by staged internal fixation was preferred for GA-I/II (51.0%) and GA-III fractures (86.0%). Nearly one-third (31.5%) of GA-IIIB fractures did not receive a soft-tissue coverage procedure. Stratifying by country socioeconomic status, surgeons in MICs more commonly utilized delayed internal fixation for GA-I/II (53.3% versus 22.0%, p < 0.001) and GA-III fractures (94.0% versus 80.4%, p = 0.002). Surgeons in MICs more commonly used primary closure for GA-I/II (88.9% versus 62.8%, p < 0.001) and GA-III fractures (32.6% versus 9.8%, p < 0.001). CONCLUSIONS This survey reports Latin American orthopaedic surgeons' treatment patterns for open tibial shaft fractures. Surgeons in MICs reported higher delayed internal fixation use for all fracture types, while surgeons in HICs more routinely avoid primary closure. Soft-tissue coverage procedures are not performed in nearly one-third of GA-IIIB fractures because of a lack of operative personnel and training.
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Affiliation(s)
- Patrick D Albright
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Madeline C MacKechnie
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Heather J Roberts
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - David W Shearer
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
| | | | - Julio Segovia
- Hospital Central Instituto de Previsión Social, Asunción, Paraguay
| | | | - Rafael Amadei
- Hospital Interzonal General de Agudos, San Martín de la Plata, La Plata, Argentina
| | | | - Theodore Miclau
- Institute for Global Orthopaedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California
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Marmor M, El Naga AN, Barker J, Matz J, Stergiadou S, Miclau T. Management of Pelvic Ring Injury Patients With Hemodynamic Instability. Front Surg 2020; 7:588845. [PMID: 33282907 PMCID: PMC7688898 DOI: 10.3389/fsurg.2020.588845] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/12/2020] [Indexed: 12/28/2022] Open
Abstract
Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.
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Affiliation(s)
- Meir Marmor
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Ashraf N El Naga
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jordan Barker
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Jacob Matz
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | | | - Theodore Miclau
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, CA, United States
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Haffner-Luntzer M, Weber B, Lam C, Fischer V, Lackner I, Ignatius A, Kalbitz M, Marcucio RS, Miclau T. A novel mouse model to study fracture healing of the proximal femur. J Orthop Res 2020; 38:2131-2138. [PMID: 32232999 DOI: 10.1002/jor.24677] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/14/2020] [Accepted: 03/25/2020] [Indexed: 02/04/2023]
Abstract
The majority of fractures, especially in elderly and osteoporotic patients, occurs in metaphyseal bone. However, only a few experimental models exist to study metaphyseal bone healing in mice. Currently used mouse models of metaphyseal fracture healing are either based on drill hole defects, lacking adequate biomechanical stimulation at the site of fracture and therefore endochondral ossification in the fracture callus, or are introduced into the distal part of the mouse femur stabilized by a locking plate, which is challenging due to the small specimen size. Therefore, the aim of the current study was to develop a new mouse model to study metaphyseal fracture healing of the proximal femur. We chose a combination between an open osteotomy and a closed intramedullary stabilization. A 24 G needle was inserted into the femur in a closed manner, then an osteotomy was made with a 0.4-mm Gigli wire saw between the third and the lesser trochanter of the femur using an open approach. Fractured femurs were analyzed using microcomputed tomography and histology at days 14 and 21 after surgery. No animals were lost due to surgery or anesthesia. All animals displayed normal limb loading and a physiological gait pattern within the first three days after fracture. We found robust endochondral ossification during the fracture healing process with high expression of late chondrocyte and early osteogenic markers at day 14 (d14). By day 21 (d21), all fractures had a bony bridging score of 3 or more, indicating successful healing. Callus volume significantly decreased from d14 to d21, whereas high numbers of osteoclasts appeared at the fracture callus until d21, indicating that callus remodeling had already started at d21. In conclusion, we successfully developed a novel mouse model to study endochondral fracture healing of the proximal femur. This model might be useful for future studies using transgenic animals to unravel molecular mechanisms of osteoporotic metaphyseal fracture healing.
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Affiliation(s)
- Melanie Haffner-Luntzer
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany.,Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, California
| | - Birte Weber
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, California.,Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Charles Lam
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, California
| | - Verena Fischer
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany
| | - Ina Lackner
- Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Anita Ignatius
- Institute of Orthopaedic Research and Biomechanics, University Medical Center Ulm, Ulm, Germany
| | - Miriam Kalbitz
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, California.,Department of Traumatology, Hand, Plastic, and Reconstructive Surgery, University Medical Center Ulm, Ulm, Germany
| | - Ralph S Marcucio
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, California
| | - Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, California
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Roberts HJ, Albright PD, Shearer DW, Won N, MacKechnie MC, Richard Coughlin R, Miclau T, Morshed S, Sabharwal S. Motivations and impact of international rotations in low- and middle-income countries for orthopaedic surgery residents: Are we on the same page? Am J Surg 2020; 221:245-253. [PMID: 33092782 DOI: 10.1016/j.amjsurg.2020.08.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/19/2020] [Accepted: 08/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite interest among North American orthopaedic residents to pursue rotations in resource-limited settings, little is known regarding resident motivations and impact on host surgeons. METHODS Surveys were distributed to North American orthopaedic surgeons and trainees who participated in international rotations during residency to assess motivations for participation and to orthopaedic surgeons at partnering low- and middle-income country (LMIC) institutions to assess impact of visiting trainees. RESULTS Responses were received from 136 North American resident rotators and 51 LMIC host surgeons and trainees. North American respondents were motivated by a desire to increase surgical capacity at the LMIC while host surgeons reported a greater impact from learning from residents than on surgical capacity. Negative aspects reported by hosts included selfishness, lack of reciprocity, racial discrimination, competition for surgical experience, and resource burdens. CONCLUSIONS The motivations and impact of orthopaedic resident rotations in LMICs need to be aligned. Host perceptions and bidirectional educational exchange should be incorporated into partnership guidelines.
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Affiliation(s)
- Heather J Roberts
- University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143.
| | - Patrick D Albright
- University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143; University of Minnesota Medical School, Department of Orthopedic Surgery, 2512 S 7th St, Suite R200, Minneapolis, MN, USA, 55455.
| | - David W Shearer
- University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143.
| | - Nae Won
- University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143.
| | - Madeline C MacKechnie
- University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143.
| | - R Richard Coughlin
- University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143.
| | - Theodore Miclau
- University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143.
| | - Saam Morshed
- University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143.
| | - Sanjeev Sabharwal
- University of California, Department of Orthopaedic Surgery, 500 Parnassus Ave MU320-W, San Francisco, CA, USA, 94143.
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41
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Bhandari M, Schemitsch EH, Karachalios T, Sancheti P, Poolman RW, Caminis J, Daizadeh N, Dent-Acosta RE, Egbuna O, Chines A, Miclau T. Romosozumab in Skeletally Mature Adults with a Fresh Unilateral Tibial Diaphyseal Fracture: A Randomized Phase-2 Study. J Bone Joint Surg Am 2020; 102:1416-1426. [PMID: 32358413 DOI: 10.2106/jbjs.19.01008] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Romosozumab is an antibody that binds and inhibits sclerostin, thereby increasing bone formation and decreasing bone resorption. A double-blinded, randomized, phase-2, dose-finding trial was performed to evaluate the effect of romosozumab on the radiographic and clinical outcomes of surgical fixation of tibial diaphyseal fractures. METHODS Patients (18 to 82 years old) were randomized 3:1:1:1:1:1:1:1:1:1 to a placebo or 1 of 9 romosozumab treatment groups. Patients received subcutaneous injections of romosozumab or the placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary outcome was the time to radiographic evidence of healing ("radiographic healing") analyzed after the week-24 assessments had been completed for all patients. RESULTS A total of 402 patients were randomized: 299 to the romosozumab group and 103 to the placebo group. The median time to radiographic healing (the primary outcome) ranged from 14.4 to 18.6 weeks in the romosozumab groups and was 16.4 weeks (95% confidence interval [CI]: 14.6 to 18.0 weeks) in the placebo group, which was not a significant difference. There was also no significant difference in the median time to clinical healing, no relationship between romosozumab dose/frequency and unplanned revision surgery, and no apparent treatment benefit in terms of physical function. The safety and tolerability profile of romosozumab was comparable with that of the placebo. CONCLUSIONS Romosozumab did not accelerate tibial fracture-healing in this patient population. Additional studies of patients at higher risk for delayed healing are needed to explore the potential of romosozumab to accelerate tibial fracture-healing. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Emil H Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Theofilos Karachalios
- Orthopaedic Department UGHL, School of Health Sciences, University of Thessalia, Larissa, Greece
| | - Parag Sancheti
- Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India
| | | | | | | | | | | | | | - Theodore Miclau
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.,Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, California
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42
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Hellwinkel JE, Miclau T, Provencher MT, Bahney CS, Working ZM. The Life of a Fracture: Biologic Progression, Healing Gone Awry, and Evaluation of Union. JBJS Rev 2020; 8:e1900221. [PMID: 32796195 DOI: 10.2106/jbjs.rvw.19.00221] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
New knowledge about the molecular biology of fracture-healing provides opportunities for intervention and reduction of risk for specific phases that are affected by disease and medications. Modifiable and nonmodifiable risk factors can prolong healing, and the informed clinician should optimize each patient to provide the best chance for union. Techniques to monitor progression of fracture-healing have not changed substantially over time; new objective modalities are needed.
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Affiliation(s)
- Justin E Hellwinkel
- Department of Orthopedic Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY.,Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
| | - Theodore Miclau
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
| | - Matthew T Provencher
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado
| | - Chelsea S Bahney
- Center for Regenerative Sports Medicine, The Steadman Clinic and Steadman Philippon Research Institute, Vail, Colorado.,Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California
| | - Zachary M Working
- Orthopaedic Trauma Institute, University of California, San Francisco (UCSF) and Zuckerberg San Francisco General Hospital (ZSFG), San Francisco, California.,Oregon Health & Science University, Portland, Oregon
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43
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Abstract
Hospital-based hip fracture programs are essential for effective, efficient care of elderly patients who have sustained hip fractures. Many of the gains in outcomes and patient survival are a result of such integrated care models. We review the rationale, elements, and benefits of such programs across the spectrum of inpatient centers, including low-volume and high-volume community hospitals and trauma centers.
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Affiliation(s)
- Eric Meinberg
- University of California, San Francisco Department of Orthopaedic Surgery, San Francisco, US; Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, US
| | - Derek Ward
- University of California, San Francisco Department of Orthopaedic Surgery, San Francisco, US
| | - Matthew Herring
- University of California, San Francisco Department of Orthopaedic Surgery, San Francisco, US; Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, US
| | - Theodore Miclau
- University of California, San Francisco Department of Orthopaedic Surgery, San Francisco, US; Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, US.
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44
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Donohoe E, Roberts HJ, Miclau T, Kreder H. Management of Lower Extremity Fractures in the Elderly: A Focus on Post-Operative Rehabilitation. Injury 2020; 51 Suppl 2:S118-S122. [PMID: 32448467 DOI: 10.1016/j.injury.2020.04.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 02/02/2023]
Abstract
Fractures in the elderly population are increasing in incidence and represent a rising burden of disease. It is difficult for the elderly population to adhere to restricted weight bearing, and immobility poses significant risks and increased morbidity. Therefore, a primary goal of fracture management in the elderly population is early post-operative weight bearing. This review examines published literature regarding lower extremity fracture management in the elderly, with a focus on post-operative rehabilitation. While extensive literature supports early weight bearing after hip fractures in the elderly, further research is warranted to provide guidelines for management of other lower extremity fractures in this population.
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Affiliation(s)
- Erin Donohoe
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Heather J Roberts
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Theodore Miclau
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Hans Kreder
- Sunnybrook Health Sciences Centre, Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada.
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45
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Affiliation(s)
- Theodore Miclau
- Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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46
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Schemitsch EH, Miclau T, Karachalios T, Nowak LL, Sancheti P, Poolman RW, Caminis J, Daizadeh N, Dent-Acosta RE, Egbuna O, Chines A, Maddox J, Grauer A, Bhandari M. A Randomized, Placebo-Controlled Study of Romosozumab for the Treatment of Hip Fractures. J Bone Joint Surg Am 2020; 102:693-702. [PMID: 31977817 PMCID: PMC7508283 DOI: 10.2106/jbjs.19.00790] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Romosozumab is a bone-forming antibody that increases bone formation and decreases bone resorption. We conducted a double-blinded, randomized, phase-2, dose-finding trial to evaluate the effect of romosozumab on the clinical outcomes of open reduction and internal fixation of intertrochanteric or femoral neck hip fractures. METHODS Patients (55 to 94 years old) were randomized 2:3:3:3 to receive 3 subcutaneous injections of romosozumab (70, 140, or 210 mg) or a placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary end point was the difference in the mean timed "Up & Go" (TUG) score over weeks 6 to 20 for romosozumab versus placebo. Additional end points included the time to radiographic evidence of healing and the score on the Radiographic Union Scale for Hip (RUSH). RESULTS A total of 332 patients were randomized: 243 to receive romosozumab (70 mg, n = 60; 140 mg, n = 93; and 210 mg, n = 90) and 89 to receive a placebo. Although TUG scores improved during the study, they did not differ significantly between the romosozumab and placebo groups over weeks 6 to 20 (p = 0.198). The median time to radiographic evidence of healing was 16.4 to 16.9 weeks across treatment groups. The RUSH scores improved over time across treatment groups but did not differ significantly between the romosozumab and placebo groups. The overall safety and tolerability profile of romosozumab was comparable with that of the placebo. CONCLUSIONS Romosozumab did not improve the fracture-healing-related clinical and radiographic outcomes in the study population. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emil H. Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada,Email address for E.H. Schemitsch:
| | - Theodore Miclau
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California,Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Theofilos Karachalios
- Orthopaedic Department UGHL, School of Health Sciences, University of Thessalia, Larissa, Greece
| | - Lauren L. Nowak
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Parag Sancheti
- Sancheti Institute of Orthopaedics and Rehabilitation, Pune, India
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47
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Abstract
Hip fractures, among the most common geriatric injuries, are associated with adverse patient outcomes and significant costs. The incidence of these fractures continues to rise with an aging population worldwide. While many factors that negatively impact patient outcomes are nonmodifiable, others, which include pre- and postoperative medical management, timing of surgical stabilization, and fracture fixation methods, are modifiable and have been shown to affect outcomes. Treatment pathways are dependent upon available resources and established systems, and comparative guidelines from different regions and countries are not well documented. This special issue seeks to highlight regional differences in hip fracture care globally and represents a collaborative work of member societies of the International Orthopaedic Trauma Association, an international association of orthopaedic societies dedicated to the promotion of musculoskeletal trauma care through advancements in patient care, research, and education. The expectation is that better understanding these differences will aid efforts to better understand, improve, and standardize existing approaches to hip fracture management worldwide.
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Affiliation(s)
- Theodore Miclau
- Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
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48
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Clark D, Brazina S, Yang F, Hu D, Hsieh CL, Niemi EC, Miclau T, Nakamura MC, Marcucio R. Age-related changes to macrophages are detrimental to fracture healing in mice. Aging Cell 2020; 19:e13112. [PMID: 32096907 PMCID: PMC7059136 DOI: 10.1111/acel.13112] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/05/2019] [Accepted: 01/17/2020] [Indexed: 12/12/2022] Open
Abstract
The elderly population suffers from higher rates of complications during fracture healing that result in increased morbidity and mortality. Inflammatory dysregulation is associated with increased age and is a contributing factor to the myriad of age-related diseases. Therefore, we investigated age-related changes to an important cellular regulator of inflammation, the macrophage, and the impact on fracture healing outcomes. We demonstrated that old mice (24 months) have delayed fracture healing with significantly less bone and more cartilage compared to young mice (3 months). The quantity of infiltrating macrophages into the fracture callus was similar in old and young mice. However, RNA-seq analysis demonstrated distinct differences in the transcriptomes of macrophages derived from the fracture callus of old and young mice, with an up-regulation of M1/pro-inflammatory genes in macrophages from old mice as well as dysregulation of other immune-related genes. Preventing infiltration of the fracture site by macrophages in old mice improved healing outcomes, with significantly more bone in the calluses of treated mice compared to age-matched controls. After preventing infiltration by macrophages, the macrophages remaining within the fracture callus were collected and examined via RNA-seq analysis, and their transcriptome resembled macrophages from young calluses. Taken together, infiltrating macrophages from old mice demonstrate detrimental age-related changes, and depleting infiltrating macrophages can improve fracture healing in old mice.
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Affiliation(s)
- Daniel Clark
- Department of Orthopaedic SurgerySchool of MedicineOrthopaedic Trauma InstituteZuckerberg San Francisco General HospitalUniversity of California San FranciscoSan FranciscoCAUSA
- Division of PeriodontologyDepartment of Orofacial SciencesSchool of DentistryUniversity of California San FranciscoSan FranciscoCAUSA
| | - Sloane Brazina
- Department of Orthopaedic SurgerySchool of MedicineOrthopaedic Trauma InstituteZuckerberg San Francisco General HospitalUniversity of California San FranciscoSan FranciscoCAUSA
| | - Frank Yang
- Department of Orthopaedic SurgerySchool of MedicineOrthopaedic Trauma InstituteZuckerberg San Francisco General HospitalUniversity of California San FranciscoSan FranciscoCAUSA
| | - Diane Hu
- Department of Orthopaedic SurgerySchool of MedicineOrthopaedic Trauma InstituteZuckerberg San Francisco General HospitalUniversity of California San FranciscoSan FranciscoCAUSA
| | - Christine L. Hsieh
- Division of RheumatologyDepartment of MedicineSan Francisco VA Health Care SystemSan FranciscoCAUSA
| | - Erene C. Niemi
- Division of RheumatologyDepartment of MedicineSan Francisco VA Health Care SystemSan FranciscoCAUSA
| | - Theodore Miclau
- Department of Orthopaedic SurgerySchool of MedicineOrthopaedic Trauma InstituteZuckerberg San Francisco General HospitalUniversity of California San FranciscoSan FranciscoCAUSA
| | - Mary C. Nakamura
- Division of RheumatologyDepartment of MedicineSan Francisco VA Health Care SystemSan FranciscoCAUSA
| | - Ralph Marcucio
- Department of Orthopaedic SurgerySchool of MedicineOrthopaedic Trauma InstituteZuckerberg San Francisco General HospitalUniversity of California San FranciscoSan FranciscoCAUSA
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49
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Clark D, Miclau T, Nakamura M, Marcucio R. AGE-RELATED CHANGES TO MACROPHAGES AFFECT FRACTURE HEALING. Innov Aging 2019. [PMCID: PMC6845056 DOI: 10.1093/geroni/igz038.321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Fracture healing follows a strict temporal sequence characterized by an initial inflammatory phase. Perturbation of the inflammatory phase may be responsible for the poorer fracture healing outcomes in older adults. Herein, we examine age-related changes to the macrophage during fracture healing. Macrophages regulate inflammation through pro-inflammatory (M1) and anti-inflammatory (M2) phenotypes. Anti-inflammatory activity is promoted via activation of triggering receptor expressed on myeloid cells 2 (TREM2). Tibia fractures were made in old (24 months) and young (3 months) mice. Immune cells from the fracture callus were analyzed via RNAseq and FACS, and fracture healing was evaluated histologically. Old mice demonstrated significantly delayed fracture healing compared to young (p<0.05). The quantity of infiltrating macrophages into the fracture callus was similar in young and old mice. However, 1222 genes were significantly differentially regulated (FDR<0.1) in callus macrophages from old mice compared to young, and old macrophages demonstrated a more pro-inflammatory phenotype. TREM2 expression was increased in macrophages after fracture in both groups but was significantly less in old mice compared to young via RNAseq and FACS (FDR<0.1, p<0.05). TREM2-/- mice demonstrated increased pro-inflammatory cytokine expression within the callus with resulting significant delays in fracture healing compared to age-matched controls (p<0.05). Inhibition of macrophage infiltration into the fracture callus significantly improved fracture healing in old mice compared to age-matched controls. Age-related changes to macrophages, including increased pro-inflammatory cytokine expression and dysregulated TREM2 expression, may explain fracture healing deficits observed in older adults. Therapeutically targeting macrophages may improve management of fractures in older adults.
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Affiliation(s)
- Daniel Clark
- University of California San Francisco, San Francisco, California, United States
| | - Theodore Miclau
- University of California San Francisco, San Francisco, California, United States
| | - Mary Nakamura
- University of California San Francisco, San Francisco, California, United States
| | - Ralph Marcucio
- University of California San Francisco, San Francisco, California, United States
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50
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Meinberg EG, Clark D, Miclau KR, Marcucio R, Miclau T. Fracture repair in the elderly: Clinical and experimental considerations. Injury 2019; 50 Suppl 1:S62-S65. [PMID: 31130210 PMCID: PMC7021229 DOI: 10.1016/j.injury.2019.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/01/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023]
Abstract
Fractures in the elderly represent a significant and rising socioeconomic problem. Although aging has been associated with delays in healing, there is little direct clinical data isolating the effects of aging on bone healing from the associated comorbidities that are frequently present in elderly populations. Basic research has demonstrated that all of the components of fracture repair-cells, extracellular matrix, blood supply, and molecules and their receptors-are negatively impacted by the aging process, which likely explains poorer clinical outcomes. Improved understanding of age-related fracture healing should aid in the development of novel treatment strategies, technologies, and therapies to improve bone repair in elderly patients.
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Affiliation(s)
- E G Meinberg
- UCSF/ZSFG Orthopaedic Trauma Institute, UCSF Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - D Clark
- UCSF/ZSFG Orthopaedic Trauma Institute, UCSF Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - K R Miclau
- UCSF/ZSFG Orthopaedic Trauma Institute, UCSF Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - R Marcucio
- UCSF/ZSFG Orthopaedic Trauma Institute, UCSF Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - T Miclau
- UCSF/ZSFG Orthopaedic Trauma Institute, UCSF Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
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